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Chapter IV

Activities of Medical Consultants


European Theater of Operations

William S. Middleton, M.D.

Part I. Chief Consultant in Medicine
    In 1942, the organizational pattern of the Professional Services Division, Office of the Chief Surgeon, Headquarters, ETOUSA (European Theater of Operations, U.S. Army), took its basic design from the organization set up for the American Expeditionary Forces of World War I in France. Circular No. 2, dated 9 November 1917, Office of the Chief Surgeon, American Expeditionary Forces, had listed eight directors of the Professional Services to serve as an element under the Division of Hospitalization. Four months later, it was disclosed that The Surgeon General of the U.S. Army had, on 11 November 1917, proposed a Consultants Service of three divisions. However, he expressed his willingness to support the plan of the American Expeditionary Forces, and, eventually, 7 of the 8 directorships of Professional Services were established in the Departments of Medicine and Surgery.2

    Unusually happy was the selection of the two leaders of this movement: Brig. Gen. John M. T Finney in surgery, and Brig. Gen. William S. Thayer in medicine. From the outset, however, the geographic dissociation of the directors, located at Neufchateau, from the General Headquarters located at Chaumont, 45 miles away, bespoke difficulties that were exaggerated when General Headquarters moved to Tours. On 18 April 1918, Col. William L. Keller, MC, was made director of Professional Services. Although his appointment afforded leadership and a measure of cohesion, his assignment to the general headquarters accentuated the physical detachment of the officers whose work he supervised. The unfortunate term "director" was changed by definition to "consultant" by Circular No. 25, dated 5 May 1918, Office of the Chief Surgeon, American Expeditionary Forces. The pattern of organization was most ambitious and was designed to be carried through at all echelons of command; namely, army, corps, and division.

    In the Medical Division, under General Thayer at headquarters, there were two senior consultants in general medicine, Col. Thomas R. Boggs, MC, and Maj. Franklin C. McLean, MC; a senior consultant in infectious diseases, Col. Warfield T. Longcope, MC; a senior consultant in neuropsychiatry, Col. Thomas W. Salmon, MC; a senior consultant in general medicine, poisoning

1 Dr. Middleton, who is the author of part I, served as editor and reviewer for the remainder of the chapter.
 2 The Medical Department of the United States Army in the World War. Administration, American Expeditionary Forces. Washington: U.S. Government Printing Office, 1927, vol. II, p.351.


by deleterious gas, Lt. Col. Richard Dexter, MC; a senior consultant in cardiovascular diseases, Lt. Col. Alfred E. Cohn, MC; and a senior consultant in tuberculosis, Lt. Col. Gerald B. Webb, MC.

    As might be anticipated, this comprehensive plan, idealistic in its conception, failed at many points through patent sources of weakness. Communication was difficult and mobility limited. As late as 2 September 1918, in a communication to the Chief Surgeon, American Expeditionary Forces, General Finney and General Thayer indicated their inability to control the distribution of skilled personnel. This fundamental defect sharply curtailed the usefulness of the consultants and led to an almost overwhelming sense of frustration. Without sympathetic cooperation at the highest levels, both within the Medical Department of the Regular Army and within the command, the potential of the consultants in fulfilling their mission was not well exploited.
    As an observer of the activities of the Professional Services at close range in World War I, the following inherent faults became apparent to the author:
(1) Overorganization; (2) concentration of highly skilled personnel at consultant levels; (3) detached leadership; (4) lack of cohesive attack; (5) difficulties in transportation, leading to immobilization; (6) inadequate professional and military rapport; and (7) insufficient time to correct these errors of organization and operation.


    With the World War I experience as background, the opportunities and the responsibilities of the Medical Consultation Service, Office of the Chief Surgeon, Headquarters, ETOUSA, in World War II, stood in sharp relief. In London, as the Army Medical Directorate Consultants Committee to the Director General of the Royal Army Medical Corps, were gathered some of the outstanding men in British medicine. As advisers to the Royal Canadian Army Medical Corps, there were four leaders in the Canadian profession. The combined experience of these Allies was available at all phases of planning and activity in ETOUSA. Their advice and assistance were invaluable, and many pitfalls were avoided through their sustaining counsel.


    On 13 July 1942, Lt. Col. (later Col.) William S. Middleton, MC (fig.77), reported as Chief Consultant in Medicine, Office of the Chief Surgeon, Headquarters, ETOUSA, then located at Cheltenham, England. On 21 July 1942, Col. James C. Kimbrough, MC (fig.78), Director, Professional Services Division, Office of the Chief Surgeon, Headquarters, ETOUSA, proposed to set up the following four separate divisions of consultants: Medicine, surgery, neuropsychiatry, and venereal disease control. Colonel Middleton indicated certain practical and functional objections to the separation of neuropsychiatry and venereal disease control from medicine. On 25 July 1942, Colonel Middleton conferred with Col. (later Maj. Gen.) Paul R. Hawley, MC, Chief Surgeon,

FIGURE 77.- Col. William S. Middleton, MC, Chief Consultant in Medicine, Office of the Chief Surgeon, ETOUSA.

ETOUSA, and urged surveys of the British and Canadian medical situations, with particular reference to the physical, tactical, medical, and educational programs in these respective services. At this conference, an adaptation of the British and the Canadian experiences to the medical needs of the U.S. Army in the European theater was urged to avoid duplication on one hand and the loss of identity on the other. In discussing the educational program for the theater, the improvement of medical services for the troops was the objective. Past efforts had fallen short of the mark, owing to a failure to reach the medical officers most in need of instruction. The interchange of medical officers of company grade on the staff of general hospitals with those in line duty was proposed at this conference.
    In the eventual plan of organization, Colonel Kimbrough included, under the chief consultant in medicine, senior consultants in time following subspecialties: General medicine, gas defense, acute infectious diseases, cardiology, tuberculosis, gastroenterology, dermatology, nutrition, neurology, and psychiatry. With the concurrence of Colonel Kimbrough, nutrition was later made the responsibility of the Preventive Medicine Division, Office of the Chief Surgeon, Headquarters, ETOUSA. In London, on 11 August 1942, Colonel Middleton met with Col. (later Brig. Gen.) Elliott C. Cutler, MC, Chief Consultant in Surgery, Office of the Chief Surgeon, Headquarters, ETOUSA, and Col. (later Brig. Gen.) Charles B. Spruit, MC (fig.79), Deputy Chief Surgeon, ETOUSA. In this conference, Colonel Cutler expressed a desire to have his senior consult-

FIGURE 78.- Col. James C. Kimbrough, MC (left) and Col. William S. Middleton, MC.

ants as a cabinet to advise him at all times within the subspecialties of surgery, including X-ray and anesthesiology. In light of the World War I experience and from a personal evaluation of the requirements of ETOUSA, Colonel Middleton outlined a plan that would maintain at headquarters a minimum of senior consultants in the medical subspecialties and a majority in a dual relationship with primary responsibilities as chiefs of immedical services in general hospitals and a subsidiary function as advisers to the theater at large in their respective fields. Upon conferring with Colonel Hawley, both chief consultants were advised that they would be held responsible for their respective functions, regardless of the manner of implementation. As anticipated, with the evolution of the medical picture in the theater, neuropsychiatry and dermatology (when venereal diseases were included in the latter) constituted areas that required the full time of the senior consultants for direction and advice. Accordingly, the senior consultants for neuropsychiatry and dermatology were attached to headquarters.
    With the approval of Colonel Hawley, a list of specialists in the United States to serve as senior consultants in the respective subdivisions of medicine in the European theater was submitted to the Surgeon General's Office on 16 August 1942. The Surgeon General's response, received on 22 October 1942, left no doubt as to further procedure, stating: "It is suggested that Consultants be obtained from men already assigned to the European Theater. Many of the

FIGURE 79.-Col. Charles B. Spruit, MC.

men listed in the basic communication hold key positions in civilian life, and cannot be obtained for the Army. Many others, if they can be declared nonessential, are required for consultant positions in the United States."
    On 25 August 1942, Lt. Col. (later Col.) Lloyd J. Thompson, MC, assigned as Senior Consultant in Neuropsychiatry, ETOUSA, reported to the theater. The Surgeon General likewise named Lt. Col. (later Col.) Donald M. Pillsbury, MC, as Senior Consultant in Dermatology, ETOUSA, and he reported for duty on 5 December 1942. On 25 December 1942, Lt. Col. (later Col.) Theodore L. Badger, MC, Chief, Medical Services, 5th General Hospital, located near Salisbury, England, was recommended as Senior Consultant in Tuberculosis, ETOUSA. Colonel Badger was the first medical officer to have the distinction of serving in the dual capacity anticipated for all senior consultants.

Plans for Gas Defense

    To Colonel Middleton, as one who had served with troops in World War I and to whom the ravages of gas warfare were familiar, the necessity for sound organization to meet such a threat weighed heavily. Opportunities to study the situation in the British Army were afforded through the courtesy of the Royal Army Medical Corps, through the good offices of Colonel Walker and Captain Hill, RAMC. On 10 August 1942, Colonel Middleton was granted every facility of the Royal Army Medical Corps School of Instruction at Boyce

Barracks, Aldershot, England. Tables of organization and plans of instruction for gas defense were carefully reviewed. The realistic attitude of the school officials indicated a sharp appreciation of the limitations in therapy. For example, oxygen therapy was to be given to the "blue" subjects of phosgene poisoning but not to the "gray."

    Colonel Walker proposed to take from 10 to 15 U.S. Army medical officers in each class, rather than the existing quota of three, as the pressure of the military situation increased. On 4 November 1942, Colonel Middleton attended the course at the M. S. Factory, Randalestown, Northern Ireland, where the program included a demonstration of the manufacture of toxic agents. The preventive measures among workers and detailed data as to the treatment of the several forms of toxic gases, including bromobenzylcyanide and benzylcyanide, phosgene, lewisite, and other arsenic-containing toxic agents, were discussed. Doctors Chiesman, Ferrie, Wilkinson, and Stopford-Taylor and Mr. Phillips afforded a most instructive day.
    Meanwhile, the key position of gas defense officer in the Office of the Chief Surgeon, Headquarters, ETOUSA, remained vacant in spite of Colonel Middleton's importunities. When Lt. Col. (later Col.) Perrin H. Long, MC, was transferred to General Hawley's office on 20 November 1942, he was assigned to duties of Acting Senior Consultant in Chemical Warfare Medicine, ETOUSA. With characteristic energy, he lent every effort to the orientation and organization of the available information in an unfamiliar field, until his transfer to the North African theater on 18 December 1942. At this time, the presence of Comdr. (later Capt.) George M. Lyon, MC, USN, in the naval office of the U.S. Embassy in London, was fortuitous. A student of gas warfare and gas defense for many years, Commander Lyon brought recognized authority to this field. His cooperation with the Army and assistance during this period illustrates one of the strongest justifications for the unification of the Armed Forces. Finally, Col. William D. Fleming, MC, the long-awaited gas defense officer, reported for duty on 23 February 1943. Three days later, in deference to Army protocol, Col. Oramel H. Stanley, MC, Deputy Surgeon, Headquarters, Service of Supply, ETOUSA, indicated that Colonel Fleming had been assigned directly to General Hawley as assistant surgeon in charge of gas defense. This function was thereupon removed from the organizational pattern of the Medical Consultation Service. The gas casualty kit assembled by Colonel Fleming is shown in figure 80.

Dual Functions

    With these minor readjustments, the ultimate plan of organization of the Medical Consultation Service, ETOUSA, was completed by the addition of Lt. Col. (later Col.) Gordon E. Hein, MC, Chief, Medical Service, 30th General Hospital, located near Mansfield, England, as Senior Consultant in Cardiology, ETOUSA; Lt. Col. (later Col.) Yale Kneeland, Jr., MC, Chief, Medical Service, 2d General Hospital, Headington, Oxford, England, as Senior Consultant in

FIGURE 80.-ETO gas casualty treatment kit.

Infectious Diseases, ETOUSA; and Maj. (later Col.) Ralph S. Muckenfuss, MC (fig.81), Commanding Officer, General Medical Laboratory A, as Director, Medical Research, ETOUSA. Colonel Badger continued to function in the dual capacity of Chief, Medical Service, 5th General Hospital, and Senior Consultant in Tuberculosis. With the growth of the theater, the basic pattern was maintained, always with the thought of utilizing the senior consultants in dual capacities, where possible. As the need developed, whether in hospital centers, base sections, or a major area such as the United Kingdom, the senior consultants in infectious diseases, cardiology, and tuberculosis continued to serve in two distinct roles. The primary responsibilities of these senior consultants to a hospital or a larger administrative unit hospital center, base section, or major area) in no way interfered with their important function of directing the theater policy within their respective specialties.  


FIGURE 81.-Col. Ralph S. Muckenfuss, MC, Director of Medical Research, ETOUSA.
    The effectiveness of any plan can be established only by the trial of experience. As stated, the administrative load in neuropsychiatry and dermatology (including venereal disease) was anticipated. Colonels Thompson and Pillsbury, operating from headquarters, discharged their onerous duties with distinction by dint of painstaking planning and assiduous effort. The early occurrence of a serious problem in the incidence of primary atypical pneumonia led the Chief Surgeon to establish a committee, composed of Colonels Kneeland and Muckenfuss and Lt. Col. (later Col.) John E. Gordon, MC, Chief, Preventive Medicine Division, Office of the Chief Surgeon, Headquarters, ETOUSA, to study this problem. This group was continued as the Advisory Committee on Infectious Diseases to coordinate the mutual effort in this area. In the interest of professional coverage for consultation in isolated units, the temporary expedient of regional consultants was invoked on 21 May 1943.3 Seventeen such consultants in medicine were named from the chiefs of fixed hospitals. The plan of base section consultants was first established in North Ireland Base Section by the appointment of Colonel Badger. With the evolution of the military program in the United Kingdom, the next phase of the Medical Consultation Service, ETOUSA, involved the movement of the following senior consultants: Colonel Kneeland to the Southern Base Section, Colonel Hein to the Western Base Section, and Colonel Badger to the Eastern Base Section.4 Eventually, base section consultants were assigned to the United Kingdom (fig. 82), Brittany, Normandy, Oise, and Delta Base Section. The Brittany Base Section had a very short life, and its medical consultant, Col. O. C. McEwen, MC, was given command of a hospital. As time passed, hospital center consultants were named in 15 centers-7 in the United Kingdom, 8 on the Continent. Medical consultants in each army afforded the direct channel of communication with the field. The names and assignments of the medical consultants who served in ETOUSA are listed in appendix A (p. 829).
 3 Circular Letter No. 89, Office of Chief Surgeon, Headquarters, ETOUSA, 21 May 1943, subject: Regional Consultants.
 4 NOTE.- The hospital center development soon made a single medical consultant for the United Kingdom a more effective agent for coordination of these groups. J. B.C., Jr.


FIGURE 82.- Staff of the Medical Section, headquarters, United Kingdom Base, England, February 1945. Col. Joseph R. Shelton, MC, Chief, Operations Division; Col. Frank E. Stinchfield, MC, Chief, Rehabilitation Division; Col. Einar C. Andreassen, MC, Chief, Operations Division; Brig. Gen. Charles B. Spruit, MC, Surgeon, United Kingdom Base; Col. Joseph H. McNinch, MC, Executive Officer, and concurrently Chief, Medical Records Division, Office of the Chief Surgeon, ETOUSA; Maj. George S. Uhde, Chief, Chemical Warfare Medicine; Lt. Col. Ralph T. Casteel, MAC, Chief, Personnel Division; Lt. Col. Margaret Schafer, ANC, Chief, Nursing Division; Lt. Col. Wayne Hayes, MC, Chief, Dental Division; Lt. Col. John H. Watkins, SnC, Assistant Chief, Medical Records Division, Office of the Chief Surgeon, ETOUSA; Lt. Col. Benjamin H. Sullivan, Jr., MC, Assistant Executive Officer, Maj. Claude M. Eberhart, MC, Chief, Preventive Medicine Division.

Channels of Communication

The use of official channels was required in all matters pertaining to military or tactical procedure. With the support of General Hawley, direct communication in purely professional matters was encouraged. By the expedient of direct professional communication, the simplified system of decentralized control afforded prompt information regarding disease trends, therapeutic innovations, and pertinent medical data, which might have been long delayed had use of regular military channels been required. In the European theater, the chief consultant in medicine and his senior consultants had direct communication with the base section, hospital center, and army consultants. This arrangement reduced the obstructive factors in dissemination to a minimum and assured prompt and adequate rapport in all matters medical. Not infrequently, the advantage was centripetal rather than


centrifugal since General Hawley's office, through this medium, was constantly in touch with all medical echelons of the theater.
    The scheme of organization did not extend beyond the level of the field army into the corps and divisions as had been planned in World War I. Although there had been early designs in this direction, it was found inexpedient and ineffective to carry the plan beyond the army level. However, through the army medical consultants, an effective medium of exchange existed on a reciprocal plane. Through 5 army consultants, 15 hospital center consultants, and ultimately 5 base section consultants, the senior consultants in medicine and the chief consultant in medicine found ready and cooperative professional communication.

    The necessity for this decentralization becomes apparent in view of the existence of over 200 fixed-hospital units in the theater. Furthermore, with the OVERLORD movement, Colonel Middleton and the headquarters-based senior consultants, Colonel Thompson and Colonel Pillsbury, were transferred to France, when the Office of the Chief Surgeon, Headquarters, ETOUSA, moved to Valognes, and later to Paris (fig. 83) and Versailles. At this time, the direct responsibility for the direction of the Medical Consultation Service in the United Kingdom devolved upon Colonel Kneeland. Under his immediate supervision came the organization and operation of the medical services within the total of 140,000 beds, represented by the fixed hospitals in the United Kingdom after D-day.

    The support of the Medical Consultation Service, ETOUSA, extended through the Chief Surgeon to the staff of The Surgeon General of the Army. In addition to the official interchanges of the Medical Department, informal professional communication was encouraged between the members of the staff in Washington, D.C., and their respective associates in the Zone of Interior and in the oversea theater. Brig. Gen. Hugh J. Morgan, Chief Consultant in Medicine to The Surgeon General, utilized continuously this expedient of informal communication as a medium for reciprocal advice. This ready exchange of professional information redounded to the improvement of medical service in the European theater. General Morgan's leadership gave intimate direction to the many major developments.
    General Morgan visited the European theater for a tour of inspection from 7 February to 21 March 1945 (fig.84). A summary of the tour was made on 28 March 1945 by Colonel Middleton to General Hawley, as follows:

    General Morgan was afforded the opportunity to observe military medicine in four armies, under field conditions. In three of these armies he followed the line of evacuation from the battalion aid post [station] to the evacuation hospital. Typical fixed installations of the Communication Zone were visited on the Continent and in Great Britain. Particular pains were taken to cover the entire range of facilities from tented units to units housed in buildings of every degree of adequacy. The medical organization of the several echelons was covered in detail by qualified members of the staff. Clinical subjects of special interest to General Morgan, such as cold injury, hepatitis, malaria and "field" nephritis, were  


FIGURE 83.-Avenue Kleber, Paris, France, showing section of buildings occupied by Office of the Chief Surgeon, ETOUSA.

demonstrated in adequate numbers to meet his requirements. Through the cooperation of the Senior Consultants in Psychiatry and Dermatology, special facilities in these fields were demonstrated to General Morgan. Through Colonel Diveley and Colonel Stinchfield, similar opportunities were afforded for the study of the program in physical rehabilitation (fig.85). The complete cooperation of the administrative and clinical divisions of all echelons of the Medical Department made this tour possible.

    The Medical Consultation Service profited immeasurably from the firsthand counsel of General Morgan on his European tour of duty.

    Colonel Middleton initiated periodic conferences of the chiefs of medical services, in the interest of the coordination and consolidation of medical practice within the fixed hospitals of the Communications Zone. The first of these conferences was held on 25 March 1943 at Cheltenham. Fourteen of the sixteen chiefs of medicine in fixed hospitals in the theater at that time were in attendance. Representatives from the Office of the Chief Surgeon, Headquarters, ETOUSA, included Colonel Fleming, Medical Gas Defense Officer; Colonel Kimbrough, Director, Professional Services Division; Lt. Col. (later Col.) James B. Mason, MC, Chief, Operations and Training Division; Col. Joseph  


FIGURE 84.-General Morgan (second from right) on visit to ETO. Others (left to right): Colonel Kimbrough, General Hawley, and Colonel Middleton, Hotel George V, Paris, France.

H. McNinch, MC, Chief, Medical Records Division; Colonel Pillsbury, Senior Consultant in Dermatology; Colonel Thompson, Senior Consultant in Neuropsychiatry; and Major Muckenfuss, Commanding Officer, General Medical Laboratory A. There were detailed discussions on the following subjects Gas defense; records; laboratory service; functions of the chiefs of medical services; distribution and utilization of medical personnel; current clinical problems in the theater; clinical procedures in communicable diseases; syphilis; shock; supply problems, including drugs, special diets, and equipment; disposition of patients; convalescent hospital facilities; evacuation and transportation of patients; educational programs; professional relations; and military responsibilities. Mimeographed transcripts of the proceedings were circularized to the hospitals of the theater and to the headquarters staff.

    The second conference of the chiefs of medical services was held at Headquarters, ETOUSA, on 30 July 1943. The chiefs of medical services of 22 fixed installations and the following representatives of General Hawley's office were present: Colonel Spruit, Deputy Chief Surgeon; Col. Edward M. Curley, VC (fig.86), Chief, Veterinary Service; Colonel Fleming, Gas Defense Officer, Colonel Gordon, Chief, Preventive Medicine Division; Colonel Kimbrough, Director, Professional Services; Col. David E. Liston, MC, Chief, Personnel  


FIGURE 85.-Convalescent patient undergoing obstacle course training at 203d Station Hospital, Stoneleigh Park, England.
Division; Colonel McNinch, Executive Officer; Col. Walter L. Perry, MC, Chief, Finance and Supply Division; Colonel Thompson, Senior Consultant in Psychiatry; Lt. Col. John K. Davis, MC, Hospitalization Division; Colonel Mason, Chief, Operations and Training Division; Colonel Pillsbury, Senior Consultant in Dermatology; and Colonel Muckenfuss, Director, Medical Research. The subjects considered were milk supply; fever therapy; intensive arsenical therapy of syphilis; anesthesia; laboratory services; current clinical problems of the theater, including respiratory infections, infectious mononucleosis, primary atypical pneumonia, poliomyelitis, mumps, encephalitis, and allergy; administrative problems, particularly involving the cooperation among hospitals; special training of nurses and enlisted men; and disposition problems. Colonel Curley presented an analysis of the problem of bovine tuberculosis in Great Britain which was timely and revealing. The presence of representatives from the several divisions of General Hawley's office led to an open forum, with most profitable discussions of such subjects as plans for special hospitals, availability of special equipment, supply and procurement of nonstandard drugs, nomination for special schools, proposed medical bulletins, and records.

    By 1944, the theater had grown to such an extent that it was necessary to divide the third conference of the chiefs of medical services into two sections. The first, held on 26 January 1944, included the chiefs of the medical services 


FIGURE 86.-Col. Edward M. Curley, VC (left), and Col. William S. Middleton, MC.
of the hospitals in the Eastern, Western, Central, and North Ireland Base Sections. The second, held on 2 February 1944, was attended by the chiefs of the medical services from the hospitals of the Southern Base Section. At the two meetings, 70 chiefs of the medical services of the respective hospitals or their representatives were in attendance. The following representatives of General Hawley's office took active part in the proceedings of these sessions: Col. J. C. Darnell, MC, Chief, Hospitalization Section; Col. Rex L. Diveley, MC, Senior Consultant in Orthopedic Surgery; Colonel Fleming, Medical Gas Defense Officer; Colonel Gordon, Chief, Preventive Medicine Division; Colonel Kimbrough, Director, Professional Services Division; Colonel McNinch, Executive Officer; Col. W. L. Perry, Chief, Supply Division; Colonel Thompson, Senior Consultant in Psychiatry; Col. W. D. White, DC, Chief, Dental Service; Lt. Col. Kenneth D. A. Allen, MC, Chief Consultant in Radiology; Lt. Col. G. D. McCarthy, MC, Hospitalization Division; Colonel Muckenfuss, Director of Medical Research; Colonel Pillsbury, Senior Consultant in Dermatology; Lt. Col. J. C. Rucker, MC, Chief, Personnel Division; Lt. Col. A. Vickoren, MC, Chief, Operation Division; Capt. William G. Craig, MAC, Personnel Division; Capt. Claude M. Eberhart, MC, Preventive Medicine Division; Capt. H. E. Gannon, MC, Supply Division; and Capt. M. D. Switzer, MC, Medical Records Division.
    In opening these sessions, Colonel Middleton outlined the organization of the medical service on a functional basis. The subjects considered were delegation of duties, training, clinical duties, consultation; clinical problems,

with the report of progress in the experimentation on the prophylaxis of acute upper respiratory infection, pneumococcal infection, typhus fever, sulfonamide-resistant gonorrhea (penicillin therapy, fever therapy); intensive arsenical therapy of syphilis; neuropsychiatric problems, including alcoholism; disposition of tuberculous patients; certain laboratory problems; outpatient department; rehabilitation; and the conduct of professional meetings. In the open forum, Vincent's stomatitis, disposition, detachment of patients, and evacuation received due consideration. The Records Division, Office of the Chief Surgeon, Headquarters, ETOUSA, made a special appeal for the accuracy of diagnostic nomenclature and stressed the importance of maintaining forms and of careful paperwork in support of statistical analyses, as well as in the soldiers' interest to establish the service connection of disabilities. X-ray supplies and equipment received full attention. Air transportation and evacuation between Northern Ireland and the United Kingdom and between the United Kingdom and the Zone of Interior were discussed. The deliberations of the earlier meetings led to the promulgation of a memorandum concerning policies of procedure for chiefs of medical services, which proved both opportune and effective.

    The conferences of the chiefs of the medical services had clearly established their extreme usefulness. By the same token, it had also become evident that further similar conferences would prove unwieldy; hence, subsequent meetings of this nature were set up on a base section level. The first of these was held on 5 May 1944, in the Southern Base Section under the leadership of Colonel Kneeland. With the further development of the theater and the attendant restrictions on transportation, these conferences were eventually limited to the hospital center level. All senior consultants, base section consultants, and any consultants were invited to these meetings, and an opportunity for the free discussion of plans and problems was afforded to members of General Hawley's office in attendance.

    The rapport of the medical officers of the U.S. Army, in general, and the staff of the Chief Surgeon, ETOUSA, in particular, with the medical profession of Great Britain was conspicuous. General Hawley and Colonel Kimbrough cultivated this relationship by every attention to social and professional amenities. Every courtesy was shown to Colonel Middleton and his senior consultants. Early in the evolution of the basic plan for the Medical Consultation Service, ETOUSA, Maj. Gen. Sir Alexander H. Biggam, RAMC, and Col. Lorne C. Montgomery, RCAMC, Chief Consultants in Medicine for the British and Canadian Armies, respectively, in every way helped to expedite the organizational plans of the U.S. Army in the European theater. Colonel Middleton regularly attended the monthly meetings of the Medical Subcommittee of the Army Medical Directorate Consultants Committee to the Director General of the Royal Army Medical Corps, under the chairmanship of General 


Biggam. The following distinguished clinicians constituted the Medical Subcommittee: General Biggam, Consultant Physician; Brigadier D. B. McGrigor, Consultant Radiologist; Brigadier J. R. Rees, Consultant Psychiatrist; Brigadier G. W. B. James, Consultant Psychiatrist; Brigadier F. D. Howitt, Consultant in Physical Medicine; Brigadier George Riddoch, Consultant Neurologist; Brigadier T. E. Osmond, Consultant Venereologist; Brigadier R. M. B. MacKenna, Consultant Dermatologist; Brigadier J. A. Sinton, Consultant Malariologist; and Brigadier Sir Lionel Whitby, Consultant in Transfusion and Resuscitation (fig.87).
    In the deliberations of this group of British clinicians, free and uninhibited discussion of mutual problems was encouraged. The regular meetings of the Army Medical Directorate Consultants Committee were held the day after the meetings of the Medical Subcommittee, under the leadership of Lt. Gen. Sir Alexander Hood. Although these sessions were important, the proceedings represented a duplication of the activities of the medical and surgical sub- committees. Hence, regular attendance, while invited, was deemed redundant.

    Under the chairmanship of Prof. John A. Ryle, the Interservices Medical Consultants Committee was organized. Representatives of the Royal Army Medical Corps, Royal Navy, Royal Air Force, Royal Canadian Army Medical Corps, Emergency Medical Service, the U.S. Army, and the U.S. Navy met in Kelvin House, London, at regular intervals to discuss mutual problems. Air Commodore Alan Rook served as its secretary. Upon the resignation of Professor Ryle, Surgeon Rear Admiral R. A. Rowlands, R.N., occupied the chair.

    From the standpoint of the Army, the fundamental aims of the Medical Department are (1) to establish and maintain high standards, both physical and mental; (2) to prevent disease and disability from trauma; and (3) to limit morbidity and mortality in disease and trauma, both battle and nonbattle. Within military circles, there can be no question as to the supreme importance of preventive medicine in reaching such objectives. In the European theater, in General Hawley's office, there was a complete meeting of the minds between the Professional Services Division and the Preventive Medicine Division. Few days passed without an interchange of information between Colonels Gordon and Middleton. As a rule, the propinquity of offices made such contacts very simple. For a short period, the detachment of the Preventive Medicine Division to London while the Professional Services Division remained in Cheltenham was immediately felt as a distinct dislocation between two divisions with a common objective. The interlocking interests of these divisions should always be borne in mind in future planning in the interest of the health of a command. Their missions are inseparable, and they can operate effectively only when interdependent.
    The medical care of the patient is secondary only to the prevention of disease and disability. The former responsibility fell clearly within the pur-

FIGURE 87.-British guests at regular series of banquets held by General Hawley and consultants for distinguished members of British medical profession. Thirelstaine Hall, Cheltenham, England, 2 April 1943. Left to right: Colonel Middleton, Brigadier Sir Lionel Whitby, Sir Edward Melanby, General Hawley, Brigadier McGrigor, and Colonel Cutler.

view of the Medical Consultation Service, ETOUSA. In the interest of the best possible medical care, the primary function of the medical consultants must perforce be clinical. At an early stage in the evolution of the theater, Colonel Middleton made clinical rounds of each hospital in the United Kingdom at least once a month. During this early period, calls for personal professional consultations multiplied these clinical exposures many times. Whenever possible, Colonel Middleton used such contacts as a teaching outlet. Aside from the obvious professional aspect, these recurring consultations with young clinicians ultimately paid dividends in the assessment of their capabilities for growth and, in turn, aided Colonel Middleton in making recommendations for personnel assignment when new and understaffed units flooded the theater. With the mounting trooplift and accelerated hospitalization program (ultimately a total of 259,725 beds, of which 183,550 were in fixed hospitals), the routine of monthly clinical rounds, which had been so profitable, was necessarily modified by decentralization. In place of a single consultant for the theater, a base section or a hospital center consultant made periodic and requested professional visits in the area of his responsibility, with distinct advantage to the service to the individual soldier.

In General Hawley's office, the Medical Records Division sent regular reports to the Professional Services Division, which had an obvious interest in


the current incidence and trends of disease. The weekly statistical reports of deaths presented an unusual challenge. These weekly lists were checked for preventable diseases by Colonel Middleton. By direct correspondence with the chief of the medical service in the hospital reporting such deaths, a copy of the complete clinical record was obtained. General Medical Laboratory A submitted a duplicate set of the histologic sections of the pathologic materials from such subjects to Colonel Middleton, so that all points of discrepancy might be reconciled. The situation having been reconstructed from the available evidence, arm analysis with appropriate observations was forwarded to the responsible medical chief. As a rule, this constructive procedure was well received. Although its value is impossible of estimation, undoubtedly, the result was intangible dividends in the improved care of the sick in this theater.

    The confidence of the Chief Surgeon, ETOUSA, in the mission of the consultants was evident in his mandate to them to offer direct advice to his Personnel Division on the movement of highly trained medical personnel. In turn, the Personnel Division depended implicitly upon the consultants of the Professional Services Division for such counsel. In the interest of the best medical service under existing conditions, there must be an optimal utilization of the available personnel. Obviously, extreme inequalities existed in many of the hospitals assigned to the Communications Zone. In the early phases of development, disproportionate professional strength was evident, particularly in the affiliated units. With the increasing demand upon the decreasing pool of medical officers in the Zone of Interior, this situation was eventually reversed. As already intimated, the existing professional assets of the theater had been carefully cataloged by Colonel Middleton on the basis of personal and professional observations in the wards of the existing units. Upon the arrival of new hospitals in the theater, personal interviews and staff conferences were arranged to assess the professional qualifications and capabilities of all medical officers on the medical services. Alarming discrepancies, both quantitative and qualitative, were disclosed as the reserve of medical officers in the United States was depleted. Some idea of the magnitude of the problem may be gathered from the fact that, in 1944, Colonel Middleton visited and interviewed the officers of the medical sections of 108 general and 11 station hospitals from the Zone of Interior and 4 general and 2 station hospitals from MTOUSA (Mediterranean Theater of Operations, U.S. Army). Colonel Kneeland likewise surveyed a group of these new units. To meet obvious deficiencies of skilled personnel in these hospitals in 1944, 58 new chiefs of medical services were assigned from the reservoir of qualified and tried internists of the affiliated units of the European theater and those which had been transferred from MTOUSA.
    The place of the affiliated hospital (fig. 88) in the reserve pattern of the Medical Department has been subjected to sharp criticism in certain quarters. Clearly, superior professional qualifications may be anticipated in these units.

FIGURE 88.- First "home" of 30th General Hospital, Mansfield, Nottinghamshire, England, affiliated unit from University of California, Berkeley, Calif.

At times, the loyalty to the mother institution may overshadow the greater need of the military situation. A natural pride in organization may bias the judgment of responsible officers, but, upon a clear presentation of the problem, cooperation in the release of highly qualified internists seriously required in other units was willingly made in the European theater. Without this source of support, the medical services of the fixed hospitals of this theater would have presented a strange mosaic of professional adequacy, ranging from superb to impossible, and the standards of medical care would have fluctuated immeasurably from one hospital to another. In this relation, the Personnel Division of General Hawley' office can not be too highly commended for their cooperation. Never was a recommendation for the movement of a medical officer in the interest of better care for the soldier made by the medical consultants without prompt compliance.

    The professional interchange of the consultants of General Hawley's office with medical officers of the armies was intimate. Frequently, advices in medical matters from the field initiated inquiry or appropriate action at Headquarters, ETOUSA, to the ultimate advantage of the U.S. soldier, while, conversely, medical information flowed freely from Headquarters, ETOUSA, to the field. In the movement of personnel, the prerogatives of the army were assiduously respected. Usually, in General Hawley's office the Professional Services Division, upon the request of an army consultant in medicine for personnel to meet certain medical needs of army units, would advise the army surgeon of its willingness to arrange, through the Personnel Division, for replacements from fixed hospitals of the Communications Zone. As mutual confidence was established, at times the army surgeon, through the intermediation of the Professional Services Division, sought the transfer of medical officers from his echelon to fixed hospitals for the better utilization of their special skills.
    In his first conference with General Hawley on 25 July 1942, Colonel Middleton emphasized the importance of the continuity of medical care throughout all echelons of the medical service. In the interest of sustained professional efficiency and, in turn, improved medical service to the troops, an exchange of officers of company grades from the field units with officers of similar rank in fixed-hospital units was proposed. With General Hawley's support, conferences were held in early August 1942 with Col. Max G. Keeler, MC, Commanding Officer, 5th General Hospital, Lt. Col. (later Col.) Mack M. Green, MC, Surgeon, North Ireland Base Section, and Col. Charles E. Brenn, MC, Surgeon, V Corps (Reinforced), relative to the implementation of such exchanges on a temporary basis. Colonel Brenn expressed his categorical objection to such a movement on the basis of the inevitable loss of medical officers from the field to the hospitals. Opposed to this viewpoint was the obvious bilateral advantage in the professional improvement of the medical officer from the field and the cultivation of an understanding of the medical problems of the field on the part of officers on exchange from the fixed hospitals. A pilot plan was initiated in the North Ireland Base Section between the 5th General Hospital and tactical units in training in Northern Ireland. These temporary

exchanges were well received and presented proof of the predicted bilateral advantage. As a result, this basic plan was given general application in the theater in the interest of the professional advancement of the medical officers and the medical care of the soldier.5

    A situation similar to the medical drought experienced by officers with field units was encountered in the medical officers of the Eighth Air Force. Indeed, medical officers attached to the dispensaries and scattered units of the Eighth Air Force became extremely dissatisfied with their professional detachment. As a result of conferences with Col. (later Maj. Gen.) Malcolm C. Grow, MC, and Col. (later Maj. Gen.) Harry G. Armstrong, MC, a program of rotation of medical officers from the Eighth Air Force, not to exceed 10 per month, to fixed hospitals in the United Kingdom was arranged to begin 20 April 1943. In time judgment of Colonel Armstrong, after certain early unfortunate experiences, the exchange of similar numbers of officers of company grade from the general hospitals to the Eighth Air Force without indoctrination was deemed unwise. The assignment of Eighth Air Force representatives was, therefore, unilateral. Although the plans were sound and although the Professional Services Division in General Hawley's office made continuous efforts to maintain the flow of medical officers, operation difficulties and passive resistance limited the success of the program.
    In a similar vein, an entirely different approach to the maintenance of clinical interest of medical officers in the field was attempted. Perhaps one of the most stultifying experiences for medical officers with field medical units is the necessity for the transfer of all seriously ill patients from tactical units to fixed hospitals for definitive medical care. Immediately upon such a movement, an interruption of the primary professional interest of the medical officer with the tactical unit occurs. Also, the opportunity for clinical contact commonly afforded through visits to the hospital of transfer is not available in the Army because either the tactical situation, transportation, or command policy may make such sporadic efforts impractical. To meet this situation, the postcard Form 306, Follow-up Card (Medical) was devised.

    The medical officer of a line or detached unit merely wrote his address on the front of this medical followup card and the name of the patient in whom he was interested on the reverse side. Pinned to the emergency medical tag or placed in the jacket of the field medical record, this medical followup card was filled out by the first medical officer rendering definitive care and mailed to the interested medical officer in the forward unit. The information on the card included the diagnosis, necessary clinical and laboratory findings, treatment rendered, disposition made, and any recommendations. General Hawley and Colonel Middleton conducted educational programs indicating the importance of maintaining this centrifugal influence of the hospital units of the theater. The utilization of this very significant expedient extended to mobile hospitals evacuating to fixed hospitals and to station hospitals evacuating to general
5Annual Report, Professional Services Division, Office of the chief Surgeon, Headquarters, ETOUSA, 1943

hospitals. In short, this expedient established a channel of medical or professional communication that afforded information as to the care and disposition of evacuated patients and that could not otherwise have been obtained.


Air Force Field Service School

    The educational programs were the function of the Operations and Training Division of General Hawley's office. The Professional Services Division was called upon to assist in planning and implementing such programs. Under the leadership of Colonel Armstrong, the Eighth Air Force developed the Eighth Air Force Provisional Field Service School at High Wycombe, England. At the request of Colonel Grow, on 6 and 13 October 1942, Colonel Middleton presented 3-hour lectures on tropical medicine. Thereafter, the topics usually covered were the common cold, influenza, pneumococcal and atypical pneumonia, and the sulfonamides. With appropriate changes in subject matter and at intervals lengthening to semimonthly and monthly, Colonel Middleton continued to participate in this program until the discontinuance of the school in the first week of May 1944. Not only did this teaching opportunity provide excellent rapport with the headquarters staff and medical officers of the Eighth Air Force but it also served to emphasize the vital requirement of the Air Force group for a broader clinical outlet.
Medical Field Service School

    On 8 September 1942, with Colonel Cutler, Colonel Middleton studied the prospects of medical teaching in the Army Medical Field Service School at Shrivenham (fig.89). The program for clinical instruction as outlined by Lt. Col. George D. Newton, MC, was deemed inadequate for the needs of the theater. Actual participation in this area was delayed, and it was not until 22 March 1943 that Colonel Middleton gave his first lectures. The initial 4 hours of lectures for medical officers were reduced to 2 hours. One hour was allotted for lectures to nurses. Topics of current medical interest in the theater, such as respiratory infections, meningococcal infections, infectious hepatitis, and rickettsial diseases, were discussed at these monthly sessions. Particular attention was given to the dignity of the sick call. In the lecture to the Army Nurse Corps representatives at the school, particular attention was given the service, functions, and responsibilities of the Army nurse. The psychology of the sick and wounded was discussed, and due emphasis was given to the role of the Army nurse as the medical intermediary for the tending medical staff.
    The Army Medical Field Service School continued its classes at Shrivenham until 13 October 1944. In the spring of 1945, it resumed operation near Etampes, France (fig.90). With the altered tactical situation, the schedule

FIGURE 89.-Formation of student medical officers, Army Medical Field Service School, Shrivenham Barracks, England.

of instruction was accelerated. This educational effort, primarily conceived by Colonel Mason (fig. 91), was directed toward the improvement of the professional opportunities for medical officers of tactical and detached units. Its successful implementation depended in a large measure upon administrative efforts of Maj. (later Lt. Col.) Bernard J. Pisani, MC (fig.92), and Capt. (later Lt. Col.) Kenneth Smith, MC, who were charged with the immediate direction of the school. From time to time, the exigencies of service led to a diversion from the primary function of these courses; namely, the instruction of medical officers of tactical and detached units. In spite of these minor defections, this overall plan may well be counted a major contribution of the theater to the improvement of medical care of the soldiers through the education of medical officers.
Professional Rehabilitation Following Cessation of Hostilities

    As early as 18 December 1943, in a memorandum to General Hawley, Colonel Middleton had proposed a plan for professional rehabilitation. This plan envisioned the reciprocal advantages of the transfer of medical officers from tactical units to fixed Army hospitals and to civilian institutions and practice in Great Britain and on the Continent after the war. Upon the cessation of hostilities, the Operations and Training Division in General Hawley's office evolved an extensive program of medical education. In addition to the decentralized plan for independent courses at the several 


FIGURE 90.-Medical Field Service School on the Continent, Etampes, France, spring 1945.
hospital centers, an intensive educational program was planned for the Mourmelon area near Rheims, under the leadership of Col. Sam Seeley, MC. Colonel Middleton proposed a preceptorial plan under leaders in internal medicine in Great Britain. This program received the support of General Hawley and his Operations and Training Division. Upon personal solicitation, a number of the representative internists of Great Britain and Northern Ireland agreed to cooperate in this important enterprise. Indeed, a few medical officers in the U.S. Army were so assigned, but all of these thoughtfully conceived plans

FIGURE 91.- Lt. Col. James B. Mason, MC.

fell short of their goal or were actually abandoned in the turmoil of redeployment in the summer of 1945. In retrospect, all of these educational plans were sound and worthy of support.
Specialty Board Certification

    At first glance, the certification of the medical officers in the specialty boards might appear beyond the interest or purview of the Medical Consultation Service. However, qualified medical officers who were denied the right of examination and certification by reason of military service, particularly in an oversea theater of operations, had a reasonable basis for a sense of discrimination. As secretary of the American Board of Internal Medicine, Colonel Middleton felt a serious responsibility in attempting to remove this potential source of irritation. On 19 April 1942, the American Board of Internal Medicine authorized regional oral examinations under the supervision of a member of the board "to meet the convenience of men in the Armed Forces," and, on 10 June 1944, the board took the official action that "while on active duty, Colonel William S. Middleton, MC, USA, and Captain William S. McCann, MC, USN, be authorized to conduct special oral examinations for eligible candidates wherever they are." This special authorization was unusual, particularly in view of the termination of the legal tenure of office of Colonel Middleton as of 30 June 1944. Under the authority so vested, the oral ex- 


FIGURE 92.- Maj. Bernard J. Pisani, MC.
amination of candidates for certification by the American Board of internal Medicine was arranged at the mutual convenience of the examinees and guest examiners. The following guest examiners cooperated willingly in this enterprise:

Lt. Col. Benjamin I. Ashe, MC, 1st General Hospital.
Lt. Col. Wardner D. Ayer, MC, 52d General Hospital.
Lt. Col. Theodore L. Badger, MC, 5th General Hospital.
Lt. Col. Elton R. Blaisdell, MC, 67th General Hospital.
Maj. Donald J. Bucholz, MC, 93d General Hospital.
Lt. Col. E. Murray Burns, MC, 46th General Hospital.
Lt. Col. Augustus H. Clagett, Jr., MC, 90th General Hospital.
Col. Cyrus J. Clark, MC, 32d General Hospital.
Lt. Col. Sander Cohen, MC, 40th General Hospital.
Lt. Col. Stanley C. W. Fahlstrom, MC, l08th General Hospital.
Lt. Col. Frederick W. Fitz, MC, 70th Station Hospital.
Lt. Col. Carl H. Fortune, MC, 49th Station Hospital.
Lt. Col. Gordon E. Hein, MC, 12th Hospital Center.
Maj. Henry B. Kirkland, MC, 110th General Hospital.
Maj. George L. Leslie, MC, 95th General Hospital.
Maj. Arthur S. Mann, MC, 91st General Hospital.
Lt. Col. Richard M. McKean, MC, 36th General Hospital.
Maj. Norman L. Murray, MC, 186th General Hospital.
Maj. Arthur D. Nichol, MC, 93d General Hospital.
Maj. Christopher Parnall, Jr., MC, l9th General Hospital.
Maj. Frank Perlman, MC, 124th General Hospital
Maj. Herbert W. Rathe, MC, 347th Station Hospital.
Capt. Bernard D. Rosenak, MC, 49th Station Hospital.
Lt. Col. Donald C. Wakeman, MC, 2l7th General Hospital.
Lt. Col. Bernard A. Watson, MC, 36th General Hospital.
Maj. Herbert B. Wilcox, MC, 2d General Hospital.
Maj. Carl R. Wise, MC, 2d General Hospital. 


    A total of 113 candidates were examined, and 4 candidates were examined twice, to make a total of 117 examinations. The results of these 117 examinations are interesting: Internal medicine, 73 (65 percent) passes, 41 (35 percent) failures; cardiovascular, 1 pass and 1 failure; and tuberculosis, 1 pass.
    It is impossible to assay the contribution of these examinations to the morale of the theater. The dependence of the Personnel Division upon such tangible data as certification by the several specialty boards in deriving the MOS (military occupational specialty) of medical officers gave this formula unusual weight in the minds of many individuals. To the cooperation of the American Board of Internal Medicine, especially the assistant secretary-treasurer, Dr. William A. Werrell, and to the guest examiners in the European theater, due credit is given for the successful discharge of this mission.


American Medical Society, ETOUSA

    Medical society meetings constitute an important element in maintaining an alert profession in civilian life. Medical Department regulations insure a continuance of this activity in the Army hospitals. Where the spirit prevails, the meetings help maintain high standards. Such was the case in the European theater. In certain hospitals, X-ray and clinicopathologic conferences added to the superb tone of professional alertness. These routine hospital meetings were supplemented by the American Medical Society, ETOUSA. The seed for this theater activity was sowed in a meeting for the discussion of hepatitis at the General Medical Laboratory A, Salisbury, England, in which, 1st Lt. (later Maj.) William L. Hawley, MC, Maj. (later Col.) Paul Padget, MC, and Colonel Gordon, of the U.S. Army; Dr. William H. Bradley, of the British Ministry of Health; and Dr. James K. McCollum of the Wellcome Laboratory participated.
    The occasion of the first anniversary of the 5th General Hospital in the European theater led to a medical and surgical conference in which Colonel Badger discussed postinoculation hepatitis; Dr. John McMichael, traumatic shock; and Dr. Eric G. L. Bywaters, crush syndrome.

    The first meeting of the American Medical Society, ETOUSA, was held on 23 June 1943, at the 298th General Hospital, Frenchay Park, Bristol, England. The commanding officer, Col. Oscar C. Kirksey, MC, and his staff were hosts. A committee on organization, composed of Colonels Knee-land and Hein, and Col. Robert M. Zollinger, MC, was named. This committee drafted a brief constitution which was adopted. The following officers were elected: President, Colonel Zollinger; vice president, Lt. Col. (later Col.) William F. MacFee, MC; secretary-treasurer, Maj. (later Lt. Col.) Clifford L. Graves, MC; councilors, Major Muckenfuss and Maj. (later Col.) Edward J. Tracy, MC. The second meeting of the society convened on 28 July 1943 at the 30th General Hospital. The commanding officer, Col. Charles B. 


Kendall, MC, and his staff presented a very instructive program. On 18 August 1943, the third meeting of the society convened at the 2d General Hospital. Under the commanding officer, Col. Paul M. Crawford, MC, and his staff, a very profitable session was held. The last meeting of the American Medical Society, ETOUSA, was held on 26 April 1944, at the l27th General Hospital, Sandhills (near Taunton), England, with the commanding officer, Col. James L. Murchison, MC, and his staff as hosts. Colonel Middleton spoke on the care of the medical casualties from the far shore. Thereafter, the tactical situation and the number and dispersion of medical units made further meetings of the society impractical. This function, in turn, devolved upon the base sections and the hospital centers. Indeed, the Western Base Section had anticipated this eventuality and had arranged for a medical meeting to be held at the 52d General Hospital, Kidderminster, on 29 December 1943. This meeting was attended by 200 medical officers.
Inter-Allied Conferences

    More far reaching in their influence were the Inter-Allied Conferences on War Medicine. In April 1942, Col. Victor Gallemaerts, Director, Belgian Army Medical Service, suggested to the British War Office the establishment of conferences on War Medicine. At that time, the difficulties in organization seemed insuperable, but the early and rapidly increasing numbers of medical representatives in the Armed Forces of the United States paved the way for a reconsideration of the subject. Colonel Cutler stimulated this movement through the offices of Mr. L. R. Broster, then surgical secretary of the Royal Society of Medicine. In the preliminary discussions, the Royal Society of Medicine offered its facilities as a meeting place and clerical assistance for the organization of the meetings. The meetings were designed "for the interchange and communication of medical experiences in the field and of the practical application of medicine to the needs of warfare, and for the exposition of the general principles of administration and organization of the medical services."6  The first of these meetings, attended by approximately 120 medical officers of the U.S. Army, was held at the Royal Society of Medicine on 7 December 1942. Maj. Gen. Sir Henry Tidy presided (fig.93). The meetings were continued until 8 July 1945. A total of 24 conferences was attended by over 6,500 officers of the Allied medical services. These sessions served as a clearinghouse for the war experiences of the Allied forces. The topics covered the entire gamut of medicine and surgery as encountered under the war conditions of the period. Stirring stories of firsthand experiences at Dunkirk, Dieppe, Lake Chad, Arnhem, Bastogne, Buchenwald, and in the Arctic convoy held the interest of large audiences derived from all services. Two hundred and twenty speakers appeared before the conferences. Among these were the Chief Surgeon and a number of representatives of the Profes-
6 Inter-Allied Conferences on War Medicine, 1942-1945, edited by H.L. Tidy and J. M. B. Kutschbach. London: Staples Press, 1947.

FIGURE 93.- Maj. Gen. Sir Henry Letheby Tidy, President, Royal Society of Medicine (center) conferring informally with Colonel Kneeland (left) and Colonel Pillsbury.

sional Services Division. General Hawley, Colonel Kimbrough, Colonel Cutler, Colonel Kneeland, Lt. Col. (later Col.) Paul C. Morton, MC, and Colonel Middleton served on the organizing committee. To the success of this effort, none contributed more effectively than the secretary of the Royal Society of Medicine, Mr. Jeffrey R. Edwards, upon whom fell much of the detailed work of organization. One hundred and twenty of the papers presented at these meetings were bound and published in 1947 as Inter-Allied Conferences on War Medicine, 1942-1945, and constitute an essential element of the official medical history of World War II.
Allied Consultants Club

    With the close rapport between the medical officers of the U.S. Army and their fellows in the Allied armed services came not only professional but also social interchange, cementing international relationships. Continued over the years of association with the British and Canadian consultants, particularly, came the natural design for the formation of the Allied Consultants Club. Broad though the term appeared, its membership was limited to the consultants in the English-speaking Allied armies. The first meeting of this group convened on 15 October 1944 at the l08th General Hospital (fig.94) in Paris, with Colonel Kimbrough presiding (fig.95). General discussions of battle trauma occupied the morning session. After luncheon, the consultants divided into two sections: 


FIGURE 94.-Rear view of 108th General Hospital, Paris, France
(1) Surgical conference under Colonel Cutler, and (2) medical conference under Colonel Middleton (fig.96). The medical conference concerned itself with the following topics: Neuropsychiatric casualties in the Army, treatment of venereal diseases, special medical problems, and the proposed sulfonamide prophylaxis of infectious diseases. Participating in this conference were: General Biggam, Consulting Physician of the British Army; Brig. E. Bulmer, RAMC, Consulting Physician, British 21st Army Group; Brigadier Riddoch, Consulting Neurologist of the British Army; Col. J. S. K. Boyd, RAMC, Consulting Pathologist, British 21st Army Group; Colonel Pillsbury, Senior Consultant in Dermatology and Syphilology; Colonel Thompson, Senior Consultant in Psychiatry; Colonel Badger, Senior Consultant in Tuberculosis; Colonel Kneeland, Medical Consultant, United Kingdom Base, and Senior Consultant in Infectious Diseases; Colonel Hein, Senior Consultant in Cardiology, Lt. Col. Nathan Weil, Jr., MC, Consultant in Medicine, Third U.S. Army; Lt. Col. Guy H. Gowen, MC, Consultant in Medicine, Seventh U.S. Army; Lt. Col. John B. McKee, MC, Consultant in Medicine, Ninth U.S. Army; Colonel McEwen, Consultant in Medicine, Brittany Base Section; Colonel Muckenfuss, Director of Medical Research, and Commanding Officer, General Medical Laboratory A; and Maj. Alfred 0. Ludwig, MC, Consultant in Neurology, Seventh U.S. Army.

FIGURE 95.- Participants at Inter-Allied Consultants Conference, 108th General Hospital, 15 October 1944.

FIGURE 96.- Col. William S. Middleton, MC (seated at table, rear), presiding at medical conference held as part of Inter-Allied Consultants Conference, 108th General Hospital, 15 October 1944. Col. Neil Crone, MC (standing), is the speaker.

    The session was continued on the morning of 16 October 1944, with a clinical program by the staff of 108th General Hospital, Lt. Col. (later Col.) Louis M. Rousselot, MC, presiding.
    The next conference of the consultants club, which in all propriety should be termed "Anglo-American Consultants Club," was held in Brussels, 11 December 1944. Conspicuous among the papers presented before the medical section was Brigadier Riddoch's stirring appeal for sustained attention to the spastic paraplegic patients.

    The third allied consultants conference (Anglo-American Consultants Club) was held in Paris, on 25 and 26 May 1945, at the l08th General Hospital. Among the topics of interest in the general session of the first day was shock. On the second day, the medical section discussed syphilis, hepatitis, malnutrition, tuberculosis, and typhus fever.
    The registrants and participants in the discussion of the medical topics insured a most profitable session. They included: Brigadier Bulmer, RAMC, Consulting Physician, 21st Army Group; Brigadier MacKenna, RAMC, Consultant in Dermatology; Brigadier Osmond, RAMC, Consultant in Venereology; Brig. J. H. Palmer, RCAMC, Consulting Physician; Brig. Robert C. Priest, RAMC, Consulting Physician, Western Command; Brigadier Withby, RAMC, Director of Army Blood Transfusion Service; Colonel

Kneeland, Consultant in Medicine, United Kingdom Base, and Senior Consultant in Infectious Diseases; Colonel Pillsbury, Senior Consultant in Dermatology and Syphilology; Colonel Fitz, Consultant in Medicine, Delta Base Section; Colonel Gowen, Consultant in Medicine, Seventh U.S. Army; Colonel McKee, Consultant in Medicine, Ninth U.S. Army; Lt. Col. Carter Smith, MC, Consultant in Medicine, Fifteenth U.S. Army; Colonel Weil, Consultant in Medicine, Third U.S. Army; Surgeon Vice Admiral Sir Sheldon Dudley, RN, Director General of Medical Services; Surgeon Rear Admiral Gordon Gordon Taylor, RN., Consulting Surgeon; Surgeon Rear Admiral Rowlands, Consulting Physician; Maj. Gen. Morrison C. Stayer, Chief Surgeon, MTO; General Tidy, President, Royal Society of Medicine; Brig. E. Boland, RAMC, Consulting Physician, British Army in Italy; Sir Claude Frankau, Deputy Director, EMS; Dean Charles Newman, British Postgraduate Medical School; Col. E. N. Alling, Commanding Officer, 814th Hospital Center; Colonel Gordon, Chief, Preventive Medicine Division; Lt. Col. (later Col.) Wendell H. Griffith, SnC, Chief, Nutrition Section, Preventive Medicine Division; Col. Esmond R. Long, MC, Consultant in Tuberculosis for The Surgeon General; Lt. Col. Hamilton Southworth, MC, Office of Scientific Research and Development; Colonel Cohen, Chief of Medical Service, 40th General Hospital; Lt. Col. Alva V. Daughton, MC, Chief of Medical Service, 48th General Hospital; Colonel Fahlstrom, Chief of Medical Service, 108th General Hospital; Colonel Fortune, Chief of Medical Service, 191st General Hospital; Lt. Col. (later Col.) Rudolph A. Kocher, MC, Chief of the Medical Service, 203d General Hospital; Lt. Col. Carl S. Lytle, MC, Chief of Medical Service, 62d General Hospital; Lt. Col. (later Col.) Herbert B. Pollack, MC, Chief of Medicine, l5th General Hospital; Lt. Col. Leonard G. Steuer, MC, Chief of the Medical Service, 198th General Hospital; Maj. Sarah H. Bowditch, MC, Assistant Military Attache, American Embassy, London; Maj. Marion Loiseaux, Consultant of the Women's Army Corps; Maj. Moses D. Deren, MC, Chief of the Medical Service, l94th General Hospital; Maj. (later Lt. Col.) Charles P. Emerson, Jr., MC, Chief of the Medical Service, 231st General Hospital; Maj. David Greeley, MC, American Typhus Commission; Maj. Richard Reeser, MC, Chief of the Medical Service, 202d General Hospital; and Capt. T. E. Caulfield, MC, Chief of the Medical Service, 230th General Hospital.

    Upon the release of Buchenwald, Dachau, and other horror centers from German control, Colonel Pollack, of the 15th General Hospital, Liege, Belgium, and Capt. Leonard Horn, MC, of the 19th General Hospital, Rennes, France, had been ordered on detached duty for service with Colonel Griffith to study and collaborate in the control of malnutrition among the released military and civilian prisoners. Colonel Pollack's analytic discussion of the subject was a highlight of this conference. The opportune presence in the theater of Colonel Long had added greatly to Colonel Badger's master plan for the management of the recovered Allied military personnel coming into U.S. fixed hospitals upon release. Some idea of the magnitude of the problem may be gained from the fact that of 1,700 of these patients received at the 46th General Hospital, 


FIGURE 97.- One of recovered Allied personnel cared for at 46th General Hospital showing debility and malnutrition characteristic of many.
975 had tuberculosis (fig.97). Of this group, 650 were in a moderate to far-advanced stage of the disease. A system of aseptic technique was combined with clean areas for the protection of the nursing and medical personnel. Although only three meetings of the Anglo-American Consultants Club were held, its very existence should be recorded as a measure of the spirit of mutual good will and confidence engendered among the English-speaking consultants through the years of their effort in a common cause. Truly, this organization serves as an object lesson in international amenities.


    The consultants of the Professional Services Division in General Hawley's office were regularly consulted by the Finance and Supply Division about problems of mutual interest. On 31 August 1942, Colonel Middleton conferred with Lt. Col. George Perkins, MC, in charge of supplies for the U.S. Army Medical Department, and with Major Gallagher, RAMC, at 39 Hyde Park Gate, London, in a survey of the availability of British drugs and chemicals for use in the U.S. Army. By all standards-- atomic weight, melting point, freezing point, solubility, measures of purity, and other criteria--drugs of

British origin were checked against the U.S. pharmacopoeial standards. Where complete concurrence existed, no change was recommended, and the assigned number in the Standard Supply Table of the Medical Department could be used interchangeably. Where differences in strength were found in articles of uncommon usage, a change in the label was recommended. In only one important area did the U.S. consultants differ with their British confreres; namely, the necessity for broadening the base of sulfonamides. The British were limited by available manufacture and supply to sulfapyridine. The American officers insisted upon the inclusion of sulfadiazine at least. On 11 September 1942, Colonel Perkins and Colonel Middleton recommended a reconciliation of the nomenclature by a listing of 14 preparations of different strengths according to their values in the British Pharmacopoeia. Apparently, these carefully considered recommendations were not completely implemented, but, on 9 February 1944, at the request of the Finance and Supply Division, Colonel Middleton reported to Depot G-30 in London to review certain available drugs from British sources with Lieutenant Smith, SnC. The drugs without a useful prospect were rejected. On 5 October 1942, Colonel Middle ton reviewed the first aid kit of an M-4 tank in the 372d Tank Battalion with Captain Moore, near Tidworth. The position of the first aid kit behind time left shoulder of the driver on the lateral wall of the forward compartment of the tank made it inaccessible to anyone except the driver. Furthermore, the kit contained no sulfonamide or morphine, and the burn therapy was limited to tannoid. A correction of these deficiencies was recommended to the Supply Division.

    The necessity for the conservation of quinine led to the preparation of Circular Letter No. 55, dated 23 October 1942, Office of the Chief Surgeon, Headquarters, ETOUSA. This circular letter recommended use of salicylates and coal-tar derivatives rather than the empirical use of quinine. The directive also stated that quinine would not be used for the treatment of conditions other than malaria. Furthermore, it stated: "Since all malarial patients will be evacuated to hospital units, no quinine will be issued to divisional medical installations. Atabrine will be used for time suppressive therapy of malaria."
    On 2 October 1942, the faculty of Oxford University gave a reception for the staff of the 2d General Hospital. Colonel Middleton represented General Hawley at this function. On this occasion, Prof. Howard W. Florey extended to Colonel Middleton an invitation to visit the William Dunn Laboratory of Pathology. With General Hawley's approval, Colonel Middieton arranged an appointment with Professor Florey for 24 October 1942. At this time, Professor Florey acceded to a plan to supervise penicillin treatment and to train teams for each of the U.S. general hospitals. The plan was to be carried out at the 2d General Hospital. The teams to be trained were to include a clinician and a bacteriologist, and a week was decided as adequate time for the necessary instruction. Lt. Col. (later Col.) Rudolph N. Schullinger, MC, Chief, Surgical Service, 2d General Hospital, had attended the reception and had anticipated the official visit by making personal observations of the clinical application of

penicillin in several institutions in the environs of Oxford. (On 18 May 1944, he submitted a report, entitled "Penicillin in the treatment of Surgical Infections," based on these early observations.) When the 2d General Hospital was agreed upon as the training center, Colonel Schullinger was named as the logical medical officer of the unit to serve as the Chief Surgeon's representative with Professor Florey. The plan was submitted to General Hawley, who approved. Complete acquiescence to the plan came from Professor Florey by return mail. He suggested that he would use his influence to have Prof. A. N. Richards send the American penicillin to Oxford.

    Medicine came naturally to its own in the application of penicillin to the treatment of infectious diseases. In one area of its application, the European theater broke new trails. Penicillin was recommended in the treatment of diphtheria carriers and of severe clinical diphtheria as an adjuvant to, not a substitute for, diphtheria antitoxin.7 Some measure of success attended this procedure.
    The table of basic allowance is the bible of the supply officers. Its periodic review and correction is required under conditions of active warfare in a foreign theater. In ETOUSA, this lot fell to the Professional Services Division in General Hawley's office. It was not an easy one, when viewed in the light of the accretion of the years and the traditional bibles of therapeutics. Interestingly, one of the most questionable of all therapeutic agents and one whose accounting gives commanding officers of Army hospitals the greatest concern, namely, spiritus frumenti, proved to have the strongest defenders at the highest levels. The tables for basic allowance--class I items--for the North African campaign were completed in some measure by the Professional Services Division. In this instance, arbitrary figures for the incidence of tropical diseases were applied to the requirement of special or specific drugs. This problem did not prove as pressing in the planning for OVERLORD, since tropical diseases are not a problem in northern Europe. However, certain secret advices indicated an unusual incidence of serious diphtheria in northern France and the Low Countries. Accordingly, a disproportionately large supply of diphtheria antitoxin was stocked for the invasion.


    The Chief Surgeon, ETOUSA, encouraged a close liaison between the Professional Services and the Hospitalization Divisions of his office. In an early survey, 4 to 6 August 1942, Colonel Middleton was requested to report to the Hospitalization Division his observations of the hospital situation in the North Ireland Base Section. This area was unusual in its primary utilization as a training center for ground troops. With the complete cooperation of the base surgeon, Colonel Green, the hospital facilities at Musgrave Park, Waringfield, Irvinetown, and Londonderry were surveyed from a physical as
  7 Administrative Memorandum No. 151, Office of the Chief Surgeon, Headquarters, ETOUSA, 27 Nov. 1944, subject: Tentative Program for the Observation of the Efficacy of Penicillin in the Treatment of Diphtheria. 


FIGURE 98.- Lt. Col. John Douglas, RAMC
well as a professional standpoint. In this relation, one detail is worthy of record. At Londonderry, the l0th Station Hospital was established in one old barracks-type building and a series of detached structures in which there was a serious fire hazard. Furthermore, Londonderry was at the end of a narrow gage railroad, and evacuation by rail depended upon a shuttle pattern. Evacuation by sea required shallow draft craft. Directly across the street from the 10th Station Hospital was a superbly constructed and equipped naval hospital. Colonel Middleton recommended the abandonment of the Army installation by the consolidation with the naval unit, as an economical and sound solution to the problem. This consolidation was particularly feasible by reason of the relatively light patient load of both hospitals. General Hawley indicated his willingness to accept the validity of the recommendation but stated that, under existing conditions, such a pooling of medical interests in the Londonderry area was impractical.

    With the invaluable assistance of Lt. Col. John Douglas, RAMC (fig.98), the Hospitalization Division, under Col. Eli E. Brown, MC, secured 90,000 beds in British installations before August 1943. The British facilities ranged from temporary conversion camps to permanent construction and from the Royal Victoria (Netley) Hospital at Southampton Water to a series of pavilion hospitals newly constructed under the Emergency Medical Service for the postwar implementation of the white paper (later the National Health Act) (fig.99). Under a mandate of General Hawley, the consultants reported upon the physical details of strength and deficiency in these hospitals. The absence of shower baths and the limitation of toilet facilities were among the commonest complaints. In many of the newer hospitals and in all of the temporary units housed in Nissen huts, the source of heat was two stoves placed at either end of the center of the ward. These stoves were stoked by lifting a lid from the top and pouring in bituminous coal from a scuttle (fig.100). The resultant smudge was inevitable, but this source of heating obtained in the United Kingdom for the duration. The open corridors without provision 


FIGURE 99.- Typical examples of hospital construction in United Kingdom for U.S. Army. A. New construction underway at East Moors, Rigwood, Hants., England, 13 January 1943. B. Typical hospital headquarters building of permanent brick construction erected for U.S. Army. 


FIGURE 99.- Continued. C and D. Temporary buildings converted for use as U.S. Army hospitals. 


FIGURE 100.- Provision of heat in Nissen-hut wards by two coal stoves.
for wind or storm break were eventually closed in some areas (fig.101). The Professional Services Division cooperated with the Hospitalization Division in improvising isolation facilities which, under the British plans, were inadequate in a majority of instances. In the adaptation of existing buildings to hospital purposes, fire hazards were occasionally overlooked, as at the 5th General Hospital and the 10th Station Hospital, Musgrave Park, Ireland, and at the 38th Station Hospital, Winchester, England (fig.102). In these instances, the consultants recommended appropriate protective devices. The elements occasionally confirmed the advice. On 20 October 1943, with Colonel Kimbrough and Colonel Zollinger, Colonel Middleton visited the 12th Evacuation Hospital at Carmarthen, Wales, to find it located in a pocketed valley. A recent rain had made a quagmire of the tent area, and the enlisted personnel and officers in mess line were knee-deep in mud and water. Needless to say, those responsible for selection at this site erred seriously in planning.

    A real challenge arose in the establishment of fixed hospitals in tented units in the field. On 22 February 1944, in a survey of the 280th Station Hospital at Shortgrove Park, commanded by Col. Howard W. K. Zellhoefer, MC, an unusually efficient expedient was observed. To combat mud and confusion, all roads and paths were laid out before any construction was begun. No one was permitted to walk on the grass or earth. The concrete foundations were laid and tents pitched as soon as the concrete dried (fig. 103). Interestingly, a similar plan employed at the 298th General Hospital, near Liege, Belgium, under Col. Walter G. Maddock, MC, commanding officer, made this installation the model of field perfection on the Continent. 


FIGURE 101.- Long, open corridors at hospital of temporary Nissen-hut construction.

    General Hawley charged his Professional Services Division with the responsibility of advising in the formulation of evacuation policy for the theater. On 10 December 1944, evidently concerned by an apparent lag in time evacuation of patients from fixed hospitals, General Hawley issued the following instructions to his chief consultant in medicine in a letter, subject: Survey of Clearance of Hospital Beds.

*    *     *     *     *     *

    4: You are to observe particularly the following:
        a. Are patients held in hospital to assist in the work of the hospital?
      b. Are patients being held in hospital purely for subjective complaints that can not be confirmed by objective findings?   
      c. Are patients for the Z/I being ordered and reported promptly? In the great majority of instances, the decision as to the ultimate disposition of a patient can and should be made within 48 hours of his admission.
      d. Are directives of this office being followed as to the limitations upon definitive treatment that will be done in this Theater?

    5: I desire that you make periodic reports to me in person with information covering specific wards and hospitals and proportion of cases found that should have been cleared before. 


FIGURE 102.-38th Station Hospital, Winchester, England, formerly the St. Swithin's School.   

    If this order be related to the tactical situation, its explanation becomes obvious. A similar communication to the Professional Services Division from the Chief Surgeon, ETOUSA, dated 21 January 1945, carried the same implication. It read:

    1. We are getting constant complaints which even though each involves only small numbers in the aggregate show that there is still need for much training of medical officers both in sorting of cases, and in disposition of such cases as are returnable to duty. I realize that there has been considerable improvement in this situation in the past six months, but there is still room for improvement.
    2. I desire, therefore, that without delay, you have a thorough survey made of every Reinforcement Depot on the Continent by competent observers. This survey:
        a. Will be sufficiently comprehensive to give a true picture of conditions. Without imposing any rules, I feel that each observer should remain at a depot for several days, evaluating the fitness for duty of every man returned from hospital during this period.
        b. Will present facts, not generalities.
        c. Will evaluate the professional competence of medical officers and the system of reexamination at Reinforcement Depots.
        d. Will at the same time educate and train medical officers on duty at Reinforcement Depots.

3. Necessary coordination will be made with GFRS.

4. Action indicated by result of survey will be presented to me in form of plan and directive.

5. Please expedite.

    With Maj. (later Col.) John N. Robinson, MC, Senior Consultant iii Urology, ETOUSA, Colonel Middleton visited the 11th Reinforcement Depot at Givet, France, and the 16th Reinforcement Depot at Compiègne, France, on 26 January 1945, and the 9th Reinforcement Depot at Fontainebleau, France, on 29 January 1945. After a careful survey and spot check upon the

FIGURE 103.- Establishment of an ideal tented hospital facility. A. All roads, paths, and flooring planned. Concrete is poured before a tent is pitched. B. Completed hospital.

situation in these units, these officers reported a remarkably good disposition record to General Hawley. Indeed, the quoted figure of 0.5 percent improper disposition proved excessive.

    The problem of disposition to the Zone of Interior for medical reasons had interested the medical consultants from the beginning of operations. The year's experience to 1 June 1943 was deemed a reasonable basis for judgment. In this period, 3,248 transfers for physical causes had been made from the European theater to the Zone of Interior. Of this group, medical reasons accounted for 1,015 transfers (31.2 percent). The important diagnoses involved were hepatitis, peptic ulcer, chronic arthritis, and bronchial asthma. Hepatitis accounted for 352 (34.6 percent); peptic ulcer (20.1 percent) was next in order of frequency. Chronic arthritis (10.9 percent) and bronchial asthma (9.5 percent) were appreciable factors in the attrition of manpower. Pulmonary tuberculosis (3.6 percent), bronchitis (2.4 percent), and rheumatic heart disease (2.2 percent), although lesser contributors to the loss of man-power, reflected the improved screening before induction and represented the occasion for continued vigilance. Arterial hypertension (1.9 percent) and bronchiectasis (1.2 percent) were the only remaining conditions accounting for more than 1 percent of the disabilities. An analysis of the records, with particular reference to the occurrence of symptoms prior to induction, led to the recommendation that chronic or recurring conditions, such as peptic ulcer, chronic arthritis, and bronchial asthma, preclude oversea assignment to an active theater of operations.


    Peptic ulcers.- In this relation, the further experience with peptic ulcer in the European theater should be a matter of record. At the urgent behest of Lt. Col. (later Col.) John M. Sheldon, MC, Chief, Medical Service, 298th General Hospital, a pilot plan for the management of peptic ulcers was instituted in that unit. This plan proposed the salvage of a group of soldiers with peptic ulcer by their assignment to limited duty under careful control and restrictions within the hospital unit. The difficulties inherent in such a clinical experiment became evident early, and the trial failed despite the cooperation of the commanding officer and the sincere efforts of the medical staff. The similar experiences of several less well-controlled attempts to retrieve patients with peptic ulcer for active service in the theater confirmed the conviction that no soldier with a history of this condition should be assigned to an oversea theater of operations. The average contribution of soldiers with this condition to the war effort was 3 months of more or less interrupted service. With transportation at a premium and hospitalization doubly expensive in personnel and materiel in oversea theaters, further trials of the utilization of these patients in the Armed Forces on limited duty should be restricted to the Zone of Interior.

    Hepatitis. - This was the first disease encountered in epidemic proportions in the European theater. Its early incidence was explained by its mologous 


serum source in the yellow-fever vaccine, but its persistence depended upon the naturally occurring virus. A survey of its epidemiology and clinical course are beyond the purview of this section. The interest from a historical standpoint lies in two directions. On 7 August 1942, Colonel Middleton proposed to Colonel Hawley a plan to label the record of all patients with hepatitis, with a thought to their later study. Furthermore, it was proposed that the identification tag of all soldiers suffering from hepatitis be given a distinctive mark and that instructions be promulgated to insure the section of the liver of such soldiers at subsequent laparotomy or necropsy. Such materials were to be forwarded to the Army Medical Museum to insure a careful registry and contribute to expanding knowledge of the evolution of the pathologic changes of this condition. The Surgeon General rejected this suggestion, and a personal letter, dated 27 January 1943, from Col. James E. Ash, MC, Curator, Army Medical Museum, maintained that complete histologic restoration of hepatitis might be expected. Although this position proved to be true in the overwhelming majority of instances in which microscopic studies of the liver were afforded subsequent to attacks of viral hepatitis, Lt. Col. D. Murray Angevine, MC, in General Medical Laboratory A, collected several instances of the progression of viral hepatitis to portal cirrhosis (Laennec's).
    In conference on 26 February 1943 with Col. John Beattie, Director, Bernhard Baron Research Laboratories, Royal College of Surgeons of England, at Finchingfield, arrangements were made to afford clinical facilities in an Army hospital for the study of the influence of sulfhydryls (sulfur-containing amino acids) on the course of hepatitis. By analogy with the action of these amino acids in protecting the liver against toxic agents, Colonel Beattie predicted distinct advantages in the management of hepatitis. On 27 February 1943, Colonel Griffith of the Preventive Medicine Division of General Hawley's office supported this position on the basis of his personal experimentation, which indicated that methionine and cystine protected the liver against cobalt and nickel poisoning. General Hawley designated the 12th Evacuation Hospital at Braintree, England, as the proper location for this study. Upon conferring with Lt. Col. (later Col.) Marshall S. Brown, MC, Capt. Austin P. Boleman, Jr., MC, was designated as the medical officer of this hospital to head the unit.

On 6 July 1943, after the transfer of the 12th Evacuation Hospital from this location, Colonel Middleton discussed the problem with Colonel Beattie and with the staff of the 121st Station Hospital. Miss Smith, of the 5th General Hospital, was transferred to this unit for laboratory duties, and Colonel Hatcher, commanding officer, and Colonel Teitelbaum, Chief, Medical Service, afforded the supporting leadership. Maj. Charles Steele, MC, and Lieut. David L. Fingerman, MC, were in clinical control, and Captain Johnstone, in the laboratory.

In a conference on jaundice at the Royal College of Surgeons on 23 November 1943, Colonel Beattie postulated the probable existence of two etiologic factors; namely, X in arsphenamine hepatitis, and Y in the naturally occurring


hepatitis. This is probably the first public reference to such a distinction. The clinical experiment on the value of the sulfur-containing amino acids in the treatment of hepatitis was extended to carbon tetrachloride poisoning and infectious mononucleosis. Certain brilliant results attended the intravenous use of methionine in carbon tetrachloride poisoning. The results in the management of infectious mononucleosis and infectious hepatitis may be translated in the simple terms of improved nutrition. In this relation, there appeared no advantage over time high-protein diet in use in the theater. However, the relapse rate among patients receiving sulfhydryls was appreciably lower than the prevailing rule.
    Motion sickness. - In all amphibious and airborne operations, particularly those involving small seacraft and gliders, motion sickness must be given serious consideration. Although the professional responsibility for this study resided in the Medical Consultants Division of General Hawley's office, the Division's role primarily was advisory. On 10 November 1943, Colonel Montgomery, Medical Consultant to the Canadian Army, and the Chief Consultant in Medicine, ETOUSA, conferred with a Canadian surgeon, Lt. William S. Fields, RCNVR, who had been engaged in research in motion sickness at the Neurological Institute, Montreal. In the judgment of this group, 30 percent of individuals had a psychic basis for this experience. The Canadian seasick remedy consisted of hyoscin hydrobromide, 0.6 mg.; hyoscyamine, 0.3 mg.; and nicotinic acid, 100 mg. The Canadian results indicated 50 percent protection from this agent. Capt. James C. Williams, MC, had been assigned by the Army Ground Forces for studies of motion-sickness preventive, U.S. Army development type, under simulated invasion conditions. His results were limited and inconclusive. In studies of troops airborne in gliders (fig.104), Lt. Col. (later Col.) David Gold, MC, with the cooperation of a regimental surgeon, 4Oth Infantry, concluded that there was some protection in the motion-sickness preventive (Sodium Amytal (amobarbital sodium) 60 mg., scopolamine hydrobromide 0.2 mg., atropine sulfate 0.15 mg.). On 17 November 1944, in a status report to General Hawley on the motion-sickness preventive, U.S. Army development type, Colonel Middleton reported on two groups of soldiers returned from the Continent to fixed hospitals in the United Kingdom after D-day. Of the soldiers analyzed, 613 had taken motion-sickness preventive, and, as control, 306 soldiers had taken no preventive. A statistical analysis of the results by Lt. Col. John H. Watkins, SnC, of the Medical Records Division in General Hawley's office indicated no significant difference in the two groups. The adverse effects, namely, blurring of vision and unusual sleepiness, obtained in only 38 soldiers (0.6 percent). From the available evidence, the following deductions were drawn:

    A. The grounds for the adoption of Motion Sickness Preventive, U.S. Army Development Type, were not sound from pharmacologic and clinical standpoints. Combined potent drugs need not show an additive effect in their composite action.
    B. The wide range of dosage and interval of administration militate against an accurate statistical analysis of the results of this particular operation; but from the available evidence,

FIGURE 104.- Troops of First Allied Airborne Army in glider during Arnhem operation

it may be stated that the agent showed no material advantage over a large controlled group. Admittedly, the latter individuals represent a group resistant rather than susceptible to motion sickness.
    C. An interesting by-effect of Motion Sickness Preventive, U.S. Army Development Type, among a limited number of airborne troops was a singular sense of relaxation. Certain of the glider troops mentioned this effect in striking contrast to their usual feeling of tension. The mild hypnotic effect of amytal and scopolamine in all probability accounts for this desirable reaction.
    More caution in the delegating of medical functions such as the administration of potent drugs by untrained lay personnel was cited.


    The establishment of physical standards was a responsibility of the Professional Services Division in General Hawley's office; hence, great interest was attached to the British and Canadian experience in this area. In a conference on 28 June 1942 with Air Commodore Conybeare and Air Commodore Rook, medical consultants to the Royal Air Force, Colonel Middleton was astonished to learn of the policy of the early rehabilitation of pilots with pulmonary tuberculosis. So pressing were the British demands for manpower that pilots under artificial pneumothorax therapy for limited pulmonary tuberculosis were being utilized as trainers. Apart from this drastic departure from the very conservative position of the U.S. Army, many other instances of

compromises in the interest of the more complete utilization of British and Canadian manpower were encountered.

    On 7 July 1943, at the monthly meeting of the Medical Subcommittee of the Royal Army Medical Consultants Committee, Brig. Frank D. Howitt, RAMC, consultant in physical medicine, reported on his study of the PULHEMS system, a plan of physical categorization which had been devised by the Canadians and which afforded a profile of the examined soldier by systems so that a composite picture of an individual could be gathered at a glance. Subsequent discussions of this subject, particularly with Colonel Montgomery of the Canadian Army, left no doubt as to its general applicability. The careful studies of Lt. Col. (later Col.) George G. Durst, MC, led to its adoption by time U.S. Army as the PULHES (Physical capacity or stamina, Upper extremities, Lower extremities, Hearing, Eyes, Neuropsychiatric status) physical profile serial. With the pressure of redeployment, Maj. Charles D. May was called to Headquarters for the interpretation of this system.

    The program of redeployment placed an overwhelming burden upon the Personnel Division in General Hawley's office, which required the continuous support and advice from the Professional Services Division. Within their respective divisions, the consultants were required to act upon the qualifications of all medical officers in the theater. The point system together with the MOS designation became determining factors in decisions as to the ultimate disposition of the medical officers. Fortunately, the mutual interests of the service and the concerned medical officer could, in a majority of instances, be protected by the consultants' personal knowledge of the officer's qualifications. Notwithstanding thus modifying circumstance, the exigencies of the situation were such as to resolve much of the actual redeployment to the cold figures of supply and demand.
    On 10 February 1945, Colonel Kimbrough returned to the Zone of Interior (fig.105). Colonel Cutler was named as time new director of Professional Services Division in the Chief Surgeon's Office, and Colonel Pisani became Colonel Cutler's executive officer. The Medical Consultation Service, ETOUSA, had remained remarkably stable throughout the period of activity of the theater. Among the senior consultants, only Colonel Hein had been lost by reason of a physical disability. His position of senior consultant in cardiology was not refilled. The total picture of the Medical Consultation Service as of 30 June 1945 may be resolved by reference to the listing of consultants shown in appendix A, p.829. In the interest of a comprehensive picture of the operation, the names of all medical consultants are included, as their inclusion gives some idea of the fluidity of the tactical situation and, by the same token, of the changing requirement for consultation service.

    With a slight lag after V-E Day, 8 May 1945, the medical situation in the European theater underwent rapid changes upon troop movement and redeployment. The Medical Consultation Service experienced even more rapid altera- 


FIGURE 105.- Col. James C. Kimbrough's farewell party on the eve of his departure. Left to right, Colonel Middleton, Colonel Kimbrough, General Hawley, and Colonel Cutler, Paris, France, February 1945.
tions. Late in June 1945, Colonel Kneeland was recalled to the Zone of Interior. No successor for him was named in the capacity of senior consultant in infectious diseases. The onerous duties that he had ably discharged as consultant in medicine to the United Kingdom Base were taken over by Lt. Col. (later Col.) Laurence B. Ellis, M C.

    As of 30 June 1945, the Medical Consultation Service, ETOUSA, had the composition listed in appendix A (p.829) with the exception of a senior consultant in cardiology; a senior consultant in infectious diseases; a base section consultant to the Brittany Base Section, which, as has been pointed out, was dissolved early in the war; and hospital center consultants to the 15th, 801st, 802d, 803d, 804th, 814th, and 819th Hospital Centers. The fact that no consultants were serving in these capacities as of 30 June 1945 reflects the tactical situation (end of hostilities in Europe) at the time. The field army consultants who served armies active in the theater remained unchanged.
    In the first week of July 1945, Colonels Pillsbury and Thompson were ordered to the United States. Both of these consultants had done superb jobs of organization and leadership in their respective fields of dermatology and neuropsychiatry and left enviable records of accomplishment in the interest of welfare of the U.S. soldier. With the rapidly evolving medical situation and particularly with the urgent demand for continuing advice to the Personnel Division in the redeployment program, Colonel Middleton requested the assignment of Colonel McEwen to the Professional Services Division as Senior

Consultant in Medicine. On 27 July 1945, Colonel Middleton was ordered to Washington by The Surgeon General to attend the Pacific conference, whereupon his duties devolved upon Colonel McEwen.


    In reviewing the record of the Medical Consultants Section, Professional Services Division, Office of the Chief Surgeon, Headquarters, ETOUSA, certain significant details come into sharper focus. The organizational pattern was based upon the organizational setup used in World War I, supplemented by sound advice from the medical consultants of the British and Canadian Armies. For the duration of active military operations, the rapport with the British and Canadian medical consultants was intimate and profitable. Through the limitations imposed by The Surgeon General, medical officers in the theater were employed in a consulting capacity, utilizing their specialized skills, rather than drawing further upon the depleted professional resources in the United States. In accordance with the principle of the most complete utilization of talent wherever possible, consultants were used in a dual capacity. Their primary responsibility remained in their assignments as chiefs of the medical services of fixed hospitals, and at the same time their special talents were used in consultative relationships to the theater. With t he growth of the theater, these keymen were assigned larger responsibilities in hospital centers and base sections while continuing to function as senior consultants in their respective sub-specialties of medicine for the theater, a plan which paid heavy dividends in its cohesiveness. Only two of the senior consultants whose administrative duties were deemed full time, namely, Colonels Pillsbury and Thompson, were stationed at headquarters.

    Before D-day, the pattern of organization had undergone a fair trial under relatively quiet conditions in the United Kingdom, where by this time almost 140,000 beds had been prepared. The Chief Surgeon, ETOUSA, was committed to the thesis that the only reason for the existence of the Medical Department in the Army is the prevention and care of the sick and injured. His complete confidence in the mission of his Professional Services Division insured the highest possible level of coordination among the several divisions of his office. From an operational standpoint, unquestionably the ability to control the distribution of trained professional personnel to the greatest advantage of the sick and wounded was the most important dividend from this farsighted policy. With the support of the Chief Surgeon, invaluable channels of direct communication for the dissemination of professional information were encouraged, to the distinct improvement of medical service. Lastly, but certainly not least in the final analysis, the medical consultants in the Professional Services Division, to whom had been assigned the task of delivering the best possible medical care to the soldiers of the U.S. Army in the European theater, were afforded every reasonable support to attain this objective. Within the personal capabilities and limitations of the individuals concerned, the measure of their success in fulfilling this mandate must rest on the record.


Part II. Senior Consultant in Dermatology and Syphilology 8


Figure 106 -Col. Donald M. Pillsbury, MC, Senior Consultant in Dermatology, Office of the Chief Surgeon, ETOUSA.

    Colonel Pillsbury (fig.106) arrived in the United Kingdom during December 1942 and was assigned as one of two full-time consultants in the Medical Consultation Service, Professional Services Division, Office of the Chief Surgeon, Headquarters, ETOUSA. Colonel Pillsbury filled the position of Senior Consultant in Dermatology and Syphilology, ETOUSA; the other full-time position was that of the Senior Consultant in Neuropsychiatry, ETOUSA.
    Making immediate contact with his counterparts in the forces of the British Commonwealth of Nations, Colonel Pillsbury found a valuable source of information in Lt. Col. (later Brigadier) R. M. B. MacKenna, Consultant in Dermatology for the Royal Army Medical Corps. Colonel MacKenna was able to recount the skin diseases most frequently found in England, the measures undertaken by the British Army to prevent and control them, and the availability of dermatologic supplies in the United Kingdom. Lt. Col. Milton H. Brown of the Royal Canadian Army Medical Corps was particularly helpful because of the experiments the Canadian Army was conducting in massive arsenotherapy of early syphilis, a subject of great immediacy in view of the marked military advantage some shortened method of treatment would have. Contact with the British Emergency Medical Service was maintained in

8 The narrative for part II was compiled by Maj. James K. Arima, MSC, The Historical Unit, U.S. Army Medical Service, in collaboration with Donald M. Pillsbury, M.D., former Senior Consultant in Dermatology and Syphilology, ETOUSA. Dr. Pillsbury contributed the summary in retrospect in May 1956.

connection with treatment of such U. S. personnel as were admitted to Emergency Medical Service hospitals.


    On his arrival in England, Colonel Pillsbury found scabies, superficial pyogenic infections of the skin, contact dermatitis, and chronic eczematous eruptions increasing in incidence. Pediculosis and various types of ringworm infections also appeared to be a problem. Inspections of hospitals and dispensaries showed that earlier diagnosis with appropriate treatment in field units and hospitals was needed in many cases to prevent disability. In the chronic dermatoses, such as atopic dermatitis and severe psoriasis, early classification and determination of prognosis would identify patients who, with no reasonable prospect of early permanent improvement, should be returned promptly to the Zone of Interior in order to prevent their becoming a heavy load on medical and nursing personnel. Many soldiers who had marked sensitivity to such items as wool, dye, and leather were incapable of full duty. Many had had these disabilities prior to induction and should not have been sent to the theater.

    The providing of dermatologic supplies in adequate amounts and the development of new drugs and emulsions were concomitant problems. For example, benzyl benzoate treatment of scabies was thought to be suitable for use in field units, but there were problems as to supply, preparation, and the best vehicle. A standard emulsion ointment as a vehicle for sulfonamides and other medicinal agents in the treatment of superficial pyogenic skin infections was also needed (p.285 and p.312).


    The field of syphilology was rife with problems of immediate concern. A schedule of treatment for venereal diseases was prescribed in a directive from The Surgeon General.9 This schedule, however, was not being followed in all units because of difficulty in obtaining Mapharsen (oxophenarsinc hydrochloride). In some instances, there had even been a complete failure in the distribution of this drug. Consequently, American Mapharsen, British Mapharside, and neoarsphenamine were all being used. Because of the conflicting evidence regarding the toxicity of these antisyphilitic drugs, considerable confusion had arisen in the minds of many medical officers. The subject had to be investigated fully and a trial of British Mapharside initiated. Such matters required the closest coordination with the Medical Supply Division of General Hawley's office, and Lt. Col. Howard Hogan, MC, was most helpful in relieving the critical supply situation.

    Colonel Pillsbury found that the standard of syphilis treatment in some hospitals could be improved and that he would have to investigate the standards
9 Circular Letter No. 74, Office of the Surgeon General, U.S. Army, 25 July 1942, subject: Diagnosis and Treatment of the Venereal Diseases.

in field units. In the U.S. Army, as in the Canadian Army, it would be necessary to hold occasional conferences of medical officers treating venereal disease because adequate direction or stimulation of interest in syphilotherapy could not be carried out by letters and directives alone. Various laboratory procedures, particularly facilities for dark-field and serologic diagnosis of syphilis, also needed improvement.

    As the new year, 1943, came, "The above would indicate," wrote Colonel Pillsbury, "* * * that this Consultant has plenty to do. It is believed that work along these lines can produce a significant decrease in disability in ETO due to diseases included in the field of dermatology and syphilology." 10


During 1943 the problems of dermatology and syphilology became more clearly defined, permitting relatively clear lines of action to overcome them. The greatest room for improvement in the field of dermatology lay in the basic processes of diagnosis and treatment in the more easily curable, most prevalent conditions. To Colonel Pillsbury, these two questions were paramount: (1) What is necessary to keep the soldier, particularly the combat soldier, from man-days lost as a result of preventable or easily curable dermatologic conditions, and (2) what types of good treatment are most applicable in forward units? The theater senior consultant in dermatology and syphilology had to avoid scrupulously the temptation to investigate rare and interesting conditions or to conquer time conditions with a reputation for chronicity. The year also saw the engagement of the enemy in the North African and the Mediterranean areas. The campaigns in North Africa provided an opportunity to outline clearly the problems--particularly in the venereal diseases--that would be met under combat conditions.


    Owing to an unfamiliarity among many medical officers of the various dermatologic conditions, the importance of skin diseases as a source of man-days lost was often overlooked. Of 2,093 admissions to the 10th Station Hospital during the later months of 1942, 10 percent were for a primary diagnosis of skin disease. The 5th General Hospital found that 6.8 percent of 7,049 admissions were for a primary diagnosis of skin disease. There were 14,408 admissions to all hospitals in the European theater during November and December of 1943. Of these, 1,035 cases were admitted with a primary diagnosis of skin disease. This was about 7.2 percent of total hospital admissions. But hospital admissions alone did not tell the whole story. Colonel Pillsbury interviewed many medical officers in both the European and North African theaters and found that the incidence of skin diseases at sick call in service and combat units ranged from 15 to 40 percent of all patients seen.11
10 Annual Report, Professional Services Division, Office of the Chief Surgeon, Headquarters, ETOUSA, 1942.
11 Annual Report, Professional Services Division, Office of the Chief Surgeon, Headquarters, ETOUSA, 1943.

    Scabies and its complications, superficial pyogenic infections, fungus infections, seborrheic dermatitis, psoriasis, and various types of dermatitis and eczema constituted over 95 percent of the cases. It was not too much to expect of all unit and hospital medical officers to diagnose properly this 95 percent of dermatologic cases, but many could not. Medical officers in ETOUSA were, in general, less well trained in the diagnosis and treatment of skin diseases than in any other specialty, with the possible exception of ophthalmology. It was the exception, rather than the rule, for general hospitals, supposedly equipped to render the ultimate standard of medical care to the soldier, to have a trained dermatologist on the professional staff. There were only five medical officers in the theater who possessed a certificate from the American Board of Dermatology and Syphilology.

    Colonel Pillsbury made particular efforts to train competent young medical officers in dermatology. This training had to be continuous, with regular supervision by the senior consultant or regional consultants in dermatology, in order to insure that the training efforts were being reflected in better standards of care.

    One means of reaching the officer in the field was through meetings and talks. Colonel Pillsbury gave lectures on the diagnosis and treatment of skin diseases in the field at both the Medical Field Service School, Shrivenham, and the Field Service School of the Eighth Air Force, using a series of personally owned colored lantern slides. The British Ministry of Health film on scabies was also shown at the Medical Field Service School. During the year, Colonel Pillsbury led discussions, by invitation, at staff meetings of 10 hospitals in the theater.

    On 12 November 1943, a meeting, sponsored by the Chief Surgeon's Office, ETOUSA, was held at the Royal Society of Medicine attended by 25 U.S. Army medical officers and certain guests of the United Kingdom and Canadian forces. Colonel Pillsbury believed that this was the first meeting devoted to dermatology ever meld under auspices of the U.S. Army. Various aspects of the diagnosis, treatment, and management of scabies, pyoderma, psoriasis, eczema, and cutaneous lesions associated with meningococcemia were considered in individual sessions. There were discussions on (1) the superficial X-ray treatment of skin diseases, (2) the types of skin diseases requiring "boarding" or producing recurring disability or both, (3) the factors delaying involution of common dermatoses, and (4) the dermatologic disability in combat units. In addition, Brigadier MacKenna gave a talk on the organization of a dermatologic service. Maj. J. H. Twiston Davies, RAMC, dermatologist for the Southern Command, discussed recent experiences in military dermatology. A subject of considerable importance at the time, and one in which the average dermatologist could not be expected to have had much experience, was the dermatologic conditions that would occur should the enemy choose to use chemical agents on a large scale. This subject was expounded admirably by Col. William D. Fleming, MC, Chief, Gas Casualties Division, Office of the Chief Surgeon, Headquarters, ETOUSA. Material emerging from this ex-

change of views and information was later published in the Medical Bulletin, ETOUSA.

    In the European theater, the vehicles for communication directed to the bulk of medical officers were circular letters of the Office of the Chief Surgeon, Headquarters, ETOUSA, and the Medical Bulletin. Circular Letter No. 77, 8 May 1943, was entitled "Diagnosis and Treatment of Scabies." In it, Colonel Pillsbury stressed the point that "only by prompt recognition of the disease before complications have developed and before other members of the unit have become infested, can scabies be controlled satisfactorily." It was pointed out that: "Unwarranted numbers of patients with scabies are being admitted to hospital in E.T.O. It is essential that medical officers should be familiar with the clinical features of this disease, so that an early diagnosis may be made, and prompt effective treatment carried out in units."

    Four articles on the recognition and care of dermatologic conditions were published during the year in the Medical Bulletin.
    Colonel Pillsbury continued to maintain the closest liaison with Canadian and British medical officers in dermatology. His relations with the Army Air Forces were extremely cordial, and ready agreement on improvements in the treatment of skin diseases was always obtained. On 2 July 1943, the chief address at time British Association of Dermatology and Syphilology was given by Colonel Pillsbury, on invitation. In his annual report for 1943, Colonel Pillsbury commented, as follows:

    This consultant has attended all meetings of Command Dermatologists, British. Participation in the discussions at this meeting has been active, on request. Brig. R. M. B. MacKenna has been extremely cooperative in making available time collected data of the RAMC and his own wide experience in military dermatology. It is felt that our relations with British in this field of medicine have been particularly happy, and future complete cooperation is assured. This is particularly valuable, in view of the absence of any direction in the field of dermatology from the Office of the Surgeon General.

    Special problems. - In any foreign theater, new medical problems arise that require special treatment methods. In the United Kingdom, the U.S. Army depended on British sources of supply for drugs and special equipment for dermatologic treatment. For example, Colonel Pillsbury realized upon his arrival in England that benzyl benzoate would be the ideal drug of choice for the field treatment of scabies. The British had shown that it was greatly superior to sulfur. The vehicle used by the British, a liquid Lanette wax emulsion, had certain disadvantages for use of troops in the field. In collaboration with British industrial chemists, an indefinitely stable and highly effective therapeutic preparation was devised for U.S. Army use (fig. 107). The developmental work with sulfonamide emulsion ointments proceeded as planned in conjunction with the Consultant in Plastic Surgery, ETOUSA, although such ointments were later discontinued because of their sensitizing properties. A very useful preparation, benzoyl peroxide ointment, was added to the nonstandard list and proved its value immediately (p. 312).

    Superficial X-ray therapy became desirable for the treatment of certain skin lesions. In conjunction with time Senior Consultant in Radiology,

FIGURE 107.- Medical officers viewing display of benzyl benzoate preparations for treatment of scabies, 5th General Hospital, Salisbury, Wiltshire, England, 1 May 1943.

arrangements were made for such therapy to be administered in selected civilian clinics, but the system did not prove to be entirely satisfactory. The facilities were limited in number and overworked, there was lack of control of the treatment given, and the possibility existed that the records of dosage would be lost. Approximately six such units were needed, but they were not available. It may be concluded that superficial X-ray therapy is not a method of treatment adaptable for use in an active theater of operations. The Finance and Supply Division of General Hawley's office was able to provide additional ultraviolet-therapy equipment, which was needed in England because of the lack of sunshine. Electrodesiccating units for the removal of partially disabling warts and papillomas were also provided and proved useful in the hands of competent medical officers. Such units were subject to misuse, however, in the hands of inexperienced physicians.

    Among other collaborations required of Colonel Pillsbury were two special studies. The first of these had to do with the determination of toxicity of certain camouflage ointments being developed by the Engineers Corps. The test involved a sample of 200 men on whom such ointments were tried for irritant effect and sensitizing capacity. It was found that the ointments were satisfactory provided the formalin contained in them was replaced by a


nonsensitizing ingredient. The other was a study conducted in conjunction with the Preventive Medicine Division of General Hawley's office to ascertain causes and incidence rates of disabling fungus infections, which were markedly on the increase. In addition to certain deficiencies in preventive measures, it was found that the wearing of heavy British-issue socks during mild or warm weather was deleterious, and proper recommendations were made to the Chief Quartermaster, ETOUSA, to remedy this situation,


    The problems that existed in the treatment of syphilis were brought to a sharp focus in March 1943, at the first general meeting of hospital medical officers in the theater for the purpose of discussing the treatment of venereal disease. This conference was called by Colonel Pillsbury in order (1) to provide an interchange of ideas and discussion of mutual problems in the field of venereal diseases, (2) to arrive at a mutual understanding and interpretation of various letters and directives from The Surgeon General and the Chief Surgeon, ETOUSA, and (3) to collect information for the Office of the Chief Surgeon, Headquarters, ETOUSA. The majority of conferees consisted of medical officers, laboratory officers, and nurses who were concerned with the control, diagnosis, and treatment of the venereal diseases. Whereas in the highest echelons, treatment and control responsibilities were clearly divided between professional and preventive medicine divisions and treatment responsibilities were further delimited with respect to gonorrhea and syphilis between the surgical and medical services, respectively, this was not necessarily the case in the field. In the smaller hospital units and commands, all of these responsibilities were, often as not, entrusted to one individual medical officer. This attendance at this conference could not be confined to those officers whose treatment responsibilities were limited to syphilis alone. Accordingly, representatives from Headquarters, ETOUSA, also included Colonel Kimbrough, Chief, Professional Services Division; Major Padget, Venereal Disease Control Officer, ETOUSA; Capt. John R. Poppen, MC, USN, from the U.S. Embassy; amid Colonels Montgomery and Brown from Canadian Military Headquarters.

    The primary problems discussed at this meeting were concerned with (1) deviation by medical officers in the field from treatment schedules specified in the 1942 Circular Letter No. 74 from the Office of the Surgeon General, (2) treatment of sulfonamide-resistant cases of gonorrhea, (3) interpretation and use of dark-field and serologic tests for syphilis, and (4) maintenance of proper records of treatment for syphilis. In addition, papers on the following subjects were read and discussed: (1) The diagnosis of early syphilis, (2) the treatment of sulfonamide-resistant gonorrhea, (3) the treatment of syphilis at a replacement depot, and (4) the difficulties in treating syphilis in a general hospital in the European theater. There was also a discussion of plans for the trial of intensive arsenotherapy of early syphilis.

    It was fortunate for Colonel Pillsbury that so much of the discussion centered on the treatment of gonorrhea, which, at a later date, was to come into his field of responsibility.

    As a result of this meeting and from experience gained through other sources, Colonel Pillsbury listed the primary problems in the diagnosis and treatment of syphilis to be (1) failure of continuity of treatment in units, (2) inadequacy of any method of prolonged treatment in men or units subject to repeated movement, (3) probable complete breakdown of antisyphilitic treatment in troops in combat conditions, (4) difficulties in maintaining adequate records and in insuring followup studies on completion of treatment, (5) inaccuracies in dark-field and serologic diagnosis of syphilis, and (6) difficulty in coordinating the efforts of all agencies concerned with the control and treatment of venereal disease.

    The syphilis register and the supplementary record.- In order to assure continuity of treatment in patients on the standard 26-week schedule of therapy, a form called the Supplementary Record of Treatment, ETOUSA MD Form 313, was devised to be carried by the patient. This form was not intended to replace the syphilis register but to supplement it. It was developed after much consideration and after similar forms had proved their worth when used by the Royal Army Medical Corps and the Royal Canadian Army Medical Corps. Colonel Pillsbury believed that the newly devised form would be useful to the individual patient after his discharge from the service as well as provide essential information should his syphilis register become misplaced. Circular Letter No. 93, 24 May 1943, Office of the Chief Surgeon, Headquarters, ETOUSA, was published to govern the use of the new form. After a 6-month trial, Colonel Pillsbury was able to report that this supplemental record had demonstrated its value beyond doubt.

    Circular Letter No. 74 from the Office of the Surgeon Gemmeral provided that, on completion of treatment for syphilis, the patient would have a final physical examination, a spinal fluid test, and a blood serology (Kahn) test. Following this, if the results were satisfactory, the patient was placed On probation from treatment with serology (Kahn) tests made at intervals of from 3 to 6 months. The regimen was theoretically sound, but in practice it broke down. The key to the breakdown lay in the handling of the syphilis register of the individual patient. The registers were filed and not consulted or, worse still, misplaced. Colonel Pillsbury found the answer to this problem in the central inspection and control of the syphilis register. Circular Letter No. 106, 25 June 1943, Office of the Chief Surgeon, Headquarters, ETOUSA, directed that the syphilis register be forwarded to the Medical Records Division, Office of the Chief Surgeon, Headquarters, ETOUSA, upon completion of treatment. Colonel Pillsbury then inspected registers that contained discrepancies. If there were serious deficiencies in the treatment or in the tests of cure, the register was returned to the forwarding unit with appropriate instructions. Otherwise, the records were filed in the Medical Records Division, and requests for followup tests were sent out to the individual's unit at the proper time. After a 6-month

interval, Colonel Pillsbury assessed the advantages of this method to be: (1) It furnished a valuable means of determining that the soldier's treatment had been adequate and of correcting deficiencies early; (2) it gave reasonable, although not absolute, assurance that followup Kahn tests would be done; and (3) it offered protection against loss of the syphilis register. It was expected, of course, that certain difficulties would arise in the system once active combat operations commenced or when the theater was dissolved at the end of the war. Moreover, it was recognized that such a system might not be applicable to a less compact theater.

    Success in establishing this system of central examination of the syphilis register was in large measure due to the wholehearted cooperation that was given by the Medical Recordis Division.

    Laboratory problems
. - Early 1943 found the situation in regard to serologic tests for syphilis unsatisfactory in several respects. Although British laboratories were very cooperative and helpful in making up for the lack of U.S. Army laboratory facilities then available, their standards varied considerably; there was no way to control the methods employed; reporting of results took many different forms; and no central reference laboratory existed fom cross-checking their work. Furthermore, the inexperience of many medical officers in the field compounded these difficulties. Samples were being collected improperly. Both Colonel Pillsbury and Major Padget were highly concerned because patients were being submitted to unnecessary antisyphilitic treatment on the basis of fallible laboratory tests, when the case history or proper interpretation of tests would indicate that the diagnosis of syphilis was highly unlikely.

    At Colonel Pillsbury's instigation, a conference was held in January 1943 between Major Padget and Lt. Col. Ralph S. Muckenfuss, MC, Commanding Officer, 1st General Medical Laboratory. As a result of this conference, Circular Letter No. 22, 4 February 1943, was issued by the Office of the Chief Surgeon, Headquarters, ETOUSA. In October 1943, it was revised and reissued by that office as Circular Letter No. 148. This directive specified control procedures, methods, and policies by limiting the performance of serologic tests for syphilis to those laboratories (fig.108) specifically designated by the Chief Surgeon, ETOUSA, setting up the means for rapid transmission of samples and reports, specifying in detail when and under what circumstances the various laboratory tests should be performed, and establishing a system of interlaboratory checks.

    When the meeting of hospital personnel concerned with the control and treatment of venereal disease was convened in March 1943, Colonel Pillsbury was able to report continuous improvement in regard to serologic tests for syphilis. With the cooperation of Colonel Muckenfuss, the laboratory situation was reaching a point where it was possible to lighten the load the British laboratories had been asked to carry. In addition, facilities and apparatus for dark-field studies had also been considerably increased.
    The closest rapport was maintained by Colonel Pillsbury with the Preventive Medicine Division and the Director of Laboratories throughout the year


FIGURE 108.- Serology Section, 1st Medical General Laboratory, Salisbury, Wiltshire, England.

in maintaining better performance of diagnostic procedures for syphilis. The need was demonstrated time and again by instances of gross errors in the performance of dark-field examinations and serologic tests. Neither was a simple procedure to be performed by amateurs.

    Intensive arsenotherapy
. - It would not be proper here to discuss details concerning the intensive arsenotherapy of syphilis. The subject is adequately covered elsewhere in this series of volumes on internal medicine in World War II. It would be most appropriate, however, to record here the part that the Senior Consultant in Dermatology and Syphilology of the European theater played in pioneering the application of this method in military medicine.

    In a letter dated 16 March 1943 to Colonel Kimbrough, Colonel Pillsbury recommended the adoption of a 20-day schedule of intensive therapy using Mapharsen or Mapharside. At that time, this was a grave and momentous decision on a subject that had engaged Colonel Pillsbury's attention from the first days of his arrival in the theater. For his guidance in making this decision there was very little of the data on the subject, although eventually data became voluminous. He had, however, a source of information in his close association with the Royal Canadian Army Medical Corps, which had already embarked on the plan experimentally. He had access to information from the Subcommittee on Venereal Disease of the National Research Council. He had personal correspondence with Dr. John H. Stokes and Dr. Joseph Earle Moore, and Major Padget also provided information and correspondence with authorities on the subject.

    The opinions of those closest to the studies connected with the intensive arsenotherapy of syphilis varied considerably with respect to toxicity and schedules of optimum treatment. The National Research Council had not approved any plan for the Armed Forces. In fact, as late as October 1942, the Committee on Medicine of the National Research Council had recommended that:

* * * intensive arsenotherapy of early syphilis (including the five-day intravenous drip method) be considered as still in the experimental stage; that the optimum time-dose relationship still requires to be established by further animal and subsequent clinical experimentation; and that at present the method cannot be recommended for routine use by the Armed Forces. 12

    The committee, following a full discussion at the meeting and later study of data circularized to the committee, somewhat modified its previous stand by recommending a reconciliation between certain experimental data and the different types of suggested methods of therapy. Pending the acquisition of these data, the committee thought that:

* * * it seems undesirable for the committee to recommend the adoption of any very short and intensive method of treatment as a general procedure in the Armed Forces. However, the Armed Forces may well investigate the applicability of these methods to their own problems under certain conditions.
12 Minutes, Thirteenth Meeting of the Committee on Medicine, National Research Council, 16 Oct. 1942.

Dr. Stokes, a member of the Subcommittee on Venereal Disease, had written in November 1942, as follows:

    It is easily conceivable that there will be situations in which * * * the methods must and should be employed. The decision to employ them in this fashion does not lie within the recommendatory power of any advisory body, as the National Research Council Venereal Disease Sub-Committee has indicated, unless that power feels it can assume responsibility for an as yet unevaluated and not intrinsically uncriticizable experiment.13

    On the other hand, the military situation facing the command in Europe indicated clearly that any prolonged method of treatment of syphilis was likely to be interrupted for various reasons, as it frequently was among operational aircraft crews. It appeared doubtful that adequate continuous treatment of syphilis could be maintained in all syphilitic patients by even the most competent and conscientious medical officers under conditions requiring extensive movement, maneuvers, or combat. Furthermore, early syphilis, which had to be treated to the point of noninfectiousness and adequate protection against infectious relapse, was the only real problem. There was nowhere near the number of cases of latent syphilis found in civilian practice in the United States. Altimough it was desirable that any method of treatment furnish reasonable protection against the development of late visceral syphilis, it could be considered unjustifiable to employ a time-consuming and difficult therapy in an active theater because of some slight reduction in the incidence of late syphilis 10 or 15 years later. In this respect, the treatment schedule outlined in Circular Letter No. 74 of the Office of the Surgeon General was, in itself, experimental. It was a 26-week compromise with the standard 12-to 18-month regimen, and there was insufficient clinical evidence to prove conclusively that it was adequate.

    The chief disadvantage of the intensive treatment of syphilis was its inherent toxicity. Another disadvantage was the fact that intensive treatment methods would require more hospital beds. Based on the prevailing incidence, in certain units, of the number of patients given initial treatment in quarters compared to the number treated in hospital, the Medical Records Division of General Hawley's office estimated that, under the existing schedule, 1.7 beds per 1,000 troops were required, while 2.6 beds per 1,000 troops would be required under methods of intensive therapy.14 This consideration was far outweighed, however, by the savings in time of medical officers and the solving of problems incidental to treatment in units.
    The out-and-out advantages of intensive methods of treatment were significant. It was estimated that infectious relapse, if it occurred, would reveal itself within 1-year after completion of treatment, thereby necessitating just a 1-year followup instead of the prevailing 2 years. Treatment could be completed in 95 percent or more cases, while being completed in not more than half
13 Stokes, J. H.: The Wartime Control of Venereal Disease. J.A.M.A. 120: 1093-1099, 5 Dec. 1942.
14 Letter, Lt. Col. D. M. Pillsbury, Senior Consultant in Dermatology, ETOUSA, to Col. J. C. Kimbrough, Director, Professional Services Division, Office of the Chief Surgeon, Headquarters, ETOUSA, 16 Mar. 1943, subject: Intensive Treatment for Early Syphilis as a Substitute for the Present Six-Month Schedule.

the patients treated otherwise. The centralization required by intensive therapy would afford better control, place responsibility for treatment in the hands of few, insure proper completion of the syphilis register, and ease problems in medical supply.

The decision to embark on intensive treatment methods having been made, there yet remained the question of determining total dosage, dosage per injection, frequency of injection, and the total time over which intensive therapy should be given. Experimentation in animals and human beings had shown that slight modifications in the last three of these variables produced considerable differences in results, particularly with respect to the maximum tolerable dose. There were positive indications in the experimental data that the longer the time over which the total required dose of arsenical was given, the less mortality there would be from treatment. Dr. Moore had suggested in a personal communication to Major Padget that a 10-week treatment schedule be used. Thus, obviously, was too long a period for hospital treatment, and such a schedule would nullify the advantages of intensive treatment. Colonel Pillsbury finally decided on a 20-day period of treatment with a total dose of approximately 1,200 mg. for a 150-pound patient. The total dose would be given at the rate of 40 mg. for the first day and 60 mg. for the succeeding 19 days.

The program as recommended by Colonel Pillsbury was approved by General Hawley and put into effect on an experimental basis in the 2d and 298th General Hospitals. It was subsequently extended to the 5th and 30th General Hospitals. The closest supervision was required on the part of the theater senior consultant in dermatology and syphilology, necessitating from 2 to 3 visits weekly. Following the successful trial in these hospitals, General Hawley approved further extension of this treatment to all general hospitals and certain other selected hospitals by Circular Letter No. 138, entitled "Intensive Treatment of Early Syphilis," issued from the Office of the Chief Surgeon, Headquarters, ETOUSA, on 10 Septemnber 1943.

    By the end of 1943, approximately 1,200 patients with early syphilis had received intensive therapy without mortality. The average period of hospitalization for each patient had been only 25 days. Although no final statements could be made at that time, it appeared that the incidence of relapse would be no higher than, if as high as, with the standard 26-week schedule, and the serologic reversal rate was apparently satisfactory.15 The Canadian Army, which had suffered 4 deaths in 681 cases treated under its 6- to 10-day regimen, also adopted the 20-day treatment provided U.S. troops. In September 1943, Dr. Moore visited the theater and was apprised of the results of intensive therapy at a meeting attended by both U.S. and Canadian medical officers engaged in supervising and operating the program. Dr. Moore considered the results highly satisfactory, advised extension of the type of treatment being given to all troops in the European theater, and wholeheartedly recommended that the 26-week schedule be abandoned entirely within the theater.
15 See footnote 11, p.283.


Recommendations Based on North African Experience

    In late 1943, Colonel Pillsbury toured representative medical installations in North Africa for the purpose of observing methods of prevention and control of venereal and skin diseases. Between 15 November 1943 and 7 December 1943, he visited all base sections of the North African theater, with the exception of the Atlantic Base Section, and inspected 10 general hospitals, 6 station hospitals, 3 evacuation hospitals, 1 division clearing station, and 3 general dispensaries. The results of his tour were reported in a letter, dated 10 December 1943, to the Chief Surgeon, ETOUSA, through the Surgeon, NATOUSA (North African Theater of Operations, U.S. Army).

    In addition to reporting conditions as he found them, Colonel Pillsbury made the following recommendations with respect to the control and treatment of dermatologic conditions and venereal disease in ETOUSA.

With respect to dermatology:     1. Continued attempts to inform and train field and hospital medical officers concerning the proper methods of initial treatment of pyoderma, fungous infections, and acute eczematous infections of the skin should be made. The early initial treatment is a crucial period in preventing undue disability therefrom. If only harm from treatment can be prevented, considerable will have been accomplished.
    2. Bathing facilities for combat troops in ETO should be checked with a view to increasing their availability. It is believed that a considerable proportion of fungous and pyogenic infections can be entirely prevented by more frequent bathing.
    3. Continued emphasis must be placed on the importance of good foot hygiene, and this must be appreciated as an essential command function. Arrangements have been made for distribution of four pairs of fresh socks weekly to combat troops in NATOUSA and it is recommended that plans for this be made in ETO.
    4. Adequate consultative service in dermatology should be available to evacuation and station hospitals which have no officer trained in this specialty. Severe and chronic cases should be referred to general hospitals for special treatment or other disposition as rapidly as possible.

With respect to venereal disease control:
    1. It is recommended that resolute and determined opposition be offered to any policy that condones the operation of houses of prostitution under Army supervision or cooperation, direct or indirect.
    2. The paramount importance of immediate venereal disease control measures in occupied territories should be appreciated. A venereal disease control officer is an essential member of the initial medical organization.
    3. It is recommended that active measures for venereal disease control be taken by whatever organization will be responsible for civilian administration. This is vital to an adequate program.

With respect to venereal disease treatment:
    1. It is recommended that intensive therapy for early syphilis be continued in combat troops as long as the supply of hospital beds so justifies.   
    2. It is recommended that resistance be offered to any attempts to combine disciplinary measures and the treatment of venereal disease. It is believed that venereal disease stockades and rehabilitation training battalions as applied to every patient with venereal disease are unjust, and frequently interfere with adequate medical care.
    3. The supply of penicillin available for treatment of sulfonamide-resistant gonorrhea should be increased as rapidly as possible consistently with the saving of lives in other infections. The saving of man days lost made possible by this method of treatment is very considerable.


In addition, Colonel Pillsbury realized the seriousness of the problem of immersion (trenchfoot) and the fact that treatment had been unsatisfactory. He recommended that every clinical and laboratory facility of the Office of the Chief Surgeon, Headquarters, ETOUSA, be made available for a thorough study of this condition with prompt transmission of results to the Surgeon, NATOUSA.


    The period 1944 through the early months of 1945 was most characteristic of the activities of a consultant in an active theater of operations and, of course, the busiest. First, there was the planning for the invasion, then the invasion itself, and, following that, the mushrooming expansion of the theater in both troops and area. The initiation of active combat meant a preponderance of surgical casualties and a relative shortage of hospital beds for the treatment of nondisabling skin or venereal diseases. There was frequent movement of units and hospitals with continuous changes in missions and functions of the supporting medical elements. Evacuation policies had to be changed frequently in accord with tactical and other considerations. The main portion of theater headquarters moved from the United Kingdom to the Continent.

    During this period, there was a complete revolution in the treatment of venereal diseases. In addition, the Medical Division of General Hawley's office was given responsibility for the diagnosis and treatment of gonorrhea, a responsibility that previously had been vested in urologists under the Surgical Division. Also, all the practices and procedures that had been carefully established during the early days of the theater now required the greatest effort and closest attention by the theater senior consultant in dermatology and syphilology to keep them operating as originally planned.
    In late 1944, Colonel Pillsbury was ordered to the Office of the Surgeon General for a period of temporary duty in the United States.
Treatment of Venereal Diseases

    Intensive arsenotherapy
.- A total of approximately 4,000 patients with early syphilis received intensive arsenotherapy between April 1943 and July 1944 without any deaths from treatment. In mid-1944, however, this type of treatment was replaced by penicillin therapy. There were some indications that intensive arsenotherapy might still be required for penicillin-resistant, cases and those suffering relapses. While intensive therapy was in progress, careful and constant supervision was required by the theater senior consultant and regional consultants in syphilologv. The resulting absence of deaths proved the value of this supervision. Incidental to this mode of treatment were the careful keeping of followup records and the preparation of papers and species in response to many requests for summaries of the U.S. Army's


experience with the method. Although Colonel Pillsbury believed that the final cure rate would be somewhere between 85 and 90 percent,16 he doubted that intensive therapy could have been administered successfully under the conditions of later 1944 because of the shortage of hospital beds and the steady decline in the level of professional attainment of officers in hospitals arriving in the theater after July l944.17

    Penicillin therapy of gonorrhea
. - The initial experience with penicillin therapy of gonorrhea in the European theater resulted in the cure of 94.7 percent of the first 1,000 patients treated. This therapy called for an injection of a total of 100,000 units of penicillin in from 5 to 10 divided doses. Its use was restricted to persons whose services were urgently needed and who could not carry out their duties efficiently while receiving sulfonamides. Later experience showed that penicillin therapy was effective in all but an almost negligible number of cases, in contrast to only 65 percent of cases successfully treated in field units with sulfonamides. Even after treatment in a hospital, there had previously been a residuum of from 10 to 20 percent of patients whose cure was very slowly effected, with complications of various sorts.18

    The availability of penicillin had almost solved this difficult problem of military medicine. There remained for the consultant and others in subordinate positions the constant effort to have this treatment performed as far forward as possible. Eventually, Circular Letter No. 107, Office of the Chief Surgeon, Headquarters, ETOUSA, was published on 25 August 1944 prescribing the penicillin therapy of gonorrhea on an outpatient status as the method of choice, except that female personnel continued to be treated in hospitals. Colonel Pillsbury, realizing the great savings in manpower and hospital facilities with the use of penicillin, paid constant attention to the penicillin supply situation and, when the opportune moment arose, recommended that penicillin be used in the treatment of all cases of gonorrhea occurring in the theater.19

    Penicillin therapy of syphilis
. - In early January 1944, it became apparent that penicillin was also destined to occupy a preeminent role in the treatment of early syphilis. Keeping close watch over all the research that was being conducted, Colonel Pillsbury was convinced that penicillin therapy would offer a method of treatment for combat troops superior to that being used. His observations in the North African theater had shown conclusively that treatment of early syphilis within combat units was interrupted and unsatisfactory. Although no one could foretell what the final longterm effects of penicillin therapy would be, it was also known that inadequate treatment early in the disease was often worse than no treatment at all. On the other hand, there
16 Later surveys of such patients, though incomplete, indicated that intensive arsenotherapy had an effectiveness at or near that of penicillin in terms of absence of relapse and the percentage of negative spinal fluid examinations. However, it was obviously much more toxic.
17 Annual Report, Professional Services Division, Office of the Chief Surgeon, Headquarters, ETOUSA, 1944.
I8 Ibid.
19 Memorandum, Professional Services Division for Chief Surgeon, ETOUSA, 20 July 1944 subject: Penicillin Therapy of Gonorrhea and Syphilis.


could be no trial of penicillin therapy for early syphilis within the theater if there was any danger of jeopardizing the supply available for conditions threatening to life or for sulfonamide-resistant gonorrhea in which penicillin was practically always curative. Colonel Pillsbury discovered that supplies for such purposes were adequate and that possibly some of the supply might not even be used before it became outmoded. Accordingly, he did not hesitate to recommend a trial, in the European theater, of penicilin in the early treatment of syphilis.20 The plan was approved and the experiment entrusted to Capt. (later Lt. Col.) C. R. Wise, MC, a regional consultant stationed at the 2d General Hospital (fig.109). When Colonel Pillsbury visited the 2d General Hospital on 3 February 1944, five cases had already received or were undergoing treatment. Three of the patients had marked Herxheimer's reaction--fever and increase in the cutaneous lesions after the first injection--but, thereafter, the early lesions disappeared with a rapidity surpassing anything he had seen after arsenical therapy.

    At the time of Colonel Pillsbury's visit to the hospital on 19 March 1944, a total of 15 cases had been treated, 8 with a total of 500,000 units and 7 with 1 million units. The method of treatment, as far as therapeutic response and absence of reactions was concerned, appeared far superior to either intensive or standard therapy.

    On the basis of these 15 cases, the 7 March 1944 minutes of the Penicillin Panel, National Research Council, and personal letters from Lt. Col. Thomas H. Sternberg, Director, Venereal Disease Control Division, Office of the Surgeon General, Colonel Pillsbury recommended, on 26 April 1944, that a combined penicillin-bismuth-Mapharsen treatment be adopted for use in the treatment of combat troops and in the small number of patients in other units in whom arsenical therapy was not possible because of sensitivity to Mapharsen.21 At about the same time, he personally recommended to the Surgeon, Eighth Air Force, that penicillin treatment for syphilis be made available for operational crews. The Eighth Air Force surgeon requested such permission from the Air Surgeon, but it was denied.

    Before his recommendations could be implemented, Colonel Pillsbury received from Dr. Stokes a personal letter dated 28 April 1944. Dr. Stokes stated that the Subcommittee on Venereal Diseases, National Research Council, had recently recommended the use of penicillin in the treatment of early syphilis, by the Army, wider conditions in which continuity of standard treatment could not be maintained. In his letter, Dr. Stokes also indicated that modification of the previously recommended plan of treatment was necessary. While these modifications were being considered, The Surgeon General, in a letter which arrived at General Hawley's office on 1 June 1944,

20 Memorandum, Senior Consultant in Dermatology for Col. J. C. Kimbrough, Chief, Professional Services Division, Office of the Chief Surgeon, Headquarters, ETOUSA, 9 Jan. 1944, subject: Penicillin Therapy of Syphilis.
21 Memorandum, Professional Services Division for Chief Surgeon, ETOUSA, 26 Apr. 1944, subject: Penicillin Therapy in Syphilis.


FIGURE 109.-Venereal disease ward, 2d General Hospital, near Oxford, England. A. Taking blood specimen in clinic. B. View of ward.


authorized the use of penicillin in the treatment of early syphilis, with certain limitations and suggestions, as follows: 22

    Because of the recognized difficulties in carrying out the mapharsen-bismuth therapy of early syphilis in active Theaters of Operation, the following recommendations concerning the immediate use of penicillin as an anti-syphilitic agent are made. It is intended that this recommendation shall apply only to previously untreated cases, and that those cases in which mapharsen-bismuth therapy has already been initiated shall continue on such treatment.
    a. That all new cases of primary and secondary syphilis be treated with pericillin in those areas or theaters where, because of the exigencies of the military situation, it may be expected that routine arsenical-bismuth therapy will not be carried out regularly.
    b. That the schedule of treatmesit be 40,000 units intramuscularly every three hours for a total of 60 doses or 2,400,000 units per case. Preliminary experience with this dosage schedule indicates that better results than those obtained with 1,200,000 units may be expected .
    c. That followup examinations should be obtained at monthly intervals for a minimum period of one year, in order that relapses may be detected early and mapharsen-bismuth therapy initiated without delay. The spinal fluid should be examined between the third and sixth month following treatment.
    d. The syphilis registers should be properly maintained and transmitted with each move of the patient to assure adequate followup. Additional methods of earmarking these patients, such as central registries, may be considered desirable.

    Following this, Circular Letter No. 86, Office of the Chief Surgeon, Headquarters, ETOUSA, subject: Penicillin Therapy for Early Syphilis, was published on 22 June 1944, citing penicillin as the drug of choice in the treatment of early syphilis in field and air forces. The prescribed treatment followed closely the recommendations of The Surgeon General, but followup procedures, particularly with respect to serologic and spinal fluid examinations, were modified to fit the needs of the theater.

    Thus it is seen that an essential part of a consultant's functions is to keep abreast of new developments, difficult as this is in an oversea theater. Although, eventually, specific recommendations reached the theater from The Surgeon General, the preliminary investigations that had been conducted within the theater proved extremely valuable. Before The Surgeon General's letter ever arrived, Colonel Pillsbury was able to coordinate in advance the implementation of penicillin therapy with the Surgeon, Third U.S. Army; the Consultant in Medicine and Venereal Disease Control Officer, First U.S. Army; and the Surgeon, U.S. Strategic Air Forces in Europe. When The Surgeon General's letter arrived, Colonel Pillsbury was able to evaluate its recommendations in the light of firsthand experience and with due consideration for the desires of those in the field. Had there been no preliminary experience with this type of therapy, a similar trial period would undoubtedly have been necessary. A few months can be very important during wartime. In this case, the significance of the few months' headstart which the European theater had in planning for penicillin therapy of syphihis is most evident. The Surgeon ________
22 Letter, The Surgeon General, to Commanding General, ETOUSA, Attn: Chief Surgeon, 24 May 1944, subject: Penicillin Treatment of Primary and Secondary Syphilis.


General's letter was received on 1 June 1944, less than a week before D-day, 6 June. Subsequent experience showed, too, that there was no reason to change the basic principles of treatment, followup, and recordkeeping that were initially established.

    When the supply of penicillin became sufficient, its use in the treatment of early syphilis was extended by theater Circular Letter No. 107, August 1944, to all cases occurring in the theater.

    Laboratory procedures
. - With extensive deployment of troops on the Continent in 1944, specimens for laboratory examination had to be shipped greater distances while, at the same time, courier service became more unreliable. Tubes for the collection of specimens were not kept in proper sanitary condition, and the drawing of specimens was more likely to be performed carelessly. Disruption in the supply of stains and antigens also interfered with the essential laboratory tests.

    Again, close liaison was necessary with the Preventive Medicine Division, Office of the Chief Surgeon, Headquarters, ETOUSA, which supervised the laboratories. In the latter months of 1944, Lt. Col. (later Col.) Arthur P. Long, MC, Chief, Epidemiology Branch of the division, investigated and, together with Colonel Pillsbury, arrived at some remedial measures. On the Continent, prepared tubes containing a requisite amount of Merthiolate (thimerosal) were put into use, and, in the United Kingdom, the practice of placing 4 mug, of sulfanilamide in spinal fluid specimens was adopted to prevent contamination. Problems in courier service eventually were alleviated to some extent by performing all spinal fluid tests on the Continent.

    Other problems
. - During this period, Colonel Pillsbury was also concerned with the management of cases of latent syphilis and neurosyphilis, the few cases of penicillin-resistant gonorrhea, and with experimentation in the use of BAL for the treatment of agranulocytic reactions to intensive arsenotherapy (p.313). TB MED (War Department Technical Bulletin) 48, in early 1944, established policies and procedures on an Armywide basis for the management and treatment of neurosyphilis. Many provisions of this technical bulletin were obviously inappropriate as applied to the European theater, and a suitably abridged and condensed version was prepared for promulgation within the theater. Satisfactory provisions were made for the treatment of penicillin resistant cases of gonorrhea by transferring them to the Royal Victoria Hospital for fever therapy under the expert supervision of Lt. Col. Ambrose King, RAMC.

    The syphilis registers
. - The practice of holding syphilis registers centrally at the theater headquarters and reviewing them there required the frequent attention of the theater senior consultant in dermatology and syphilology. The problem of finding the necessary time to review registers became more acute when the theater headquarters was divided into two portions, one on the Continent and one remaining in the United Kingdom Base. Colonel Pillsbury was on the Continent, and the registers were kept at the Medical Records Division, United Kingdom Base. As time passed, it became more necessary


for Colonel Pillsbury to scan these registers personally since they were used to assess and collect data on the results of intensive therapy and penicillin therapy. Colonel Pillsbury eventually found himself spending 2 or 3 days at regular 2- to 3-week intervals to review the syphilis registers on which there were questions as to the adequacy of treatment provided.

    Colonel Pillsbury was able to report, in August 1944, that, through 20 August, 8,471 had been received in the Medical Records Division for advice, closure, and holding for followup checks. The medical decisions on all these were rendered by the Professional Services Division. An analysis of 1,920 registers received between 15 June and 22 July 1944 showed that 536 (28 percent) had been returned to units for information essential to closure or further treatment, 925 (48 percent) had been closed and sent to the Office of the Surgeon General, and 459 (24 percent) were lucid for followup tests. Colonel Pillsbury considered this analysis representative of the usual workload.

    In a letter to Colonel Pillsbury, dated 18 September 1944, Colonel Sternberg in the Surgeon General's Office wrote of this system in warmly laudatory terms:

    We get in fifteen hundred registers a week and we have to check them all over to see that they are satisfactory and return those which are not. It is a real pleasure to get in a box from ETO and it saves us a tremendous amount of work. I would like to adopt your system for our method of handling in the ZI but it is absolutely out of the question because of several thousand new cases of syphilis a month in addition to eight to ten thousand inducted syphilitics per month, which would require a tremendous office staff just to handle them.

Treatment of Skin Diseases
    The treatment of skin diseases saw no such dramatic changes as those that occurred in the treatment of the venereal diseases. The only advances that approached these in significance were the local penicillin therapy of certain dermatologic conditions and the use of DDT in combating pediculosis. Improvements were made by the strenuous application of more superficial measures, such as emphasizing standard methods of treatment, shifting skilled personnel to where they could do the most good, insuring adequate supplies of drugs, and centralizing hospitalization facilities for the treatment of skin conditions, it was still just as essential during this period, as it was during the earliest days of the theater, to emphasize to the point of monotony the dangers of overtreatment.

    To a considerable extent, the difficulty lay in the inadequate professional training of many medical officers in the diagnosis and treatment of skin diseases, a deficiency of medical school training that the Army could overcome only in part. On 26 June 1944, in a letter to Brig. Gen. Hugh J. Morgan, Chief Consultant in Medicine to The Surgeon General, Colonel Pillsbury wrote:

    I have been very much impressed with the extreme variation in training in dermatology which is offered by various medical methods. The teaching in this specialty in some schools is very inadequate, either because of lack of time on the curriculum or because of poor pedagogic methods. I feel deeply on this score, and intend to do something about it after the war.


There is no reason in the world why every medical student should not become perfectly familiar with the characteristic picture and the chief variations of the eight or ten diseases which will comprise over 90% of all skin cases. He should also be well ingrained in the standard methods of treatment, at least to the point where he will not do harm by treatment. Competent internists are often surprisingly inept in dermatologic diagnosis I think this is largely attributable to poor teaching methods in the past, to a failure to arouse their interest, and to the abominably complex terminology of dermatology.

    On the other hand, the difficulty also lay in the fact that there were some basic disturbances in skin physiology for which available methods of treatment were, at best, unsatisfactory. The only solution to these problems lay in extensive scientific investigations on a much broader physiologic base than in the past. In the letter to General Morgan just mentioned, Colonel Pillsbury stated that the following conditions falling in this category were of particular significance in the European theater: (1) Inflammatory eruptions of the hands and feet, including especially the disturbed vasomotor states that regularly accompanied them; (2) itch; (3) psoriasis; (4) seborrheic dermatitis; (5) fungus infections of all types both in their preventive and therapeutic aspects: (6) allergic conditions of various types, including atopic dermatitis, in which methods of treatment were highly unsatisfactory and too cumbersome for military medicine; (7) pyodermas, with a great need for more rapidly acting, nonsensitizing methods of reducing bacterial flora of the skin; and (8) warts, particularly plantar.

    In spite of the difficulties encountered, there were, nonetheless, indications that the efforts made to improve care and treatment of skin diseases were paying dividends. Scabies, although posing a constant threat, never approached the staggering rates of World War I, when it was responsible for some 30 percent of all evacuations from the British Expeditionary Force. The number of patients evacuated to the Zone of Interior for skin diseases remained constantly low, approximately from 30 to 40 cases per month.23

Planning for Invasion of the Continent
    Venereal diseases
, - After visiting the North African theater, Colonel Pillsbury was impressed with the absolute necessity of coordinated plans for the prevention and control of venereal disease on the Continent after D-day. There were also intelligence reports which indicated that venereal disease among the civilian population of France and the Low Countries was increasing. This factor, plus the shortage of drugs and physicians in those countries, indicated that exposure of U.S. soldiers to persons with infections venereal disease would be greatly increased and that a rise in the venereal disease rate could be expected. It was obvious, owing to several factors, that venereal disease in combat soldiers would be badly handled within the army areas unless special provisions were made. There would be a shortage of facilities in field and evacuation hospitals for adequate diagnosis, and the large number of surgical casualties would have priority over patients with venereal disease.

23 Sec footnote 17, p. 196.


    In North Africa, these factors had led to erroneous diagnoses and unwarranted evacuation of patients to fixed hospitals with the resultant loss in manpower. It was now fully realized that a patient with active venereal disease would prove to be just as much a casualty from the standpoint of combat usefulness as a man with a crippling wound and presented, moreover, a great opportunity to reduce noneffectiveness within the armies. Improved methods of treatment had made it possible to care adequately for such diseases entirely within an army area and, in almost all instances, to return the patient to his unit entirely cured. Obviously, the closest correlation of duties and responsibilities of various medical officer's concerned with venereal disease control and treatment activities was indicated.

    On 4 January 1944, in a memorandum to Colonel Kimbrough, Colonel Pillsbury recommended that a meeting be held to consider all aspects of the venereal disease problem and to formulate plans that would better anticipate and provide for the complex problems that could be expected to arise. In addition to himself, he suggested that the following attend: Chief, Preventive Medicine Division, and Chief, Professional Services Division, Office of the Chief Surgeon, Headquarters, ETOUSA; Venereal Disease Control Officer, ETOUSA; Consultant in Urology, ETOUSA; and representatives from the Eighth Air Force and First U.S. Army.

    The meeting was held on 29 January 1944, Colonel Pillsbury and Major Padget were directed to formalize the recommendations of this ad hoc committee. The memorandum prepared by these two officers on 15 February 1944 and presented to General Hawley discussed general considerations on which the recommendations were based and made specific recommendations with respect to prevention, prophylaxis, punitive measures, diagnosis, and treatment of venereal diseases.

    The recommendations with respect to diagnosis were (1) that facilities for the differential diagnosis of ulcerative penile lesions be made available as far forward as possible--it was believed that evacuation hospitals were the most advanced hospitals in which the necessary procedures could be carried out satisfactorily--and (2) that Kahn tests for syphilis be performed only as far forward as station hospitals.

The recommendations concerning treatment were fourfold, as follows:

    1. That the policy of treatment of gonorrhea in units be continued.

2. That treatment for acute urethritis be given promptly, whether or not laboratory facilities for the examination of smears were available.

3. That intensive treatment of early syphilis be continued and that it be administered as far forward as facilities would permit. The policy of giving such treatment only in fixed hospitals designated by the Chief Surgeon, ETOUSA, should be continued.

4. That a strong policy be adopted against the establishment of venereal disease stockades or other similar treatment centers in which disciplinary and punitive measures might interfere with the adequate medical care of patients with venereal disease.


    Following this conference, Colonel Pillsbury was busy coordinating activities with other divisions in theater headquarters and particularly in working with representatives of the First U.S. Army and, when it arrived in Europe in March of 1944, with the Third U.S. Army. In addition, it was necessary for him to confer with the many subordinate consultants in the various supporting commands and fixed hospitals that were designated to receive the evacuees.

    As D-day approached, Colonel Pillsbury was able to report on the problems that had been given first consideration and the plans that the First and Third U.S. Armies had completed.24 At this stage, it appeared that the following were problems that would have to be overcome:

1. Misdiagnosis of penile ulcers because of a lack of dark-field equipment or unfamiliarity of medical and laboratory officers with dark-field diagnosis, unwarranted dependence on spirochetal stains or on gross morphologic characteristics of ulcers for diagnosis, and misdirected attempts to do diagnostic serologic tests for syphilis in evacuation hospitals.

2. Evacuation of venereal patients too far back in the combat or communications zone because of a lack of facilities for proper diagnosis, the pressure of more crucial medical or surgical problems in evacuation hospitals, and the lack of interest on the part of medical officers in forward units in properly caring for the venereal diseases.

3. Regarding all venereal disease as an offense requiring disciplinary measures.

4. Serious and dangerous interruption of continuity of treatment for syphilis.

5. Persistence in sulfonamide therapy for gonorrhea for unjustified lengths of time.

The medical personnel of the two armies had fully accepted the general principle that early diagnosis and treatment of venereal diseases had to be accomplished within the armies and that the administrative and technical means were at hand to achieve this end. Accepting also the fact that very few medical officers were really competent in the diagnosis of ulcerative penile lesions, they were in agreement that some centralization of facilities was necessary. Accordingly, the First U.S. Army planned to set up a center for the diagnosis and treatment of such patients in a convalescent hospital. The professional service of this center was placed in charge of an expert venereologist, Capt. (later Maj.) James M. Howell, MC, transferred thereto from the 10th Station Hospital. A unit of the army laboratory, with an expert dark-field technician and serologist, was also attached.

    The Surgeon, Third U.S. Army, however, favored centralization to a less degree. He planned to attach a platoon of a clearing company to each of three evacuation hospitals to care for venereal disease patients in tented expansions to these hospitals. A medical officer trained in venereal diseases was to be
24 Memorandum, Colonel Pillsbury, for Chief, Professional Services Division, Office of the Chief Surgeon, headquarters, ETOUSA, 14 May 1944, subject: Diagnosis and Treatment of Venereal Diseases in the Combat Zone.


assigned to each of these hospitals and dark-field and serologic facilities provided from the army laboratory.

    All concerned generally agreed that penicillin should be used for the primary treatment of gonorrhea occurring in combat troops and that, under any circumstances, persistence in sulfonamide treatment for periods longer than 10 days was inadvisable. The surgeons of both armies wanted to introduce time penicillin treatment of early syphilis as soon as possible.
    As D-day became imminent and it was realized that, of the two armies, only the First would make the initial assault on the mainland of Fortress Europe, a meeting was held in the Office of the Surgeon, Headquarters, First U.S. Army, to make final plans for the diagnosis and treatment of venereal disease in the First U.S. Army. It was attended by Lt. Col. (later Col.) John W. Claiborne, Jr., MC, Commanding Officer, 4th Convalescent Hospital; Lt. Col. Cornelius A. Hospers, MC, Commanding Officer, 10th Medical Laboratory, First U.S. Army; Lt. Col. (later Col.) Tom F. Whayne, MC, First U.S. Army Group; Maj. Samuel L. Stephenson, Jr., MC, Venereal Disease Control Officer, First U.S. Army; and Captain Howell, 4th Convalescent Hospital. The final plans adhered closely to the original plans just described for the First U.S. Army. In addition, the decision was made that penicillin would be used for time treatment of early syphilis. Personnel from First U.S. Army agreed to provide necessary information on cases so treated so that there could be proper followup of these patients. It was also agreed that the number of spinal fluid examinations at the venereal disease center of the 4th Convalescent Hospital would, initially, be kept to an absolute minimum. It was further agreed that routine tests for closure of syphilis registers were out of the question for some time. In addition, Colonel Claiborne and Major Stephenson earnestly requested that Colonel Pillsbury participate on the spot in helping to set ump and initiate operations of the venereal disease center. The Surgeon, First U.S. Army, concurred in this request, and it was approved by the Chief Surgeon, ETOUSA.25

    As the Third U.S. Army made final preparations to cross the Channel in July 1944, the Surgeon, Third U.S. Army, voiced a desire to modify the preliminary plans. He wanted permission either to conduct intensive arsenotherapy in hospitals within the army or to use the standard 26-week schedule of therapy.26 He was assured there was every reason to believe that the supply of penicillin would permit its use in all cases of early syphilis arising in the army and that provision would be made for transfer of patients to general hospitals for intensive arsenotherapy should penicillin be unavailable. The Third U.S. Army surgeon, nevertheless, stood fast in his demands. Accordingly, permission was granted Third U.S. Army to conduct intensive arsenotherapy in specifically designated hospitals, when and if necessary, in place of penicillin

25 Memorandum, it. Col. D. M. Pillsbury, for Col. J. C. Kimbrough, Office of the Chief Surgeon, headquarters, ETOUSA, 21 May 1944, subject: Venereal Disease Diagnosis and Treatment in First Army.
26 Memorandum, Professional Services Division, for Chief Surgeon, ETOUSA, 3 July 1944, subject: Management of Syphilis in Third Army.


therapy. The stipulation was added that a medical officer trained in intensive arsenotherapy must be transferred to the hospital so designated.

    When put to test in combat, the plans formulated by First U.S. Army proved outstandingly successful. During the first 4 months of operation, 947 patients were admitted to the venereal disease center of the 4th Convalescent Hospital. Of these, 88 had to be transferred, either to another section of the convalescent hospital or to a general hospital. Thus over 90 percent of those admitted were returned directly to duty. Moreover, the diagnosis of a venereal disease was confirmed in only 9 of the 88 patients not returned directly to duty. The practice of treating venereal disease at one central place conserved beds in more active installations and permitted the concentration of trained personnel so that more effective treatment could be administered.27

    The plan worked best, however, when the army was confined to a relatively small front The army laboratory (fig.110) was located with the convalescent hospital, and it was not necessary to detach a unit to perform the dark-field and Kahn examinations. As the army expanded and the situation became mobile, the hospital and laboratory separated, and patients had to be moved from 5 to 100 miles for laboratory examinations at a time when transportation was scarce and the vehicular routes congested. Eventually, a portion of the laboratory had to be assigned to the hospital as called for in the original plans. Contrary to the advance planning, the laboratory performed extensive spinal punctures, not only for diagnosis but for the closing of syphilis registers. The fluids were transported to the United Kingdom by aircraft, but during the first month of operation over 50 percent of the specimens reached the central laboratory in an unsatisfactory condition. Again, the wisdom of the advance plans was supported. Spinal punctures for the closing of syphilis registers had to be deferred. Above all, the greatest problem was the immobility of the venereal disease center as a part of a convalescent hospital. The front at one time so outdistanced the center that another unit had to take over its functions temporarily. There was not enough transportation to move the center and not nearly enough personnel or equipment to establish two centers that could continue to advance by leapfrogging.

    When the use of penicillin had proved itself in the duty-status treatment of gonorrhea and in the treatment of early syphilis, the venereal disease treatment plan for the Third U.S. Army was eventually modified, in practice, to parallel that of the First U.S. Army.

. - The planning for care of dermatologic patients was based on the fact that the dermatologic load in a hospital was directly proportional to its station hospital functions and the number of troops in its immediate area of responsibility. This meant that the majority of these patients would eventually be seen on the Continent. Furthermore, any need to evacuate patients from the Continent to the United Kingdom or the Zone of Interior would represent a serious failure in professional service since in most derma-

27 Annual Report, Professional Services Division, Office of the Chief Surgeon, Headquarters, ETOUSA, 1944, with Exhibit D, thereto.


FIGURE 110.- l0th Medical Laboratory, First U.S. Army, La Cambe, France, 24 July 1944. A. Setting up the laboratory tents. B. Serology tent.


tologic conditions cure and return to duty was feasible within the limits of any reasonable evacuation policy, such as 30 days. On these premises, the decision was made to supply hospitals being transferred to the Continent with specially trained medical officers insofar as the number of officers permitted. The remaining officers who would have to care for the severe and disabling dermatologic cases evacuated to hospitals in the United Kingdom were centralized in hospital groups to permit the optimum care and management of such patients.

Hospitalization and Evacuation
    At frequent intervals, Colonel Pillsbury was required to take an active part in solving hospitalization and evacuation problems insofar as they concerned patients with diseases of the skin or venereal diseases. In most cases, the problems were local; that is, their solution rested in the hands of surgeons on the staffs of subordinate commands. Problems in this area were usually discovered during field trips. In other cases, reports of improper or unsatisfactory treatment revealed that the cause and the cure lay in the establishment and enforcement of evacuation procedures or hospitalization plans.

    For example, in late 1944, after the theater had grown tremendously, there occurred sporadic cases of patients being evacuated during the course of penicillin treatment for syphilis. This interruption of treatment necessitated the initiation of another complete series of treatments and was wasteful of medical facilities, personnel, and supplies, and, in addition, jeopardized the ultimate cure of the patient. Colonel Pillsbury had to confer with the surgeons and representatives of commands in which such discrepancies were occurring in order to fix stringent requirements for the completion of treatment mice it was started.

    In another instance, the French had requested help in the treatment of early or sulfonamide-resistant cases of gonorrhea, which were accumulating in the French Military Hospital at Val de Grace. Colonel Pillsbury inspected the hospital and discovered that 30 or 40 patients a month were admitted who required penicillin therapy. Arrangements were made to care for these cases in the 217th General Hospital with the approval of the Surgeon, Seine Base Section, in whose area the hospital was located, under conditions satisfactory to the French and the hospital authorities.

    Previously, centralized treatment centers for dermatologic care in the United Kingdom were mentioned. These had to be established because hospitals arriving from the Zone of Interior were staffed by increasingly less experienced and less well trained medical officers. On the other hand, the number of dermatologic patients in each general hospital was so small as to occupy only a fraction of the time of a specialist.

    Obviously, two solutions were possible--centralization of patients or the use of peripatetic consultants. Both were used, but the former proved much the more effective. In September 1944, such a center was in operation at the 192d General Hospital of the 15th Hospital Center. Here, there was


assurance of accurate diagnosis and disposition. Such centralization also facilitated the collection of information as to the incidence of various conditions and effectiveness of treatment. Moreover, patients could be further centralized on one or two well-run wards with adequate facilities for special examination and sufficient supplies of the common ointments, solutions, and other necessary medicinals. Above all, specialized dermatologic wards helped to insure the interest of wardmen and nurses in the care of these patients. Good treatment effected in this manner paid off in the saving of hospital-bed days per patient. The difference in length of hospitalization between good diagnosis and treatment and bad was particularly marked in dermatologic conditions.
Classification, Training, and Assignment of Personnel

    The adequacy in numbers and in training of dermatologists was the primary personnel problem, owing to the fact that diagnosis and treatment of diseases of the skin could not be standardized to the extent that standardization was possible in the venereal diseases. In addition, some older officers with special training in dermatology were so immersed in the specialty and so narrowed in their outlook as to make them unadaptable to Army medical practice and to duty outside their particular specialty. On the other hand, medical officers trained in dermatology in the 10 to 15 years before the war in certain civilian graduate centers proved extremely valuable. It was this small group that carried the load as regards the return to duty of really difficult cases. The number of medical officers in the theater with any training in dermatology, including A, B, C, and D classifications, was 47 as of the end of 1944. This number was so few that a trained dermatologist could not even be assigned to each general hospital in the theater, although well-conceived hospitalization policies alleviated this need. However, when the First U.S. Army indicated a need for a dermatologist to be assigned to the army surgeon's staff, Colonel Kimbrough flatly refused to consider such an assignment of dermatologists.28

    The problem of providing adequate service with a limited number of officers was met by interviewing and assessing the professional qualifications and experience of each dermatologist and assigning him where he could be most fruitfully employed. Those who were not full-trained dermatologists but were filling positions as such were also interviewed to determine their ability to carry the load expected of them and to help them acquire any training or experience that would make them more capable. Some officers whose professional qualifications justified their assignment as ward officers in dermatology and syphilology in a general hospital nevertheless required training in methods particular to the theater and in military hospital administration procedures. In September 1944, all dermatologists assigned to _________
28 Memorandum Lt. Col. D. M. Pillsbury, for Chief, Professional Services Division, Office of the Chief Surgeon, Headquarters, ETOUSA, 24 Oct. 1944, subject: Report of Visit to First and Third Armies with Comment No. 2, Col. J. C. Kimbrough to Chief Surgeon, ETOIJSA, thereto.


hospitals in the United Kingdom were classified as "medical officers of top special ability, fully qualified to act as regional consultants in dermatology and venereology," and "medical officers with special training, but for various reasons not quite so well qualified to act as regional consultants." In December 1944, Colonel Pillsbury and Maj. (later Lt.. Col.) Charles J. Courville, MC, who had functioned as the theater senior consultant in dermatology and syphilology during Colonel Pillsbury's temporary duty in the United States, classified all dermatologists in the theater as to their professional ability.

    It was no small problem to keep track of dermatologists during the height of activities in the theater. Either the units to which dermatologists were assigned would be moved or the hospitalization responsibilities of the units would be changed. A hospital center whose consultant in dermatology was assigned to one of its compomment general hiospitals would suddenly find itself without a consultant when the particular general hospital was transferred elsewhere. A dermatologist assigned to a particular hospital would suddenly find himself treating no skin diseases and performing sundry other duties upon change of the hospital's mission. Malassignments, once they had been permitted to occur, were difficult to correct, and exceedingly delicate readjustments were sometimes necessary. To effect transfers, Colonel Pillsbury had to obtain concurrences from the individuals concerned, from the commanding officers of gaining and losing hospitals, and often from one or more area commands. Commanding officers of hospitals and surgeons of commands, jealous of their prerogatives, often refused to countenance transfers of personnel that were desired by the theater senior consultant in dermatology.

    The direct instructional and training activities engaged in by Colonel Pillsbury, or carried on under his supervision, included the following: (1) Instruction to medical officers in field medical and hospital units regarding the diagnosis and treatment of common skin diseases through lectures at the Medical Field Service School and the Eighth Air Force Field Service School; (2) continued widespread showing of the Ministry of Health film on scabies; (3) providing opportunities for medical officers to attend professional meetings and conferences, such as the monthly meetings of the section of dermatology, Royal Society of Medicine; (4) frequent and timely articles in the Medical Bulletin of the European theater; and (5) on-the-job training of interested young medical officers with some training in dermatology or venereology.

    The on-the-job training took two forms. One way was to place potential specialists in charge of a ward and have their work frequently supervised and reviewed by visiting consultants. These visits were made at least once weekly. Another method was to place the trainee on temporary duty at an installation where a qualified medical officer was operating a large service. A typical report of on-the-job training accomplished with four medical officers is as follows:

    1. The following officers were on detached service at this hospital for training in the technique of 20 day intensive arsenotherapy from 16 April 1944 to 29 April 1944 * * *


    2. In the training of these officers our facilities and cases were used to give them experience in clinical and laboratory diagnoses of various venereal diseases and the technique of administrating arsenicals. Problem cases and treatment reactions were discussed in group meeting and ward rounds. They became familiar with the administrative details by preparing the records for admission and discharge of patients. In addition a discussion on this subject was given by the registrar of this hospital.

3. The group as a whole was enthusiastic and cooperative and gave evidence that when placed in charge of this type of patient would be able to give a good account of themselves. It might be mentioned that none of these men have had the opportunity of practicing clinical medicine for approximately two years.29

Visits to Field Installations

    Colonel Pillsbury found it essential to make frequent recurrent visits to hospitals and installations in the field These visits enabled him to have a grasp of the general situation as it really was at the operating level. It also enabled him to check on the manner in which programs and directives were being carried out, to consult on difficult cases, to conduct ward rounds, and to advise the hospital, local command or, when necessary, the theater headquarters on problems he had discovered (fig.111). Coming on top of his other duties, field trips took a considerable toll of his time and energy. Field trip duty was hard unremitting labor, but essential work, and the theater senior consultant had to be durable.

    Some visits to hospitals were conducted for limited, specific purposes; others were concerned with more general matters. During the period when many casualties from the North African and Mediterranean theaters were being received in the United Kingdom, there occurred frequent cases of an irritating dermatitis variously referred to as ''Sicilian itch'' and ''desert sores.'' These had to be seen by the European theater senior consultant in dermatology. During Colonel Pillsbury's period of temporary duty in the United States, Major Courville surveyed all hospitals in the Normandy and Brittany Base Sections to evaluate services for the treatment of dermatologic and venereal disease patients, particularly with respect to the qualification of medical officers assigned to these duties.30 When General Morgan visited the theater in March 1945, Colonel Pillsbury was one of those who accompanied General Morgan and Colonel Middleton through various medical facilities and installations on the Continent.

Research and Development

    During the period of 1944-45, which was occupied primarily with medical support of the Army in combat, time was nevertheless found for activities in applied research, principally directed to the solution of problems as they arose in the theater, for which there was no immediate available answer.

    29 Letter, 298th General Hospital, to Chief Surgeon, Western Base Section, ETOUSA, 4 May 1944, subject: Training in Intensive Arsenotherapy.
    30 (1) Letter, Maj. C. J. Courvillo to Surgeon, Normandy Base Section, ETOUSA, 20 Nov 1944, subject: Facilities for Treatment of Dermatologic and Venereal Disease Cases in Normandy Base Section. (2) Letter, Maj. C. J. Courville to Surgeon, Brittany Base Section, ETOUSA, 1 Dec. 1944, subject: Survey of Facilities for Treatment of Skin and Venereal Cases in Brittany Section.


FIGURE 111.-Colonel Pillsbury (second from right) putting across a point to (left to right) Col. David E. Liston, Deputy Chief Surgeon, ETOUSA; Col. Angvald C Vickoren, Chief, Troop Movements and Training Branch, Operations and Training Division, Office of the Chief Surgeon; and Col. Howard W. Doan, Executive Officer, Office of the Chief Surgeon.
    Preparations for use in scabies
. - The preliminary work done in the developing of benzyl benzoate for the treatment of scabies has been described (p.285). During 1944 and 1945, benzyl benzoate was used on an increasingly wide scale in spite of occasional supply problems. It proved highly satisfactory, especially for treatment given in unit dispensaries. The rate of cure, provided the therapy was carried out with strict adherence to a few simple details, was more than 95 percent. The benefits resulting from development of benzyl benzoate as a treatment for scabies was not to be limited to the European theater alone. In early 1944, The Surgeon General requested information on the results of its use in Europe, and, in reply on 24 January 1944, General Hawley gave him detailed information on all aspects of the matter. Among other things, General Hawley was able to state that the emulsion and method of treatment in use had proven satisfactory as regards clinical effectiveness, nonirritativeness, and stability in the temperatures encountered in the European theater (except Iceland, where it was not used). He also stated that the formula was not necessarily the ideal one and that some compromise with shortages of material had been necessary.
    In the spring of 1944, a trial was conducted at the 7th General Dispensary and the 49th Station Hospital on the use of a new louse repellent in the treatment of scabies. This preparation, made up of DDT and benzocaine, turned out to be useless as a scabicide. 


    BAL for arsenical intoxication
. - In late 1943 and early 1944, when the intensive arsenotherapy of early syphilis was reaching its height, some 1 percent of those being treated showed severe reactions to the arsenicals used. Information was available indicating that BAL was highly effective in the treatment of arsphenamine dermatitis. Colonel Pillsbury attempted to obtain a small supply of the preparation from the Office of the Surgeon General without success. Successful arrangements were then made locally in England to obtain ampules of BAL ointmnent (OX.217) from Prof. R. A. Peters, Department of Biochemistry, Oxford University. Although Colonel Pillsbury thought that BAL was proving to be of value in treating severe reactions to arsenotherapy, many factors, such as the limited supply of BAL, movements of hospitals, and treatment with penicillin instead of arsenotherapy, militated against the setting up of any conclusive test of its worth.31

    Penicillin ointment for superficial skin infections
. - Many medical units throughout the theater devised methods of using penicillin for the external treatment of superficial infections of the skin. A British proprietary preparation, Lanette Wax SX, was favored initially as an emulsion base. Later, standard U.S. Army emulsion bases proved satisfactory. Ordinary lubricating jelly and Mennen's Brushless Shave cream were also good. The primary problem was the keeping qualities of the penicillin incorporated into these bases. Here again, the experiences in the European theater were asked for by The Surgeon General, and a report was submitted.32

    Slow absorption of penicillin
. - If there had been some way of administering a large amount of penicillin so that it could have been absorbed slowly, the benefit to combat troops in the treatment of gonorrhea would have been tremendous (fig.112). Work was being done on the problem in the Zone of Interior. The Strategic Air Forces in England had attempted a single-injection treatment of gonorrhea with 100,000 units of penicillin, but the rate of cure had not been satisfactory. Colonel Pillsbury informed Colonel Middleton that the development of such an item was too great an undertaking for the theater at that time under combat conditions. His judgment was confirmed when considerable technical difficulties were encountered in the United States in the development of penicillin in oil.33

    After Colonel Pillsbury had an opportunity to observe firsthand the progress that was being made in the United States in developing a slowly absorbed penicillin preparation, attempts were made to produce some of the material locally in the theater using British sources of supply. When General Morgan visited the theater in February 1945, he brought samples of a successful preparation with beeswax used as a base and made up in strength of 500,000 units per cubic centimeter.
31 (1) Memorandum, Professionsi Services Division, for Chief Surgeon, ETOUSA, 28 Feb. 1944, subject: BAL Ointment (OX.217) for Arsenical intoxication. (2) Memorandum, Professional Services Division, for Col C. P. Rhoads, Gas Casualties Division, Office of the Chief Surgeon, Headquarters, ETOUSA, 27 July 1944, subject: BAL (OX.217) in Treatment of Reactions to Mapharsen.
32 Letter, Col. D. M. Pillsbury, to Brig Gen. Hugh J. Morgan, Office of the Surgeon General, U.S. Army, 8 Aug. 1944.
33 Memorandum, Col. D. M. Pillsbury, for Col. W. S. Middleton, Chief Consultant in Medicine, Office of the Chief Surgeon, Headquarters, ETOUSA, 21 Oct.1944, subject: Technical Data Reports.


FIGURE 112.- Standard preparation of penicillin for use. Distilled water, 10 cc., is added to sealed vials containing 100,000 Oxford units of sodium penicillin.

Professional Activities

    Meetings and conferences
. - The years of active warfare saw no letdown in the number and variety of meetings and conferences. Colonel Pillsbury continued to attend the conferences of command dermatologists held by the British Army and, at one of the conferences, presented a talk on the nomenclature of skin diseases used in the U.S. Army. The British had requested this presentation in conjunction with a contemplated revision of the nomenclature used by the British Army. Addresses were also made before the Society for the Study of Venereal Diseases; the Section of Medicine, Royal Society of Medicine; the British Association of Clinical Pathologists; and the Inter-Allied Conference on War Medicine. Maj. (later Lt. Col.) Winfred P. Killingsworth, MC, from the Office of the Surgeon, Headquarters, Third U.S. Army, through arrangements made by Colonel Pillsbury, also gave a talk on penicillin therapy of venereal diseases before a gathering of the Inter-Allied Conference on War Medicine lucid in London during late 1944. Colonel Pillsbury's most important address during this period was made before the International Conference on Venereal Diseases, sponsored by the U.S. Public Health Service and held at St. Louis, Mo., on 9 November 1944. While on temporary duty in the United States, he also attended and spoke briefly at the conference of medical consultants held by The Surgeon General at Ashford General Hospital, White Sulphur


Springs, W. Va., and at the meeting of service command venereal disease control officers held at St. Louis on 8 November 1944.

    Writing and editing
. - Colonel Pillsbury assumed editorship of the Medical Bulletin of the Chief Surgeon's Office, European Theater of Operations, in August 1944. It was felt that the great advances being made in many fields of military medicine in the European theater, front the standpoint of both administration and professional care, were not being adequately circulated. As editor of the bulletin, Colonel Pillsbury was specifically responsible for (1) stimulation of medical officers in all echelons in the writing of papers suitable for publication, (2) collecting and abstracting of material from various meetings, (3) editorial revision of papers, (4) submission of papers to qualified experts for review and revision, and (5) recommendation of changes in format of the bulletin in conjunction with Col. Howard W. Doan, MC, General Hawley's executive officer. Much emphasis was placed upon the many new developments in the management of battle casualties in clearing stations and evacuation hospitals.

    As a contributor to the bulletin, Colonel Pillsbury with his subordinate consultant associates published papers on the proper handling and shipment of specimens for serologic examination, on a method for preventing contamination of spinal fluid, on the indications for spinal fluid examination in the management of syphilis, and on penicillin therapy in gonorrhea.
    The following directives emanating from the Office of the Chief Surgeon, Headquarters, ETOUSA, were drafted by Colonel Pillsbury during this period: Circular Letter No. 31, 10 March 1944, subject: The Diagnosis and Reporting of the Venereal Diseases; Circular Letter No. 34, 6 March 1944, subject: Management of Simple Skin Diseases; Circular Letter No. 49, 30 March 1944, subject: Amendment of Circular Letter No. 22; 34 Circular Letter No. 86, 22 June 1944, subject: Penicillin Therapy for Early Syphilis; Circular Letter No. 103, 9 August 1944, subject: Management of Neurosyphilis; and Circular Letter No. 107, 25 August 1944, subject: Treatment of Gonorrhea and Syphilis with Penicillin.


Donald M. Pillsbury, M.D

    As has been noted elsewhere in this volume, the consultant system instituted by the Chief Surgeon, ETOUSA, was unique in the Armed Forces of the United States in 1942. The Office of the Surgeon General, U.S. Army, lacked adequate consultant representation of the various branches of clinical medicine at the beginning of the war and never achieved representation completely. In the field of dermatology, for instance, in which great disability was encountered, especially in the Southwest Pacific Area, there was no consultant representation in the Office of the Surgeon General until the war was almost over. The system
34 This circular letter first authorized the use of penicillin for the treatment of gonorrhea occurring in combat troops and air crews


adopted in the European theater was based upon the "Advisor" scheme of the Office of the Director General, Royal Army Medical Corps, and the professional representation was essentially similar.

    It is the firm belief of the writer that the availability of competent consultant service in any large body of troops is essential to a high degree of professional medical service. On the other hand, the number of consultants must not be inordinate, to avoid wasting high-grade professional personnel. The representation among various branches of medicine, surgery, psychiatry, and the laboratories will vary somewhat depending upon the incidence of particular diseases and of combat casualties among the body of troops concerned. Obviously, consultants are justified only in large bodies of troops; for example, in a field army or a higher command.

    Certain advantages of the consultant system may be put down, as follows:

    1. Provided the consultants concerned are aware of the actual medical situation on a day-to-day basis, from adequate reports and continuous observation in the field, the origins and growth of important medical problems can be detected very promptly. An impending situation will frequently be suspected by a competent consultant long before it appears in official reports through channels in the form of significant disability rates.

2. Provided the distances of travel do not make it impractical, regular consultant visits to medical installations of all types make possible personal consultation on large numbers of patients in the light of the latest information and the broader experience that a competent consultant may be presumed to have.

3. A consultant group furnishes a means for exchange of technical information through special channels on an informal basis, and this is very useful. However, it must be done with the greatest care, in order not to infringe on the administrative functions and responsibilities of commanders.

4. The consultant is in a position to alert the surgeon of a command to the need for the preparation and distribution of technical bulletins or, in some instances, a need for command directives, particularly in the field of preventive medicine.

5. A respected and acceptable consultant can be of considerable assistance in the maintenance of morale and effectiveness among medical officers, particularly those who have been long away from home or who are working in isolated stations. The reverse effect may, however, result if the consultant is ill informed, brusque, or personally objectionable.

6. One of the most useful functions of a consultant is the evaluation of the special and general professional competence of medical officer personnel. Specialty numbers are frequently an uncertain guide in respect to a medical officers true effectiveness; to evaluate an officer properly, personal contact with him and observation of his work are essential. In such evaluations, however, the consultant must exercise the utmost discretion and remain aware of the responsibilities of command and of personnel officers in this regard.


    In an atmosphere of mutual respect, however, transfers and other changes essential to good professional care in any unit can ordinarily be effected without difficulty or friction.

    It should be pointed out that the relatively static conditions obtaining in the European theater in the years 1942 to mid-1944 (with the exception of the Army Air Forces) permitted the gradual absorption and indoctrination of consultants. It seems doubtful that such a condition will exist in any future war, and planning for such an organization must be made beforehand if it is ever to be effective.

Certain attributes that characterize an effective medical officer apply equally to consultants, but there are additional stresses and responsibilities that require a broader professional background and a high degree of diplomacy. These may be summarized as follows:

1. The professional competence of the consultant must be of a high order; he cannot depend too greatly upon rank and military customs to gain the true professional respect of his fellow medical officers, however junior. A consultant who too consistently gets beyond his depth professionally will soon become ineffective.

2. In a large theater of operations, it is impossible, however, for a chief consultant to function effectively at too low a rank, particularly in dealing with commanding officers of hospitals and senior officers in other command and staff positions. The absence of any approved table of organization for consultants in ETOUSA was a source of some difficulty in this respect but was overcome to a great extent by the continuous staunch support and backing of the Chief Surgeon.

3. A consultant who is not well indoctrinated in Army administrative processes will have difficulty in attaining full effectiveness, regardless of his professional competence, and may encounter repeated official or personal difficulty because of lack of knowledge of simple rules of procedure. The experienced medical officer develops an acute sense of when to proceed through channels and when to cut across, when to be official and when to be personal. This requires many years of experience to realize fully, but the rudiments of the game may be learned in a few months of study.

4. The most useful consultant is one with a real breadth of professional vision and willingness. Complete restriction to a narrow specialty is ordinarily impossible because the consultant is regarded as a representative of the surgeon and therefore reasonably cognizant of the mature and scope of the chief problems being encountered. He may find himself of little usefulness at times if he refuses to function outside of some very narrow branch of medicine and surgery. Moreover, such an attitude may be destructive to the total effort if it leads to competition among specialists for increasing recognition of their respective activities, without regard for the relative contribution that each may make.

5. Under some circumstances, a medical officer in particuilar fields must serve both as a consultant and as an active practitioner in any or all types


of medical installations, ranging from a general hospital to a battalion aid station. Under such circumstances, it is of vital importance that this dual responsibility be recognized by the commanding officer of the unit concerned.
    Although the preceding comments are my considered opinions, they could, nonetheless, be illustrated by numerous incidents and personalities which constitute the historical record.

Part III. Senior Consultant in Neuropsychiatry 35


    The Senior Consultant in Neuropsychiatry, ETOUSA, Col. Lloyd J. Thompson, MC (fig.113), reported for duty on 25 August 1942 to the Office of the Chief Surgeon, Headquarters, ETOUSA, then located at Cheltenham, England. He was placed under the overall direction of Colonel Middleton, Chief Consultant in Medicine, ETOUSA, in keeping with the organizational plan of General Hawley's office and the precedent established in World War I, Colonel Thompson was the second consultant in neuropsychiatry to be appointed by The Surgeon General during World War II.

    Colonel Thompson soon realized that he would be engaged in much staff work and activities of an operational and planning nature. At the time of his arrival, the functions of a consultant were as yet unspecified in War Department doctrine or directives. It was the general understanding that the primary duty of a consultant was to coordinate and supervise effectively the strictly professional aspects of problems involved in providing hospital care to patients.36 Colonel Thompson had to initiate the necessary steps to establish special facilities for the care of neuropsychiatric patients, evacuation plans and policies with respect to them, and specialized training and educational activities for those entrusted with their care. In conjunction with the supply service, he had to insure that adequate supplies and equipment peculiar to treatment of neuropsychiatric cases were always available. The problems in neuropsychiatry, insofar as Colonel Thompson was concerned, were obviously those concerned with the development and management of a broad mental health program.

    Colonel Thompson found that there was a definite need for current, reliable data to serve as a basis for his plans and a need for tangible evidence to bolster his arguments for their support in discussions with those persons in a position to approve or disapprove them.

    The British, who by this time had had nearly 3 years of experience in the war, were very cooperative in providing useful data, information, and counsel.
35 (1) The narrative for this section was compiled by Maj. James K. Arima, MSC, The Historical Unit, U.S. Army Medical Service, in collaboration with Lloyd J. Thompson, M.D., formerly Senior Consultant in Neuropsychiatry, ETOUSA. Dr. Thompson contributed the summary in retrospect in May 1956. (2) Unless otherwise noted, this section is based on the following documents prepared by Colonel Thompson: Annual Reports of Senior Consultant in Neuropsychiatry, ETOUSA, for 1942, 1943, 1944, and 1945 (first haif); the official diary of Colonel Thompson; and preliminary manuscripts submitted by Colonel Thompson to The Surgeon General for the history of neuropsychiatry in World War II.
36 Letters, The Surgeon General, to Commanding General, Services of Supply, 28 May 1942 and 23 June 1942, subject: Coordination and Supervision of Medical Service in Station Hospitals.


FIGURE 113.- Consultants in medicine, European theater. (Right, top) Col. Lloyd J. Thompson, MC, Senior Consultant in Neuropsvchiatry, Office of the Chief Surgeon, ETOUSA; (left, bottom) Col. Ernest H. Parsons, MC, Acting Senior Consultant in Neuropsychiatry, Office of the Chief Surgeon, ETOUSA; (right, bottom) Lt. Col. Jackson M. Thomas, MC, Chief, School of Military Neuropsychiatrists, ETOUSA.

    During the first month of his tenure, Colonel Thompson spent considerable the studying the neuropsychiatry organization and experiences of the Royal Army Medical Corps and the Royal Canadian Medical Corps. Brigadier J. R. Rees, Consultant in Psychiatry to the British Army at home, and Col. F. H. van Nostrand, Consultant in Psychiatry to the Canadian Army, were extremely helpful. In company with these officers, Colonel Thompson visited many garrisons, training activities, and hospitals to observe first hand the practice of psychiatry in the British forces. He also attended meetings and conferences of their psychiatric staffs and was later to become a regular participant in meetings of their command consultants. In order to share this


newly found knowledge with those who could most profit by it, Colonel Thompson sent special reports to The Surgeon General on the organization and operations of the British psychiatric services. In particular, Colonel Thompson was impressed by the efforts of the British to venture beyond the limits of hospital practice and to emphasize prevention rather than cure.

    The British, on the other hand, revealed that they had found much of value in the U.S. Army Medical Department history of neuropsychiatry in World War I,37 particularly in coping with their own early problems concerning neuropsychiatric activities in World War II. They referred to parts of the work as a "bible." Colonel Thompson also found it useful as a reference and a guide in forming policies and organizing units and services.
    Current analytical and statistical data for U.S. troops, however, were lacking. It was necessary to create, in conjunction with the Medical Records Division, Office of the Chief Surgeon, Headquarters, ETOUSA, special forms for reporting neuropsychiatric cases. One form was devised for the use of psychiatrists in writing up diagnoses and dispositions for submission to the Office of the Chief Surgeon. Another form was to be made out by both the medical officer and the individual's commanding officer on all patients referred for psychiatric consultation or treatment. It provided background history on such matters as convulsive disorders and head injuries and provided special information desired on flying personnel.

    The North Ireland Base Section was a closely knit, relatively independent command. It had an early start in the European theater. Here were marshaled the forces necessary for the invasion of Africa in late 1942. Capt. (later Lt. Col.) Frederick R. Hanson, MC, working as neuropsychiatric consultant to U.S. Army forces in that command and part-time consultant to British forces, had coordinated the neuropsychiatric services in that area, established outpatient and consultation services to care for neuropsychiatric problems outside of hospitals, and was maintaining close liaison with ground forces in the screening, assignment, and classification of personnel in combat units and replacement centers. Need for similar services would doubtless arise in other parts of the theater. With the invasion of Africa on 8 November 1942, the exodus of troops from Northern Ireland put an end to most of these particular activities.

Hospitals and personnel in 1942.
- At the time of Colonel Thompson's arrival in the theater, there were 3 general hospitals--2 in England and 1 in Northern Ireland--and 2 station hospitals. All the psychiatric wards were filled to capacity. Each hospital had one qualified neuropsychiatrist on the staff, and some had one or two assistants with practically no previous experience or training in the specialty. In addition, four partly qualified medical officers were attending the British School of Neuropsychiatry. There was also one recently assigned neuropsychiatrist at Headquarters, Eighth Air Force, Capt.
37 The Medical Department of the United States Army in the World War. Neuropsychiatry. Washington: U.S. Government Printing Office, 1929, vol. X.


(later Lt.Col.) Donald W. Hastings, MC,38 and one at the headquarter's of the North Ireland Base Section, Captain Hanson. Each hospital had one ward for psychiatry, but in only one was there a closed ward, a mere makeshift. It was necessary to send nearly all disturbed psychotic patients to British mental hospitals. There were a few nurses who had had some psychiatric training, but none of the wardsmen had had any previous experience. Plans had already been furnished British contractors who were building additional hospitals for the U.S. Army; but for closed-ward neuropsychiatric patients, these plans provided for only two small cell-like rooms, designed with only one small, barred window near the ceiling. These rooms were inconveniently situated with respect to latrine and other ward facilities and the efficient use of ward attendants.

    In September 1942, the U.S. Army negotiated for the use of the Exeter City Mental Hospital in England. The hospital was built in 1885, but, in spite of its age, it appeared that it would prove satisfactory. On 23 December 1942, the 110th Station Hospital moved into the Exeter Hospital. It was planned to relieve the 110th Station Hospital with a neuropsychiatric hospital unit that was expected shortly from the United States.

    Upon review of the situation, Colonel Thompson recommended that all general hospitals have at least two separate psychiatric wards, one open and the other closed. He supervised preparation of plans for the conversion of one general ward to a mental ward in each general hospital. He was assisted in this project by a hospital architect in the Hospitalization Division, Office of the Chief Surgeon, Headquarters, ETOUSA. Colonel Thompson also submitted recommendations for the establishment of a neuroses center where treatment conducive to return of patients to duty could be rendered in an atmosphere removed from the influence of sick, wounded, or psychotic patients.
    By the end of 1942, two other general hospitals had been established, and the 5th General Hospital had been transferred from Ireland to England.

    Division psychiatrists
. - During a visit to the 1st Infantry Division in September 1942, Colonel Thompson found that a psychiatrist had been assigned to the division surgeon's office a year and a half before but that the most recent tables of organization no longer provided for a division psychiatrist. Yet there was evidence of the excellent work done by this psychiatrist in the 1st Division; plans had even been worked out for his functions during combat. This situation brought about much discussion by Colonel Thompson with other medical and line officers on the need for a division psychiatrist. In World War I, a similar need had been discovered, and the assignment of one psychiatrist to each division was authorized in early 1918. Although the type of warfare had changed, there was even indication that a division psychiatrist would be very valuable throughout the long training period and that his value in combat as well, especially in the diagnosis and treatment of fatigue, concussion, and neurosis cases, seemed unquestionable. Accordingly, Colonel Thompson initiated a

38 Captain Hastings was later replaced by Capt. (later Maj.) Douglas D. Bond, MC, who served until the end of the war.


recommendation to The Surgeon General for reestablishment of the position of division psychiatrist 39 It was not until considerably later, however, that it was authorized (p.344).

    This was the first time that Colonel Thompson submitted recommendations for a change in Army organization, but it was not the last. He was to find that one of his key functions would be the submitting of recommendations for the establishment of new tables of organization and changes in existing tables. Furthermore, the impetus for submitting such recommendations was, eventually, not only to originate from the consultant himself but from other sources as well.

. - As Colonel Thompson became thoroughly familiar with the prevailing situation, it was clear that the first and most logical step would be the establishment of special facilities for the handling of seriously disturbed, psychotic patients. A more difficult but equally essential project was the setting up of special wards in all fixed hospitals for both open- and closed-ward care of neuropsychiatric patients. The most important and apparently insurmountable task was that of providing the framework throughout all elements of the theater to prevent, recognize early, and alleviate the more commonly occurring neurotic and psychopathic states. In spite of the fact that the experiences of World War I were fully documented, that the early British experience in World War II was readily available, and that a working organization had been initiated in Northern Ireland, it was an inescapable conclusion that the European theater as a whole would be making a completely fresh start,


Key Personnel
    As the theater expanded and his activities became more diversified, Colonel Thompson found that he could not give all projects the amount of personal attention they required, particularly special, long-term projects of such a nature that they could not be established by directive alone and then carried through solely on the initiative of medical officers in subordinate echelons. In some cases, the projects required close coordination and supervision by one centralized authority. In others, one well-qualified individual could carry on the project better than many others on a part-time basis. Colonel Thompson found he had to rely on a few unusually well qualified and dependable neuropsychiatrists to take the onus of carrying through many such projects. As special requirements arose these few officers were called upon time and again and were often shifted from one assignment to another as dictated by the situation.

    With few exceptions, these officers conducted their special project while still assigned to a hospital unit. In some cases, it was their primary duty; in others, it was an additional duty; and, in a few cases, the officers were placed
39 Letter Col. P. R. Hawley, MC. Chief Surgeon, ETOUSA. to The Surgeon General, U.S. Army, 3 Nov. 1942.


on temporary duty with the particular activity they were supporting. In only two instances were officers placed on duty with the theater headquarters to augment the professional staff. Maj. (later Lt. Col.) Paul V. Lemkau, MC, filled in for Colonel Thompson during the latter's temporary duty to the United States in December 1944 and January 1945. Maj. (later Lt. Col.) Douglas M. Kelley, MC, in February 1945, was assigned for duty with Colonel Thompson as the consultant in clinical psychology.

In 1942, Colonel Thompson, having in mind one who could be trained in both neurology and psychiatry, had requested an additional officer to act as coordinator of hospital neuropsychiatric activities. Some months later, an officer arrived in the European theater who, although well trained in neurology, did not have the other necessary requisites for the position. Any further overtures to obtain an assistant were not favorably considered. Colonel Thompson also suggested the appointment of full-time neuropsychiatric consultants in base sections to serve in a capacity similar to base section medical and surgical consultants. This recommendation was also not accepted. 40

Hospitalization and Evacuation
    The policy of providing inpatient, outpatient, rehabilitation, and consultation neuropsychiatric services in all station and general hospitals was adopted early. It was a policy designed to establish closer rapport between psychiatrists in hospitals and the general duty medical officer in the unit, thus opening the door for emphasis on preventive aspects of psychiatry. Since the combat elements did not have neuropsychiatrists as a part of their organization at that time, this policy served also to take the practice of neuropsychiatry into the environs where neuropsychiatric problems originated. For Colonel Thompson, the translation of this policy into practice involved frequent visits to hospitals to make sure that qualified personnel were assigned to neuropsychiatric positions and that everything was being done, within the means available, to provide adequate facilities, equipment, and service. The most fruitful results, however, could be obtained only through extensive educational and training activities.

Specialized hospitals

    The creation of hospitals solely for neuropsychiatric patients was a step taken with considerable reluctance. It was considered extremely important to keep neuropsychiatry intimately related to and part of general medicine. However, the general hospitals and larger station hospitals did not have the facilities to hold and care for psychotic patients.
    Moreover, as time went on, there was ever-increasing evidence that, in the care of neuropsychiatric patients who actually required hospitalization, specialized facilities would have certain distinct advantages over nonspecialized hospitals. This was particularly true of nonpsychotic patients for whom there
40 Letter, Lloyd J Thompson, M.D., to Col. John Boyd Coates, Jr, MC., 1 May 1956.


was a good prognosis for recovery and return to useful duty. It was apparent that a total atmosphere capable of inducing a desire to return to duty had to be created in order to salvage patients in this category. It was further apparent that, in order to create such an atmosphere, the patient capable of rehabilitation had to be segregated from psychotic and from nonneuropsychiatric patients as well. General Hawley, the theater Chief Surgeon, had acknowledged early the need for these facilities and maintained continuing interest in their establishment and operations.

    36th Station Hospital
. - This was the first neuropsychiatric hospital to be established in ETOUSA. When it arrived at Liverpool on 13 January 1943, the situation was unique in that this was the only neuropsychiatric hospital in the theater until much later in the war when units from the Mediterranean theater were transferred to ETOUSA. The 36th Station Hospital was the special neuropsychiatric unit that had been expected (p.321). It was commanded by Lt. Col. (later Col.) Ernest H. Parsons, MC (fig. 113), who was an experienced neuropsychiatrist and who had been a Regular Army officer for 12 years.

    The hospital unit had been well trained in the Zone of Interior and was ready to function efficiently upon arrival. With a minimum of staging, the hospital replaced the 1l0th Station Hospital at Exeter. Ten days after its arrival in the theater, on 23 January 1943, the 36th Station Hospital (fig.114), admitted its first patient, although the directive announcing its opening and functions was not published until 6 days later.41 The unit was designed as the hospital of choice for definitive treatment of neuropsychiatric patients. It received patients only from other station and general hospitals.

    An obvious problem was presented, however, in that this installation, with a rated 384-bed capacity, would not be able to meet the needs of the theater. Colonel Thompson made a detailed study of prevailing psychiatric rates and those of World War I. The solution appeared to lie in the establishment of a separate center for neurotic patients. Colonel Thompson reasoned that neurotics who did not respond to treatment in a short time should be isolated from the physically ill before symptoms became too fixed. A center for neurotics required ordinary facilities for hospital care and treatment, but the unique part and heart of the center would be a training camp where patients could live a normal military life with drill, physical training, and the like. Colonel Thompson recommended that a station hospital at Moreton Hampstead be used for this purpose. He further recommended that, to save personnel, the neuroses center and the 36th Station Hospital be combined into one unit with a single overhead.42

    General Hawley studied the recommendations carefully but saw objections to the hospital at Moreton Hampstead. There was some question whether it

41Circular Letter No 20, Office of the Chief Surgeon, Headquarters, ETOUSA, 29 Jan. 3943, subject: Hospitalization of Neuropsychiatric Patients.
42 Letter, Lt. Col. L. J. Thompson to Col. J. C. Kimbrough, Director, Professional Services, Office of the Chief Surgeon, Headquarters, ETOUSA, 14 Feb. 1943, subject: Estimate of Needs for Hospitalization for Neuropsychiatric Disabilities in E.T.O.


FIGURE 114.- 36th Station Hospital, Exeter, England.

had sufficient facilities for expansion, particularly sewers and powerlines. Also, this installation would be 18 miles away from the 36th Station Hospital, and General Hawley doubted that two hospitals that far apart could be operated efficiently under a single administration. He concurred in the plan for combined facilities but suggested that another 250-bed hospital be used for the neuroses section.

Colonel Thompson had no alternative but to go to the 36th Station Hospital and work out plans for the establishment of a training adjunct to that hospital. By mid-March, a training company had been activated. An Air Corps captain, who was a convalescent patient, was designated as its commanding officer. Quarters were arranged and operated as barracks. A rigid, daily schedule of military activities was initiated. The program also included work details, occupational therapy, group discussions, and full information and education activities. Without too much difficulty, an atmosphere of return to duty was created (fig.115). The return-to-duty rate for nonpsychotic cases soon rose to over 50 percent.

    In April 1943, Colonel Thompson submitted revised estimates, project ed to January 1944, of theater needs for neuropsychiatric beds. These estimates emphasized the need for a larger facility for more serious psychotic cases and the immediate need for a special rehabilitation hospital for nonpsychotic cases. 43 At the 30 June 1943 meeting of the Medical Consultants Subcommittee,
43 Letter, Lt. Col. L. J. Thompson to Col. J. C. Kimbrough, Director of Professional Services, Office of the Chief Surgeon, Headquarters, ETOUSA, 30 Apr. 1943, subject: Future Needs for Hospitalization of Neuropsychiatric Patients.


FIGURE 115.- Training section of 36th Station Hospital. A. Wards with atmosphere of military barracks. B. Patients receiving military instruction in identification of aircraft.


FIGURE 116.- Closed ward at 36th Station Hospital.

Colonel Thompson reported to Colonel Middleton that the census at the 36th Station Hospital had remained over 300 for the past few weeks. Owing to a great variety of patients, ranging from acutely disturbed psychotics to mild neurotics and passive homosexuals, there had to be several subdivisions within the hospital. As at any specialized facility, the dispersion factor was high, and at any given time one subdivision could be overcrowded while another had several vacant beds. Colonel Thompson emphasized the point that it could never be hoped to equal by actual occupancy the estimated bed capacity of 384. Under the circumstances, the training-company barracks were being encroached upon and the work of the training company, which was so important in getting men back to duty, was being hampered. There was an increasing number of men being sent back to duty, but, since some were being sent out prematurely to make room for new patients, there remained the possibility of relapse in some cases. Colonel Thompson emphasized again the urgent need for a neuroses unit. For the time being, as the need arose, more closed wards could be provided at the 36th Station Hospital (fig.116), for psychotic patients if such a separate neuroses unit could be established elsewhere.

    Colonel Middleton brought Colonel Thompson's statements to the attention of General Hawley. Eventually, General Hawley and Col. Charles B. Spruit, MC, Deputy Chief Surgeon, ETOUSA, agreed on the hospital site at Barnstable to receive the overflow of neuropsychiatric patients. It was not until late September, however, that Colonel Spruit discussed with Colonel Thompson the possibility of using the hospital at Barnstable as a neuroses center. Colonel Spruit pointed out that, although it was intended in the future to use this hospital for neurotic patients, at the moment it had to take all types of patients and be used to provide medical care for the Assault Training Center. He


directed that inquiries be made into the possibility of obtaining land in the environs of the hospital. It was found that ground space for outdoor military and athletic activities was entirely inadequate and additional ground could not be obtained.

Neuroses center for treatment and rehabilitation

    General Hawley had always maintained an active personal interest in the establishment of the neuroses center, and, on 2 October 1943, Colonel Thompson conferred with him on the matter. Shortly thereafter, it was suggested to Colonel Thompson that a station hospital site at Shugborough Park be considered for his neuroses center. On 23 October 1943, Colonel Thompson inspected the installation at Shugborough Park and found that there were almost 100 acres of land that could be used for the purpose intended. On 27 October 1943, he visited the Southern Base Section and conferred with the base medical consultant and the commanding officer of the 36th Station Hospital regarding personnel and other details, and, on 8 November 1943, he conferred with chiefs of various divisions in General Hawley's office who would be concerned with the opening of the hospital.

    The problems did not end with finding a site, however. The 4th Convalescent Hospital, which was originally designated to be converted into a neuropsychiatric unit and operate the center, was claimed for assignment to the First U.S. Army.

    312th Station Hospital
- This station hospital, a nonspecialized unit which had recently arrived from the Zone of Interior, was then selected to operate the facility at Shugborough Park. Upon recommendations initiated by Colonel Thompson, the Southern Base Section transferred key individuals, including Colonel Parsons, from the 36th Station Hospital to the 312th Station Hospital. There was an adjustment of other personnel so that, eventually, two neuropsychiatric hospitals were manned in the theater without bringing in additional personnel from the United States. The 3l2th Station Hospital was officially opened on 1 December 1943, and the first patient was admitted on 3 December 1943, nearly 10 months from the time that the establishment of such an installation was first recommended.
    The plan of function that had been evolved at the 36th Station Hospital was adopted. After initial workup of each case, with a decision as to type of treatment, the patient spent from 10 days to 2 weeks in the treatment section. Following this, he was transferred to the training or rehabilitation wing, such transfer being the needed step between hospital care and duty. Officers of the training section were, initially, line officers who had been wounded in action in the North African theater. The return-to-duty rate averaged 80 percent, which was remarkable since the patients represented failures received from other hospitals.44 The 3l2th Station Hospital continued to maintain this record of performance throughout the subsequent months of its operations on the Continent.

44 Thompson, L. J.: Neuropsychiatry in the European Theater of Operations. New Eng. J. Med. 235: 7-1l, 1946.


Holding center for psychoses

    96th General Hospital
. - To fill the need defined in April 1943 (p.325) for a larger facility for the care of more serious psychotic patients, a site near Malvern was chosen in August 1943, and the facility was opened by the 56th General Hospital in November 1943; subsequently, in January 1944, it was operated by the 96th General Hospital. Of particular significance was the fact that this hospital was organized according to T/0&E 8-550S (Table of Organization and Equipment) that was proposed by the European theater for a neuropsychiatric general hospital and approved by the War Department. As with the 312th Station Hospital, however, the 96th General Hospital, a nonspecialized general hospital unit arriving from the Zone of Interior, had to be transferred into a specialized neuropsychiatric unit by exchanging qualified neuropsychiatric personnel available in the theater for nonneuropsychiatric medical officers arriving with the unit.

    The primary mission of this hospital was that of a holding unit. It was ultimately responsible for the care and disposition of nearly all psychotic patients in the theater. The 96th General Hospital was also responsible for the disposition of neuropsychiatric patients determined by other hospitals to be incapable of rehabilitation for duty in the theater. A need for such a unit was well vindicated following the invasion of the Continent. For example, in October 1944, the census of the 96th General Hospital was 1,206 with over half of these patients awaiting evacuation to the Zone of Interior.

Transit hospitals

    Forces that invaded the Continent on D-day were provided medical support in the United Kingdom in two phases (fig. 117). First, boat- and air-evacuated casualties were received at transit hospitals located along the southern shores or at airfields. Then all casualties were transported by hospital train or other conveyance to general hospitals in the United Kingdom. In the early days of the invasion, all casualties, including neuropsychiatric, were completely intermingled upon arrival at transit hospitals, and the primary considerations governing their transfer to other hospitals were convenience in movement and availability of beds.

    It was impossible, at this time, to sort patients on the Continent and evacuate them to designated transit hospitals for further evacuation to a specialized treatment center, as had been recommended. Triage of neuropsychiatric patients at transit hospitals for transportation to specialized treatment centers also was recommended but could not be done. Neuropsychiatric patients were surprisingly low in number and their arrival at transit hospitals so haphazard and sporadic that they could not be grouped together for a single shipment. The heavy load upon limited transportation facilities and the necessity of adhering to straightforward transportation schemes did not permit transfer of small groups of patients from one hospital to another at crosscurrents to the general flow of traffic. This situation continued for neuropsychiatric casualties until well into August 1944.


FIGURE 117.- Evacuation in United Kingdom in support of Normandy invasion. A. Ambulances preparing to accept casualties from docked LST, Weymouth England, 10 June 1944. B. Ambulatory patients being loaded into bus at Weymouth, England, 10 June 1944.


FIGURE 117.- Continued. C. Hospital train being loaded at Shelborne, England, 15 June 1944. D. Evacuation aircraft arriving at Membury Field (near Swindon), 18 June 1944.


    Troublesome consequences of this largely unavoidable situation were soon to appear. The replacement depot reported that, between D-day and 2 July 1944, more than 100 neuropsychiatric patients had been sent back to duty too soon. About half of them had been on neuropsychiatric services in general hospitals, but apparently the psychiatrists had been too enthusiastic in applying their indoctrination of sending patients back to duty as soon as possible. The remaining half were patients who had been initially admitted for a primary diagnosis other than neuropsychiatric but whose neuropsychiatric symptoms appeared at the replacement center. Colonel Thompson had to visit as many general hospitals as quickly as possible in order to analyze and correct the situation on the spot. Colonel Parsons was also called upon to help.

    The general situation grew worse as the tactical situation grew more fluid on the Continent. By 1-15 August, the third U.S. Army had joined the offensive, and the first fixed hospitals had begun to establish themselves in Normandy. Before most of these hospitals could begin operating efficiently, they were far outdistanced by the rapidly expanding front. Psychiatric casualties evacuated from the field armies were being shunted from hospital to hospital with no treatment except sedation. Evacuation policies that limited holding of patients to not more than 10 days prohibited institution of any worthwhile psychotherapy. The First U.S. Army had countered loss of personnel by establishing procedures, on 10 July 1944, whereby neuropsychiatric casualties could be reassigned to limited duty within the army. Heretofore, a casualty either had to be returned to duty with his unit or evacuated out of the army. The Third U.S. Army established procedures for reassignment of casualties to limited duty within the army similar to those established by the First U.S. Army. This policy relieved the situation somewhat but was by no means an answer to the greater problem of what to do with those casualties which the armies themselves could not handle.

Advanced neuropsychiatric units

In World War I, the American Expeditionary Forces had found it necessary to establish neuropsychiatric units immediately to the rear of the combat areas. Having foreseen the recurrence of such a situation, Colonel Thompson had recommended as early as January 1944 that a unit be equipped and trained to operate as an advanced unit for receiving neuropsychiatric casualties from a field army. At various times prior to the invasion, he had recommended that personnel of the 36th Station Hospital, and later the 312th Station Hospital, be trained and employed for such a mission.45

In July 1944, Colonel Thompson held a conference attended by the Commanding Officer, 312th Station Hospital, the Deputy Chief Surgeon, ETOUSA, the Chief, Planning Branch and the Chief, Training Branch,
45(1) Letter, Lt. Col. L. J. Thompson to Col. J. C. Kimbrough, Director, Professional Services Division, Office of the Chief Surgeon, Headquarters, ETOUSA, 26 Apr. 1943, subject: Psychiatric Teams for Service During Combat. (2) Letter, Senior Consultant in Neuropsychiatry, ETOUSA, to Chief Surgeon, ETOUSA, 31 Dec. 1943, subject: Psychiatric Services in the U.S. Army in NATOUSA. (3) Letter, Col. L. J. Thompson to Col. Wm. S. Middleton, Chief Consultant in Medicine, ETOUSA, 22 Jan. 1944, subject: Psychiatric Report for Medical Subcommittee.


Operations Division, Office of the Chief Surgeon, Headquarters, ETOUSA. Colonel Thompson informed the conferees that, from D-day to D-plus-34, 2,012 neuropsychiatric casualties, excluding those with secondary neuropsychiatric conditions, had been evacuated to the United Kingdom. He calculated that a hospital located just back of the First U.S. Army would receive some 400 patients weekly. With a 3-week schedule of treatment, 1,200 beds would be necessary. But such a hospital could return to duty nearly 90 percent of the patients admitted--half of them back to combat--thus saving considerable evacuation to the United Kingdom. In view of these considerations, Colonel Thompson suggested that a 1,000-bed general hospital would adequately cover personnel needs for the establishment of such a hospital. The conferees evolved a plan to organize this special neuropsychiatric unit.

    This plan was dubbed Colonel Thompson's "triangular plan" by Colonel Middleton because it involved three hospitals. It consisted of taking a general hospital arriving from the Zone of Interior in August 1944 and designating it a neuropsychiatric hospital, filling it with trained personnel from the 312th Station Hospital, bolstering the remnants of the 312th Station Hospital with trained personnel from the 36th Station Hospital, and leaving a nonspecialized station hospital (the 36th) with the residue of personnel. It was further planned that the general hospital unit would start staging 1 September 1944, move to ADSEC (Advance Section), Communications Zone, on 21 September, and commence to function on 1 October 1944. The location was to depend on the situation, but it was agreed that it should be well forward and easily accessible from army evacuation points. The scheme was duly presented to Colonel Kimbrough in a memorandum dated 19 July 1944 and its approval announced by Colonel Middleton at the next meeting of the Chief Surgeon's Consultant Committee. The 130th General Hospital was earmarked for this purpose.

    130th General Hospital
. - The plan progressed well up to the point where the 130th General Hospital arrived on the Continent on 4 September 1944 and a choice location had been designated for it at Ciney, Belgium (fig.118). A month later, 5 October 1944, Colonel Thompson was obliged to go to Operations Division of General Hawley's office and report that the hospital was not yet able to operate and that the situation was becoming urgent. The equipment for the hospital had not arrived.

    On 30 October and 1 November 1944, Colonel Thompson again conferred with Operations Division. While discussing admission and disposition policies pertaining to the l30th General Hospital with the chiefs of the Evacuation Division and Operations Division (chart 3), Colonel Thompson was chagrined to learn that there was still some question as to how this hospital would function. However, he did learn, on 2 November 1944 from the Supply Division of General Hawley's office, that the equipment had been located on 1 November, was loaded on trucks, and was on the way to the hospital.

    While Colonel Thompson was at the hospital on 6 November 1944, the first truckload of supplies arrived. That very evening, a staff meeting was


FIGURE 118.- l30th General Hospital, Ciney, Belgium.

held, and problems incident to beginning operations were discussed. It was learned that the commanding officer had already agreed with Headquarters, ADSEC, Communications Zone, to use the main hospital building for general hospital and station hospital purposes (fig.119). The psychiatric service was to be in tents, and in prefabricated buildings previously erected by the Germans (fig.120). The training company was to be located at a chateau about a mile and a half from the hospital proper (fig.121).

    On 7 November 1944, Colonel Thompson inspected the facilities and then attended a meeting at Headquarters, ADSEC, when all commanding officers of hospitals in the vicinity were in attendance. Problems in the handling of neuropsychiatric casualties were discussed with them and it was evident that many of these problems would be solved upon opening of the l30th General Hospital. Later the same day, plans for evacuation to and from the l30th General Hospital were completed with the Deputy Chief Surgeon, ETOUSA, and Chief, Evacuation Division, Office of the Chief Surgeon, Headquarters, ETOUSA. A draft of the directive announcing these plans was drawn up.
    On 17 November, the hospital was opened and the first patients admitted. A week later, the hospital was receiving medical and surgical patients but very few neuropsychiatric patients (fig.122). Colonel Thompson brought this fact up at the Chief Surgeon's Consultant Committee meeting of 24 November1944. Although realizing the necessity for the present arrangement, he expressed the hope that Communications Zone neuropsychiatric patients would soon be able to get suitable treatment at the l30th General Hospital.


CHART 3.-Flow chart of patients at 130th General Hospital from admission to disposition

The Deputy Chief Surgeon, Col. Liston, replied:

    We certainly hope you can. I speak for all of us. These 14 hospitals in UK are reasonably up to T/O strength. I might mention that these hospitals are those supposed to have arrived here in September and operating. For reasons outside our control we don't have them. If we did have them, certainly the 130th could operate in the manner we intended it should operate from its inception. The problem is finding enough beds for the patients we have. As soon as possible, I hope that we will be able to isolate this hospital for what you want to use.46

    Before the situation could be amended, the Germans struck in their winter offensive of 1944, known as the Battle of the Bulge. The hospital was engulfed by advancing German forces. Most of the patients and personnel were evacuated, but the commanding officer and a few volunteers remained behind to care for nontransportable cases.

    According to an account given Colonel Thompson by Colonel Parsons, some German officers had come to the door of the hospital in few days before Christmas. They stated that the hospital was surrounded and that the Germans expected the commanding officer to take care of German casualties that might be sent there. No German officers were assigned to take over the hospital, and Colonel Parsons did the best he could and did receive several German casualties. On or about 27 or 28 December 1944, while sitting in his office, Colonel Parsons looked at his telephone and decided to see if it was still connected. To his surprise, he was able to get through to some head- _______
46 Minutes of meeting, Chief Surgeon's Consultant Committee, 24 Nov. 1944.


FIGURE 119 - Medical ward, main hospital building, 130th General Hospital.

quarters in Liége and was told to sit tight because Allied troops would soon be coming back through that area.47

Shortly thereafter, U.S. troops regained the area, and the hospital acted as a field hospital and evacuation hospital for these troops mounting the counteroffensive.

    On 6 and 7 February 1945, Colonel Thompson again inspected this hospital and found that it was acting as a station hospital for the 11th Replacement Depot, Headquarters, ADSEC, and nearby Air Force installations. The census was 1,242 patients, of which only 119 were neuropsychiatric. On the afternoon of 7 February, the commanding officer of the hospital and Colonel Thompson held a conference with Colonel Liston and the Chief, Evacuation Division, Office of the Chief Surgeon, Headquarters, ETOUSA. The desire to return the hospital to its primary function seemed to be well understood, and cooperation toward this end was promised. But two weeks later, other hospitals in close proximity to the l30th General Hospital were receiving many more neuropsychiatric patients than the 130th General Hospital. On 18 March, a conference was held with the chief of the Evacuation Division on this matter. Although he was not very optimistic about the use of this specialized neuropsychiatric hospital, owing to transportation difficulties, he agreed to issue

47 See footnote 40, p. 323.


FIGURE 120.- Psychiatric service in tented section, 130th General Hospital.

specific instructions to ADSEC, Communications Zone, that all neuropsychiatric patients from First and Ninth U.S. Armies should be sent to the 130th General Hospital.

    After receiving a report from Lt Col. (later Col.) William G. Srodes, MC, neuropsychiatrist of the First U.S. Army, that he had been tagging neuropsychiatric patients for the 130th General Hospital but they were not getting there, Colonel Thompson took another trip to the l30th General Hospital. He found that the commanding officer had conferred with Headquarters, ADSEC, Communications Zone, and the Commanding Officer, 8l8th Hospital Center, and had brought about an agreement that all neuropsychiatric patients coming into the center would be transferred directly to the 130th General Hospital. Visiting Headquarters, ADSEC, Colonel Thompson found that the medical staff there had a good understanding of the needs for early treatment of neuropsychiatric cases and were in full agreement with plans for the evacuation of such patients to the l30th General Hospital. He learned, furthermore, that all neuropsychiatric patients coming out of the First and Ninth U.S. Armies went to the 8l8th Hospital Center at Liege (fig.123), and it was only a little over an hour from there to the l30th General Hospital at Ciney. The medical liaison officer from the Ninth U.S. Army was seen, and he confirmed the fact that all cases from that army came through the 77th Evacuation Hospital and were tagged for the l30th General Hospital.


FIGURE 121.- Headquarters. Rehabilitation (training) Section, 130th General Hospital.

    Visiting the 818th Hospital Center, he found there, too, that the commanding officer, Col. Robert B. Hill, MC, and his evacuation officer were in complete agreement with the necessity of transferring all neuropsychiatric patients to the 130th General Hospital, In fact, Colonel Hill was anxious to get the training section of the l30th General Hospital firmly established and operating so that the chateau which hat been designated for the training section of that hospital would not be lost to the Medical Department through lack of use. Colonel Hill stated that he had a large bus that could be used for transporting patients to the 130th General Hospital. He also remarked that the l30th General Hospital was using its own transportation to take patients to the replacement depot near Liége daily, and there was no reason why this transportation could not be used to take neuropsychiatric patients from the 818th Hospital Center to the 130th General Hospital.
    Finally, Colonel Thompson visited the 28th and 56th General Hospitals, Liége, Belgium, and the 298th General Hospital. These were part of the 818th Hospital Center and were receiving the bulk of neuropsychiatric cases in the center. They did not have a very clear picture of the relationship of the 130th General Hospital to the center. When the situation was explained, these hospitals promised their full cooperation. During the course of these visits, it was learned that the 818th Hospital Center did not hold patients over 10 days, which was an added argument for the use of the l30th General Hospital.

    These efforts by Colonel Thompson brought results. For the first time since the hospital began operating, neuropsychiatric admission began to ex-


FIGURE 122.- Surgical ward, 130th General Hospital.

ceed all others. This continued through the last week in March and most of April 1945 (figs.124 and 125). By that time, however, the front had again so far outdistanced the general hospitals that orderly evacuation to the 130th General Hospital was not appropriate in many cases. At the same time, the emphasis in the theater changed from that of saving and rehabilitating manpower to that of boarding and evacuating patients to the Zone of Interior as rapidly as possible. Accordingly, patients were being flown to large centers in and about Paris (fig.126), bypassing intervening installations (p.457).

    51st Station Hospital
. - The 51st Station Hospital was a special neuropsychiatric unit which had been organized in North Africa and had worked its way up through Italy. It came into the European theater in November 1944 as a fully equipped and efficiently working unit with much experience. When Colonel Thompson visited the hospital on 29 November 1944, it was located at Dijon and was receiving neuropsychiatric patients from the Seventh U.S. Army and a limited number from the Third U.S. Army. Colonel Thompson thought it would be feasible for the 51st Station Hospital to receive neuropsychiatric patients directly from both Third and Seventh U.S. Armies. In that way, the hospital could perform a mission identical to that of the 130th General Hospital for the First and Ninth U.S. Armies. The hospital, however, was already quite far to the rear.

    Colonel Lemkau, acting for Colonel Thompson during the latter's temporary duty in the United States, attempted to implement this plan on a firmer basis. The support of the Surgeon, Southern Lines of Communication, was


FIGURE 123.- Buildings and grounds of 818th Hospital Center, Liege. Belgium

obtained. On 29 December 1944, the 51st Station Hospital was moved up to Lunéville. Nevertheless, it was never close enough to the armies it was supporting for the efficient discharge of its mission. Neuropsychiatric casualties could not be evacuated to it in the numbers planned. Furthermore, as with the l30th General Hospital, the mission of the 51st Station Hospital was decidedly altered during the German winter offensive. Surgical teams were attached, and the hospital's mission became surgical.


The establishing of specialized hospitals for the care of neuropsychiatric patients was a tremendous project requiring great effort by all concerned. When established and operating as planned, the results were well worth the effort; however, owing to the tactical situation, they could not always be used as intended. Difficulties encountered in establishing these specialized facilities were illustrative of the type of problems met in the general area of hospitalization and evacuation. In addition to specialized facilities, Colonel Thompson was involved in planning and establishing policies for evacuation and hospitalization of neuropsychiatric patients within field units, to and from other fixed hospitals, and from the theater to the Zone of Interior. The latter was, at times, a particularly difficult problem. Certain aspects of the handling of neuropsychiatric patients in field units during combat are discussed under the heading that immediately follows.


Neuropsychiatric Services With the Field Armies

    It was necessary for Colonel Thompson to have at all times accurate knowledge of the state of mental health of all troops in the theater and of what was being done to maintain mental health, for as an adviser in his specialty to General Hawley he had to provide dependable information and to submit appropriate and timely recommendations, either on his own initiative or in response to specific direction by his superior officers. As a staff officer in the headquarters of the theater commander, it was also his duty to supervise activities within his special field in all subordinate echelons to insure that established theater policies, procedures, and doctrine were being adhered to and successfully carried out.

    In accordance with the general responsibilities and duties of a staff officer, a consultant did not exercise command. He could not lawfully give direct orders in his own right to commanders of subordinate units. However, as an officer on the theater Chief Surgeon's staff--and in exercising staff supervision-- he was bound only to stay within limits of the policies and directives of the theater commander and the technical (medical) doctrine established by General Hawley. Inspections and visits enabled him to observe activities in the field and offer on-time-spot suggestions for correction of any deficiencies observed. When changes in technical doctrine or establishment of new doctrine were necessary, he could make appropriate recommendations for their adoption to General Hawley (through Colonel Middleton and Colonel Kimbrough). When it was found necessary to issue orders to commanders of subordinate echelons, he could again submit specific recommendations through his immediate superior officers and General Hawley. Upon approval of his recommendation, Colonel Thompson was usually called upon to prepare for General Hawley or the theater commander, as appropriate to the case, proper directives implementing their decisions.

    Field Army psychiatrists
. - In his day-to-day dealings with the Armies, Colonel Thompson found it expedient to use technical channels. His technical channel of communication with Armies was through the consultant in neuropsychiatry to the Army surgeon. In neuropsychiatric circles, this officer was commonly referred to as the Army psychiatrist. In a letter, 8 July 1944, to Col. (later Brig. Gen.) William C. Menninger, MC, Consultant in Neuropsychiatry to The Surgeon General, Colonel Thompson described his relationship with the Army psychiatrist as follows:

In one of your recent letters you asked about the Army psychiatrist. I presumed that you knew about this since they arrived over here already appointed in that position. However, Lt. Col. Srodes did replace the psychiatrist who originally came with that Army. The Army psychiatrist is the only position between mine in the Office of the Chief Surgeon and the division psychiatrist. He acts as Consultant in the Office of the Army Surgeon, and supervises the work of the division psychiatrists, as well as the psychiatric services in the evacuation hospitals, and the special N.P. unit. I can report that we have excellent men in the positions.


FIGURE 124.- Neuropsychiatric program at main hospital, 130th General Hospital. A. Physical evaluation on admission. B. Recreation shuffleboard in tented area. C. Physiotherapy.


FIGURE 124.- Continued. D. Occupational therapy. E. Evaluation of treatment. F. Determining disposition of patient and recommended assignment.


    During the major portion of the fighting in Europe, the Army psychiatrists were: Colonel Srodes, First U.S. Army; Maj. (later Lt. Col.) Perry C. Talkington, MC, Third U.S. Army; Maj. Alfred O Ludwig, MC, Seventh U.S. Army; Lt. Col. (later Col.) Roscoe W. Cavell, MC, Ninth U.S. Army; and Lt. Col. (later Col.) Joseph S. Skobba, MC, Fifteenth U.S. Army.

    In the early days of the theater, a vigorous program was embarked upon to carry the principles of preserving mental health to men and officers of the line. With the concurrence of the First U.S. Army, Colonel Parsons spent considerable time and effort to carry out this program He lived with the units, held daily instructional periods, and joined informal conferences among the officers in the evenings. The work was carried on later by Colonel Srodcs. When division psychiatrists were appointed in late 1943, much of this activity was passed on to them (p.321). Guidance of division psychiatrists and of general-duty medical officers, as well, was effected through the Army psychiatrist and formal instruction at the school of neuropsychiatry established at the 3l2th Station Hospital in the United Kingdom.

    Tactical organizations and units in North Africa
. - The inadequacy of plans and preparations for neuropsychiatric services, particularly in tactical organizations and units, was suddenly placed in sharp focus when final preparations were being made in October 1942 for the North African invasion. Except for the unofficial and opportune presence of a psychiatrist in the 1st Infantry Division, it was evident that psychiatry would be represented no further forward than general hospitals. The 400-bed evacuation hospitals had a table of organization position for a neuropsychiatrist, but no such units were in the theater at that time.

    At the suggestion of General Hawley, Colonel Thompson visited Col. John F. Corby, MC, who had been designated surgeon for U.S. forces involved in the operation. Colonel Thompson advised him to consider more seriously the problem of handling neuropsychiatric casualties and urged that he take along a consultant in neuropsychiatry. Colonel Corby did not seem inclined to accept Colonel Thompson's advice but did say that, if the need for a psychiatrist developed, he hoped that one could be provided the force. Colonel Thompson assured him this would be done, and he discussed this eventuality with Captain Hanson, Colonel Parsons, and some other psychiatrists, as well as with Colonel Middleton. There was general agreement that Captain Hanson, because of his previous experience, would be the logical one to go.48 The invasion of North Africa took place on 8 November 1942. Not long thereafter, on 21 January 1943, a cablegram was received in the European theater from the North African theater, reading: "Select competent psychiatrist for assignment to ABS." It was brought to Colonel Thompson's attention a few days later. Conferring with General Hawley, Colonel Thompson proposed his own name along with that of Captain Hanson. General Hawley selected Captain Hanson for the assignment. Prior to departing for North
48 See footnote 40, p. 323.


FIGURE 125.- Activities at the Rehabilitation (training) Section, 130th General Hospital. A. General view of wards. B. Patients arriving in area.


FIGURE 125.-Continued. C. and D. Physical conditioning.


FIGURE 125.-Continued. E. Group psychotherapy. F. Military training utilizing sandtable.


FIGURE 125.-Continued. G. Information and education activities. H. Retraining shop in radio repair.


FIGURE 125.-Continued. I. Retraining shop in auto mechanics. J. Retraining in draftsmanship.


FIGURE 126.-91st Medical Gas Treatment Battalion, Giessen, Germany. Patients were evacuated to Paris, France, or directly to United Kingdom, April 1945.


Africa, Captain Hanson met in conference with Colonel Thompson, Colonel Parsons, and other neuropsychiatrists. Out of these conferences came a tentative plan for the organization and operation of neuropsychiatry in the combat zone, the soundness of which later developments confirmed in many respects. The plan also contained a proviso that detailed recommendations of diagnosis, treatment, and disposition would be forwarded to Colonel Thompson after further study under combat conditions.

In November 1943, Colonel Thompson was given permission to visit the North African theater. He departed on 13 November 1943 and remained in North Africa until 15 December 1943. There he studied U.S. Army records and statistics, observed neuropsychiatric cases within a few hours after evacuation, interviewed medical officers, and visited clearing stations, evacuation hospitals, general hospitals, and a convalescent hospital. He studied Canadian reports and statistics, interviewed several division psychiatrists, and observed the Canadian 15th General Hospital. He conferred with the British adviser in psychiatry, interviewed British corps psychiatrists and observed their corps exhaustion centers, and observed advanced psychiatric wings of general hospitals, general hospitals, and casualty clearing stations.

Upon his return, Colonel Thompson submitted detailed reports on his observations of United States, Canadian, and British forces in North Africa and Italy.49 He also made recommendations dealing with the function and training of medical officers in line organizations; indoctrination of line officers; selection, appointment, and training of division psychiatrists; organization, functions, and training of neuropsychiatric personnel in evacuation hospitals; establishment and training of a cadre for forward neuropsychiatric hospitals; hospitalization in specialized facilities in the United Kingdom; and the rehabilitation and return to duty of psychoneurotic casualties. In these recommendations, he stated that such matters as methods of treatment, evacuation procedures, and diagnostic terminology should be explicitly set forth in directives, but the indoctrination of all personnel in basic tenets had to be accomplished through formal courses and personal informal contacts.

Colonel Thompson’s recommendations were published on 6 January 1944 as Circular Letter No. 2, Office of the Chief Surgeon, Headquarters, ETOUSA, subject: Early Recognition and Treatment of Neuropsychiatric Conditions in the Combat Zone. At this stage in the development of the European theater, the document was most succinct, yet comprehensive, and remarkably prescient. No need was found to change it during the period of combat operations in the theater, and much of the material on diagnosis and treatment was later incorporated in the Manual of Therapy, European Theater of Operations.

49 (1) Letter, Senior Consultant in Neuropsychiatry, to Chief Surgeon, ETOUSA, 23 Dec. 1943, subject: Canadian Psychiatric Services in North Africa and Italy. (2) Letter, Senior Consultant in Neuropsychiatry, to Chief Surgeon, ETOUSA, 31 Dec. 1943, subject: Psychiatric Services in the U.S. Army in NATOUSA. (3) I.etter, Senior Consultant in Neuropsychiatry, to Chief Surgeon, ETOUSA, 31 Dec. 1943, subject: British Psychiatric Services in Middle East, North Africa, and Italy.


    Exhaustion centers
. - However, the most pressing problem at this time was the provision for neuropsychiatric services behind the divisions. In North Africa, two small station hospitals were used, which held patients for not over 14 days. These hospitals, which received patients directly from evacuation hospitals, had returned over 60 percent of them to noncombat duty in base sections, whereas other fixed hospitals had returned over 60 percent of their neuropsychiatric patients to the Zone of Interior. When Major Hanson visited the European theater in mid-January 1944, a conference was held with Colonel Spruit. In attendance were Major Hanson, Colonel Srodes and Colonel Thompson. Major Hanson was very influential in showing the need for special neuropsychiatric facilities between evacuation hospitals and general hospitals in the rear. Colonel Thompson suggested that personnel could be trained and made available at the three neuropsychiatric hospitals in England and such a special hospital could be brought into existence when the need arose. Colonel Spruit was convinced that a special forward neuropsychiatric hospital was needed, but he was of the opinion that it should be a field hospital under army control. At any rate, there was concurrence in the general principle, and the way was opened for further planning.

At this stage, Colonel Thompson felt that the evacuation hospital with its organic neuropsychiatric facilities and personnel should do all in its power to treat and return neuropsychiatric casualties to duty. The additional hospital that he was proposing was to take care of patients the evacuation hospitals could not send back to duty and for whom there was good prognosis for quick recovery. Apparently, the First U.S. Army did not want to change its prevailing practices in the employment of its hospitals, and there were no field hospitals available for establishing holding facilities for exhaustion cases as contemplated by Colonel Spruit.

At the Medical Consultants Subcommittee meeting of 2 March 1944, Colonel Thompson was able to report that the basic principles had now received full support of General Hawley and that an apparently suitable compromise measure had been reached. While continuing to entertain the possibility of using a field hospital, thie First U.S. Army had decided to make a 250-bed neuropsychiatric hospital based on a separate clearing company reinforced by neuropsychiatric personnel from evacuation hospitals. This meant that early treatment would be carried out in this special hospital at approximately the same level of evacuation as the evacuation hospital. The only objection that Colonel Thompson saw to this plan was the fact that the neuropsychiatric casualty would have to go through the evacuation hospital before getting to the special neuropsychiatric unit, and lengthening, by that much, the chain of evacuation and delaying early treatment.

The First U.S. Army made the invasion on 6 June 1944 and two weeks later had established two exhaustion centers based on Colonel Srodes’ plan of reinforced clearing companies. Colonel Thompson wrote to Colonel Menninger on 8 July 1944, as follows:


    I note that the special N.P. unit, which was made up from a clearing company, and called an “Exhaustion Hospital” is functioning very well with the army. Patients returning to this area have come back well treated through sedation, and approximately 90 percent had the term Exhaustion on the E.M.T.

On 3 August 1944, Colonel Thompson wrote:

Bill Srodes, the Army Psychiatrist, is keeping a cool head and is extremely helpful to the Division Psychiatrist. His arrangement of filling the two exhaustion centers instead of psychiatric services in Evacuation Hospitals seems to be working well. I should like to see another good try at the use of Evacuation Hospitals before I would say that Srodes set-up is better.

When Colonel Menninger visited the theater in September and October of 1944, it was generally agreed that the centralized exhaustion center provided the best service. Before Colonel Menninger departed, Colonel Thompson promised to submit detailed recommendations on the organization and equipment of an exhaustion center. On 11 November 1944, Colonel Thompson wrote to Colonel Hanson, as follows:

`    On the last day of Menninger’s visit in this theater, we spent most of the time discussing the question of the best Army NP. unit. * * * we came to the conclusion that the Field Hospital, with its three platoons, seemed to be the very best arrangement that could be set up. Colonel Menninger was going to recommend this through his office and I have already put it in writing for this theater. However, we have not gone into great detail about T/O and T/E, and your information along this line will be greatly appreciated. Eventually, it is hoped that a definite and separate N. P. unit based on these plans may become a permanent fixture. But, as we all know, this will take a great deal of time.

Since Colonel Srodes had been concerned with the planning of these exhaustion centers from the time of their inception in the European theater, Colonel Thompson visited him on 8 February 1945 and discussed the matter further with him. Colonel Srodes agreed to submit a detailed table of organization and equipment which the theater believed should be considered a permanent War Department organization.

In other armies that eventually fought in the European theater, psychiatric services behind divisions were variously handled in the absence of theater or War Department specifications. The Third U.S. Army kept its psychiatrists in evacuation hospitals, as originally suggested by Colonel Thompson, but had, in addition, a convalescent hospital to take the overflow from the evacuation hospitals. Colonel Thompson thought that this system worked well for the type of combat engaged in by this army. The Seventh U.S. Army used clearing companies to set up two exhaustion centers in the same manner as the First U.S. Army and had indeed used this system in the North African theater even before its use in the First U.S. Army. The Ninth U.S. Army set up one exhaustion center using a medical gas treatment battalion augmented by psychiatrists from evacuation hospitals. When field hospitals became available, this army immediately put them into use for the holding and treatment of neuropsychiatric patients in the army area.


    Rest periods for the combat so1dier. - Another matter of great moment to all combat forces in the theater was the concept of using rest periods for individual soldiers and units as a motivating factor in preventing loss of manpower from psychiatric disorders. The impetus for this idea arose in a report from The Surgeon General. 50 In sober, matter-of-fact language, the report pressed home the point that, unless an infantryman is motivated to look forward to a ‘‘break,’’ he has nothing to look forward to but “death, mutilation, or psychiatric breakdown.” Citing data from experiences of the Fifth U.S. Army in Italy, the report showed how a soldier in combat wore out “just as an average truck wears out after a certain number of miles.’’ Obviously, the problem was how to get this information translated into appropriate action. Most psychiatrists or other medical personnel realized these facts and had been trying with varying degrees of success to apply them in their units. The approach now chosen was most direct and pointed. The Surgeon General’s report was appropriately edited to include only those facts that were of immediate concern to a commander of a unit or organization. A terse, forwarding command letter, dated 4 October 1944, emanating from the theater headquarters read simply: “It is desired that copies of the inclosed extract from a report of the Office of the Surgeon General be furnished to the commanders of all organizations down to, and including, regiments and similar units.’’

As the staff officer of the theater most directly concerned, it remained for the theater senior consultant in neuropsychiatry to observe how the stated principles were being carried out, supervise their implementation where applicable, and recommend corrective action where indicated. Colonel Thompson visited the recreation center of the XIX Corps in November 1944. The center used five small hotels located in Valkenburg, Netherlands. Together, they accommodated 300 enlisted men and 34 officers. Men came for 48 hours of rest during which they were more or less on their own. Ample opportunity for recreation as well as bathing and getting new clothes were provided. Nembutal (pentobarbital sodium) was administered the first night, if implicated, but, otherwise, no medical treatment was carried out. The center was under the control of line officers, but a medical officer was in attendance.

During this same visit to units of the Ninth U.S. Army, Colonel Thompson inspected the recreation center of the 30th Infantry Division, which was located in a large monastery in Kohlscheid, Germany, and could house 1,000 to 1,200 men at one time. Soldiers came for 48-hour periods. At this rate, it was estimated that combat troops could be rotated to this center every 3 weeks. In fact, at the time of Colonel Thompson’s visit, the first group to have visited the center had returned for its second visit. There were not enough beds for all of them, and some men had to sleep on blankets on the floor. In addition to a medical officer, there was a dentist, and the men had an opportunity to talk to a chaplain, a finance officer, and a representative of the judge advocate. The soldiers had a chance to bathe and get dry clothes.

50 Monthly Progress Report, Army Service Forces, War Department, 31 Aug. 1944, Section 7: Health. (Colonel Thompson was also aware of the benefits gained in World War I where divisions were relieved in turn from trench warfare.)


A dance band played at each meal. The plan was similar to those employed by other divisions in the XIX Corps.

These and similar visits, plus information from other sources, indicated a need for more common understanding of the principles involved and a standardized program of rest for infantry divisions throughout the theater (fig.127). Accordingly, on 14 November 1944, Colonel Thompson recommended that command action be taken to implement such a standardized program. Colonel Kimbrough recommended approval of the plan to General Hawley. But on this and numerous other occasions, any plan suggested, collided immediately with the objection that there was a serious shortage of manpower in the combat areas. In his capacity as the preventive medicine officer of the 12th Army Group, Col. Toni F. Whayne, MC, did everything possible, at his level, to arrange for units in that command to have some relief from the ardors of constant combat. It was an uphill fight 51

Special Projects for Nonmedical Agencies

Behavior varies from “normal,” well-integrated adjustment at one pole to the disintegration of the psychotic at the other. It is a continuum which cannot be cut up into tight nosological groups. Accordingly, it was impossible to draw a line which absolutely separated neuropsychiatric cases from the rest. A broad line of distinction had to be arbitrarily drawn. The more obvious neuropsychiatric cases were funneled into medical channels and came within the purview of the Medical Department, while agencies other than medical often invited the concern of the theater senior consultant in neuropsychiatry in the more borderline cases. The types of cases involved were in the nature of mental deficiency, inaptitude, instability, minor psychoneuroses, and pathologic personality types. Many of the patients manifested no noticeable organic or functional disorders but required medical consultation to eliminate this possiblity. Later, certain combat-exhaustion cases were to fall into this borderline category also.

    Replacement depots. - Replacement depots (later called reinforcement depots) in the European theater came under an organization initially known as the Ground Forces Replacement System. The surgeon of this command was Lt. Col. (later Col.) George G. Durst, MC. In addition to receiving and assigning individuals as replacements, depots received and assigned all personnel who had been discharged from hospitals after assignment to a detachment of patients. It was this latter function that originally resulted in conferences between Colonel Thompson and Colonel Durst. Proper assignment of neuropsychiatric patients following rehabilitation was a crucial factor in their complete recovery. As time went on, there were needs for psychiatric services at replacement depots arising from other sources, such as large numbers of casuals who offered physical complaints in absence of demonstrable organic disease, numerous dischargees arriving from disciplinary training

51 See footnote 40, p.323.


FIGURE 127.- Rest center for divisions of VI and XV Corps, Seventh U.S. Army, Nancy, France, March 1945. A. Men arriving at rest center. B. Issue of blanket and clean clothes after showering.


FIGURE 127.-Continued. C. Meal served by attractive French waitresses. D. Cigarettes and candy purchased at post exchange.


centers in the United States and from within the theater, and occasional problems of maladjustment in cadre personnel.

There was no authorization for a neuropsychiatrist in the table of organization of a replacement depot. When the 33d Station Hospital was brought in to serve the 10th Replacement Depot in April 1943, an opportunity was presented to provide psychiatric service to that depot, and, although there was no specific position for a neuropsychiatrist on the staff of the station hospital, a neuropsychiatrist was assigned. Once assigned, he was placed on detached duty with the depot. Except for a short period when Capt. (later Maj.) Benjamin Cohen, MC, was actually assigned to the 10th Replacement Depot, this system of placing officers on detached and/or temporary

duty with the depot had to be resorted to. By August 1944, it was necessary to have two full-time neuropsychiatrists attached to this depot from the 3l2th Station Hospital. Thus reduced the effective medical strength of the hospital, but there was no other satisfactory expedient.

When the Ground Forces Reinforcement Command was established on the Continent, the 19th Reinforcement Depot was activated at Etampes, France, with functions similar to the 10th Reinforcement Depot in the United Kingdom. Other depots were also established, but the 19th Reinforcement Depot was the key installation in receiving rehabilitated patients for reassignment to noncombat duties. Here again, an officer had to be provided on temporary duty from the 130th General Hospital. On 19 November 1944, whole discussing with Colonel Durst the reassignment of patients who were being sent back to duty by the 130th General Hospital, Colonel Thompson promised that Captain Cohen--then assigned to that hospital--would be placed on detached service at the l9th Reinforcement Depot to initiate and supervise neuropsychiatric consultation services, but it was not until March 1945 that he could be released and reassigned to this duty.

With a small number of neuropsychiatrists borrowed from hospitals, a great deal was done in the replacement depots toward insuring the supply of only mentally and emotionally qualified soldiers to combat duties, making the maximum use for noncombat duties of soldiers who were unstable, rehabilitating soldiers who were still capable of improvement, and eliminating from military service soldiers who were grossly unfit. The relationships established in this way with the replacement system also helped solve problems of primary concern to the theater senior consultant in neuropsychiatry, as will be noted in what follows.

While Colonel Thompson was on temporary duty in the United States, he attended the first conference of psychiatrists in charge of consultation services at replacement training centers in the Zone of Interior. He learned that there were 33 such centers with consultation services, including, in addition to the psychiatrist, clinical psychologists and psychiatric social workers. At the time Colonel Thompson returned to the European theater, manpower shortages in combat units were becoming acute. A plan was under way to take thousands of soldiers from Communications Zone units and train them in


four replacement depots for assignment to combat duties. In addition, another depot was to be designated as an officer candidate school. In many respects, the situation was similar to that of replacement training centers in the United States. Colonel Thompson reasoned that an organized consultation service would be most appropriate and recommended that a service modeled after those in the United States be established. The Ground Forces Reinforcement Command also requested similar services. General Hawley did not concur in the recommendations and request. He interpreted such work to be concerned with basic training and stated that a theater of operations was no plate to embark on basic training.

    Disciplinary centers. - Information had come to Colonel Thompson from the British, from the experiences of Captain Hanson in Northern Ireland, and other sources neuropsychiatric services might be required in detention centers. On 5 February 1943, at a conference of the Chief Surgeon’s Consultant Committee, Colonel Thompson expressed the need for study of this subject, which aroused the immediate concern of General Hawley. General Hawley quoted statistics indicating that less than 1 percent of offenders were restored to full duty from disciplinary barracks and that only a very low percent age of these ever made good afterwards. He said the staff should keep in mind the possibility of detailing a man permanently on the staff of the disciplinary center for the purpose of studying offenders, should the work grow in sufficient proportions to warrant it. In reply to a question by General Hawley, Colonel Thompson said there was an officer available in the theater who had knowledge and experience in the field of criminal behavior.

Again the problem lay in the lack of a mechanism by which a psychiatrist could be assigned and again it was solved by placing neuropsychiatrists on temporary duty with disciplinary centers from a medical installation to which they had been assigned for this purpose. The first incumbent was obtained from the 36th Station Hospital and placed on duty with Disciplinary Training Center Number 1 at Shepton Mallet, England. These officers had to be selected with great care because General Hawley insisted that the neuropsychiatrists assigned had to be of the highest order. “Those people [the neuropsychiatrists] have got to be pretty solid,” he maintained. “or they [disciplinary center personnel] won’t car whether they have any psychiatrist or not.” 52

By the end of 1944, stockades of various base sections had grown in number as well as in census, and stockades at replacement depots were equally well populated. Neuropsychiatric service had been well accepted by disciplinary training centers. The increase in malefactors also resulted in requests for additional neuropsychiatrists to help in disciplinary, rehabilitation training. It was no longer feasible, however, to continue depriving hospitals of trained neuyropsychiatrists for this duty. In January 1945, it was necessary to confer with the Office of the Provost Marshal, Headquarters, ETOUSA, and submit

52 Minutes, Chief Surgeon’s Consultant Committee meeting, 30 April 1943.


recommendations for permanent modifications of time table of organization of a disciplinary training center to provide for neuropsychiatry personnel. The recommended changes were approved. Qualified psychiatrists were found to fill the newly created positions.

Although results at these centers were not gratifying in terms of men returned to useful duty, the work of the neuropsychiatric personnel was of considerable value to the theater and the Army as a whole in many ways. Case records were worked up on all individuals, and expert opinion was provided in medicolegal aspects of disciplinary procedures, thus assuring justice to the individual prisoner and broadening the scope of military corrective measures. Special studies developed techniques in dealing with the military offender and uncovered personality factors that could help identify his type in the unit or at an induction center.

    Special training units. - In early 1944, it was realized in the ETO that special training units would be needed so that maximum use could be made of marginal soldiers who couldn’t adapt to nominal military assignments and yet were not sufficiently mentally ill to be admitted to medical treatment facilities. It was hoped that considerable numbers of physically fit men could be put to gainful use who were otherwise serious liabilities to the military effort. Thus, the project for recouping this lost manpower involved the establishment of a recovery center. On 20 February 1944, Colonel Thompson explained the project to Colonel Menninger, as follows:

We are just about to open another activity called the recovery center. This will be under line officers, and the trainees will be those in whom no definite mental disorder exists, but who manifest poor adjustment through incorrigibility, repeated physical complaints without demonstrable basis, and unwillingness to work, or inaptitude for any special work. The object is to fit these men, through special military training, for assignment to labor units or similar organizations in this theater. All soldiers going to the recovery center will be screened through the 312th Station Hospital (N.P.).

On 6 February 1944, Colonel Thompson was summoned to General Hawley’s office and conferred with his executive officer, Colonel Doan, on correspondence proposing the establishment cut of the recovery center. On 9 February, Colonel Thompson accompanied Colonel Spruit to Headquarters, Western Base Section, ETOUSA, where they conferred with the Surgeon, Western Base Section and inspected the proposed site at Havdock Camp, approximately 20 miles from Liverpool. This camp had a capacity for 250 to 300 men with sufficient room for expansion by tentage. The Western Base Section surgeon expressed a strong desire to have a full-time medical officer and some enlisted personnel on the table of organization of the center because a dispensary was obviously needed. It had been previously agreed that no psychiatric personnel would be required. Conferring later in the day with G-1 (personnel and administration) of Western Base Section, it was discovered that no cadre personnel had been selected pending receipt of definite word from Headquarters, ETOUSA, to go ahead with the project. The conferees agreed that it would be desirable to have on the staff of the recovery center


one or more line officers who had been incapacitated from frontline service in the North African theater.

The question of whether trainees should be screened by psychiatric personimel before assignment to the recovery center was raised. Plans called for all trainees to be screened by the neuroses center at the 312th Station Hospital before assignment to the recovery center. At the Chief Surgeon’s Consultant Committee meeting of 25 February 1944, Colonel Kimbrough, however, stated that he thought this procedure was very cautious and a little bit drastic. General Hawley replied that all psychiatrists in the theater had to be agreed on this screening for if they were all allowed to send individuals directly to the recovery center, there would be no reason to maintain the neuroses center at the 312th Station Hospital. But when the recovery center was established, the 96th General Hospital as well as the 312th Station Hospital was authorized to send patients directly to this center. Eventually, after invasion of the Continent when troops were deployed over a wide geographical area, all general hospitals were permitted to send patients directly to the recovery center.

Capt. (later Lt. Col.) Robert H. Sipes, Inf., was designated commanding officer, and the center was officially established on 17 March 1944 as the Services of Supply Recovery Center.53

Operations at the center proceeded smoothly. Psychiatric consultation was available from a nearby hospital. Colonel Thompson was required to do little but check periodically on the type of personnel being sent there and advise on training programs. The one problem the center encountered lay in the fact that it belonged to no particular service. Although the recovery center was rehabilitating men, it did not come under the Rehabilitation Division, Office of the Chief Surgeon, Headquarters, ETOUSA, because it was not desirable, psychologically, to have it associated with the medical service.

A year after the center was established, it had received a total of 1,278 men for training. Disposition had been made of 996 patients, of which all except 41 had returned to duty in the theater. Approximately half of those returned to duty went to general assignments in combat units. The Ground Forces Reinforcement Command commented very favorably on the graduates of the center. Colonel Thompson thought that the unit made good soldiers out of the majority of the trainees.54

    Quartermaster work battalions. - The role and importaimce of a consultant are sometimes not clearly defined when he is not consulted or when his advice is not accepted in a matter that concerns him. Instances can be found in both civil and military administrations. The European theater also provided an example.

In September 1944, over 4,500 enlisted men and officers, mostly combat-exhaustion patients, had been assigned to the detachment of patients of two general hospitals and subsequently detached to a Quartermaster work battalion. The Quartermaster battalion had placed these men in companies

53 General Orders 37, Western Base Section, Services of Supply, ETOUSA, 17 Mar. 1944, sec. II

54 See footnote 44, p.328.


widely scattered over all of France, and the hospitals had no further control over them. Colonel Thompson was faced with the problem of screening these men and officers in order to make a decision on each case for definite assignment or rehospitalization.

The situation had its birth in the few weeks following D-day when there was no way to dispose of combat-exhaustion patients evacuated out of the First U.S. Army except to send them back to the United Kingdom. On 12 July 1944, Colonel Thompson had already conferred with Brig. Gen. (later Maj. Gen.) Albert W. Kenner, Chief Medical Officer, Supreme Headquarters, Allied Expeditionary Force, and the Surgeon, First U.S. Army, on the objection to letting neuropsychiatric patients ‘‘escape’’ to England. On the following day, plans had been made with the Chief of Staff, First U.S. Army, to establish at an early date a recovery center similar to the one in England to handle certain patients very carefully screened by the army’s exhaustion centers.

On 23 July 1944, in reply to a proposal that combat-exhaustion patients ‘‘escaping’’ from an army be handled in replacement depots for rehabilitation and training, Colonel Thompson recommended that such patients remain under medical (psychiatric) care and treatment until a definite decision could be made as to return to combat, noncombat assignment, on further evacuation. He qualified his recommendations by saying that this did not preclude establishment of special labor units composed of graduates of recovery centers similar to that in the United Kingdom and reiterated that patients currently being sent there were not the ordinary run of exhaustion patients but incorrigible psychopaths and borderline mental defectives.

Meanwhile, unknown to the theater senior consultant in neuropsychiatry, the Commanding General, ADSEC, had been directed in no uncertain terms by a letter from theater headquarters, dated 26 July 1944, on how to dispose of “cases of Battle Exhaustion not immediately returnable to combat but who no longer require medical treatment and supervision * * * .” The letter directed that such patients, still capable of some service and certified by medical authorities as not being returnable to combat for at least an extended period, should be assigned to a detachment of patients of a Communications Zone hospital designated by the commanding general of ADSEC and should be formed into units for hard labor.

In a cable to the War Department, permission was then requested to form such labor units over and above the theater troops basis. The cable stated that the purpose was to provide a situation more strenuous than combat in which pyschiatric casualties could be placed. The matter was referred to The Surgeon General who strongly opposed the plan because of its punitive implications. The War Department accepted The Surgeon General’s opposition to the measure and disapproved the request.55

Subsequently, in a memorandum to G-1, Headquarters, ETOUSA, dated 4 August 1944, General Hawley expressed his personal views on combat ex-

55 Menninger, William C.: Psychiatry in a Troubled World. New York: The MacMillan Co., 1948, pp. 208-209.


haustion. General Hawley maintained that psychoneurosis was a condition, not a disease, that its basic cause was insufficient courage, and that fear was its primary motivating factor. He ventured the opinion that if cowards were summarily executed, there would be no psychoneurosis. He singled out as the great administrative and medical problem that group of soldiers who just did not have sufficient courage to sustain themselves in battle. This group, General Hawley wrote, included those who with only very great difficulty could ever be restored to combat but who could still be salvaged for some useful service. General Hawley stated that he was unalterably opposed to returning this group of soldiers to duty in normal units, combat or service, because it would be ‘‘merely placing rotten apples in barrels of sound ones.’’ The milder cases more appropriately described by the term “combat exhaustion”--those who crack after months of acceptable combat service–“real psychoneuroses,’’ and the obviously psychotic, the General wrote, were being taken came of.

General Hawley suggested that, organized into special units under specially selected officers and noncommissioned officers and properly administered, some useful work could be had from the problem group. Such units, he contunued, “* * * should be worked hard. They should be quartered and fed under no better conditions than combat troops. There should be no attractive considerations to invite soldiers into such units.’’

The whole point of General Hawley’s memorandum was this. He asserted that this problem soldier would always exist in as long as he could escape combat by recourse to psychoneurosis, that it was up to command to face this problem squarely and realistically, and that the alternative questions facing the command were: Should this group of problem soldiers be made use of or should they be discharged from the service to be replaced with new drafts upon the population?

Over one thousand patients that had accumulated in the exhaustion centers of the First U.S. Army were received at the 5th General Hospital when it opened on the Continent on 1 August 1944. Within 3 or 4 days, 1,360 neuropsychiatric patients were turned over to the 90th Quartermaster Battalion. They were screened in 2 days by a group of 9 neuropsychiatrists drawn from staging general hospitals, and only 21 patients were hospitalized for further treatment. By mid-August, over two thousand patients had been turned over to the 90th Quartermaster Battalion while still assigned to the detachment of patients, 5th General Hospital. In late August, administrative control of the labor companies to which these patients had been sent was transferred to the 96th Quartermaster Battalion, and subsequent assignment of incoming patients was to the detachment of patients, 19th General Hospital. By the end of August, the number of patients so detached and dispatched to work units had reached over 4,500.

With the understanding that the 130th General Hospital (p.333) was to open on the Continent on 1 September 1944, Colonel Thompson had recommended on 14 August 1944 that prevailing practices be allowed to continue, provided patients were sent to the 90th Quartermaster Battalion only after


proper sorting at army neuropsychiatric units, the 77th Evacuation Hospital, or general hospitals. He further recommended that screening by psychiatrists continue at the 90th Quartermaster Battalion and that plans be made for a more definite assignment of patients placed in service work units.

Following up his recommendations, Colonel Thompson initiated plans for the screening and disposition of these patients in conjunction with the Hospitalization Division, Office of the Chief Surgeon, Headquarters, ETOUSA, and Colonel Durst of Ground Forces Reinforcement Command. A list of neuropsychiatrists to perform the screening was submitted on 6 September 1944, Captain Cohen was initially placed in charge.

Meanwhile, the Commanding Officer, 96th Quartermaster Battalion, had requested that a study be made of the condition of his men, and Maj. Roy L. Swank, MC, neuropsychiatrist of the 5th General Hospital, made a longitudinal study of 3 companies over a period of 3 weeks and conducted a cross-sectional, spot-check study of 13 companies comprising 3,000 men during 1 week. The study revealed that many of these men still had handicapping symptoms, many were growing more concerned about their condition, and in quite a few instances they had been curbed and held under more strict regulations than others doing similar work.

The screening procedure ran into the same sort of problems that beset setting up the l3Oth General Hospital. Almost no screening was done during September. Colonel Thompson conferred on 5 October 1944 with Colonel Durst, Maj. (later Lt. Col.) William H. Barnard, MC, of the Hospitalization Division, and Captain Cohen. He added five more neuropsychiatrists to the screening team at the l9th General Hospital. Major Barnard and Colonel Thompson visited the hospital on 13 October 1944 to work out more details as to the reassignment of men attached to the Quartermaster battalion and found that only two neuropsychiatrists had arrived and just 208 men had been screened. The next day, Colonel Thompson checked on the whereabouts of the psychiatrists ordered to the l9th General Hospital and placed four more on the list. On 17 October 1944, Colonel Thompson again visited the hospital, this time with Colonel Menninger, who was visiting the theater. Six psychiatrists were present, of whom three were recent arrivals. Over 800 patients had been screened, but it was discovered that most of these were recent arrivals at the l9th General Hospital from other hospitals rather than patients with the 90th and 96th Quartermaster Battalions. Word had also just been received that the only noncombat assignment open to those going back to duty would be as prisoner-of-war guards and military police, Colonel Durst had to be called upon to rectify this situation.

On 1 November 1944, approximately half of the men had been screened, but the process was absolutely at a standstill because Normandy Base Section had not found transportation to get approximately 2,000 men to the hospital. Nine psychiatrists were present at this time, and their need in hospitals from which they had been withdrawn was becoming critical. Moreover, half of the patients screened had to be hospitalized. That afternoon Colonel Thompson


met with representatives of the Hospitalization Division and the Deputy Chief Surgeon, ETOUSA, and urged that the screening be expedited. It was apparent that the screening was not getting the command support it required. Colonel Thompson voiced the opinion that the Medical Department was shirking its responsibility for providing adequate treatment. Following the conference, Colonel Thompson submitted a memorandum to Colonel Kimbrough on 1 November 1944 reviewing the situation from its beginning and including recommendations and statements made in the conference.

On 3 November 1944, a letter from the theater commander directing the Commanding General, Normandy Base Section, to expedite the screening process at the 19th General Hospital was brought to Colonel Thompson’s attention. But one week later, he discovered that patients were still not being sent in from Normandy Base Section. During the remainder of the month, however, patients began arriving at the rate of some 200 per day, and the screening for all intents and purposes was completed as of the end of November. Isolated groups remained unscreened until V-E Day.

The conclusions of the examining board of psychiatrists that conducted the screening was that these men were not significantly helped by 1 to 3 months of noncombatant work therapy. Of 4,588 enlisted men examined, 2,503 (55 percent) required hospitalization. Of 51 officers examined, 47 (91 percent) required hospitalization.56

A later sampling of the hospitalized group covering 467 patients revealed that 41.8 percent were boarded to the Zone of Interior. If this rate was reliable, the total return-to-duty rate of those who had been in the Quartermaster battalions would still be less than 60 percent . A still later followup study of 1,000 cases--500 hospitalized and 500 returned to duty directly-- indicated that some 80 percent of the total 1,000 were on duty in the theater.

At the same time (October 1944), the 312th Station Hospital in England with its mental rehabilitation work had returned 89 percent to duty, and, significantly, the patients reaching the 312th Station Hospital were those who had gone through unsuccessful attempts at rehabilitation in all subordinate echelons of the evacuation chain for neuropsychiatric casualties.

Following his visit to the European theater, Colonel Menninger commented on the method of handling these cases, as follows:

Many of these had had inadequate treatment, having come directly from Exhaustion Centers. Despite this fact, it was reported that these men assigned to work in ordnance jobs, stretcher bearers in hospitals, and elsewhere had made excellent records. A superficial survey, however, indicated that many were noticeably maladjusted and this fact, plus the irregular method of carrying them as patients from the 19th General Hospital, made it necessary to develop a different plan.

In evaluating the results of the practice, he mentioned the fact that, in such patients with inadequate treatment, ‘‘* * * their guilt reaction, their feelings of inadequacy and the atmosphere of impersonalness at replacement

56 Letter, Board of Psychiatrists, 19th General hospital, to Chief Surgeon, ETOUSA, 26 Nov. 1944, subject: Report on the Mental Status of “Combat Exhaustion” Personnel Attached to the 90th and 96th Quartermaster Battalions.


depots can all combine to continue and increase the neurotic disability and thus convert transient neuroses into permanent, pension-seeking chronic neuroses.”57

The fact remains, nevertheless, that some of General Hawley’s statements were borne out by the experiment as reported by the board of psychiatrists who conducted the screening. The more seriously ill members of the companies tended to ‘‘re-infect’’ the others, thus handicapping the improvement of the less ill. There was a considerable number of ‘‘repeaters’’--men who were treated with apparent success in a forward medical echelon, returned to combat, and then relapsed after a very short period of time and had to be evacuated a second or third time. Finally, as General Hawley had predicted, there could be no doubt that this extra manpower provided considerable help during a most critical time in gaining the initiative on the Continent.

Neuropsychiatric Education and Training

Education and training were always continuing requirements in all aspects of medical activities in the European theater. An extensive program was especially needed in the field of neuropsychiatry because of marked differences between practice in an oversea military theater and civilian practice. Very few indeed were the officers in the theater who, at the time of Colonel Thompson’s arrival, possessed military experience in this specialty. Those who followed were in many cases equally inexperienced, as were ancillary personnel–nurses, social workers, clinical psychologists, and attendants. The vast differences in civilian training and experience also necessitated a training and indoctrination scheme to establish order and understanding; otherwise, chaos would have resulted had each been allowed to practice in his own way.

In 1942, U.S. Army medical officers were being sent to a British Army training center for neuropsychiatrists at Northfield, one of two installations where neurotics from the British Army were being rehabilitated for useful duty. The course was an excellent one. However, it was believed that there would be distinct advantages in having a school maintained by and for the U.S. Army. First of all, the course at Northfield lasted 3 months, which Colonel Thompson thought too long. Furthermore, after completing the British course, the trainee still had much to learn about methods and procedures used in the U.S. Army. When one considered the fact that there had been more than 250 neuropsychiatrists with the American Expeditionary Forces in November 1918, it was an obvious impossibility to ask the British to train that many or more U.S. Army officers who would make up the full force in Europe in the days to come.

The U.S. Army had established the Medical Field Service School at Shrivenham, England, and there was a similar school operated by the Eighth Air Force. All training for medical elements was controlled and supervised

57 Letter, Col. W. C. Menninger, MC, Director, Neuropsychiatry Consultants Division, Office of the Surgeon General, to The Surgeon General, U.S. Army, 13 Nov. 1944, subject: Report of Visit of Colonel William C. Menninger, MC, to Installations in the European Theater of Operations, 7 Sept. to 24 Oct. 1944.


by the Operations and Training Division, Office of the Chief Surgeon, Headquarters, ETOUSA, although the Army Air Forces school was relatively independent. However, a course in neuropsychiatry would not be opened at the Medical Field Service School because of the lack of qualified instructors and lack of case work. When the 36th Station Hospital arrived in England, the facilities and personnel to operate a school of neuropsychiatry became available. After preliminary discussions with the hospital’s commanding officer, Colonel Parsons, a memorandum was submitted by Colonel Thompson on 25 January 1943, proposing the opening of such a school at this hospital. The proposal was favorably considered and detailed plans were pursued to open the school.

In agreement with Colonel Parsons, Maj. (later Lt. Col.) Jackson M. Thomas, MC (fig.113), 36th Station Hospital, was selected to take charge of the school. Major Thomas was a well-qualified psychiatrist, a diplomat of The American Board of Neurology and Psychiatry, and an associate in psychiatry at the Harvard School of Medicine, Boston, Mass. Others on the hospital staff were also well qualified to instruct in particular fields.

    From the start, it was the aim of the school to make the instruction as objective and practical as possible. In short, the courses were designed to meet the needs of the theater. The teaching procedure was explanation, demonstration, application, and examination. There were lectures, clinical conferences, and ward application under supervision of the clinical staff of the hospital. Later, demonstration teams were organized with personnel of the hospital taking roles in depicting battlefield neuropsychiatry in action.

Every opportunity was eagerly grasped to bring those with firsthand experience to the school so that students could hear directly about conditions under varying types of combat and with different types of troops. Officers returned from North Africa and other Mediterranean areas, either by rotation or as casualties, supplied this type of information, and reports from the consultant in neuropsychiatry in the North African theater provided excellent detail. British neuropsychiatrists, both civilian and military, aided materially.

Before the actual opening of classes, however, many details had to he ironed out. Complete courses of study had to be presented for approval to the Training Division, Office of the Chief Surgeon, Headquarters, ETOUSA. There was a lack of teaching aids, texts, and reference material. Because of the limited number of neuropsychiatrists in the theater, Colonel Thompson often had to make arrangements personally with commanding officers of prospective trainees for their attendance. This sometimes involved shifting neuropsychiatrists. temporarily, to cover vacancies resulting from an officer’s being detached to the school. The school finally opened in April 1943, the first medical specialist school to be opened in the European theater.

The first course was for 13 neuropsychiatrists from general, station, and evacuation hospitals to satisfy the immediate needs of the theater, and it lasted throughout April 1943.

At the 30 April 1943 meeting of the Chief Surgeon’s Consultant Committee, Colonel Middleton informed the conferees that the first course had been


completed and that 10 nurses and 9 enlisted men from general and station hospitals had been enrolled for a course to take place during May 1943. He also reported that Colonel Thompson planned to give four courses in June consisting of 5 1/2 days each for medical officers from field units. There were to be 10 medical officers in each course. In addition, neuropsychiatrists from hospital staffs were to be sent to field medical units for a period of 2 weeks in order to gain experience and learn about life in a line unit.

General Hawley commented, as follows:

    I follow with a great deal of interest the training of the general medical officer and battalion surgeon in psychiatry. I hope he can be given something helpful and a little knowledge won’t become a dangerous thing if we don’t give him the idea that he is an expert psychiatrist after a week. I think it is correct to check the scope of the instruction given * * *. I think a great deal can be done in courses like this--not attempting to go very deeply into the subject * * * give him some very practical suggestions. I think the assignment of the officers at the 3d Station Hospital in the field is a splendid idea. It will give them very much background. I think it might well be extended to other people in the hospitals. The people in the hospitals like to know how people in the field are getting along.

All the courses that had been initiated were continued, as needed, until the end of July 1943. At about this time, a majority of the neuropsychiatnsts in hospitals had attended the school, and commanders of hospitals arriving in the theater found it difficult to release their neuropsychiatrists for 30 days so soon following their arrival. The combat units also had to curtail sending medical officers to the short courses, and two groups of flight surgeons had been instructed in their stead. Consequently, only one 2-week course for hospital enlisted men was given during August 1943. The time had come for a reexamination of the educational and training needs.

In the meantime, however, Col. Roy D. Halloran, MC, Chief, Neuropsychiatry Division, Office of the Surgeon General, U.S. Army, had written on 1 June 1943 to inform Colonel Thompson of the school of neuropsychiatry that had been established at Lawson General Hospital, Atlanta, Ga., under the direction of Col. William C. Porter, MC, assisted by Lt. Col (later Col) M. Ralph Kaufman, MC. Sometime later, Colonel Halloran wrote suggesting that it would be a good idea to have some neuropsychiatrists with experience in combat or in observing and treating combat neuropsychiatric casualties relate their experiences at the school. Colonel Thompson agreed that it was a splendid idea but expressed his apprehension over losing permanently any experienced officers.

Then, on 20 August 1943, Colonel Halloran wrote to Colonel Thompson as follows:

We are losing the executive officer of the school of military neuropsychiatry and chief assistant to Col. Porter, the Director. Lt. Col. Kaufman is being assigned to foreign duty and therefore, we find it necessary to locate someone who can teach military neuropsychiatry from the dynamic standpoint. I am wondering whether we could borrow the services of Major Jackson Thomas, whom you have been using in this connection in your area. Naturally we would replace him with a neuropsychiatrist who could be used in a similar capacity. I have in mind Major Howard Fabing, who is an excellent neurologist as well


as psychiatrist and has been assistant to John Romano at the University of Cincinnati. In fact, he was formerly with the Cincinnati Unit and is now chief of a section in one of our large station hospitals. He is very anxious to come to your area. Perhaps some such exchange at this time would prove mutually beneficial.

As you may understand, we are attempting to indoctrinate the large number of neuropsychiatrists that we have on duty at the hospitals of the Ground Forces and Air Forces and adapt their civilian talents to military problems. We feel it would be valuable if we could have the services of someone who has been familiar with the active problems in a theater of operations. If you are unable to send Jackson Thomas, perhaps you could pick someone else who has teaching experience and whose instruction would be considered fundamentally sound.

The next letter, dated 14 September 1943, received by Colonel Thompson from Colonel Halloran, stated: ‘‘I have heard indirectly that Maj. Jackson Thomas is to come to us for the purpose of teaching at the School of Military Neuropsychiatry, which is to be moved to a new unit in New York so that advantage may be taken of study of casualties newly returned from the various theaters.’’ The letter confirmed the fact that Maj. (later Lt. Col.) Howard D. Fabing, MC, was being sent and added that Major Fabing had experience from service in World War I, had a wide acquaintance in England, and was very anxious to serve the European theater. ‘‘I believe that he will make an excellent teacher and coordinator, especially along the lines of organic neurology,’’ concluded the letter.

As a direct result of losing Major Thomas, formal instruction at the school of neuropsychiatry remained suspended until Major Fabing arrived in November 1943. Throughout this whole period beginning in late 1942, General Hawley continued to stress the need for training general medical officers in field units and the indoctrination of their line officers as well. It was during this largely unavoidable lull in formal educational and training activities that the talents of Colonel Parsons were directed to the indoctrination of line officers, as described elsewhere. In cooperation with the Surgeon, V Corps, a temporary measure was adopted to continue the training of general medical officers from line units. Major Kelley was obtained from the 30th General Hospital and conducted a 1-week course using the facilities of three hospitals. Psychotics were seen at the 36th Station Hospital, combat neuropsychiatric casualties from North Africa were used in instruction at another hospital, and neuropsychiatric patients who had been “combed’’ out of divisions were available at the third.

By the time Major Fabing arrived in the theater, a major change in the hospitalization of neuropsychiatric patients was being completed. The 36th Station Hospital was being reserved for psychotic patients while neurotic patients and most of the staff of the 36th Station Hospital, as well, were being sent to the newly created 312th Station Hospital. This change also necessitated a relocation of the school of neuropsychiatry. Definite plans had been announced to commence immediately extensive and concentrated training of medical officers in line units and mobile hospitals, but instructions had to be assumed to suspend sending trainees to the school until the new facilities were


ready. Colonel Middleton and Colonel Thompson both gave considerable personal attention to helping Major Fabing and the 312th Station Hospital prepare to resume instructional activities. Consideration now had to be given also to division psychiatrists. These had just recently been authorized by the War Department. Their training was a matter of prime concern since many of them were capable, general medical officers who had been picked for the position but who had no real experience in neuropsychiatry.

As a year of constant buildup with its attendant problems drew to a close, on 28 December 1943 at the Chief Surgeon’s Consultant Committee meeting, General Hawley again expressed his concern and interest in the educational program, asking particularly about the indoctrination of combat doctors in combating battle neuroses, ‘‘It got off to a splendid start,’’ he said. “What is its present state?’’ Colonel Kimbrough and Colonel Thompson were both able to inform him that the indoctrination of medical officers in line units from the battalion level and above and the training of division psychiatrists was to start momently. General Hawley said the program should be pushed.

And pushed the program was. The total effort was directed at personnel in line units and evacuation hospitals. Under the direction of Major Fabing, 700 general medical officers received the special 1-week course in neuropsychiatric fist aid from 27 December 1943 to 15 July 1944. The Chief Surgeon’s Operations and Training Division reported that, by the time D-day arrived, practically all medical officers in combat units who would come in contact with battle casualties had been through this course. During the same period--from the reopening of instruction at the 312th Station Hospital to D-day--40 evacuation hospital neuropsychiatrists, 80 evacuation hospital nurses, and 160 evacuation hospital and clearing company enlisted men were trained in courses specially designed for them. In addition, Major Lemkau, of the staff of the 3l2th Station Hospital, trained 15 division neuropsychiatrists in January and February 1944 at the school of neuropsychiatry.

While this program was going on at the school, personnel of general and station hospitals were not entirely neglected. As new hospital units arrived in the theater or were created, neuropsychiatric personnel were given the opportunity to spent 2 weeks at hospitals specializing in neuropsychiatry for on-time-job training under experienced officers, nurses, and enlisted men.

On 7 July 1944, about a month after D-day, Colonel Thompson wrote to Dr. Edward A. Strecker (fig.128), who had visited the theater shortly before, that all the invasion plans for handling neuropsychiatric casualties had worked out satisfactorily and casualty rates were lower than anticipated. “I cannot but feel,” said Colonel Thompson, “that part of this is due to our education of the officers, and division medical officers.”

When Colonel Thompson was able to visit more units in combat at a later date, many officers expressed gratitude for the indoctrination they had been given. Comments made in a letter, dated 2 March 1945, from the division neuropsychiatrist of the 69th Infantry Division to Colonel Menninger illustrate well the sentiments of many. He wrote:


FIGURE 128.–Dr. Edward A. Strecker (second from right) viewing the monuments at Stonehenge, Salisbury Plains, Wiltshire, England, with (left to right) Colonel Thompson, General Hawley, and Col. Raymond E. Duke, MC, 16 March 1944.

I am sending herewith the material used in lectures on Combat Exhaustion. We are indebted to the 312th for an excellent course and this material was reproduced. Since writing I obtained their film on Combat Exhaustion and showed it to all NCO’s and officers in the 369th Med Bn as well as most O’s in the detachments.

We have been in combat since the 10th [February and the indoctrination is paying dividends.

The film on combat exhaustion mentioned in the paragraph quoted was produced at the 312th Station Hospital in conjunction with the Army Pictorial Service of the Signal Corps. It showed the work being done there, the specific treatment given, the work of the mental-rehabilitation unit, and the teaching being given in the school of neuropsychiatry. There were some difficulties with the scenario and production of the film because of its range and scope. The film, which was in scenario in March 1944, was completed in the autumn of that year and was first shown publicly at the Empire Theater for personnel in General Hawley’s office on 20 November 1944 with a running time of 1 hour. Later, copies of the film were distributed throughout the Army by Signal Corps film libraries. Copies were presented to the British, who had previously provided the U.S. Army with a generous number of prints of their film on combat neuroses.


Colonel Thompson lectured to almost all classes of medical officers going through the Medical Field Service School at Shrivenham. He frequently held clinics, ward rounds, and lectures at individual hospital installations, Professional meetings of medical officers of the Allied forces also presented educational opportunities.

In the waning stages of the war and the period immediately following the cessation of hostilities, the theater senior consultant arranged for participation by neuropsychiatrists in the broad educational program that was set up in the European theater. The general scope and intent of this program were described by Colonel Middleton (p.253). A school of neuropsychiatry was reestablished at the 191st General Hospital, Paris, France, to give a comprehensive review of neurology and psychiatry while paying considerable attention to recent developments in general medicine. More advanced refresher courses were arranged for U.S. Army officers at teaching centers and hospitals in England, but redeployment was so rapid that full advantage could not be taken of the opportunities that were richly provided.

Visits in the Field

Although Colonel Thompson had to devote a tremendous amount of his time and energy to staff work at the theater headquarters, he still found or made time to visit units and installations in the field. There was more than enough to occupy him at theater headquarters alone. In addition, there were the obligations of liaison with representatives of the other Allied forces, participation in projects sponsored jointly with British civil and military medical authorities, and the amenities in communication with these. But to sacrifice visits and inspections in the field to these other activities would have meant reciprocal loss in consultant effectiveness. Regardless of the thoroughness of plans, the clarity of announced policies, or the accumulation of large amounts of data, the proof of their worth could be measured only in terms of their application in the field. The feedback from visits to the field was the servomechanism that directed the proper course of neuropsychiatric activities in the theater.

In broad terms, these visits to the field could be divided into two types, special and routine. Special visits were necessitated or suggested by some specific problem or activity. These included such matters as requested consultations, the solution of local personnel problems, inspection of hospital construction or modification, meeting advance parties of units due to arrive in the theater, and accompanying visitors to the theater on tours of installations.

The routine visits--although they could hardly be called routine in the sense that no two visits were exactly alike--were for the most part undertaken to see what was being done, to make corrections on the spot if necessary, and, generally, to get the consultant’s feet on the ground. They helped him better to evaluate the capabilities and limitations of personnel and facilities with respect to the care of neuropsychiatric patients. Bits of information obtained on visits to individual installations or units eventually fitted together to show


definite trends and patterns. On particular occasions, the observations made were so significant that he would ask for a special report on the situation from the installation or activity visited. These reports, with appropriate comments by Colonel Thompson, could then be brought to the attention of his superiors in the Chief Surgeon’s Office, as well as in the Office of the Surgeon General. Thus, he was enabled to keep General Hawley and his staff informed of significant events and problems in the field in a fully documented manner. Again, these routine visits to the field provided opportunity to answer questions and establish better rapport and understanding with those who were charged with actually carrying out the neuropsychiatric policies and procedures of the theater.

At least half of Colonel Thompson’s time was spent in these special or routine visits in the field.

Personnel Management

Personnel management problems were time consuming and required good judgment and diplomacy. Many of the problems were obvious but were either impossible of immediate solution or were difficult to solve because many restrictions and concurrences were entailed. Very close liaison was required with the Personnel Division, Office of the Chief Surgeon, Headquarters, ETOUSA. Colonel Middleton also maintained close supervision over personnel matters, and, because of their often delicate nature, his arbitration was required in cases of conflicting interests and to insure the best and proper use of all personnel specialized in fields that were his concern.

There was first and always the need to know the abilities and location of neuropsychiatric personnel in the theater. Much of this information could only be obtained by personal interview and observation of the individual’s work. One of the first things Colonel Thompson did upon his arrival in the theater, however, was to obtain through Colonel Halloran the complete listing of psychiatrists and their qualifications as established by the National Research Council. Although this list did not help him locate individuals, it enabled him to pick out the qualifications of those he met personally or impersonally as names in correspondence crossing his desk.

In late 1942 and early 1943, there were many assignments of neuropsychiatrists. Some were brought to Colonel Thompson’s attention directly from the individuals concerned by letter, word-of-mouth, or during inspections, and many in letters from Colonel Halloran. As late as July 1944, when the Third U.S. Army was staging for movement to the Continent, such assignments could be found. An acquaintance of Colonel Thompson’s, and a qualified neuropsychiatrist, was a general duty medical officer in an armored medical battalion. Colonel Thompson wrote to this officer, as follows:

I understand that your unit is part of the Third Army and I am writing to Major Talkington, consultant in psychiatry for that army, so that he may make contact with you and see whether you can be placed. I shall issue the usual challemuge to him that if you are not needed in the army set-up we have need for psychiatrists elsewhere, but I am sure that he will find a psychiatric assignment for you.


    A most important reason for knowing who the psychiatrists were, their qualifications, and their location was to be able to fill vacancies quickly without materially interrupting services. This last was no small task when one considers that, in spite of existing shortages in the theater and losses through normal attrition, personnel had to be found to fill the positions of evacuation hospital and division neuropsychiatrists as these positions were created and to fill vacancies in station and general hospitals arriving in the theater without their full complement.

Another problem in personnel management was that of promotions. First of all, tables of organization were often extremely inadequate or inequitable in the rank given neuropsychiatrists with excellent professional training or those who were required to handle a greater load than provided for in the tables of organization. Among the latter were neuropsychiatrists withdrawn from evacuation hospitals to man exhaustion centers. In the same category were those assigned to small hospitals for convenience and placed on duty with replacement centers, disciplinary barracks, and other temporary-duty assignments of considerable importance.

A solution, albeit not entirely satisfactory, to a problem of this nature was that attempted at the 36th Station Hospital.

With reference to K * * * ‘s promotion, I am still wrangling with lesser lights. The situation is this: We are organized under a Table of Organization which left no vacancies whatever nor opportunities for promotion. Here I have progressed to the point of getting higher authority to admit that our Table of Organization must be a separate or a special T/O. Our bed capacity is considerably greater than we figured in the States and the rank appropriate will go in. In addition, I am holding that men who are trained militarily and professionally proficient to be diplomats of the American Board should hold the grade of major. By these devious means I hope to get him up in the not too distant future. He is the number one man of the list but there are several others * * * Frankly there is no valid lieutenant in the outfit. None of the men are tyros. Keep your fingers crossed while I make every possible move to squeeze these through.58

Two commitments made by the Office of the Surgeon General as to personnel were rewards of Colonel Thompson ‘s trip to the United States. It was agreed that a certain allotment of graduates from the schools of neuropsychiatry in the Zone of Interior could be sent to the European theater upon request. Additionally, Colonel Menninger promised, whenever possible, to make known, by name, to Colonel Thompson the officers who were being placed in units to be activated for assignment to the European theater.

    Clinical psychologists. - A personnel problem of sizable proportions arose. In early 1945 in the commissioning of clinical psychologists (fig.129). Enlisted clinical psychologists began arriving in the European theater in September 1944 in hospitals coming direct from the Zone of Interior. 0n 2 October 1944, War Department Circular No.392 was published announcing provisions for the commissioning of these enlisted clinical psychologists. On 21 December 1944, a command letter was issued by the theater headquarters

58 Letter, Lt. Col. F. O. Parsons, MC, 36th Station Hospital, to Dr. Winfred Overholser, 27 Jan. 1943.


FIGURE 129.-Enlisted clinical psychologist working with patient at 130th General Hospital, Ciney, Belgium.

promulgating provisions of the circular to all unit commanders. In January 1945, applications began to trickle in and, in February, a great number appeared.

At first, Colonel Lemkau, who was acting consultant in neuropsychiatry during Colonel Thompson’s temporary duty in the Zone of Interior, and then Colonel Thompson began to interview each applicant. It was also proposed that the applicant be given a practical test as well as an interview because personality was so important in this specialized type of work, and the manner in which he approached and dealt with patients was critical.

At about this time, a letter was also received from Lt. Col. (later Col.) Morton A. Seidenfeld, AGD, chief clinical psychologist in the Neuropsychiatry Consultants Division, Office of the Surgeon General, pointing out certain complaints he had received from clinical psychologists in the European theater as to their assignments and duties. As applications increased in number, Major Kelley was appointed Consultant in Clinical Psychology, ETOUSA, and assigned to the office of the theater senior consultant in neuropsychiatry to work under his direction. Major Kelley was admirably suited for this assignment. In addition to being a well-qualified psychiatrist, he was an associate member of the American Psychological Association and was the author of a text on the Rorschach method of personality testing by projective techniques.

In March 1945, Major Kelley made a thorough study of the work being done by clinical psychologists in hospitals on the Continent, and a number of important facts were elicited. In some hospitals, the psychiatrists and clinical psychologists were cooperating well, the psychologist assisting the psychiatrist


in the work of the neuropsychiatric section. In more than a few hospitals, clinical psychologists were being employed outside the neuropsychiatric services. In these cases, the commanding officer and psychiatrist did not understand how to make proper use of the clinical psychologist. In most instances of this nature, it was found that the psychiatrist was totally unfamiliar with the usual duties of clinical psychologists and consequently had not properly employed them as full-time assistants.

Since it was obvious that many clinical psychologists were not being properly employed, steps had to be taken to correct the situation. As a rule, an explanation of their functions sufficed to convince the commanding officer of a hospital to reassign them to appropriate duties. Administrative Memorandom No. 17, Office of the Chief Surgeon, Headquarters, ETOUSA, was published on 17 March 1945, to outline the duties of the clinical psychologist. A brief article on the same topic was also published in the Medical Bulletin, Office of the Chief Surgeon, ETOUSA.

In addition, meetings attended by neuropsychiatrists and clinical psychologists were held on the Continent and in the United Kingdom by Colonel Thompson, Major Kelley, and hospital center neuropsychiatric consultants. At these meetings, attempts were made to reach a mutual understanding as to the functions of clinical psychologists and to place the responsibility for their proper use on the shoulders of the hospital neuropsychiatrists.

Finally, every clinical psychologist who submitted a complaint that he was being improperly employed was personally interviewed by Colonel Thompson or Major Kelley. The subject was also made a matter of inquiry in routine hospital visits by the theater senior consultant and hospital center consultants in neuropsychiatry. In almost all instances, satisfactory adjustments were made.

A special function was evolved through coordination with the Adjutant General’s Office, Headquarters, ETOUSA, in the use of a team made up of clinical psychologists and enlisted helpers in screening limited-assignment personnel who were being discharged from hospitals. Individual classification records (WD AGO Form 20) were brought up to date to show the nature of the patient’s limited-assignment requirements, and recommendations were made as to his future assignments. The service was extended to all categories of limited-assignment personnel. At one hospital, a team made up of 1 psychologist and 2 assistants, during the period from 14 March 1945 to 25 May 1945, completed qualification cards and recommended assignments on all discharged patients--medical and surgical cases as well as psychiatric. A total of 1,190 patients were interviewed, and a followup at the replacement depot showed that, with only occasional exceptions, the assignment recommended by the psychologist was followed without change.

The work of clinical psychologists was severely handicapped by the lack of testing instruments, and efforts to obtain them met with only limited success. Further plans for group meetings, education, and other activities of clinical psychologists had to be discontinued following V-E Day. In all, 608 applica-


tions were processed by Colonel Thompson and his associates as of 30 June 1945. Of this number, 533 were rejected. The remaining 75 applications were forwarded to the War Department, which rejected an additional 33, approved 15 for commissioning, with decision still pending on the remaining 27.


   Colonel Thompson found it well-nigh impossible to conclude any carefully controlled, rigidly organized, research projects in the strictest sense of the term ‘‘research.’’ Basic research with the classic design of control and experimental groups was usually out of the question. Proposals for conducting some well-conceived projects of this nature had to be rejected. On the other hand, certain studies had to be done in order to gain information necessary for the intelligent studies had to be done in order to gain information necessary for the intelligent carrying out of the consultant’s mission. The reader should realize that the basic treatment methods that were taken up and used in the theater–narcotherapy, insulin therapy, electric shock therapy, diagnosis by electro-encephalogram–were all, to a considerable extent, applied research at that time. (Fig.130) Actually, most of the research accomplished in the theater was of this same applied type. Since something had to be done, a course of action was selected using the best information available, and the results were assessed in any way possible for the purpose of improving techniques. Another type of research accomplished in the field of neuropsychiatry was in the nature of statistical or questionaire studies.

    Blast syndrome. - One of the problems that defied conclusive results was that which became known as ‘‘blast syndrome.” The problem arose in the first weeks following D-day. On 15 July 1944, Colonel Thompson described it in a memorandum to Colonel Kimbrough as follows:

The problem of how much symptomatology was due to organic disturbances produced by blast, and how much was due to emotional factors was brought up at almost every visited center. Practicalhy nine out of ten of the psychiatric patients gave a history of having been near exploding shells, and they related this to the onset of their symptomatology, some saying that they were blown out of the foxholes by a shell. In many there was a statement that they could not remember what happened for a period of time. It appeared that there was a danger of attributing too much symptomatology to organic damage, and thereby reverting to the old conception of ‘‘shell shock’’ of the last war. The general opinion was expressed that unless there was evidence of damage to the central nervous system, as shown by neurological signs or evidence of blast in other parts of the body, as shown by ruptured ear drums, hemoptysis, or other visceral signs, the diagnosis of blast syndrome would not be made in forward areas. Certain other differential points were discussed such as evaluation of amnesia which in organic conditions is usually retrograde and cannot be fully recovered under Pentothal [Sodium] hypnosis. Further studies of this problem will be carried out at hospitals at the base in cooperation with the senior consultant in neurosurgery.

When Colonel Thompson was at the Office of the Surgeon General in early January 1945, the possibility of studying blast conditions with electroencephalograms at the front was discussed. Colonel Thompson suggested to Lt. Col. William H. Everts, MC, Chief, Neurology Branch, Neuropsychiatry Consultants Division, Office of the Surgeon General, that two electroencephalographic


FIGURE 130.- Psychiatric treatment, 130th General Hospital, Ciney, Belgium. A. Electric shock. B. Administration of insulin.


FIGURE 130.-Continued. C. Equipment for producing abreaction under narcosis. D. Patient undergoing narcotherapy.


FIGURE 131.-Maj. Howard D. Fabing, MC.

machines be provided for this work near the front. One would be used at a clearing station so that records could be started as soon as possible, and the other would be further back, perhaps at the 13Oth General Hospital, where daily records could be continued.

In the meanwhile, Major Fabing (fig.131), who had been the director of the school of neuropsychiatry, was permitted to conduct his own studies on blast syndrome. He found that by using Pentothal Sodium (thiopental sodium) hypnosis and appropriate sound effects, a patient who claimed to have been rendered unconscious for some time by a nearby explosion could regain his memory for the entire period of ‘‘unconsciousness.’’ When this experience had been relived in detail, an injection of 10 cc. of Coramine (nikethamide) was given, and the patient was awake in less than a minute. Eventually, the patient was able to write his own account of the episode. By this method, Major Fabing was able to return 90 percent of his 80 cases to duty.

    Ergotamine tartrate studies. - On 31 May 1944, The Surgeon General forwarded to the Chief Surgeon, ETOUSA, two excerpts from publications that dramatically told of the use of ergotamine tartrate as a remedy for ‘‘shell shock” and “battle reaction.” The letter concluded: “We do not have any experience whatever with the use of this and know nothing further than what these articles state but you may want to suggest their trial in the hands of some competent individual.”

After Colonel Thompson had written to him that ergotamine tartrate was being tried out in two hospitals, on 20 July 1944, Colonel Menninger wrote:


    We want to think of Ergotamine Tartrate as being on an investigative level at the present time. In other words, we want to be sure that it is very cautiously used and we want to get the results from its use in a few places as to its indications, main effects and side eflects, and results. We don’t propose to issue it except under your authority * * *

On 3 August 1944, Colonel Thompson wrote Colonel Menninger a brief résumé of what was being done with the drug.

We have been using Ergotamine Tartrate under control conditions at the 312th Station Hospital. This work is being done under Major Paul Lemkau. A return report on this should be available before long. Major Lemkau believes that there is value in the drug--that equally good results are obtained with the insulin and narcosis therapy. I should add that a group of 10 control patients in the same ward benefitted almost as much on sugar capsules and all the nursing attention that the other patients received, so maybe it is the general atmosphere and the “total push’’ methods, are the important thing, and at any rate it is difficult to judge the value of any type of therapy in such a setting.

Colonel Thompson forwarded the report on the use of the drug to Colonel Menninger on 24 August 1944 with the following comment:

I am enclosing a copy of an account of our experience with Ergotamine Tartrate as written up by the medical officers of the 312th Station Hospital who did the work. Further investigation along this line is being continued and at the present moment they are attempting to combine this therapy with modified insulin so as to give the gain in weight which seems to be necessary. The use of this drug will be confirmed to our three N.P. hospitals until we know more about it.

These studies were examples of the type of research that could not be carried on except in an active theater. The acute conditions observed in patients recently evacuated from battle were not to be found in sufficient numbers in the United States.

    Morale Service opinion survey technique. - On 27 October 1943, Colonel Halloran wrote to Colonel Thompson introducing Dr. Samuel Stauffer and Dr. Carl Hovland of the Morale Service, Army Service Forces. Colonel Halloran stated that these were men of outstanding ability who had worked closely with the Office of the Surgeon General and that Dr. Stauffer was one of the first to recognize that preventive psychiatry and morale were actually the same subject and had been instrumental in establishing liaison between the Morale Service and the Neuropsychiatric Branch of the Surgeon General’s Office. Colonel Halloran added: ‘‘To my mind, the opinion survey technique for studying problems of human behavior has been a development of major importance in this war. It offers perhaps the most promising approach of any to problems of military psychiatry. Dr. Stauffer and Dr. Carl Hovland are highly skilled in the use of this technique and have already conducted surveys of considerable value in this field.”

On 24 March 1944, Dr. Kimball Young, a personal representative of Maj. Gen. Frederick H. Osborn, Chief, Information and Education Division, War Department, visited Colonel Thompson to cement further close working relationships between the medical and morale services.

From this beginning throughout the life of the theater, this close relationship was maintained. In a way, it could be said that the Morale Service


(later known as Research Branch of information and Education) provided the means for conducting studies which the neuropsychiatrist wanted to have done but for which he had no facilities for accomplishing. Their reports were read with interest from the Chief Surgeon down to medical officers in the lowest echelons.

Even the facilities of this research organization were not able, however, to conduct a survey that was particularly desired by Colonel Menninger. A questionnaire had been used for a cross-section survey of troops in the United States with valuable and interesting results. Colonel Menninger wanted to have it applied to from 1,000 to 1,500 normal subjects who had 90 or more aggregate combat days on duty with an infantry battalion in order to determine how certain factors considered peculiar to neuropsychiatric patients appear in normal troops.59 After many conferences and preliminary studies, it was advised by higher officials in the Research Branch of Information and Education that it might not be worthwhile to start the study at that particular time (March 1945). It was agreed that it should be held up until there was absolute certainty that the study could be carried through to completion, either in the European theater or some other theater.

Other studies. - In addition to the foregoing, some significant followup studies were completed, requiring the cooperation of field units, the Ground Forces Reinforcement Command, and the Information and Education Division. A particular cogent and interesting study was that of approaching combat exhaustion on an epidemiologic basis. This study was, to a certain extent, prompted by the fact that some individuals in the theater thought there would be a sudden drop in neuropsychiatric casualties when soldiers found they could be evacuated for cold injuries. Col. John E. Gordon, MC, Chief, Preventive Medicine Division, Office of the Chief Surgeon, Headquarters, ETOUSA, had amassed considerable data concerning the epidemiology of trench foot, which could be readily related to neuropsychiatric incidence for the same periods. Like data were available at subordinate commands. The completed study showed a remarkable similarity of conditions attendant on cold injury and neuropsychiatric breakdowns.


Supply personnel were able to handle problems of procurement, cataloging, storing, issuing, and the like to a certain point, but when a decision was required as to exactly what was needed, where it had to be, and in what amounts, the answer could only come from the using parties. So it was that as early as October 1942, Colonel Thompson made recommendations for the amount of sedative drugs required for every 10,000 men in combat. A later study revealed a lack of certain items in installations where they would be needed, and revised recommendations were submitted on 7 December 1942. Periodically thereafter, the Supply Division, Office of the Chief Surgeon, Headquarters, ETOUSA,

59 Letter, Col. L J. Thompson, to Col. O. N. Solbart, Chief, Special Services Division, ETOUSA, 11 Nov. 1944.


would circulate lists of items to be stocked for confirmation by the respective consultants. Sometimes substitutions or deletions were suggested. For example, on 25 April 1944, the Supply Division suggested that Nembutal ( pentobarbital sodium) be substituted for Sodium Amytal (amobarbital sodium). Colonel Thompson had to disapprove the proposal on the basis that indications differed for the use of the two drugs, and Sodium Amytal was the drug of choice in many psychiatric conditions.

Throughout most of the life of the theater, electrical machines for shock therapy and for electroencephalography were in critically short supply. Initially, three electro-shock machines were borrowed from the British. In January 1943, Colonel Thompson discovered that the 5th General Hospital had had an electroencephalographic machine but was forced to leave it in the Zone of Interior owing to shipping priorities. It was alleged that lack of shipping space was also preventing the receipt of electric shock apparatus. When it was learned that funds were available at the 5th General Hospital for the purchase of an electroencephalographic machine, Colonel Thompson visited the Bruden Neurological Institute at Bristol, England, and was ultimately able to procure one British-made machine.

   Colonel Thompson brought this situation of shortages to Colonel Menninger’s attention by letter on 2 May 1944 “ * * *because I thought that you might be helpful if the requests come through your office.” Colonel Thompson was astonished at the reply, dated 10 May 1944, which read: “To my knowledge we haven’t had any official request for such and you might check on that.” By July 1944, the Supply Division, Office of the Chief Surgeon, Headquarters, ETOUSA, had informed Colonel Thompson that a “fair number” of electric-shock machines were on their way. It was not until Colonel Thompson returned from his temporary duty to the United States that a specialist in electroencephalographic techniques and electric-shock treatment from the Surgeon General’s Office came to the theater and worked out details for supplying such machines and requirements for the personnel to run them. Finally, an additional supply of electric-shock apparatus arrived from the Zone of Interior in early 1945.

A request submitted by Colonel Thompson in March 1945 for psychologic tests, answer sheets, and scoring keys also was largely unfulfilled. As of the first of June 1945, the only materials that had arrived were Army General Classification Tests which were already in the theater; 50 sets of Rorschach cards, which were procured directly from Switzerland; and 25 sets of Thematic Apperception Test pictures. More important tests, such as the Wechsler-Bellevue Intelligence Scale and the Minnesota Multiplasic Personality Inventory, were not forthcoming. Those tests that were made available had to be provided on a priority basis to units scheduled for redeployment to the Pacific area.

Within the armies, neither the division psychiatrists nor units used as exhaustion centers had been provided the additional or special equipment needed to cope with the number of neuropsychiatric casualties encountered.


This was particularly true of the division psychiatrist. He required facilities capable of holding and curing for some 150 casualties, but tables of organization and equipment made no provision for this, and local arrangements had to be made to obtain the equipment. Such arrangements were best made where command surgeons and other staff officers had sympathetic understanding of the need for neuropsychiatric facilities. Colonel Thompson devoted much effort toward this end on his visits to the armies, corps, and divisions. Eventually, most division psychiatrists were routinely supplied with such essential medical items as reflex hammers and ophthalmoscopes. The only means of definitely solving these problems, however, was by new tables of organization and equipment on modifications of existing tables.

Professional Publications, Meetings, and Societies

Professional literature was always in demand, particularly by Colonel Thompson and the school. Through the courtesy of Dr. C. C. Burlingame, Colonel Thompson was able to obtain sufficient copies of abstracts published by the Institute of Living, Hartford, Conn., for his use and for use in classes in neuropsychiatry. A request submitted to Colonel Menninger for reports made by the Morale Service and publications of the Josiah Macy, Jr., Foundation was equally productive. Eventually, provision was made by The Surgeon General to supply all division psychiatrists with a full file of reports published by the Morale Service entitled ‘‘What the Soldier Thinks.” In addition, a basic set of reference texts was provided each division psychiatrist. Many individual officers subscribed to various professional journals. Some subordinate consultants in neuropsychiatry also procured publications for their commands.

The Editorial Board, Office of the Chief Surgeon, Headquarters, ETOUSA, was established on 21 October 1944 by Office Memorandum No. 23. Colonel Thompson was appointed as one of its members. The board was required to review manuscripts of papers to be presented for publication or to be read before a society which published such papers in its journal. As a result, Colonel Thompson personally read, reviewed, and commented on the many papers touching upon the subject of neuropsychiatry that were submitted to the board. In conjunction with the Public Relations Officer, Office of the Chief Surgeon, Headquarters, ETOUSA, Colonel Thompson was required to advise and comment on stories by reporters in the theater on the subject of neuropsychiatry.

Meetings of various societies and organizations provided opportunities to exchange information and meet coworkers. They created a general feeling of cooperation and good will among all those attending.

The theater senior consultant in neuropsychiatry and psychiatrists in the field participated in the activities and meetings of all the larger organizations, such as the Inter-Allied Conference on War Medicine, the European Theater American Medical Society, and the various base section medical societies (fig 132) Papers concerning neuropsychiatry presented by Colonel Thompson at


FIGURE 32.-Col. Lloyd J. Thompson, MC, meets with distinguished neuropsychiatric consultants at the Inter-Allied Consultants Conference, 108th General Hospital, Paris, France, 15 October 1944. Left to right, Col. Lloyd J. Thompson, MC, Chief Consultant inNeuropsychiatry, ETOUSA; Lt Col. Roscoe W. Cavell, MC, Consultant in Neuropsychiatry, Ninth U.S. Army; Lt. Col. William E. Srodes, MC, Consultant in Neuropsychiatry, First U.S. Army;  Maj  Ellis Bonnell, MC, Neuropsychiatric Service, 108th General Hospital; Maj. Alfred O. Ludwig, MC, Consultant in Neuropsychiatry, Seventh U.S. Army; Col. William A. Menninger, MC, Consultant in Neuropsychiatry to The Surgeon General; and Lt. Col. Frederick R. Hanson, MC, Chief Consultant in Neuropsychiatry, MTOUSA.

the Inter-Allied Conferences on War Medicine were reproduced in the postwar publication of that organization.60

On 13 February 1943, a meeting of the U.S. Army psychiatrists was held at the Royal Society of Medicine in London. In addition to the needs of psychiatric sections of general hospitals and the Senior Consultant in Neuropsychiatry, ETOUSA, there were present the Consulting Psychiatrist for the Royal Canadian Army Medical Corps; a representative of the Consulting Psychiatrist of the Royal Army Medical Corps; the Chief Consultant in Medicine, ETOUSA; and the Commanding Officer, the 36th Station Hospital. Colonel Thompson presided, and each psychiatrist presented a paper on some aspect of psychiatric services in this theater.

The three British services - Army, Navy, and Air Force - along with the Canadian forces had an informal organization of psychiatrists which met every


60 See footnote 6, p. 258


3 months. At first, Colonel Thompson was the only U.S. Army representative at its gatherings, but, in November 1943, all U.S. Army and Navy neuropsychiatrists were invited to join, and the organization became essentially a psychiatric association of the Allied Armies in Europe. Its meetings, which were commonly referred to as the interservices meeting of psychiatrists, were held at the Royal Society of Medicine in London. One of the high points in these gatherings was the session of 25 March 1944 devoted to rehabilitation work. At this meeting, Colonel Parsons explained in detail the rehabilitation program that was being carried out at the 3l2th Station Hospital.

In addition, Colonel Thompson represented the U.S. Army at the special Psychological and Psychiatric Liaison Committee meetings held at the offices of the War Cabinet in London; at conferences of command psychiatrists of the British forces; at conferences of the British Emergency Medical Service psychiatrists; and at meetings of the Services Subcommittee of the War Cabinet’s Expert Committee on the Work of Psychologists and Psychiatrists. The latter was an extremely important association for Colonel Thompson, since the Services Subcommittee consisted of consulting psychiatrists and psychologists from all the British services.

Cooperation From Without the European Theater

This account would be incomplete if it were limited to dealings with strictly medical elements and individuals within the theater. The job that was done, and done with a conspicuous degree of success, would never have been possible without outside help.

Colonel Thompson was fortunate in having and maintaining frequent direct contact with the Neuropsychiatry Consultants Division, Office of the Surgeon General. The benefits were mutual and extended into all spheres of military neuropsychiatric activities. At first, contact was infrequent and relatively formal through approved military channels and by military letter, and these continued to be used for matters of importance requiring official cognizance, particularly policy matters. However, the way was opened for informal and personal communication in mid-1943.

On 1 June 1943, Colonel Halloran wrote Colonel Thompson as follows:

Until recently it was necessary for all communications from overseas consultants to pass through official channels. However, we have now received information that overseas consultants in the field should be encouraged to communicate with this office personally at least once a month. In this way we may be able to familiarize ourselves with many problems and receive information which will guide us in formulating advisory policies.

In reply to this letter, Colonel Thompson wrote: “It is a great relief to know that overseas consultants can communicate personally and directly with your office. In the past I have had considerable material which I thought would be of interest and value to you.”


   When Colonel Menninger became Chief, Neuropsychiatry Consultants Division, Office of the Surgeon General, in December 1943, the relationship established by his predecessor was continued. On 25 January 1944, Colonel Menninger wrote Colonel Thompson, as follows:

My stay in this office has been so short that I am still a long way from being oriented. I do have a very definite impression, however, that the lines of communication between us here and you over there have been very thin. I would like so much to know the dope from you and I presume you will be interested in knowing of events which occur around here. I’m going to try to get out a letter to consultants each two or three weeks just to let you know what we are doing and what is happening. I know that even in this country I felt very much isolated from The Surgeon General’s Office and we do want to be of as much help to you as we possibly can.

A few months later, Colonel Menninger was still intent on establishing personal communications with Colonel Thompson on a sound and continuing basis, and on 22 March 1944, he wrote: “I am keen to know what’s going on over there and any suggestions your have for me * * *. So much of our work is necessarily extremely interlaced with yours and it’s a very great handicap for both of us that we don’t know more of the details of each other’s planing.”

In September 1944, Colonel Menninger visited the European theater. Organizations in the combat zone were the primary goals in his itinerary. Accompanied by Colonel Thompson, he visited army and division psychiatrists and inspected evacuation hospitals, field hospitals, exhaustion centers, and clearing stations of many divisions on the line. Colonel Menninger then viewed neuropsychiatric work in fixed hospitals with particular attention to problems at the 130th General Hospital and the screening of patients from Quartermaster work units at the l9th General Hospital. Wherever he went, there were informal conferences with neuropsychiatrists in the field and direct exchange of opinions, ideas, and information.

In the United Kingdom, Colonels Menninger and Thompson were escorted by Brigadier Rees and Lt. Col. George R. Hargreaves on a grand tour of British military and civilian neuropsychiatric facilities. Among the installations visited were the Army Selection Training Unit (Royal Army) at Leeds, England, the Royal Army Medical Corps neurosis hospital at Bellsdyke, a primary training wing in the Scottish Command where the process of testing and placing recent inductees was observed, and “Gordenburn,” the neurosis hospital of the University of Edinburgh. While in the field commands of the British Army, the visitors took part in a meeting at York, England, of British Army regional psychiatrists of the Northern Command. Two of the talks at this conference were given by the U.S. Army representatives, Colonels Menninger and Thompson. A meeting sponsored by Dr. David K. Henderson, Professor of Psychiatry, University of Edinburgh, was held with civilian psychiatrists in the vicinity of the university. A visit was paid Maj. Gen. J. A. Manifold, Surgeon, Scottish Command. Finally, Colonel Menninger attended a series of conferences arranged by the British in London.


    Upon his return to the United States, Colonel Menninger wrote a complete account of his trip to the European theater.61 In this report he commented:

Visits From The Surgeon General’s Office

    My impressions in contacts with the professional consultants in the theater, and particularly with the medical officers in the hospitals, are that my visit was very much appreciated because it indicated an interest on the part of The Surgeon General in their situation. I believe it was an indication of the need for and value of rather frequent contacts between the professional groump in The Surgeon General’s Office and the professional group in the field.

<>    In December 1944, Colonel Thompson returned to the United States for a period of temporary duty, from 12 December 1944 to 15 January 1945. While in the United States, Colonel Thompson presented the major address on combat exhaustion before the Research Association in Nervous and Mental Diseases, and acted as a member of the commission of the organization. Colonel Thompson spent some time at Mason General Hospital on Long Island, New York, where neuropsychiatric cases evacuated from all theaters were to be seen, and at the neuropsychiatric convalescent facility at Camp Upton. He attended the first conference of psychiatrists in charge of consultation services at replacement training centers, which was held at Aberdeen Proving Ground. There was much to discuss, and many plans and special arrangements were made at the Neuropsychiatry Consultants Division, Office of The Surgeon General.

    There were other visits to the European theater from personnel of the Surgeon General’s Office, representatives from other War Department agencies, and from the Office of Scientific Research and Development and National Research Council. All of these visits, either directly or indirectly, eventually had profound effect on the conduct of neuropsychiatric services in the European theater and the Army at large.

    The first of these other visits was made in March 1944 by a group headed by Maj. Gen. Norman T. Kirk, The Surgeon General of the Army. He was accompanied by Maj. Gen. David N. Grant, the Air Surgeon, and Dr. Strecker. Dr. Strecker was a member of the special war committee appointed by the American Psychiatric Association, the president of the association, and a civilian consultant in psychiatry to the Secretary of War. He was concerned, primarily, with neuroses affecting combat aircrews. Brig. Gen. Malcolm C. Grow, Col. Elliott C. Cutler, MC, Lt. Col. (later Col.) Herbert B. Wright, MC, Col. R. B. Hill, MC, and Colonel Thompson joined the commission in its visits to field installations (fig. 133). Practically all general and station hospitals in England servinmg Army Air Force units were visited. Dr. Strecker interviewed personally many flying personnel who were patients. At all these installations, there were conferences with the psychiatrists. Of particular interest to the visitors was the rehabilitation center of the 307th Station Hospital, which was doing an exceptional job in returning wounded aircrew

61 See footnote 57, p. 366.


FIGURE 133.- Stanbridge Earls, Hampshire, England, rest home for officers suffering from flying fatigue.

personnel to duty, and the 347th Station Hospital, which was the special treatment center for operational fatigue of flying personnel. A highlight of the tour was the visit by the entire commission to the 312th Station Hospital where the treatment and rehabilitation of nonpsychotic patients was seen. Medical officers attending the school of neuropsychiatry were engaged in conference, and a complete presentation was given by the school’s demonstration unit of what the neuropsychiatrist might encounter at a casualty clearing station. On 20 March 1944, an evening dinner was given by Col. Rex L. Diveley, MC, Senior Consultant in Orthopedic Surgery, ETOUSA, and Colonel Thompson for members of the commission and their opposite numbers in consultation in orthopedics and psychiatry from the British services.

    Some time after the visit of this commission, Colonel Thompson wrote to Colonel Menninger on 2 May 1944 and expressed the hope that Dr. Strecker had been able to call on him to tell about the visit in the European theater. “I am sure,” Colonel Thmompson ventured to say, “that he brought back with him considerable first hand information thmat cannot be expressed in writing.” In a reply dated 10 May 1944, Colonel Menninger wrote in confirmation: “Ed Strecker did stop to see us and told us in considerable detail about the <>situation. The official reports come through more slowly.”

    Colonel Thompson had to decline a proposal by Dr. Strecker for holding examinations of the American Board of Neurology and Psychiatry in the European theater, desirable as this would have been. Colonel Thompson had


indeed received more than a few applications and queries regarding such examinations but it would have been too difficult to find the time and place for them at that time, when the invasion of the Continent was just 1 month old.

    Brig. Gen. Hugh J. Morgan, Chief Consultant in Medicine to The Surgeon General, visited the European and Mediterranean theaters in March of 1945. General Morgan was not interested in neuropsychiatric activities per Se, but his broad interests and extensive visits to units within each of the field armies in combat brought out many observations and interviews with key personnel. General Morgan was able to assess keenly the types of medical units being used, the missions they were performing, and their capabilities and limitations. In a memorandum dated 19 April 1945, he reported the results in detail to the Chief, Operations Division, Office of the Surgeon General. <>
Colonel Thompson spent the entire month of April 1945 with a special commission sent to the European theater to study psychoneurotics. The commission consisted of Col. Lucius A. Sa!isbury, MC, IGD; Col. Peter Schmick, GSC; Lt. Col. Herbert O. Peet, IGD; Colonel Everts; and Lt. Col. Walter O. Klingman, MC. In the latter part of 1944, a commission made up of Colonel Salisbury and four civilian psychiatrists had conducted a study of the treatment of psychoneurotics being carried out, in the Zone of Interior. As a result, the Secretary of War asked the Inspector General for a report on the same topic from the theaters. One commission was sent to the Pacific area, and this one had come to Europe and was to proceed later to the Mediterranean theater.

    Two days were spent in orienting the group and planning the itinerary. The first day of the tour was spent in long conferences with General Kenner at Supreme Headquarters, Allied Expeditionary Force, and with Col. (later Maj. Gen.) Alvin L. Gorby, MC, and Colonel Whayne, both of the 12th Army Group. From there, each army in combat was visited; that is, the First, Third, Seventh, and Ninth U.S. Armies. In each army, medical as well as other personnel were interviewed at all echelons from army and corps headquarters down to units within the divisions. In this way, opinions were obtained from commanders of major organizations, various staff sections, and medical officers. Every type of medical treatment facility in use was observed from division clearing stations back to exhuastion centers supporting evacuation hospitals. Early in the tour, the 51st Station Hospital, which was a specialized unit supporting Third and Seventh U.S. Armies, was inspected thoroughly. After the tour through the armies, a similar thorough study was made of the 130th General Hospital and its rehabilitation center, which was the terminus of neuropsychiatric evacuation from First and Ninth U.S. Armies.

    Facilities and medical staffs of Eighth and Ninth Air Forces were also visited, including the rest homes of Eighth Air Force in the United Kingdom and the bomber field at Polebrook. While in the British Isles, the group made a complete study of treatment of neuroses as conducted at the 3l2th Station


Hospital-the “last ditch’’ rehabilitation center for neurotic patients in the theater. The 96th General Hospital, the holding center for psychotic patients, was also observed.

    The work by this group during April 1945 was the most comprehensive on-the-spot assessment possible at that time. It included all facets of the whole problem-command and medical-as it pertained to psychoneurosis in the European theater. The seriousness and interest with which the members of the group proceeded about their work proved to be a real stimulus wherever they went. The following excerpt from a letter written on 25 April 1945 by Maj. Alfred O. Ludwig, MC, Consultant in Neuropsychiatry, Seventh U.S. Army, to Colonel Menninger, shortly after the visit of this group to his area, illustrates this feeling:

     I had the pleasure of meeting Lt. Col Everts when he visited us with the most recent of the many investigating committees that have “looked into” our affairs in the past two years. He, of course, was thoroughly familiar with what we have been trying to do, as well as with the various circumstances that influence the NP rates over here, but it was with very considerable satisfaction that I expounded some of our ideas to the other non-medical gentlemen. We tried to give them a very frank opinion, backed with facts and figures, as to the reasons for the situiation, and emphasized particularly some of the things over which the medical department has no control.

    On 21 April 1945, another commission arrived in the European theater from the Zone of Interior, made up of civilian consultants in neuropsychiatry to The Surgeon General. Its overall mission was to study the psychodynamics of combat exhaustion. The commission was composed of Drs. Leo H. Bartemeier, chairman, and John Romano, Karl Menninger, John C. Whitehorn, and
Lawrence S. Kubie. Its raison d’être was the fact that the clinical manifestations of psychoneurosis in combat differed considerably from typical psychoneurotic reactions, and, as the clinical picture changed more or less rapidly as the patient was evacuated to the rear, reliable information was needed for correlating psychopathology in forward areas with subsequent treatment methods. It was assumed that psychiatrists in the Army, and particularly the group at the lower echelons, did not have time and might not be professionally equipped to underertake such research. The contemplated project had the complete approval of the Office of Scientific Research and Development and was strongly endorsed by Brig. Gen. William A. Borden, New Developments, War Department. Earlier durung the year, when The Surgeon General approached General Hawley on the feasibility of the project, an invitation was extended by General Hawley for a commission of this nature to be sent to the European theater.

    The commission had intended to proceed in pairs or individualy to different active fronts. However, the collapse of German resistance in many areas militated against such a plan. Colonel Thompson advised the members of the group to travel together. Because he was engaged in touring with the group headed by Colonel Salisbury, Colonel Thompson obtained the services of Colonel Parsons to escort them. The civilian commission covered practically


the same ground as the earlier commission, but its members were able to spend much more time at the 130th General Hospital and with British neuropsychiatrists. Unfortunately for the commission, there were almost no new battle casualties.

    A complete report was made by the commission upon its return, in which it noted the peculiar advantage it had in dealing with military neuropsychiatric patients.62

    Being civilians facilitated the obtaining of information from some patients. It also enabled us to identify ourselves very readily with either privates or officers . . . because we were not, in fact, in any one of these positions ourselves . . . We were not under any compulsion or obligation to find ways of gettimig men back to duty. It was our function only to study the conditions without the necessity of serving any utilitarian purpose by which Army doctors are always bound and constrained.

    If any one individuual outside the European theater left a permanent mark upon the theater’s neuropsychiatric activities, that person was Colonel Hanson, Consultant in Neuropsychiatry, NATOUSA (MTOUSA). Even before Colonel Thompson’s arrival in the theater, when Colonel Hanson had been assigned to the North Ireland Base Section, ETOUSA, he had written a letter to the Chief Surgeon, ETOUSA, on 10 August 1942 citing the need for a much better organized, equipped, and extensive neuropsychiatric service in the European theater. The letter so impressed General Hawley that he had used it as the basis for requesting a full-time neuropsychiatric consultant of suitable high caliber to organize and operate such a program as proposed by then Captain Hanson.63

    It has been mentioned previously that, before departing for the North African theater, Colonel Hanson, with Colonel Thompson, had worked out a plan to be used in combat that was amazing in its foresight. When the European theater was in the process of making firm plans for mounting the invasion of the European Continent, Colonel Hanson had accompanied Colonel Thompson back to Europe from North Africa and helped sell the basic system, which was ultimately used in all field armies in Europe. At the same time, he gave lectures to students at the school of neuropsychiatry that were most acute and timely. His reports, verbal and written, were the basis for a significant part of the indoctrination of line medical officers and neunropsychiatrists in mobile hospital units at the school of neuropsychiatry.

When Colonel Menninger visited the theater, Colonel Hanson was able to join him with Colonel Thompson and make the visit more fruitful, both in terms of what Colonel Menninger was able to find out on his trip and the immediate benefit of the trip to neuropsychiatrists in field units with whom conferences were held. Forms devised by Colonel Hanson were used with but
62 Report of Psychiatric Mission, Office of Scientific Research and Development, European Theater of Operations, 16 April 1945-16 July 1945.
63 Letter, Col. Paul R. Hawley, Chief Surgeon, ETOUSA, to Surgeon General, US. Army, 15 Aug. 1942, subject Neuropsychiatric Treatment in the Theater of Operations.


slight modifications in the European theater. When Colonel Thompson was asked to recommend tables of organization and equipment for division psychiatrists, hospitals to be used as examination centers, and special general hospitals for neuropsychiatrists, he found it good practice to ask for Colonel Hanson’s advice with respect to these matters.

    An indication of the regard which Colonel Thompson had for Colonel Hanson may be found in the following letter which Colonel Thompson wrote to Colonel Hanson on 24 February 1944, after Colonel Hanson’s first return visit to the European theater:

    I should have written to you before this time to thank you for all time help which you gave psychiatry in this theater. The men at our N.P. hospitals are still talking about your visit and the good your talks did for the personnel. You certainly did help getting things over to Colonel Spruit, and the plans which we made with him are going forward in spite of the fact that he recently moved on to another assignment.
    Following Colonel Hanson’s second visit to the European theater, Colonel Thompson wrote, on 11 November 1944: “Once more let me say that your visit in this theater was extremely helpful and stimulating. We all look to you as the pioneer in things that we are now trying to do.”

    In concluding this section, the aid given by the British forces, the Morale Services of Army Service Forces, and the Adjutant General’s Office should be mentioned. Their contributions have been described in other parts of this survey. Colonel Thompson, in turn, found occasion to give advice and counsel to consultants in neuropsychiatry from the other Allied nations. The London office of the Rockefeller Foundation always maintained an enlightened and active interest in neuropsychiatric educational activities of the theater. The Josiah Macy, Jr., Foundation and the Institute of Living were always helpful in providing much needed literature.

    Finally, another passage from the report of the commission headed by Doctor Bartenmeier may he quoted here, for it summarizes the singular effectiveness of the arduous task of saving manpower and relieving neunropsychiatric losses as it was carried out in ETOUSA.64 The report reads:

    Among the most recent statistics which the commission have were those presented by Col. Lloyd J. Thompson, and Col. W. S. Middleton, at a meeting with Maj. Gen. Paul R. Hawley, the Chief Surgeon, and his consultants in Paris on 24 May 1945. The commission attended this meeting and learned that 17 percent of those casualties in the ETO who were returned to the Zone of Interior were suffering from neuropsychiatric disabilities. (This is in contrast to figures of 42 percent said to have been reported from other theaters.) The commission also learned that 80 percent of all NP. cases in ETOUSA have been returned to various kinds of military duty. Perhaps even more dramatic was the report from one of the special U.S. military hospitals to the effect that 5,000 men were returned to some kind of military duty from this installation during the period of one year. If these thousands had not been treated they would have presumably been lost to the theater and would have returned home chronically ill. It is the opinion of the commission that this report is a high tribute to the effective work of army psychiatrists.

64 See footnote 62, p. 392.



Lloyd J. Thompson, M.D.

    Perhaps the Senior Consultant in Neuropsychiatry, ETOUSA, should have been a chief consultant on a level with the Chief Consultants in Medicine and Surgery, ETOUSA. Such an arrangement would have been in keeping with the situation that existed in the Office of the Surgeon General. However, at no time during my 3 years in the European theater was there any difficulty in working “under” Colonel Middleton. In fact, on numerous occasions there were distinct advantages aind always I had the feeling of working “with” Colonel Middleton. With other personalities this might not have been true.

    I want to express again my great appreciation of the generous help and loyal cooperation given by Brigadier Rees of the Royal Army Medical Corps. Colonel van Nostrand of the Royal Canadian Army Medical Corps, and by their fellow officers throughout the war in Europe. In my first contact with Colonel Middleton I suggested that psychiatry should be concerned with prevention and the earliest possible treatment and should not wait for psychiatric casualties to be admitted to general hospitals. I soon found that the English and Canadian psychiatrists had been applying this idea since the begirmning of the war.

    My appreciation of the loyal and prodigious assistance given by the numerous neuropsychiatrists in our own army was expressed verbally and individually long ago but should be recorded here.

    The first great surprise and challenge that came after reporting for duty in August 1942 was the discovery that the position of division psychiatrist had been dropped from the table of organization some years previously. Having known several of the division psychiatrists of World War I and having heard their accounts, it seemed that this position would still be a key one, although the type of warfare had changed. Looking back on subsequent experiences, I feel certain that eacd division could have used two psychiatrists to great advantage. Of course, there was not the quantity of trained personne to permit even an experiment in this direction.

    Originally it was thought that when necessary, division neuropsychiatric casualties would be evacuated from the clearing stations to evacuation hospitals. Apparently, this was standard operating procedure. However, at this level a great deal of experimenting was done. The First U.S. Army pioneered (on the basis of experience in North Africa and Italy) in establishing exhaustion centers manned mostly by psychiatrists from the evacuation hospitals. In contrast, the Third U.S. Army kept psychiatric services in its evacuation hospitals, but established in one convalescent hospital a holding and treatment center fom neuropsychiatric patients. There were still other modifications of service at this level and arguments concerning the best plan may still be going on.  At the end of the war, it appeared that the Third U.S. Army plan had been best for its particular type of combat in its sweep from Normandy into Germany. In the First U.S. Army, as well as in the other armies where exhaustion centers


were established, their plan worked equally well and seemed suited to their functions.

    The establishment of the specialized neuropsychiatric hospitals just back of army areas, with their emphasis on rehabilitation, certainly had strong support from General Hawley regardless of opposition from other sources. The plan to have such a rehabilitation center just back of the First and Ninth U.S. Armies and another just back of the Third and Seventh U.S. Armies seemed logical. Because of delay in establishing these centers and because of their use for other purposes, the plan never came to full fruition. On the other hand, the specialized neuropsychiatric hospitals in England fulfilled their functions beyond expectation. While speaking of these neuropsychiatric hospitals, the brave action of Colonel Parsons, commanding officer of the 130th General Hospital, during the Battle of the Bulge should be recorded again and again. He remained behind as the only medical officer with patients who could not be evacuated while the German Army swept by and beyond his hospital.

    Having these separate neuropsychiatric units-exhaustion centers within the armies, rehabilitation hospitals just back of army areas as well as in England, and at the same time, adequate psychiatric services in evacuation, general, and even station hospitals-may have seemed like “having your cake and eating it, too.” Considering the magnitude of the psychiatric problems as well as the results obtained, this apparent overlapping seems to have been necessary.

    Psychiatric participation in organizations outside of Medical Department activities, such as replacement depots, and disciplinary centers was a much needed function that was fulfilled in a somewhat makeshift manner. Most of these functions had to be ‘‘sold’’ and when ‘‘bought’’ the lack of psychiatric personnel as well as of command backing often produced embarrassing situations.

    The formation of units for hard labor came as a surprise to psychiatrists and perhaps to the majority of medical officers. Who was to decide just which combat-exhaustion soldiers should be assigned to labor battalions and which should be treated as casualties and receive psychiatric care remained an open question. This unanswered question is of tremendous importance in all branches of the services and at all times. The answer lies not only in the moral fiber of the individual but in the atmosphere of morale, leadership, and motivation that surrounds the individual from the time of induction until signs of breakdown appear. In respect to this question, psychiatrists were often considered as being too soft. At times and under certain individual circumstances, such may have been the case. Generally speaking, however, we attempted to steer a common-sense middle course.

    The part played by the theater school of neuropsychiatry and other educational efforts is worthy of further commendation. The numerous division psychiatrists, ftontline medical officers, and many others who received indoctrination at the school were responsible for enhancing the success of the neuropsychiatric program. The accomplishments of Major Thomas and later Major Fabing in carrying out the mission of the school were far beyond expecta-


tions. They were ably assisted by other psychiatrists, but I shall not list their names for fear of slighting someone by an inadvertent omission.

    It remains my conviction that an assistant in the office of the theater senior consultant in neuropsychiatry could have been used to great advantage. An assistant in neurology was asked for, anticipating that this might be a neurropsychiatrist who would have adequate knowledge about neurology, electroencephalography, hospital organization, physical therapies, and even clinical psychology. Such an assistant could have carried on many functions while the senior consultant was out of the office.

    My visits to North Africa, from 13 November to 21 December 1943, and to the United States, from 12 December 1944 to 15 January 1945, were surely essential. Visitors coming into the theater contributed immeasurably to the neuropsychiatric and other programs, but it is to be recognized, without detracting from their valued assistance, that time had to be spent with them. The Surgeon General of the Army and the Air Surgeon, accompanied by Dr. Strecker, were present during March 1944. Colonel Menninger arrived in September 1944 for a tour of duty lasting about 6 weeks. His visit gave impetus to many sagging operations and started new ones. A group of visiting officers undcr Colonel Salisbury came early in April 1945 to study the functions of neuropsychiatry in the European theater. Their through investigations were extremely helpful. Before these visitors had departed, another group of civilian psychiatiists under Dr. Leo Bartemeier came for further studies. The latter group remained until 4 July 1945. Later, they produced a very valuable and well documented report on many aspects of neuropsychiatry in the European theater.

    The foregoing account concerning visits and visitors has been given mainly to record the great value received from those who came and stayed to help, as they did, but the account seems to indicate also that the senior consultant needed an assistant in his office.

    Acknowledging the betterment of neuropsychiatric services during the war in Korea but hoping that another war will never occur, wherein our examples will again have to be referred to, I want to close this brief personal summary by expressing thanks to and admiration for my immediate superior officers, Colonel Middleton, Colonel Kimbrough, and General Hawley.

Part IV. Senior Consultants in Infectious Diseases and Tuberculosis, and Medical Consultation in Subordinate Commands 65

    The preceding parts of this chapter first reviewed the overall medical consultant system in the European theater and continued with detailed dis-
65 The narrative for this part was compiled by Maj. James K. Arima, MSC, The Historical Unit, U.S. Army Medical  Service, In collaboration with Yale Kenneland, Jr., M.D., and Theodore L. Badger, M.D., former Senior Consultants In Infectious Diseases and Tuberculosis, ETOUSA, respectively. Drs. Kneeland and Badger contributed summaries in retrospect in mid-1956.


FIGURE 134.-Consultants in medicine, European theater. (Left) Lt. Col. (later Col.) Yale Kneeland, Jr., MC, Senior Consultant in Infectious Diseases, Office of the Chief Surgeon, ETOUSA; Consultant in Medicine, Office of the Surgeon, Southern Base Section; and Consultant in Medicine, Office of the Surgeon, United Kingdom Base. (Right) Lt. Col. (later Col.) Theodore L. Badger, MC, Senior Consultant in Tuberculosis, Office of the Chief Surgeon, ETOUSA; and Consultant in Medicine, Office of the Surgeon, Normandy Base Section, ETOUSA.

cussions of the work of the two full-time Senior Consultants in Dermatology and Neuropsychiatry, ETOUSA. Almost all the others-whether senior, base section, regional, or hospital center consultants-held dual positions.

    Col. Yale Kneeland, Jr., MC, Col. Theodore L. Badger, MC (fig. 134), and Cob. Gordon E. Hein, MC, the Senior Consultants in Infectious Diseases, Tuberculosis, and Cardiology, ETOUSA, differed in the role each played to a limited degree among themselves and to a considerable degree from the two full-time theater senior consultants, Colonels Pillsbury and Thompson. As a group, they were more concerned with the investigation of specific problems and the establishing of theater policy in their respective fields of specialization, while overall operational and administrative functions were assumed by the Chief Consultant in Medicine, ETOUSA, Colonel Middleton. No regional or hospital center consultants were appointed in medical specialties other than dermatology and syphilology and neuropsychiatry. Supervision and consultation at hospital and field army level were accomplished by regional, hospital center, or army consultants in general medicine. The regional and, later, hospital center consultants were, in turn, supervised by base section medical


consultants, who, for a major part of the active life of the theater, were also the theater senior consultants in their specialties.

    Finally, there were many medical officers with unusual talents assigned to specific projects or studies in conjunction with the solving of theater medical problems. Their participation in the theater’s consultant activities must be mentioned to round out this account.

    Accordingly, this final section of the history of medical consultants in the European theater will discuss the more significant medical problems in the context in which they occurred, except for those special fields already covered, in an endeavor to indicate the contribuntion of each consultant to the solution of a particular problem and to show in proper perspective the integrated functioning of the consultant system as a whole.

Atypical Pneumonia

    One of the first medical problems to strike the fledgling European theater was an increasing number of cases of atypical pneumonia in the early fall of 1942. At that time, the specific characteristics of the disease were far from common knowledge among members of the medical profession at large. It was only in the mid and late 1930’s that atypical pneumonia had been recognized as a distinct entity with an unknown causative agent, which was definitely not a pneumococcus. In both England and the United States, the resistance of some pneumonias to sulfonamide therapy had emphasized this distinction. The Secretary of War, upon recommendation by The Surgeon General, had appointeol a small civihiamm commission to study an epidemic of pneumonia at Camp Claibourne, La., in the summer of 1941. The commission concluded that the epidemic was one of atypical pneumonia. Following recommendations by this commission, The Surgeon General established the Commission on Acute Respiratory Diseases. As a result of preliminary studies by these bodies, the classification “Primary Atypical Pneumonia, Etiology Unknown” was added, for the first time in March 1942, to the list of diseases reportable on the weekly statistical health report.

    In the fall of 1942, the disease was appearing in ever-increasing numbers in the European theater. Cases occurring at this time were often mild, and symptoms varied considerably. There were no specific diagnostic manifestations to make identification simple. In spite of the usually benign course of the disease, convalescence was relatively bong, frequently requiring hospitalization for a month or more. Little was known of the residual effects of atypical pneumonia, and there was the possibility that some soldiers were being returned to duty without sufficient rehabilitation.

    On 20 October 1942, Coboneb J\Iiddbeton wrote to Air Commodore Alan F. Rook, RAF, asking for information on British experience with the disease. On 22 October 1942, Colonel Middleton wrote to each of the medical officers


who were concerned with the diagnosis and treatment of atypical pumeumonia in the theater’s three general and two station hospitals.66 He informed them of the incidence of atypical pneumonia in the five hospitals; told them of a survey being done by the Preventive Medicine Division with participation by the Professional Services Division, both in the Office of the Chief Surgeon, Headquarters, ETOUSA, and the assistance of the 3d Station Hospital; and concluded with the following:

Clinical, X-ray and laboratory observations must be accurately recorded to capitalize upon the current experience in the interests of better service to the soldiers. In the light of certain observations, it is suggested that X-rays of the chests of soldiers suffering from apparently mild respiratory infections be taken, particularly when they report from units in which atypical pneumonia has occurred. There is reason to believe that an appreciable percentage of these patients will show pneumoniitis to the X-ray. This office will serve as a clearing house for such clinical experiences as you may wish to report.

    By November 1942, the incidence of atypical pneumonia seemed to be reaching its peak. Medical officers at the hospitals continued to submit repoits in reply to Colonel Middleton’s letter of 22 October. On 21 November 1942, in a memorandum to General Hawley, Colomel Middleton recommended that a committee be appointed to coordinate and pursue the study of atypical pneumonia from its epidemiologic, clinical, and laboratory aspects, and suggested as members Colonel Kneeland, Colonel Gordon, and Major Muckenfuss. Colonel Kneeland was Chief, Medical Services, 2d General Hospital, and had been one of the members of the Secretary of War’s special commission which had made the preliminary investigations at Camp Claibourne, La., in 1941. Colonel Gordon was Chief, Preventive Medicine Division, Office of the Chief Surgeon, Headquarters, ETOUSA, and Major Muckenfuss, an experienced virologist, was Commanding Officer, General Medical Laboratory A.

    General Hawley quickly approved the proposal, and Special Order No. 23 establishing the committee was published by the Office of the Chief Surgeon, Headquarters, ETOUSA, on 23 November 1942.

    With Colonel Kneeland serving as president and chairman, Major Muckenfuss as the recorder, and Colonel Gordon as the third member, the committee met at General Medical Laboratory A on 12-13 December 1942. First, the committee decided that a circular letter should be prepared embodying material recently published in War Medicine 67 and directing that undue incidence should be reported directly to General Hawley’s office. This directive was to be prepared by Colonel Gordon and to be published by General Hawley. Next, the committee considered the possibility of there being a change in clinical character of this disease and a greater influence of secondary infection in the days to come. Colonel Kneeland agreed to discuss with the necessary individuals the need to observe cases closely for such changes. Finally, it
66 Letter, Lt. Col. Wm. S. Middleton, to Lt. Col. Yale Kneeland, 2d General Hospital, Lt. Col. T. H. Badger, 5th General Hospital, Lt. Col. Gordon E. Hein, 30th General Hospital, Maj. James R. May, 3d Station Hospital, and Capt. Sidney G. Page, Jr., 151st Station Hospital, 22 Oct. 1942, subject: Incidence of Atypical Pneumonia.
67 Moore, G. B., Jr., Tannenbaum, A. J., and Smaha, T. G.: Atypical Pneumonia in an Army Camp. War Med. 2: 61.5, 1942.


was resolved that laboratory investigations directed towards identification of the etiologic agent should be governed by the general principle of doing only those things that could be carried out to advantage in a theater of operations, avoiding the intensive type of investigation that would duplicate studies under way by the special commission in the Zone of Interior. Direction of laboratory investigations on the disease in the European theater was the province of Major Muckenfuss.

    The circular letter on atypical pneumonia was completely in December and published by the Office of the Chief Surgeon, Headquarters, ETOUSA, on 7 January 1943, as Circular Letter No. 2. It gave a brief history of the disease; noted prevailing epidemiologic factors; discussed clinical features, differential diagnosis, management of hospital cases, pathologic studies, and related virus infections; and closed with a paragraph on special reporting procedures. The medical officer responsible for the medical service of a company, or a detachment of similar size, was ordered to report directly to the Office of the Chief Surgeon, Headquarters, ETOUSA, by telephone the occurrence of three or more cases of primary atypical pneumonia within 1 week in the company or detachment concerned. Likewise, whenever a hospital admitted three or more cases in any one week from a company or detachment, the hospital commander was directed to report the fact by telephone directly to the Office of the Chief Surgeon, Headquarters, ETOUSA.

    In the meanwhile, Lt. Cob. Joseph C. Turner, MC, 2d General Hospital, had been assigned to Medical General Laboratory A to conduct laboratory studies on atypical pneumonia. By mid-February 1943, he had made a discovery that appeared to throw light on the immunology of the disease. On 16 February 1943, Colonel Kneeland wrote to Colonel Gordon as follows:

    Thanks ever so much for your letter reporting on Atypical Pneumonia. The disease seems to have dried up here except for one very seriously ill officer-which is rather bad luck, for Joe Turner has just got hold of a serological change which, if it turns up in other cases of the disease, might be very interesting indeed. He’s going over to the 2d Evac. tomorrow to get blood from their new cases, and if the thing looks promising he’ll be very anxious for more material. Therefore, do you suppose you could let me know of any new cases you hear of, particularly severe ones?

    In reply, Colonel Gordon was able to provide Colonel Kneeland immediately with “what is essentially a complete list of atypical pneumonia cases since Feb. 1st.”

    By the end of April 1943, Colonel Turner had gathered enough data to show with considerable reliability that there was an increase in cold agglutinins (autohemagglutinins) in patients convalescent from primary atypical pneumonia. The minutes of the 30 April 1943 meeting of the Chief Surgeon’s Consultant Committee, record Colonel Middleton reporting as follows: “It has been shown that there is a development of cold agglutinins after one week of illness, with a building-up and then subsequent falling-off. The process is found in a few other conditions and may have wider ramifications and contribute to our knowledge of immunology.” Colonel Turner was able to publish


his findings in a British publication 68 at about the same time that the results of independent studies on the phenomenon were published in the United States 69

    The studies conducted in ETOUSA demonstrated again the place of research in a theater of operations during wartime. Soon after the results had been obtained, the technique of a cold-agglutinin test as a promising aid in the differential diagnosis of pneumonia was promulgated in the European theater.70 Had this preliminary work not been done, months might have elapsed before the theater could have put the test to practical use, and, by that time, the invasion of the European Continent would have precluded any efficient trial of the method.

    Prior to publication of the technique, the atypical pneumonia committee had met at the 1st Medical General Laboratory (fig. 135) on 19 September 1943 to consider the accummulated data on atypical pneumonia and to plan further studies, with Colonel Turner attending by invitation. The committee agreed to arrange for the collection of a large amount of data on the incidence of cases showing a rise in titer of cold agglutinins during the disease. The purpose was to obtain additional information as to the clinical value of the tests and also to accumulate records that might be used later in determining the incidence of second attacks. It was realized that there were no existing data on the question of immunity conferred by one attack of the disease. The conferees also suggested that another way to study active immunity would be to have medical officers make a special effort, in cases of atypical pneumonia, to determine by careful history taking whether the patient had ever had a previous attack. Finally, the committee suggested that the chiefs of medical services of hospitals be urged to keep the bacterial flora of the sputum from patients with atypical pneumonia under as close scrutiny as the hospital laboratory facilities would permit. It was considered important to bear constantly in mind the possibility of secondary bacterial infection and, in particular, to note any preponderant micro-organism.

    In the spring of 1944, there was a sharp rise in the incidence of both atypical and lobar pneumonia without the rise in the common respiratory diseases or influenza such as commonly precedes an increased incidence of primary bacterial pneumonia. It was believed that much of the reported incidence of lobar pneumonia was due to a misdiagnosis of cases of primary atypical pneumonia. During March and April of 1944, the incidence of primary atypical pneumonia reached mild epidemic proportions but did not reach the peak of 1942. The disease always remained an important consideration in medical planning, however, because it did not have a seasonal distribution.

68 Turner, J. C.: Development of Cold Agglutinins in Atypical Pneumonia. Nature, London 151:419, 1943.
69 Peterson, O. L., Ham, T. H., and Finland, M.: Cold Agglutinins (Autohemagglutinins) in Primary Atypical Pneumonias. Science 97: 167, 1943.
70 Letter, Office of the Chief Surgeon, Headquarters, ETOUSA, to surgeons of all base sections and commanding officers of all U.S Army hospitals, 24 Nov. 1943, subject: Technique of Cold Agglutinin Test for Use in Differential Diagnosis of Pneumonia.


FIGURE 135.-1st Medical General Laboratory (foreground) and town of Salisbury, Wiltshire, England, 1914.

    In the European theater, efforts to study atypical pneumonia contributed to increased efficiency in diagnosis and better care of the sick soldier. Considerable data were collected, but no important conclusions could be drawn during the war years. However, the studies conducted by the U.S. Army in the United Kingdom and the attention the Army gave to the disease probably contributed also to the increased interest and better understanding of atypical pneumonia on the part of British medicine, both military and civilian.


    In World War I, rigid physical examinations of recruits had excluded from service some 50,000 men. Neventheless, more than 2,000 men had died of tuberculosis in the Army, and the admission rate in Army hospitals had averaged 19 per 1,000 troops per year. Tuberculosis was the leading cause of discharge for disability because of disease. 71 In the period between the two wars, much had been learned about the pathogenesis of tuberculosis and much was done to establish the superiority of roentgenographic to physical examination for screening. In the Second World War, however, information available

71 The Medical Department of the United States Army in the World War. Communicable and Other Diseases. Washington: U.S. Government Printing Office, 1928, vol. IX.


in the European theater indicated that only 51 percent of recruits called to induction stations before March 1941 had been examined by X-ray and that large numbers had not been done up to January 1942. It was not until after Mobilization Regulations 1-9, dated 15 March 1942, were put into effect that routine roentgenograms were made of the chest of all inductees.72

    There was clearly need for an early assessment of the tuberculosis problem in the European theater. Accepting the recommendations of Colonel Middleton, General Hawley, on 2 January 1943, appointed Colonel Badger, Chief, Medical Service, 5th General Hospital, as Senior Consultant in Tuberculosis, ETOUSA.

    Colonel Badger appraised the tuberculosis situation and, in a letter to Colonel Middleton on 8 February 1943, reported that the British Army was not using preenlistment X-ray screening. During the first 2 years of war, Colonel Badger found that 86 percent of tuberculosis in the British Army had appeared within the first year and 41 percent during the first month of active training. The British had considered using mobile X-ray units, but nothing had been done to implement their use as of February 1943, except in the Royal Air Force, which was screening all enlistments with 35-mm. fluorographic units. Wing Comdr. R. R. Trail, RAF, insisted that the procedure be supervised and run by medical officers with wide experience in clinical chest disease; there was also a radiologic adviser to each X-ray unit. Two very significant facts learned also by Colonel Badger were these: (1) Fresh milk in the United Kingdom was not being pasteurized, and 11 to 20 percent of fluid milk contained viable tubercle bacilli; and (2) manpower problems required the Royal Army to sort cases with very minimal lung lesions into those unfit for service, those fit for light work, and those fit for only sedentary jobs.

    Colonel Badger reported that the Canadian Army, on the other hand, was examining all candidates by X-ray and was rejecting approximately I percent. A report by a Canadian Army medical officer in 1942 showed that, of 104 cases of tuberculosis which developed in personnel while they were in the Army, 92 percent occurred in soldiers with a negative preenlistment X-ray. The Canadians had attempted no mass X-ray surveys after original preenlistment screening, but contacts of open cases were being examined by X-ray, and active cases were being boarded back to Canada. Like the British, the Canadian Army studied small lesions at their general hospital in the United Kingdom and, wherever possible, reclassified for duty patients with such lesions.

    In his report, Colonel Badger estimated that the tuberculosis hazards for U.S. Army troops would be as follows: (1) Early exacerbation of subclinical cases admitted to service withount X-ray of the lungs; (2) association with unscreened British’ troops and civilians; (3) drinking of infected milk; (4) the effects of combat such as excessive fatigue, changes of nutrition with

72 (1) Long, E. R.: War and Tuberculosis. Am. Rev. Tuberc. 45: 616, 1942. (2) Long, E. R., and Jablon, S.: Tuberculosis in the Army of the United States in World War II-An Epidemiologieal Study with an Evaluation of X-ray Screening. Washington: U.S. Government Printing Office, 1955.


marked loss of weight, and malnutrition; and (5) time yet undetermined effects of intercurrent respiratory infection.

    Colonel Badger reported these facts at the Chief Surgeon’s Consultant Committee meeting of 5 February 1943. In addition, he reported a reversal in the ratio of pleurisy with effusion to parenchymal involvement as compared with the usual ratio found in civilians. Reliable data could only be obtained by spot surveys with fixed equipment already in medical installations. He indicated that surveys of field units that had been in the theater 1 year or more and of units that had only been in Europe 6 months would be desirable. Colonel Badger estimated that these surveys would involve 2,000 or more chest films.

    When asked whether the use of microfilms was feasible, Colonel Badger replied that they were less accurate than full-sized films. General Hawley said that getting 2,000 or more people into a hospital for X-ray examination would dislocate training and other hospital activities. He agreed to the survey only if it could be done by going into camps with a mobile apparatus and using it, perhaps after supper, without causing any dislocation of the work and routine of troops. He suggested that the developing could be done at the nearest hospital during the day. Colonel Kimbrough, Chief, Professional Services Division in General Hawley’s office, said that Lt. Col. (later Col.) Kenneth D. A. Allen, MC, Senior Consultant in Radiology, ETOUSA, and the Operations and Training Division, Office of the Chief Surgeon, Headquarters, ETOUSA, could work out a suitable portable apparatus. Colonel Cutler, the theater chief consultant in surgery, asked if a survey of hospital personnel would suffice, and Colonel Badger replied that he thought not; he himself, had in mind a survey of the 29th Infantry Division. General Hawley agreed that it would be profitable to screen such men as the labor troops and the engineers who had been working in the mud. Colonel Badger then specifically asked General Hawley if he (Colonel Badger) had the authority of General Hawley to obtain a portable apparatus and embark on the survey. General Hawley assented but said that before Colonel Badger went into any divisions, he (General Hawley) would first like to write to the division surgeons for concurrence.

    Colonel Badger then raised the question of milk and food being provided U.S. troops by American Red Cross canteens, saying he had observed fresh cow’s milk being served to troops (fig. 136). He recommended inspection of premises and employees wherever U.S. soldiers were served food. General Hawley said that he would take up the matter with the American Red Cross comissioner in Great Britain and would ask for some sort of sanitary control over the milk, foodhandlers, and sanitation in American Red Cross establishments.

    There remained two problems to be settled before Colonel Badger could embark on his spot survey. One was the matter of obtaining permission to enter a unit to conduct the survey, and the second was the creation of a


FIGURE 136.-The Washington Club, premier American Red Cross club, London, July 1942.

mobile X-ray unit. Regarding the former, Colonel Middleton conferred further with Col. Oramel H. Stanley, MC, Deputy Surgeon, Headquarters, Services of Supply, ETOUSA, who thought it would be desirable to avoid official channels of communication on such a matter. In order to proceed with the survey, it was agreed that Colonel Badger should write to the surgeon of a major command or the commanding officer of a smaller unit, as appropriate to the case, and request permission to take chest X-rays for a turberculosis survey which had been authorized by General Hawley. Colonel Stanley believed that General Hawley would approve this procedure, and General Hawley did approve it at a later date.

    Colonel Middleton also asked Colonel Allen for guidance in assembling a portable X-ray unit and for advice in the technical aspects of taking, developimig, and interpreting roentgenograms. Colonel Allen was more than willing to help since he hoped, in the future, to establish mobile field X-ray units himself. Colonel Badger embarked on the program in late February 1943. He met only the most cordial acceptance of his proposals for making


tuberculosis surveys in units. For example, Cob. C. W. Brenn, MC, Surgeon, V Corps, wrote to Colonel Badger on 22 February 1943, as follows:

    1. The Chief of Staff, V Corps (Reinf.) has granted authority for you to personally contact commanding officers of units where you wish to make X-ray and/or other surveys, and to make such arrangements as may be mutually acceptable.

    2. It is suggested that you present a copy of this letter when first contacting a unit commander.

    The mobile X-ray unit was quickly assembled using equipment and personnel available at the 5th General Hospital (fig. 137). Capt. (later Lt. Col.) Magnus I. Smedal, MC, Chief, X-ray Service, 5th General Hospital, took an active interest in setting up this equipment, and his help later in reading the X-rays was an indispensable contribution. The commanding officer, Colonel Keeber, gave the project his wholehearted support.

    As eventually constituted at the 5th General Hospital, the mobile X-ray unit, which was composed of a standard Picker portable X-ray unit and a Clark-field tent, was transported in a 1/2 ton truck and set up in a vacant Nissen hut at the unit surveyed. The equipment, when packed, measured 67 1/4 cubic feet and weighed 1,663 pounds. One carryall was used to transport the team of 1 officer and 7 enlisted men. Of the latter, 1 was an X-ray operator; 2 were darkroom workers and plate changers; 1 functioned as the runner, cassette carrier, and truck driver; 1 prepared number strips; 1 positioned markers; and 1 was a noncommissioned officer who maintained records.

    The unit was customarily set up and working within an hour after arrival. Chest films, 14 x 17 inches, were taken at the average rate of 90 an hour, including a 10-minute stop each hour to rest the team. The maximum number of X-rays taken per hour was 137. The team was carefully trained in the technique of rapid mass production and worked with great efficiency. All roentgenograms were developed at the 5th General Hospital and were interpreted there by Colonel Badger nmntl Captain Smedal.73

    During the months of February and March 1943, a total of 2,542 persons was examined. Troops from fixed and field medical units, combat engineers, and the infantry made up the sample. In a letter dated 27 April 1943 to Colonel Middleton, Colonel Badger reported on the results of the survey and noted, as follows:

    * * * The incidence of re-infection tuberculosis of 0.9 percent is not bad. I, of course, do not have the clinical check-up of all these cases, but repeated X-rays of not less than a month apart show either no changed parenchymal processes or by stereoscopic vision the lesions are revealed as dense fibro-calcific affairs.

    Some of those about which I feel somewhat concerned I have carefully avoided calling “healed” lesions. I have requested a re-X-ray of the doubtful ones again in two months, and met with only the greatest co-operation and interest. My impression in regard to this problem at the moment has not changed from the recommendations which were submitted at the last meeting. If there is any question of movement in the 29th Division it may be wise to call in two of their men from strenuous field duty.

73 Letter, Senior Consultant in Tuberculosis, to Chief Medical Consultant, ETOUSA, 17 Dec. 1943, subject: Annual Report of Division of Tuberculosis.


FIGURE 137.-Demonstration of mobile X-ray unit assembled at 5th General Hospital.
    I am planning to send to each of those units a report of the X-ray findings also so that they may be incorporated in their Service Records.

    In  his efforts to collect additional data on the tuberculosis sitiuation, Colonel Badger sent out followup letters to the 112th and 342d Engineers, the 53d Medical Battalion, and the 115th Infantry, 29th Infantry Division, on suspected caes of tuberculosis. He also asked for and received, through the Medical Records Division, Office of the Chief Surgeon, Headquarters, ETOUSA, a table showing incidence of tuberculosis in the Iceland Base Command from 20 November 1942 to 9 April 1943. A survey of the 30th General Hospital was completed, and additional enlisted men from the 53d Medical Battalion and the 5th General Hospital were examined by X-ray to complete the survey of those units. Particular attention was given to the survey of nurses in the general hospitals because of their known accessibility to infection. Colonel Badger proposed a  survey of nurses of the l0th Station Hospital, but Colonel Middleton disapproved this plan for reasons which clearly expressed the purpose and limits of the spot survey. On 20 March 1943, Colonel Middleton wrote to Colonel Badger, as follows:

    With the completion of the survey of the nursing personnel of the 5th and 30th General Hospitals, you will have a total of 138 subjects, which figure represents over 10 percent of the Army Nursing Corps in this Theater. This ratio will be far higher than the general


group. Furthermore, the conditions surrounding the 10th Station Hospital nursing personnel are largely duplicated in the 5th General nursing group.

    For these obvious reasons and the necessity of keeping this original spot survey within reasonable limits, the project to X-ray the 47 nurses of the 10th Station Hospital is disapproved.

    As the problem is evolved on the completion of the initial spot survey, the over-all policy for the Theater will be evolved, so that no group will be neglected in the long run.

    On 8 June 1943, Colonel Badger also arranged with the Medical Records Division in General Hawley’s office to obtain information as to final diagnosis of hmospital admissions in time European theater initially diagnosed as pleurisy, tuberculosis, hemoptysis, and spontaneous pneumothorax. Colonel Badger prepared a list of all patients on whom he wanted the information, giving the names of each, their diagnosis, and the hospitals to which they had been admitted.

    When all these additional data were assembled and amalgamated with the original data, the total sample of officers, nurses, and enlisted men examined roentgenograpimically amounted to 3,031 cases (fig. 138). Of these, 2,143 (approximately 71 percent) had entirely negative X-ray films. Only 35 cases of reinfection tuberculosis were found (1.1 percent of time total). In April 1943 when Colonel Badger made his report to Colonel Middleton, the followup of these 35 lesions of reinfection was still being carried out, and final results were pending X-ray examination of units that had been on the move. Only 1 of these 35 cases was classified as minimal active tuberculosis, but it had not been necessary to remove any individual from duty because of X-ray findings. In addition to Captain Smedal, Capt. (later Maj.) Samuel P. Asper, Jr., MC, 5th General Hospital, had helped considerably in this phase of the tuberculosis survey. A complete analysis of these data was submitted in an interim report by Colonel Badger to Colonel Middleton who, in turn, had the report forwarded to The Surgeon General.

    At the meeting of the Medical Consultants Subcommittee held on 25 June 1943, Colonel Middleton reported that Colonel Badger had found no evidence of a need for a mass survey at this time but had recommended that another spot survey be carried out in September or October 1943. Specific recommendations regarding a mass survey would be withheld until after the next spot survey which might lead to the establishment of an overall policy for the theater. Also at the meeting, Colonel Middleton suggested that a separate project consisting of X-ray examination of soldiers in the 29th Infantry Division who had had no previous chest films might be carried out.

    Col. Esmond R. Long, Consultant in Tuberculosis to The Surgeon General, on 11 August 1943, in acknowledging receipt of Colonel Badger’s interim report noted that:

    * * * In the 3,031 persons examined, 1.1 percent had evidence of re-infection type tuberculosis in their X-ray films. It is gratifying to note that 90 percent of the cases discovered were in the minimal stage, and that of the entire group of 35 cases, only five were considered to be clinically significant.


FIGURE 138.-Col. Theodore L. Badger, MC, examining chest X-ray films in connection with the tuberculosis survey, 5th General Hospital, Salisbury, Wiltshire, England, 1 May 1943.

Attention is called to the fact that the arrested parenchymal lesions noted do not necessarily represent induction errors. Mobilization Regulations 1-9 permit acceptance of men with arrested tuberculous lesions of minimal extent, provided they do not exceed 5 sq. cm. in total area in flat films, and their stability has been established by study of a series of films. Similar regulations apply in the case of officers.

Further data, indicating the results of followup on these cases, are awaited by this office with interest.

Colonel Badger had expressed the opinion at the 25 June 1943 meeting of the Medical Consultants Subcommittee that not all patients with minimal lesions need be returned to the Zone of Interior, and Colonel Middleton had asked him to prepare an outline of proposals for dealing with patients with minimal lesions. Colonel Badger had then attempted to draw up criteria for dealing with these patients in terms of the formula of the 5-sq.-cm. area mentioned by Colonel Long. Both Colonel Middleton and Colonel Allen objected to a simple mathematical formula as the sole criterion. On 25 August 1943, Colonel Middleton wrote to Colonel Badger, as follows:

If you share my objections to this criterion of the diameter of calcified lesions, you will certainly add some qualifications, such as the clinical history of probable activity and the age of the subject. Colonel Allen has suggested a 30 year limit, but the final definition is in your hands. What I am driving at is avoidance of a definition that fails to take into account the vital pictures of biologic resistance, and attempts to fix eligibility according to mathematical rules.


Final decision had to await the results of the second spot survey, planned for September or October 1943. The survey was carried out as scheduled in generally the same manner as the first, except that it concentrated upon medical and infantry troops-the 49th and 168th Station Hospitals and the 5th Infantry Division-recently arrived in the United Kingdom after considerable service in Iceland. In addition, considerable numbers of personnel from units in the Eighth Air Force were also examined by X-ray. Total examinations amounted to 3,634 roentgenograins of the chest. The results again indicated that there was no significant incidemice of unrecognized tuberculosis among U.S. troops, that a mass survey was not indicated at that time, and that periodic spot surveys were the most appropriate means of determining whether an significant changes in the incidence of tuberculosis had occurred.74

In this second survey, X-ray examination of the personnel of the 49th Station Hospital in Scotland was conducted by that hospital, and the plates were then forwarded to Colonel Badger and Major Smedal for reading. Another innovation concerned the field trial of an experimental auxiliary X-ray unit established by Colonel Allen. Sometime before the survey was begun, Colonel Middleton also wrote, in his letter of 25 August 1943 to Colonel Badger, as follows:

I am pleased that you are affording Colonel Allen an opportunity of testing his field unit at the time of your next survey. From the personal conversations, I realize that he is loath to make such requests, in fear that you may think that he wishes to encroach upon your provinces. I know that he has no such design but visualizes this is the only project in which he can test his field unit to a useful end without setting up an artificial program.

On 21 September 1943 in a formal letter from the Office of the Chief Surgeon, Headquarters, ETOUSA, to the Surgeon, Southern Base Section, it was requested that Colonel Badger give an experimental auxiliary X-ray unit a 30-day field test and report on the adequacy of the equipment and the quality of the technical work performed. Unfortunately, Colonel Allen was on temporary duty in the North African theater during the latter part of September and the first half of October 1943 ; thus, when the auxiliary X-ray unit (fig. 139) was turned over to Colonel Badger, equipment difficulties had not yet been satisfactorily resolved, and the three enlisted technicians were not yet adequately trained. As a result, no field trials were conducted, but Colonel Badger was able to experiment further with the equipment, train the enlisted men and make recommendations for modification.75

During the period of this second survey, the 35 individuals with parenchymal lesions previously discovered were followed up through Colonel Long, who wits able to trace 13 preinduction X-rays and to reinterpret them in the light of subsequent findings in the European theater. No significant differences were noted, and there were only minor variations of interpretation, owing to poor X-ray films. This small study confirmed the accuracy of procedures being used in the European theater that showed that very little of importance

74 See footnote 73, p. 406.

75 Eventually, 12 auxiliary x-ray units were employed during combat in the European theater.


FIGURE 139.-Col. Kenneth D. A. Allen’s mobile auxiliary X-ray unit set up in the field.

had been permitted to escape the induction screening. Those who had escaped detection presented for the most part old fibrotic, apparently healed lesions, which had not broken down in an oversea theater.76

Within less than 1 year, considerable data had been assembled from the two spot surveys and the collateral studies. In addition, a special series of 578 chest films had been made on prsonnel of the Woman’s Army Corps in England. The total number of individuals examined by X-ray amounted to 7,243. The senior consultant in tuberculosis could now, with assurance, submit recommendations for the establishment of theater policy on the disposition of tuberculous patients. This he did on 12 November 1943, in a letter to Colonel Middleton, who concurred in all but one detail; namely, the place of gastric washings in the diagnosis of tuberculosis. ‘‘If we are to take the position that any essential element in laboratory diagnosis is a ‘burden’,’’ Colonel Middleton wrote to Colonel Badger, on 15 November 1943, “we close our doors to certain invaluable aids.’’

    On 28 December 1943, Colonel Badger, in submitting to Colonel Middleton revised recommendations in which the ultimate decision for disposition was placed on the individual examiner, wrote the following:

No fixed scheme of classification for disposition of tuberculosis covers every case of disease. Therefore the following criteria for disposition diverge from MR 1-9 on the basis

76 (1) See footnote 73, p. 406. (2) letter, Senior Consultant in Tuberculosis, ETOUSA, to Office of the Surgeon General, att: Chief of Division of Tuberculosis (Thru: Office of the Chief Surgeon, Headquarters, ETOUSA), 14 Nov. 1943, subject: X-ray of Soldiers in ETO Compared With Interpretation of Induction X-rays.


of experience gained in the E.T.O. They are presented to serve as an objective basis on which the examiner may make his decision of disposition in an active theater of operations.

Certain of the lesions described present a precarious prognosis unless followed carefully over a period of months by clinical and X-ray observation. Under battle conditions in this theater such follow-up would be difficult if not entirely impossible and the evaluation of parenchymal lesions must be carried out to the best of the ability and wisdom of the examiner at a single hospital period of observation.

In addition, Colonel Badger gave detailed recommendations for (1) cases to be boarded to the Zone of Interior, (2) cases to be returned to full duty, (3) cases to be returned to noncombat duty, (4) a yardstick to determine activity in small lesions of doubtful stability, and (5) procedures for the follow up under battle conditions of individuals with small tuberculous lesions.

The revised recommendations were approved by Colonel Middleton on 9 January 1944. The salient points were published on 22 February 1944 in Administrative Memorandum No. 22, the Office of the Chief Surgeon, Headquarters, ETOUSA, to surgeons of all base sections and commanding officers of all U.S. Army hospitals. The yardstick for determination of activity in small lesions of doubtful stability, published as paragraph 6 of the directive, was as follows:

* * * The clinical, laboratory and X-ray study necessary to clarify the status of the small parenchymal lesion, thought to be tuberculosis, should fulfill the following minimal standards:

a. Hospitalization for at least a week, with limited ward activity.

 b. Complete history and physical examination with special reference to tuberculosis or other pulmonary background.

c. Four hourly temperature, pulse and respiration, which will be charted for clearer detection of elevations.

d. X-ray and fluoroscopic study of the lungs on the 1st and 7th day of admission.

e. Complete blood and urine examination.

f. Sputum examination daily for tubercle bacilli, except where sputum is scanty, repeated 3-day concentrated specimens will be used.

In addition, sedimentation rate, aspiration of gastric contents only with guinea-pig inoculation, and the tuberculin test were listed as additional procedures, not necessary routine. The directive concluded with the following paragraph:

X-ray and clinical follow-up of individuals with small tuberculous lesions in this theater Battle conditions in this theater do not permit of clinical and X-ray observation for follow-up. The proper evaluation of these parenchymal lesions depends upon the ability and wisdom of examiner during a single hospital period of observation using paragraph 6 as the basic yardstick for evaluation of these lesions not proven to be active tuberculosis. Individuals presenting an undue risk of reactivation or who may become a source of tuberculous infection will be evacuated to ZI.

In addition to the directive, Colonel Badger prepared an article for the Medical Bulletin, European Theater of Operations. This article explained the underlying considerations for the decisions that had been made and elaborated on some of the finer points of the directive.



On 12 July 1943, a letter from the Office of the Chief Surgeon, Headquarters, ETOUSA, instructed commanding officers of all U.S. Army hospitals and general dispensaries to send to time 298th General Hospital all allergic patients under their care who required greater diagnostic and therapeutic facilities, making the necessary arrangements in advance with time Commanding Officer, 298th General Hospital.

The 298th General Hospital was an affiliated unit from the University of Michigan. Lt. Col. (later Col.) John McF. Sheldon, MC, Chief, Medical Service, 298th General Hospital, had brought with him a small but representative selection of testing extracts as well as some therapeutic material from the allergy clinic of the University of Michigan Hospital. Previous to the designation of this hospital as the allergy center, a number of allergic inpatients and outpatients had been seen by Colonel Sheldon. When it became apparent that allergic manifestations would present an increasing medical problem, more material for skin testing and desensitization had been acquired from the University of Michigan Hospital, and Colonel Sheldon was also able to obtain additional diagnostic British grass pollen from Dr. David A. Williams, Llandough Hospital, Cardiff, South Wales.77 Thus, the opportune combination of the foresightedness and initiative of an individual medical officer and the affiliation of the unit with a university hospital had made possible a specialized allergy center.

In evaluating the hay fever problem, Colonel Sheldon said, at the second conference of the chiefs of medical services held on 30 July 1943:

It is a seasonal disease, particularly in reference to pollinosis. It is only within the past year that Dr. Williams, University of South Wales, has carried out adequate observations throughout a large portion of the country. His information is not published. He has shown me his data. Particularly the grass family and specifically those closely pathologically related to Timothy produce pollens for a rather short season, approximately 6 weeks. Our experience this year has follow-ed this pattern. We had rather a high rise in late June, which dropped in July. Timothy, plantain and the orchard grass group seemed to be the predominant offenders. * * * We do not expect to have any important seasonal pollinosis, with the exception of that occasional case of hay sensitivity. We do not expect any of those patients w-ho had difficulty with time ragweed family at home to have any trouble here. Grass sensitive people have just as severe symptoms here as in the States. I do not believe that it is a great problem. There is also a question of sensitivity to that unknown factor that occurs in old houses. These patients respond markedly to dust extracts.

    Following Colonel Sheldon’s remarks, Colonel Middleton commented: “We have not enough men or materials to duplicate the study of sensitivity in many centers. For the time being those patients who do not respond to ordinary measures should be sent to the 298th General Hospital.”

    During the first 6 months that the allergy clinic was operating at this hospital, 293 consultations were held, and 98 cases of bronchial asthma were evacuated to the Zone of Interior. In 1944, the 298th General Hospital planned

77 Annual Report, 298th General Hospital, European Theater of Operations, United States Army, 1943.


to have a separate ward for allergy and bronchial asthma patients. The anticipated greater need for diagnostic and treatment materials precluded continuation of the former informal means of obtaining them; requisitions were made through regular medical supply channels instead. Preparations for the invasion of the Continent and a change in mission for the hospital, however, prevented carrying through many aspects of these plans.78


At a meeting of the Inter-Allied Conferences on War Medicine, Colonel Middleton reported the following: “In November 1943, an ominous situation confronted us in an explosive epidemic of virus A influenza. Fortunately it was an inter-pandemic episode, free from complications and mortality. Had it been the first wave of a true pandemic, the invasion of the Continent would have been handicapped by the second and complicated sequence.” 79

Epidemic influenza in England had been appearing in the odd-numbered years with a larger wave every fourth year. According to this schedule, a moderate outbreak should have occurred in January 1943 and a severe outbreak in January 1945. Had this expected influenza visitation of January 1945 actually come about, its effects would have been severely felt by the U.S. Army whose hospitals, at that time, were filled to capacity with surgical and cold injury cases.80

As it was, the Committee on Infectious Diseases composed of Colonels Kneeland, Gordon, and Muckenfuss, at its meeting of 19 September 1943 (p. 401), had already made preliminary plans in anticipation of the occurrence of influenza. The committee had suggested the following:

In view of the fact that influenza may at any time become an important cause of disability (and with the experience of the last war in mind), it is considered wise to keep a close watch on influenza-like conditions under treatment in hospitals. Here one is confronted with a disease where definition is extremely difficult, and in which routine reports may give a thoroughly misleading picture. As the appraisal of influenza requires a uniform critique it was suggested that the consultant make periodic visits to station hospitals in order to keep abreast of the situation.81

As with atypical pneumonia, the committee thought that, under the direction of Colonel Kneeland, it would be wise to collect limited amounts of sera for antibody determination. Limited-scale virus studies could then be made by Capt. (later Lt. Col.) Joseph E. Smadel, MC, at the 1st Medical General Laboratory.

Just as the committee had anticipated, indications of influenza appeared first in the fixed hospitals of the theater. The 108th, 32d, and 5th General

78 Annual Reports, 298th General hospital, 1943 and 1944.

79 Inter-Allied Conferences on War Medicine. Progress in War Medicine Since 1939, sec. XIII. Edited by H. L. Tidy. London: Staples Press, 1943.

80 The full implications of what would have occurred and observations on what actually transpired have been described by Colonel Kneeland in the chapter on respiratory diseases in “Medical Department, United States Army, Internal Medicine in World War II. Volume II. Infectious Diseases.” [In preparation.]

81 Letter, Lt. Col. Yale Kneeland, Senior Consultant in Infectious Diseases, to Col. William S. Middleton, Chief Consultant in Medicine, ETOUSA, 27 Oct. 1943, subject: Meeting of the Atypical Pneumonia Board.


Hospitals and the 130th Station Hospital reported almost simultaneously a significant change in the clinical expression of respiratory diseases during the first week in November. Major Smadel established marked increase in the titer of antibodies to virus A in typical subjects of the epidemic disease. 82

Colonel Kneeland, attending the Chief Surgeon’s Consultant Committee meeting of 22 November 1943, commented on the spread of influenza in the U.S. and British Armies in the theater, where it had aroused a great deal of interest and some alarm. He assured the conferees that there was no reason to regard this epidemic as anything like that of 1918. He said that a brief note was being published in the Medical Bulletin of the European theater and that a directive was being promulgated.

    The directive, he said, would first cover clinical aspects of the disease, pointing out that it is mild and almost invariably uncomplicated. Medical officers would be exhorted to give the term “influenza” a fairly limited and precise significance, applying the diagnosis on epidemiologic grounds to an explosive disease of the clinical character described, occurring in groups and not in isolated cases. The directive would emphasize that the precise identification of the etiologic agent could only be made by a study of antibody titers in convalescents as opposed to acute symptoms in the clinical case. Because only a limited number of these examinations could be made at the 1st Medical General Laboratory, it was urged that serum specimens be sent through channels, while the 1st Medical General Laboratory should be consulted as to the desirability of submitting samples from various types of cases. Finally, Colonel Kneeland reported, the directive would cover treatment by the statement that it is systematic. It would note that sulfonamides are contraindicated as being of no benefit except in complications, and these almost never occur.

The meeting later turned into an open discussion of the epidemiology of influenza and the possibility of identifying factors that made the current epidemic skip a year and occur so late in season. The theme underlying this discussion was, of course, an attempt to determine whether it would be possible to predict the future occurrence of an epidemic of influenza.

The outbreak of upper respiratory disease continued throughout November. For the week ending on 26 November 1943, there were 11,300 cases of acute respiratory infection among United States elements in the theater. Some 600 of this number were reported as influenza, although it seemed likely that much more than this was true epidemic influenza. The peak incidence of these upper respiratory infections was reached during this week, but the peak in the curve of reported influenza did not occur until the week ending on 3 December 1943. After that date, there was a steady decline which paralleled the decline for all respiratory disease.83 Influenza was never again a problem. Many theories were later proposed explaining the occurrence of influenza at this time which, as if by fate, coincided with that period of the European theater when it could best cope with the problem.

82 Annual Report, Chief Consultant in Medicine, ETOUSA, 1943.

83 Essential Technical Medical Data, Headquarters, ETOUSA, for months of November and December 1943.



The 1st Infantry Division was moved from Sicily to the United Kingdom in the first part of November 1943. Within a month, the division reported over 200 cases of malaria in hospitals or on quarters. At about the same time, 27 cases of malaria occurred in a bomber group which had recently arrived in the United Kingdom via the southern ferry route. There was every indication that the number of cases would increase with the shift of more troops to England from the Mediterranean theater. 84

Colonel Middleton obtained data as to the actual incidence of clinical malaria from hospitals where cases were appearing. Two lengthy directives (Circular Letter No. 117 dated 12 August 1943, and Circular Letter No. 142 dated 17 September 1943) had been published by the Office of the Chief Surgeon, Headquarters, ETOUSA, with respect to the management of malarious patients, but these were generally a mere restatement of opinions received from the Office of the Surgeon General. The immediate need was for more specific instructions to meet the sudden rising incidence of malaria in the theater. Accordingly, from the data at hand, the Office of the Chief Surgeon, Headquarters, ETOUSA, on 16 February 1944, published Circular Letter No. 24 on the management of the convalescence of malaria. The circular letter emphasized dietary, therapeutic, and psychologic means of insuring early convalescence and rehabilitation of debilitated and depressed malarious patients while avoiding serious relapses or postponement of complete convalescence.

Colonel Middleton was aware, however, that there were many unanswered questions as to the course of tertiary malaria and the efficacy of various regimens of treatment. In a letter to Colonel Middleton, General Morgan in the Surgeon General’s Office, suggested approaches to the study and solution of some of the most pressing questions. Colonel Middleton called upon Colonel Muckenfuss and Maj. (later Lt. Col.) Henry P. Colmore, MC, to meet with him as an informal malaria committee. Major Colmore, who was then assigned to the 2d General Hospital, was undoubtedly the best qualified officer in the theater in the field of tropical diseases. Among other positions, he had recently been an associate on the staff of the School of Tropical Medicine, San Juan, P.R.

The malaria committee met at the 1st Medical General Laboratory on 10 March 1944 and made plans for a controlled study of benign tertian malaria. The study envisaged a pursuit of two problems: (1) Would the natural course of the disease lead to a spontaneous “burning out”? (2) What were the effects in various dosages of certain agents such) as quinine, Atabrine (quinacrine hydrochloride) and Plasmochin Naphthoate (pamaquine naphthoate)? It was proposed that subjects for the study could be obtained from volunteers suffering relapses of malaria. It was agreed that Major Colmore should be placed on temporary duty at the 1st Medical General Laboratory to conduct these studies. The plan was submitted to General Hawley for approval the

84 Essential Technical Medica Data, Headquarters, ETOUSA, for November 1943.


following day. General Hawley initially disapproved the study but upon further consideration reversed his decision. 85

Major Colmore was able to begin the malaria study on 14 April 1944.86 At the outset, a problem appeared which prevailed throughout the study. The first 16 soldiers queried refused to volunteer for the experiment because of their desire to rejoin their organizations and buddies. As the invasion fever reached a higher pitch, this desire on the part of individuals to return to their units increased. There were also those who refused to cooperate because of past experiences with the disease. During the 1½ month period of the study, only 24 volunteers were obtained. Among the volunteers, there were extremely few cases that met the criteria required for a study of spontaneous remission; that is, chronic recrudescent uncomplicated benign tertian malaria.

Accordingly, therapy was withheld from no individuals. In order to determine whether the small number of chronic recrudescences was merely a chance finding in the small group of 24 volunteers, Major Colmore questioned patients at the 3d Station Hospital and examined the files of the Surgeon, 2d Armored Division, where there was a record of 2,454 individuals with one or more attacks of malaria. He determined that the recurrence rate for benign tertian malaria was not a problem and that it compared favorably with figures quoted for civilians living under less rigorous conditions. The interviews and examination of records also revealed that there was a sudden increase in the incidence of malaria in March, April, and May, which was attributable to the characteristic late relapse of benign tertian infection rather than to the chronically recrudescent type.

Furthermore, the study of the relative effectiveness of antimalarial therapy, including a comparison of Atabrine and quinine, with the necessary followup procedures, was precluded by the impending invasion. Accordingly, Maj or Colmore spent a considerable period of the malaria study in devising a code for the classification of different patterns of relapses and recurring malaria and analyzed the records of patients using this code.

Accepting Major Colmore’s recommendations, Colonel Middleton discontinued the study in late May 1944. Partly as a result of Major Colmore’s studies, however, it was possible to plan for the expected incidence of malaria in the coming invasion. Plans for the reception and treatment of casualties with relapsing and recrudescent malaria were made by Colonel Middleton with Colonel Kneeland, acting in his capacity as Consultant in Medicine, Southern Base Section, and with Lt. Col. (later Col.) Neil L. Crone, MC, Consultant in Medicine, First U.S. Army. On 18 May 1944, Colonel Middleton conferred with General Hawley and Colonel Gordon as to the missions and functions of preventive medicine personnel vis-a-vis agencies for the clinical treatment of malaria during the coming operations. On 20 May 1944, all the previous

85 Memorandum, Professional Services Division, for Chief Surgeon, ETOUSA, 11 Mar. 1944, subject: Proposed Research on Malaria, with comment 2. thereto.

86 Letter, Maj. H. P. Colmore, 1st Medical General Laboratory, to Chief Consultant in Medicine, Office of the Chief Surgeon, Headquarters, ETOUSA, 1 June 1944, subject: Study of Malaria.


theater directives on the treatment and management of malaria were rescinded and replaced by one comprehensive and pertinent directive, Circular Letter No. 73, Office of the Chief Surgeon, Headquarters, ETOUSA.

Other Activities

Among other activities engaged in by medical consultants in the European theater, the following are worthy of mention in concluding these paragraph on the buildup of U.S. Army forces in the United Kingdom preparatory to the invasion of continental Europe.

Typhus commission. - Colonel Kneeland was a member of a three-man typhus commission from the European theater which visited the Near East and the North African theater in February and March of 1944. 0ther members were Lt. Col. (later Col.) Emory C. Cushing, MC, an epidemiologist representing the Preventive Medicine Division, Office of the Chief Surgeon, Headquarters, ETOUSA, and Major Smadel. The commission made a team approach to the study of typhus and submitted its findings, by letter, dated 2 March 1944, from Headquarters, First Medical General Laboratory, to the Chief Surgeon, ETOUSA, subject: Report of Mission on Typhus, ETO. A complete discussion of typhus fever in World War II can be found in other volumes of this history.

Recommendations concerning heart diseases. - Colonel Hein called attention to the possibility of traumatic heart diseases which could easily be overlooked. One possible source of heart damage was low oxygen pressures at high altitudes; another was accidents, as when a heavy object falls upon the soldier. Electrocardiographic equipment was placed in all general hospitals and proved very useful in making reliable decisions for the disposition of patients. Placement of electrocardiographic equipment, and basal metabolism apparatus as well, in certain station hospitals was on several occasions recommended to General Hawley, but hie remained opposed to the extension of these functions to station hospitals. Courses in the use of electrocardiographic equipment were given at the European theater Medical Field Service School. As a result of recommendations on arterial hypertension made by Colonel Hein, it became acceptable policy to retain in the theater those individuals whose only abnormality was an elevation in blood pressure.87

Penicillin study. - Colonel Kneeland on 1 June 1944, submitted a report to Colonel Middleton on a study of nearly all cases (except venereal diseases) treated with penicillin on the medical services of U.S. Army hospitals in the United Kingdom over the preceding 8 months. Owing to shortages of penicillin, its use in medical cases was limited to those in which it was thought essential to recovery. In only a few cases of lobar pneumonia and one of meningitis was it used deliberately for experimental purposes as the only therapeutic agent. It was impossible to draw any conclusions from many cases in which it had been used in conjunction with other agents; other patients were

87 Minutes of meeting, Medical Consultants’ Subcommittee, 24 Jan. 1944.


first treated with penicillin when obviously moribund. There were, nevertheless, some cases in which the diagnosis was unequivocal, and the effect of penicillin could be clearly discerned.

Limited as he was by the type of data available and considering the shortage of penicillin, Colonel Kneeland ventured to say that the paucity of cases for study in itself indicated that, apart from venereal disease, there were comparatively few medical cases in Army hospitals that absolutely required this antibiotic. Sustaining previously known fact, there was evidence that penicillin was the most effective agent available at the time against general infectious due to staphylococcus. It also appeared to be highly effective against the meningococcus and the pneumococcus, although its superiority to sulfonamides in these fields was not unequivocably demonstrated. Nevertheless, Colonel Kneeland thought that its use was indicated as an adjunct to sulfonamide therapy in overwhelming infections due to either of these bacteria. Lastly, Colonel Kneeland stated that, when penicillin was employed in mixed infections, the results were likely to be disappointing.

This pennicillin study concluded by Colonel Kneeland, limited as it was in many ways, was nevertheless of considerable importance in making plans for the next phase of operations in the theater.


First and foremost in the minds of all stationed in the United Kingdom was an eventual assault on the Continent. As the buildup in England and Northern Ireland continued until it seemed as if the United Kingdom were completely saturated with the tremendous concentration of men and materiel, excitement over the invasion rose to fever pitch. However, the sober picture of thousands of battle casualties and soldiers becoming seriously ill under time primitive conditions of land warfare served to temper, for the medical officer, excitement over the prospect of coming to grips with the enemy on his own ground. To insure the U.S. soldier prompt medical attention regardless of how or when the need for it arose, plans that were flexible, practical, and always current were required. To this end, each division of General Hawley’s office maintained a policies-and-procedures document for mounting the operation. Colonel Middleton, accordingly, contributed to the policies-and-procedures document of the Professional Services Division, Office of the Chief Surgeon, Headquarters, ETOUSA.88

Preparatory Measures

Regardless of how worthy a plan might appear on paper, it could never be more effective than the means available to implement it. The primary problem was one of personnel. There should have been qualified medical officers

88 Memorandum. Chief Consultant in Medicine, for Chief Surgeon, ETOUSA, 5 Apr. 1944. subject: Medical SOP. for Evacuation from “Overlord.”


in all echelons of evacuation and in all installations where casualties from the operations could be expected, but thus was not the case. The problem has been discussed elsewhere (p. 248), but it is worthy of note here that, as early as February 1944, Colonel Middleton had surveyed the fixed hospitals of the theater and had compiled a list of 89 officers who could be used to strengthen units arriving from the Zone of Interior or transferred elsewhere as required.89 Even at a time when the invasion was imminent, a survey of key fixed hospitals revealed the need to replace the chiefs of medicine in two general hospitals.

Forward medical echelons were provided with large amounts of diphtheria antitoxin, and motion-sickness preventives were issued on the basis of 10 capsules per individual. In addition, a 2 weeks’ supply of Atabrine was provided each soldier with a previous history of malaria. The U.S. Army in the European theater was dependent upon British sources for many items of supply, among which were respirators. Through the auspices of the Medical Subcommittee, Army Medical Consultants, Committee of the Royal Army, Colonel Middleton was able to obtain a promise for 18 respirators to be used in time amphibious operation.90

Colonel Middleton and his subordinate consultants in the base sections insisted in all their contacts with hospitals that the medical service must be prepared to function under the central leadership of the commanding officer to insure teamwork under stress. In order to achieve this flexibility, 4 officers from the medical service were trained to head shock teams working under the direction of the chief of surgical service, and 2 officers from the medical service were trained in anesthesia. These arrangements applied to all 750-bed station and 1 ,000-bed general hospitals, with a proportionate ratio of officers to be trained for these functions in the medical services of smaller hospitals (fig.140).91

Initially, it was thought that triage of patients according to their diagnoses would be possible at the hards where patients were to be unloaded following evacuation across the Channel by ship. Accordingly, Colonel Middleton and Colonel Kneeland, the latter in his capacity as the medical consultant for the Southern Base Section, selected and designated a well-trained clinician for each point of triage. Specific plans were also made by Colonels Middleton and Kneeland for the evacuation of patients with communicable diseases and all those who were seriously ill to designated hospitals.92

After the transit hospitals were designated (p. 329), Colonel Middleton made a tour through each of them to give personal instruction in certain basic principles of reception and evacuation of medical casualties. In addition, field hospitals were to be set up in close vicinity to the hards as holding units to

89 Memorandum, Professional Services Division, for Chief Surgeon, ETOUSA, 24 Feb. 1944, subject: Medical Officers Available for Transfer to Units.

90 Memorandum, Professional Services Division, for Chief Surgeon, ETOUSA, to Mar. 1944, subject: Medical Subcommittee, Army Medical Consultants’ Committee.

91 Essential Technical Medical Data, Headquarters, ETOUSA, for June 1944.

92 See footnote 88, p. 419.


FIGURE 140.-Type of shock ward envisioned by Colonel Middleton, in actual operation in the 110th Evacuation Hospital, Clervaux, Luxembourg, 3 March 1945.

receive casualties who could not stand the 15- to 20-mile ambulance trip to the transit hospitals (fig. 141). 93 Colonels Middleton and Kneeland made a survey of all these hospitals in the early spring of 1944 and drew the following conclusion, which was included in the theater chief consultant’s evacuation plans for OVERLORD:

The qualifications and professional performances of the several officers of the Medical Services have been carefully reviewed with the Consultant in Medicine of the Southern Base Section * * *, It is our measured judgment that the strength and professional abilities of the involved units are equal to the anticipated task. However, to avoid confusion under the pressure of operations, it is urged that a reserve of qualified internists be set up in the Southern Base Section for mobilization upon demand. In all probability a number not to exceed four (4) for each of the Transit Hospitals would meet any need.

At what turned out to be nearly the last minute, two elements of the basic plan were charged. There was to be no medical triage at the hards. There were to be no specialized hospitals for the treatment of specific conditions. The seriously ill and those with communicable diseases were to be sent to the most accessible transit hospital. The category of nontransportable patients was to include the following: Communicable diseases, meningococcal infections, pneumonia and pneumococcal infections, septicemia, diabetic coma, uremia, coronary occlusion, bleeding peptic ulcer with dangerous blood loss, and serious pulmonary hemorrhage. It was expected that these patients after

93 See footnote 79, p. 414.


FIGURE 141.- Receiving area, 58th Field Hospital near Weymouth, England, 12 June 1944.

appropriate treatment would become transportable within a very short time, whereupon they would be removed to a more remote hospital.94 The only triage which could be carried out was the sorting of transportable and non-transportable patients at the transit hospitals.

Throughout this whole preliminary period, Colonel Middleton held frequent conferences with the medical consultants in the First and Third U.S. Armies and Southern Base Section to correlate and define their respective functions. This having been done, Colonel Middleton delegated the responsibility for supervising the reception and movement of medical patients in transit hospitals to Colonel Kneeland.

Estimate of the situation. - Only a month before the invasion actually took place, Colonel Middleton thought that the medical services of the theater would be faced with the following situation:

An accurate estimate of time expected load of time OVERLORD OPERATION must depend upon a number of unavailable factors. However, upon past experience in overwaters operations the categories may be divided into three groups, namely, wet, wounded and sick. Provision should be made for the exhausted, wet soldiers who are not sick or wounded. Past experience has indicated that they prove a considerable load upon hospital beds for hours or at most a few days * * *

94 Letter, Office of the Chief Surgeon, ETOUSA, to Surgeon, Southern Base Section, ETOUSA, attention: Consultant in Medicine, 30 Apr. 1944, subject: Provision for Care of Medical Casualties Evacuated From “Overlord.”


Obviously, the wounded will constitute the overwhelming majority of early casualties. This predominance will probably amount to 80 percent of the total for the first 24 hours. For the first week it is estimated that the total load will be 60 percent surgical, and 40 percent medical. After the first week a fair estimate will reverse this figure. On this basis, 400 medical patients may he anticipated out of each 1,000 evacuees to the near shore. For the first week of such an operation, a fair estimate would give an overall figure of 25 percent neuropsychiatric casualties. Hence, 250 of the 400 medical patients would be neuropsychiatric, and 150 sick. On the basis of available data, 100 of these medical patients would be seriously ill and 50 would have lesser ailments. After the first week it is predicted that the figures for neuropsychiatric and medical patients will be reversed.95

The Invasion and Its Aftermath

On 4 June 1944, just 2 days before the invasion, all consultants in the Office of the Chief Surgeon, Headquarters, ETOUSA, received the following directive from Colonel Kimbrough:

In the continental liberation, the members of the consultant group will carry out their duties its consultants in the transit hospitals and other hospitals in echelons in the rear of the transit hospitals.

The consultants’ activities in echelons forward of the transit hospitals will be carried [out] at the direction of the Chief Surgeon, ETOUSA, and the surgeons of such echelons.

These restrictions were no hardship to the theater chief consultant in medicine since he had, from the beginning, planned to operate in this manner.

On D-day, 6 June 1944, Colonel Middleton by chance had arranged for a field trip to three transit hospitals, the 38th Station Hospital and the 48th and 158 th General Hospitals at Stockbridge, Hantshire, and Odstock, respectively. The units had received orders to evacuate all transportable patients, and Colonel Middleton observed that they carried out this mission with great facility and complete lack of confusion. Refraining from further movement in the area of transit hospitals, Colonel Middleton, for a period of about 3 weeks, confined his activities to fixed hospitals of the rear echelon of the Communications Zone. His observations, made during June 1944, were as follows:

    The expeditious, thouqhtful and adequate reception of hospital trains and convoys. This circumstance applied almost universally and was most conspicuous in new and untried units. Their pride in accomplishment was only equaled by the Chief Consultant’s appreciation of the strides in organization made under pressure (fig. 142).

    Condition of patients. As a clinician, one could not escape the impression of the uniformly good physical status of all patients. Hundreds of temperature charts were reviewed, with fever as the rare exception, a circumstance in startling contrast to the experience of World War I.

    Special problems. Isolated instances of hemothorax and pneumothorax led to the early suggestion of the assignment of an officer from the Medical Service to each surgical ward receiving such patients. This opportunity for co-ordinated effort has been early implemented to the advantage of the wounded soldier.

    Minor casualties. In the original medical S.O.P., attention was called to the desirability of diverting “wet” soldiers from lines of evacuation. An oversight of this principle led to the occasional movement of variable personnel well to the rear, into fixed hospitals, when a change of clothing might have returned them to active duty from shipboard or at the wards

95 See footnote 88, p. 419.


FIGURE 142.- Reception of hospital trains and convoys. A. Ambulances being loaded at quayside, Weymouth, England, 10 June 1944. B. Ambulatory patients arriving by motor convoy at trainside for further evacuation inland.


FIGURE 142.- Continued. C. Care and attention on hospital train during evacuation in England.

(fig. 143). An amazingly high incidence of trivial wounds, that might well have received simple dressings and returned to duty, was encountered in these hospitals (fig. 144).

    Morale. The general observation of extremely high morale contrasts with reports from certain other operations. This reaction unquestionably reflects upon the quality of the command as well as the stability of the soldier. With few exceptions these men were keen to return to the fight. It pays to have handling operations, so expensive in manpower and materiel, well covered by naval and air protection. The soldiers commented at great length upon these advantages.

    Medical casualties. The proportion of medical evacuees from the continent has risen from approximately 3 percent for the first week to 5 percent for the second week and 10 percent for the third. These figures are far below the anticipated level, a circumstance which may be explained by the policy of evacuation from the far shore, or by the unusual health of the command in France. Certainly, we may anticipate adequate care of the sick, whatever the command policy may be.

Relapsing malaria has been the most frequent cause of evacuation. In all instances this may be traced to a discontinuance of supervision of Atabrine therapy, although a two weeks’ supply was afforded to each soldier with a previous malarial history.

A specific problem presents itself in the unexpectedly low incidence of shock neurosis. Colonel Thompson’s figure of 2.4 percent contrasts rather sharply with the British figure of 10-12 percent for the same operation. Again, this may reflect the unusual selection of troops for this operation, or the high morale of the same. It will be most interesting to evaluate the experience in the light of prophylactic measures taken against battle fatigue and neurosis us the indoctrination of line officers as well as medical officers of the First Army. 96

96 See footnote 91, p. 423.


FIGURE 143.- ”Wet” casualties of Normandy invasion reach English shore, 7 June 1944.

It is the customary fate of predictions that they must be modified in the light of subsequent events, and plans based upon them must also be changed. For Colonel Middleton, the change was a favorable one. The light load of medical evacuees gave him an early opportunity to survey the medical situation in the First U.S. Army. The Chief Surgeon, ETOUSA, and Surgeon, First U.S. Army, both approved an early visit by Colonel Middleton to the combat zone (fig. 145). During the period from 29 June to 2 July 1944, Colonel Middleton was provided every facility for the observation and study of medical operations on the Continent. Upon his return to England, he summarized his findings as follows:

    Distribution of casualties. In the period from 6-23 June, approximately 2,664 medical patients have been received in the hospitals of the First Army. This number represents approximately 9 percent of the total casualties. In the same period, 2,007 (8 percent) neuropsychiatric subjects have been admitted. The combined figure of 17 percent represents a very small proportion of the total physical load.

    Hospital facilities. Under combat conditions the establishment, activation, mobilization and movement of evacuation hospital units have been effected expeditiously and smoothly. This circumstance has insured available beds for all casualties, medical as well as surgical.

    Special hospital facilities. Perhaps the most outstanding innovations in the accommodation of army hospitalization to the special needs have been the establishment of Combat Exhaustion Hospitals and the utilization of the 4th Convalescent Hospital for the care of venereal diseases, among other casualties. The diversion of these constant drains upon the beds of mobile hospitals insures a far greater flexibility in the utilization of such facilities for the traumatic conditions of combat.


FIGURE 144.- Typical shipload of walking wounded and nonbattle casualties arriving at Weymouth, England, 12 June 1944

    Team work. Under the pressure of combat conditions, all ranks and grades of the Medical Corps have been welded into an effective machine for the care of the sick and wounded. Particular commendation is due the members of the Army Nurse Corps and enlisted personnel, whose arduous duties are being cheerfully and competently fulfilled. The esprit de corps is excellent.

    Professional services. The high quality of leadership of the [Medical] Consultant of the First Army is reflected in the standards of medical service to soldiers in all institutions visited. This guidance is not only administrative but it has also taken the form of direct professional consultation, educational effort through the Medical News Letter of the Surgeon of time First Army, and personal precept on every available occasion.

    Special medical problems. No communicable disease has yet been encountered in epidemic proportions. Occasional instances of mumps, meningitis, pneumonia (pneumococcal and atypical), dysentery and German measles have been reported.

Malaria alone presents a problem of numerical proportions sufficient to require special thought * * *

Pleurisy has been an occasional problem. The [Medical] Consultant has recommended that pleurisy without effusion (dry) be observed for a period of several days, and if the temperature [drops] to normal within three or four days, the patients be retained in the Army. Pleurisy with effusion is immediately evacuated to fixed hospitals in the Communication Zone.

    Primary atypical pneumonia. Primary atypical pneumonia has not been a problem, but in the absence of serious constitutional symptoms and early fall of temperature to normal, such patients may be retained in the Army.


FIGURE 145.- Normandy beachhead at time of Colonel Middleton’s visit, 1 July 1944.

    Bacterial pneumonia, Meningococcal infection and Infectious hepatitis will be sent to hospitals in the Communication Zone.97

In addition to the foregoing, Colonel Middleton observed and reported on the handling of venereal disease, and neuropsychiatric practices which have been described in Parts II and III, respectively of this chapter.

As of the end of July 1944, the medical load in the field and in fixed hospitals in the theater continued to be surprisingly light. No communicable disease had occurred in epidemic proportions.

In a survey of 15 general hospitals with respect to personnel professional qualifications, it was found that of 248 medical officers 71 had had only 9 months of internship. The deficiencies in special skills had to be compensated by continuing the policy of moving proved internists from units older in the theater to newly arriving units.98

As of the end of August 1944, the medical load of the theater, including neuropsychiatric cases, was 15 percent as compared with 85 percent for surgery, with relapsing malaria the only continuing problem of any proportions. The mobility of the armies (fig. 146) and the policy of keeping towns out of bounds had limited contacts with civilians and forestalled the anticipated increase in communicable disease, including gonorrhea and syphilis.

97 See footnote 91, p. 420.

98 Essential Technical Medical Data, headquarters, ETOUSA, for July 1944.


FIGURE 146.- Breakthrough at St. Lô, medical personnel and equipment of Advanced Section, Communications Zone, move through ruins of St. Lô

During August, 1 station and 11 general hospitals were surveyed. For this survey, Colonel Middleton had to call upon Colonels Hein and Kneeland, who were then consultants in medicine to the Western and Southiern Base Sections, respectively. With few exceptions, the hospitals surveyed required better qualified personnel to fill the top positions in their medical services. In consequence, there was a dilution in the professional skills of the stronger, older units of the theater, but with these transfers there also came an opportunity for well-merited promotions.99


The occurrence of malaria during this period resulted from two conditions in almost all cases; that is, relapses of early clinical malaria or clinical expressions of earlier parasitism without actual disease. Most of the cases were limited to four divisions which had previously served in the North African theater. The more common cause was relapsing malaria. This occurrence had been anticipated by providing Atabrine for suppressive treatment, and the appearance of clinical malaria in large numbers during this early phase of combat operations indicated breaches in Atabrine discipline or failure in the supply of Atabrine. Exposure, physical chilling, and the excitement of combat (through release of

99 Essential Technical Medical Data, Headquarters, ETOUSA, for August 1944.


adrenalin by the emergency mechanism of Cannon) may have been factors in precipitating attacks.

Colonel Crone, of the First U.S. Army, divided patients manifesting clinical malaria into complicated and uncomplicated cases. Complicated eases were defined as those having more than three relapses with one or more of the following conditions: Splenomegaly, anemia, or continued debility. Patients with these conditions were discharged from the Army. The uncomplicated cases were the objects of concern as to possible saving in manpower. These patients were initially treated in immobile hospitals of the army for a period of time necessary to fit them for ambulatory treatment in the 4th Convalescent Hospital assigned to the First U.S. Army. Colonel Crone estimated that for 75 percent of the patients the period spent at the convalescent hospital was 5 days. This policy effectively and noticeably reduced evacuation of malaria casualties to the United Kingdom, while at the same time use of the convalescent hospital as a holding facility kept these patients from overburdening and clogging the main lines of evacuation.100

By the end of July, the medical service in the First U.S. Army had done all it could to control the malaria situation and to advise commanders of necessary corrective measures. However, there was no abatement of the incidence of clinical malaria. The 91st Gas Treatment Battalion had been brought in to care for the increased load and was caring for some 400 malarious patients at this time. By all criteria, the supply and the dosage of Atabrine had been adequate to meet the needs for the affected individuals of the four divisions known to contain all of the potential malarious subjects. On 29 August 1 944, Colonel Middleton was obliged to advise General Hawley concerning malaria control, as follows:

Obviously, the problem has continued beyond reasonable limits for causes that are now controllable. Atabrine in full doses for suppressive purposes 0.1 gram daily will prevent the clinical manifestations of malaria in an overwhelming majority of instances. The attrition in manpower from this cause has not been disabling, but the Command responsibility for the active administration of the drug should be reiterated in the interest of more effective control.


At a meeting of the Medical Consultants, Subcommittee held in January 1944, Colonel Badger mentioned his concern over a certain lack of consideration for the individual tuberculous patient in his processing and evacuation to the Zone of Interior. Colonel Middleton asked him to look into the matter and submit recommendations at a later date. The impending invasion of the Continent and the dissolution of specialized treatment facilities supplied urgency. Heretofore, tuberculous patients to be evacuated to the Zone of Interior had been transferred to the 298th General Hospital for care and therapy until transportation became available.

100 See footnotes 91, p. 420, and 98, p. 428.


The day after the invasion took place, 7 June 1944, Colonel Badger hastened to submit his recommendations to Colonel Middleton concerning the treatment and evacuation of tuberculous patients. He urged that pneumothorax treatment be used only for the emergency case of tuberculosis or when delay would be injurious to the patient because of hemorrhage or the progressive nature of the disease. He pointed out that collapse therapy was best initiated and carried on when the course of treatment would not be interrupted by frequent transfer of the patient from one operator to another and, usually, when preceded by a month to 6 weeks of absolute bed rest with good diet and nursing care. Colonel Bad!ger noted:

The necessity for frequent refills to the early stages of pneumothorax treatment, and the complications associated with the interruption of treatment in the course of transport, entail hazards for the patient which will either cause delay in transfer to the Zone of Interior, or necessitate conduct of the case by numerous medical officers of varying ideas and experience in collapse therapy. Delays in refills and complications associated with early pneumothorax treatment have been proven unavoidable during the numerous evacuation episodes that mark the course of every transportation to the Zone of Interior.

In addition, Colonel Badger urged that boarding and evacuation procedures be materially speeded up in patients admitted to general hospitals with a definite diagnosis of tuberculosis. He noted also the practice of allowing patients with serofibrinous pleurisy, whose temperature had returned to normal and whose fluid had been absorbed, to return to the Zone of Interior as ambulatory cases.101 He strongly recommended that all patients with active tuberculosis be returned to absolute bed rest for the entire trip.

All of Colonel Badger’s recommendations were amplified and incorporated into a directive which was issued from the Office of the Chief Surgeon, Headquarters, ETOUSA, as circular Letter No. 100, dated 25 July 1944. This circular concluded with the statement: ‘‘Recommendations for treatment at absolute bed rest for time entire trip will be entered on the patient’s medical record by the medical officer in charge.’’

In the meanwhile, Colonel Badger had been transferred to the Office of the Surgeon, Forward Echelon, Communications Zone, and subsequently to the 15th Hospital Center, while still retaining his position as the Senior Consultant in Tuberculosis ETOUSA. Shortly after D-day, Colonel Badger conducted a field through station and general hospitals in the Western Base Section to discuss and evaluate tuberculosis problems. He had also requested a report from the chief nurse of the European theater, showing cases of tuberculosis and serofibrinous pleurisy among nurses who had been evacuated to the Zone of Interior. His survey confirmed the fact that tuberculosis was at its lowest ebb and did not constitute a serious problem.102 The report on the incidence of tuberculosis in nurses, although not equated for differences in the numbers of

101 Letter, Lt. Cot. T. L. Badger, to Col. E. R. Long, Chief, Division of Tuberculosis, Office of the Surgeon General, 1 July 1944.

102 Letter, Lt. Col. T. L. Badger, to Surgeon, Western Base Section, ETOUSA, 2 July 1944, subject: Report of the Senior Consultant in Tuberculosis.


nurses, nevertheless seemed to indicate a considerable increase in the second year of the theater’s activities.

In a letter to General Hawley on 14 August 1944, Colonel Badger recommended a spot survey by X-ray for tuberculosis in nurses in 2 general and 2 station hospitals, which had been in the theater from 18 to 24 months, and in 2 general and 2 station hospitals, which had been in the theater 3 to 6 months. He assured General Hawley he would impress each hospital that these X-rays were to be taken at their convenience and when their workload was slack. Colonel Allen, the theater consultant in radiology, approved the use of X-ray films to conduct this spot survey involving 584 nurses, and both Colonels Middleton and Kimbrough recommended approval. General Hawley, however, replied to Professional Services Division as follows: “I am sorry but we are fighting a very rapid war at this moment and such surveys will have to wait until this thing slows down a bit.”

And indeed, the fighting was turning into rapid pursuit. The Allies, having emerged from the hedgerows of Normandy, appeared to be on the verge of an unimpeded onslaught to the Rhine and into the Lowlands.


By the end of September 1944, most of the theater headquarters had moved to France, including General Hawley’s office. In its wake, a separate command under Communications Zone headquarters had been established in England effective as of 10 September 1944, 103 and designated the United Kingdom Base Section. Its surgeon was Colonel Spruit, formerly the theater deputy chief surgeon. Colonel Kneeland was named as his consultant in medicine. On the Continent, the Communications Zone had been solidly established with six base sections and the Advance Section, Communications Zone. Thirty general hospitals had been moved to the Continent, of which eighteen were operating. At the front, the Third U.S. Army had entered combat on 1 August and was now assaulting the Siegfried Line on the central front south of the First U.S. Army. The Ninth U.S. Army had entered combat in early September during the siege of Brest and other French ports, and the Seventh U.S. Army, after landing in southern France on 15 August 1944, had advanced northward and during September came under the operational control of the European theater commander. The battle for Germany itself had just begun.

This splitting of medical resources between the United Kingdom and the Continent placed Colonel Kneeland in a unique position among the medical consultants subordinate to the chief consultant in medicine. First of all, the evacuation policy on the Continent was 30 days, while for the theater as a whole it was 180 days. This meant that the greater part of definitive treatment was being carried out in the United Kingdom. Colonel Kneeland’s duties, as a member of the Professional Services Division, Office of the Surgeon,

103 General Order No. 35, headquarters, Communications Zone, ETOUSA, 15 Aug. 1944.


United Kingdom Base, were to (1) review treatment procedures, (2) select individuals for professional training, (3) supervise research in military medicine, (4) control activities of hospital center medical consultants, and (5) inspect and evaluate professional care in the United Kingdom.104 Colonel Middleton, engaged across the Channel, had to delegate many of his own supervisory functions, particularly in research activities, to Colonel Kneeland. He had to delegate to him also many of his close associations with British medicine, both civilian and military, which had proved so profitable in the past. For example, Colonels Kimbrough, Cutler, and Middleton, as chief of professional services and chief consultants in surgery and medicine, respectively, formerly represented General Hawley at meetings of the Penicillin Trials Committee of the British National Research Council. This function had to be delegated to the surgical and medical consultants of United Kingdom Base.

The first problem to be discussed in this period originated in the United Kingdom.

Sulfadiazine Prophylaxis

The Army Air Forces in Britain requested permission of the Chief Surgeon to use sulfadiazine as a prophylaxis against respiratory infections and presented information from the Air Surgeon as to its efficacy. There were certain conditions in the theater, however, that militated against an uncritical approval of the proposed project. The request was referred for consideration to the Committee on Infectious Diseases which was to meet on 28 September 1944. Later, the committee coordinated its deliberations with Colonel Gordon, who had not been present at the September meeting.

The committee defined limited indications for the use of sulfadiazine as a prophylaxis. Two such limitations were when pivotal individuals had to be maintained in a state of excellent health and when certain communicable diseases had reached specified critical levels. The committee recommended a period of 4 weeks as sufficient to protect against risks of major epidemics and pointed out specific controls that should be observed in administering the drug. The committee concluded its comments, as follows:

This Committee agrees that the results of sulfadiazine prophylaxis may well prove to be as satisfactory as The Air Surgeon’s memorandum would indicate. It still, however, is opposed to the idea of distributing a powerful drug on a very large scale as a command function unless considerations of importance in regard to the war effort warrant such distribution. It is for this reason that the Committee has taken its position that the indications for sulfadiazine prophylaxis are strategic.

Sulfadiazine prophylaxis admittedly does not control virus diseases, including influenza, and it is not strikingly efficacious against secondary bacterial infections of a mixed character, including pneumococcal infections. In the past two years, meningitis and streptococcal infections, which are most favorably [affected] by sulfadiazine prophylaxis, have not been epidemic in this Theater. Thus when the question is considered in relation to SOS troops in the United Kingdom, the Committee is opposed to sulfadiazine prophylaxis unless the pattern of epidemic disease is materially altered.105

104 Annual Report, United Kingdom Base, 1944.

105 Essential Technical Medical Data, Headquarters, ETOUSA, for September 1944.


The committee voiced no objection against trial use of the drug by the Army Air Forces. It also recommended that a small controlled experiment on the prophylactic use of sulfadiazine be carried out in one or more hospital units of the theater.

Col. Joseph C. Turner Chief, Medical Services, l54th General Hospital, near Wroughton, England, was selected to conduct the limited study recommended by the committee. He divided half of the hospital’s enlisted complement into two experimental groups-one receiving 0.5 gm. of sulfadiazine daily and the other receiving 1.0 gm. daily. The other half served its controls. The Eighth Air Force in England conducted a clinical trial in the prophylactic use of sulfadiazine in four stations of its Air Service Command. There were a few toxic reactions, none severe. However, several Air Force patients who were admitted to hospitals for diseases other than upper respiratory infection became toxic from the additional therapeutic administrations of the drug. Colonel Spruit had to notify all hospitals to ask Air Force patients if they had had experimental doses of sulfadiazine prior to initiation of sulfonamide therapy.106

The drug trials at the 154th General Hospital and in the Eighth Air Force Air Service Command were continued throughout the winter of 1944-45. In the meantime, TB MED (War Department Technical Bulletin) 112, issued 1 November 1944, authorized the prophylactic use of sulfadiazine at the discretion of the theater commander, under circumstances and by methods practically identical with those previously recommended by the Committee on Infectious Diseases. As a result, sulfadiazine was used prophylactically in other isolated instances with varying results.

In his final report on his experiments, Colonel Turner noted that the results of such tests hinged to a considerable extent on the pattern of disease that chanced to unfold. In this case, the winter proved noteworthy for the rarity of severe diseases of the respiratory tract, and hemolytic streptococcal infection was seldom seen.

“Thus the epidemiological conditions developing in this experiment were not strictly comparable to those obtaining for most groups reported on by others,’’ wrote Colonel Turner. ‘‘They set, rather, the question of how sulfadiazine prophylaxis will influence upper respiratory tract disease which is mild and mixed and non-streptococcal in character.’’

After almost 5 months of trial, Colonel Turner found the answer to this question. He reported: “The incidence of mild upper respiratory infection was about the same for both treated and control groups. Sulfadiazine did not appear to influence the occurrence of colds or of chronic upper respiratory infection.’’ 107

The Air Force study, on the other hand, indicated the following results from use of prophylactic sulfadiazine: (1) A reduction in the noneffective rate due to respiratory disease (patients admitted to hospitals and quarters) as well

106 See footnote 104, p. 433.

107 Essential Technical Medical Data, headquarters, ETOUSA, for April 1945.


as for those treated on a duty status, (2) a similar reduction in the incidence of gonorrhea, and (3) a reduction in the number of individuals that would probably have been affected by a diarrheal outbreak in which the etiologic agent could not be definitely identified. The results were, however, inconclusive with respect to the pneumonias. 108


As the concentrated attacks on the defenses of the German homeland grew in intensity, more and more prisoners were captured. Together with the increased influx of German prisoners, the first sporadic cases of diphtheria were seen. This had been expected, and the supply of antitoxin was adequate. By mid-October 1944, when Colonels Middleton and Pillsbury made a tour through the medical installations of First and Third U.S. Armies, diphtheria was occurring in increasing numbers among prisoners of war, and cases had appeared in U.S. troops. It was observed that penicillin was proving to be remarkably efficacious in the treatment of diphtheria. To date, it had been used primarily in patients sensitive to foreign serum or in the few instances where antitoxin was not immediately available. Colonel Middleton advised extending the use of penicillin to patients with grave toxemia, for whom the combined administration of diphtheria antitoxin and penicillin might offer a better prospect than antitoxin alone. Colonel Middleton also considered the possibility of penicillin application to the carrier state.

It was necessary first to gather data on the actual efficacy of penicillin in the treatment of diphtheria while discouraging its immediate acceptance as a substitute for antitoxin. To facilitate obtaining this data, the Office of the Chief Surgeon, Headquarters, ETOUSA, issued Administrative Memorandum No. 151, dated 27 November 1944, which furnished advice on the consolidation of information gained from treated cases and which recommended the dosage to be followed. The formula advised was 25,000 units every 2 hours (300,000 units a day) for 7 days. The directive also required prompt reports on cases thus treated.

Next, since early results its to treating diphtheria carriers with penicillin in the foregoing schedule were indeterminate, a more positive and directed study was obviously necessary. Prof. Sir Alexander Fleming of the Penicillin Clinical Trials Committee, British Medical Research Council, advised substituting topical applications for intramuscular injections. He suggested using a suspension of 500 units penicillin per cubic centimeter of normal saline solution or oil as a nebulizer for the nose and throat. In addition, it was proposed that troches containing 500 units of penicillin and capable of solution in the mouth in from 15 to 20 minutes be used.

Lt. Col. (later Col.) Rudolph A. Kochier, MC, Chief, Medical Service, 203d General Hospital, Garches, France, used the spray and troche treatment on 22 diphtheria carriers (all German prisoners of war). During the course of

108 Report, Eighth Air Force, Office of the Surgeon, 27 Mar.1945, subject: Prophylactic Use of Sulfadiazine on Eighth Air Force Personnel.


the study, he found it expedient to double the strength of penicillin. The spray was used every 2 hours and the lozenge every hour during the day. The Corynebacterium diphtheriae disappeared completely from the cultures of the nose and throat of 14 of the 22 carriers. The remaining eight had badly diseased cryptic tonsils, and there was only irregular, if any, control of the noxious flora with penicillin. Tonsillectomy effected a relief of the carrier state in all eight of these subjects.109

The problem of diphtheria among U.S. troops was never great in terms of its incidence, but many deaths from diphtheria continued to occur during the remainder of the war. It appeared that a considerable number of these fatalities could have been avoided. The disease now occurred so infrequently in the United States that a new generation of clinicians had arisen who had had no opportunity to become familiar with its various clinical manifestations. There was also blind dependence on laboratory confirmation of the diagnosis, which too frequently delayed its recognition and, for many reasons, was itself not always infallible. Finally, The Surgeon General sent a special commission to study diphtheria in the European theater. Further discussion of the disease must be reserved for that portion of this narrative pertaining to the post-hostilities period, when diphtheria became a matter of relatively greater concern.

Cold Injury

In mid-September 1944, the Allies had attempted to outflank the Siegfried Line at its northern terminus using two U.S. and one British airborne division as the primary assault elements. The massive airborne operation was executed precisely, but, despite the heroic efforts of the British 1st Airborne Division to hold a bridgehead across the Neder Rhine in the vicinity of Arnhem, German defenses were equal to the occasion. The Siegfried Line could not be turned, and the Allied armies along the entire Western Front had to attack the enemy frontally. There was fierce fighting, and progress was slow. Behind the lines, there had to be a tremendous logistical buildup of sufficient proportions to sustain a march to and beyond the Rhine.

Meanwhile, the weather turned cold and wet, presaging the coldest winter in Europe in a number of years (fig. 147). There was a distinct rising trend in the incidence of upper respiratory infections amounting to from 60 to 70 percent of total hospital admissions,110 For the first time since D-day the armies were now having a preponderance of medical over surgical patients.” 111 In November, the evacuation and hospitalization situation became critical. On two occasions, there was no evacuation from army areas for an 18- to 24-hour period because of a lack of hospital trains and hospital beds on the Continent. On four different occasions during the month, there was no evacuation from the Continent to the United Kingdom, either by sea or air. On 24 November

109 Essential Technical Medical Data, Headquarters, ETOUSA, for February 1945.

110 Minutes, Chief Surgeon’s Consultant Committee Meeting, 27 Oct. 1944.

111 Essential Technical Medical Data, Headquarters, ETOUSA, for October 1944.


FIGURE 147.- Aidmen of 94th Division treating injured soldier on typical cold and dreary day, near Tittingen, Germany, 15 January 1945.

1944, the l5th General Hospital was destroyed by V-1 bombs which the Germans were raining into the northern areas of concentration. Five hospital trains destined for the First U.S. Army had to be diverted to evacuate patients from the destroyed general hospital. Another hospital train was derailed and lost to the evacuation effort. For the last 18 days of November, there were no normal beds available in Paris, and at times approximately 4,000 patients lay on cots and litters in corridors, dayrooms, and offices. The appearance of trenchfoot cases in overwhelming numbers placed a critical added strain on the inadequate facilities for evacuation and hospitalization.112

In mid-December, von Runstedt launched a vigorous counterattack through the frozen forests of the Ardennes. The Battle of the Bulge had begun. The Germans had been able to muster greater strength than expected, and considerable Allied strength was required to meet it. It was not until late January that the Allies won back all the ground they had lost. At a the when surgical and neuropsychiatric casualties were at their highest, the incidence of cold injury reached epidemic proportions 113

While prevailing Army practices usually delegated the care of cold injury to the surgeons, the brunt of this care actually fell upon the medical services.

112 Essential Technical Medical Data, Headquarters, ETOIJSA, for November 1944.

113 A complete, comprehensive, and authoritative discussion of cold injury in the European theater is contained in “Medical Department, United States Army, World War in. Cold Injury, Ground Type.” Washington: U.S. Government Printing Office, 1958.


In the European theater, it was primarily the number of surgical casualties that naturally diverted this charge to the medical services.114 For example, the 100th General Hospital, Paris, France, during 1944 admitted 1,101 trench-foot, 20 immersion foot, and 314 frostbite cases to the surgical service, but all except those requiring amputation were cared for by the medical service.”115 The 7th General Hospital, Herts, England, in an attempt to equalize the volume of work between medicine and surgery, admitted nearly all cold injury cases to the medical service. These patients were not transferred to the surgical wards except in the event of some complication requiring surgery. In this way, the hospital reported, surgical officers were relieved of a great amount of administrative work and could devote more time to the treatment of battle casualties.

In looking back on this situation, Colonel Kneeland, the United Kingdom Base medical consultant, noted as follows:

In nearly all hospitals within the United Kingdom, trenchfoot was regarded as a medical problem, except in the small percentage of cases with extensive gangrene. With a bed occupancy well above the normal capacity, the problem of treatment and disposition of these cases was a very pressing one. Most of our medical officers were wholly inexperienced in this condition and much of the available technical data dealt with more severe types of cold injury than were occurring on the Western front. Broadly speaking, the majority of cases were relatively mild. Only about 10 percent had gangrene and most of the gangrene was in the form of superficial skin necrosis. In 90 percent of the cases, therefore, one was dealing with soldiers whose skin was intact, who had comparatively few objective signs of cold injury, but who had varying degrees of subjective discomfort.

With a demand for hospital beds on the one hand and a pressing need for infantry riflemen on the other, the disposition of these cases became of the utmost importance. Because of our lack of experience, the medical consultant felt on very insecure ground in giving advice to chiefs of services and it was his duty to obtain experience and create a working hypothesis as rapidly as possible. This was essential for the following reasons - if men were unnecessarily boarded [to the Zone of Interior], loss in manpower would be very serious to the fighting forces, as the great majority of cases occurred in the Infantry; on the other hand, if men were kept in the hospital who could not be returned to duty within the evacuation policy of the theater, the congestion of hospital beds might prove disastrous. It was the duty of the medical consultant, therefore, to frame some sort of coherent policy which could be disseminated to all the hospitals.116

Colonel Middleton was particularly concerned over the lack of information on which to base a theaterwide policy. Speaking about trenchfoot at the 24 November 1944 meeting of the Chief Surgeon’s Consultant Committee, he said: “As you all know, not only is this an important problem, the most important single problem in the theater at the present time, but we have no measurements of either injury or of convalescence.” At the 30 December 1944 meeting of the committee, Colonel Middleton remarked on the prevailing idea that 50 percent of cold injury cases entering army mobile hospitals were being evacuated to Communications Zone hospitals. Of this 50 percent, anywhere from 5 to 35 percent were being returned to duty. Said Colonel

114 Essential Technical Medical Data, headquarters, ETOUSA, for December 1944.

115 Annual Report, 100th General Hospital, 1944.

116 Annual Report, United Kingdom Base, 1 Jan. 1945-30 June 1945.


FIGURE 148.- Chest respirator used in treatment of cold injury.

Middleton: “It is entirely too wide a variance of the ability, or of the opinion of the surgeon as to the ability to rehabilitate. In considering the work in this particular field, I think it would be very desirable to get some criteria of injury and repair.” Colonel Cutler, the theater chief consultant in surgery, replied: “I don’t think we have much to say about it yet.”

Under the overall guidance of Colonel Knieeland, Capt. (later Lt. Col.) Robert A. Kennedy, MC, 125th General Hospital, Dorsetshire, England, was placed on temporary duty at the 7th General Hospital to conduct studies there under the supervision of Lt. Col. (later Col.) Laurence B. Ellis, MC. Captain Kennedy had had considerable experience in treating cold injury on Attu and had devised a respirator for the treatment of cold injury cases (fig. 148). Colonel Ellis was an experienced physiologist and thoroughly acquainted with experimental techniques in physiology.

The basic principle of Captain Kennedy’s procedure was to cause hyperventilation through negative pressure applied to the thorax encased in an aluminum jacket. His hypothesis was that such negative pressure, transmitted to the thoracic cavity, would tend to improve venous and probably lymphatic flow from the extremities. This, in turn, would improve the oxygen supply to the damaged tissues of the feet as well as diminish the edema of these parts.

Supply difficulties, particularly in obtaining the exact type of respirator, prevented experimentation on as extensive a Scale as would have been desirable. Nevertheless, early results were favorable, and patients treated in the respirator improved at a more rapid rate both subjectively and objectively than patients treated by other methods. Physiologic studies of the


circulation of patients under treatment were initiated to obtain information on the mechanism of the respirator’s action and on the pathologic physiology of the injury itself. Measurements of the femoral venous pressure showed an immediate and significant drop when the apparatus was in action.117 Later findings were an interesting commentary upon the deeper order of the pathologic changes. Relapses occurred in convalescent patients, and patients with deeper cold injuries experienced considerable pain when the respirator was used.118

The study was continued until April 1945. It was completed under the direction of Capt. (later Maj.) Mark Aisner, MC, who had previously assisted Captain Kennedy. In general, the conclusion was that this type of apparatus was of value in reducing the edema and symptoms of patients in the acute stage of cold injury, especially within the first 2 or 3 weeks after development of trenchfoot. The hospital stay of patients in this category so treated was definitely shortened, and a larger number of them returned to duty; but, in gross numbers, the method could not be considered as having been of importance during the trenchfoot epidemic. Furthermore, patients with pure frostbite and those severe cases not treated until after the third or fourth week showed little or no permanent response. Valuable information was obtained as to the effects of the treatment on periphieral circulation and its usefulness in the treatment of trenchfoot.119

Another study begun in November 1944 was to have more immediate effect on the treatment of cold injury. At the 110th Station Hospital, Lt. Col.. (later Col.) Theodore Golden, MC, thought that if he were to take a group of 25 patients and exercise them as soon as possible, he could rehabilitate them faster. He found that 5 weeks after exposure all 25 patients could actively engage in some work around the hospital and 12 of the group could complete a 5-mile march. Colonel Middleton reported these encouraging findings at the 30 December 1944 meeting of the Chief Surgeon’s Consultant Committee. General Hawley wanted to know how serious the injury was. Colonel Kneeland explained that, on the whole, he would say the injury was of somewhat more than average seriousness. There were several patients with gangrene, but now all were walking. Colonel Cutler, in confirmation, made the following statement:

In connection with the findings of those cases described by Colonel Middleton at the 110th, many times there are necrotic areas on the skin which appear as black, dry gangrene, but time has shown that in many cases this is very superficial. The foot we have studied, microscopically, which came off a man who died of pneumonia-not trenchfoot-revealed that the deeper tissues were in pretty good shape and that the superficial damage was to the capillaries. This is in line with the studies by Colonel Golden and his group at the 110th SH who have revealed a high rate of recovery under exercise as the chief therapeutic agent.

As a result of these and other similar studies,120 it soon became obvious that most cold injury cases could be returned to duty within from 6 to 8 weeks

117 Annual Report, 7th General Hospital, 1944.

118 See footnote 114, p. 438.

119 (1) Semiannual Report, 7th General hospital, 1 Jan. 1945-30 June 1945. (2) See footnote 116, p. 438.

120 See footnote 113, p. 437.


if proper physical training was started early enough. Such treatment became routine. The 188th General Hospital in Gloucestershire, England, reported that, after such a period of observation and rehabilitation, 90 percent of the patients suffering from trenchfoot, frostbite, and exposure were returned to either full or limited duty.121 In summary, Colonel Kneeland wrote:

Material aid was given by Lt, Col. Theodore Golden of the 110th Station Hospital, Lt. Col. Laurence B. Ellis of the 7th General Hospital, and Lt. Col. Samuel Millman of the 188th General hospital. These three officers conducted active programs of investigation and treatment in connection with trenchfoot and, as a result of their experience, the Consultant in Medicine was able to say, with some assurance, that the majority of trenchfoot cases could be returned to some form of duty in the theater, provided that active muscular rehabilitation was started as early its possible. This point of view was disseminated to the various hospitals through the hospital center consultants in medicine and it was believed worthwhile and undoubtedly responsible for the conservation of manpower. More, this active program resulted in a diminution in the disability of those who could not he returned to duty. Trenchfoot was far and away the most important medical problem of the winter.

When General Morgan visited the theater in February 1945, he brought a plan for the study of heparin in Pitkin menstruum in the treatment of trenchfoot. A tentative plan was established to treat 50 patients with third-degree changes. These patients were to be selected from three different armies. However, a sudden change in the weather lowered the incidence of cold injury before that treatment plan could be effected.

Although the load of cold injury cases receded dramatically with the advent of spring, problems concerning patients with cold injury did not stop there. There was the dermatologic problem of the subsequent fate of cold injury patients which Colonel Pillsbury, the theater senior consultant in dermatology, found reason to be concerned about. He felt that these soldiers had altered skin, were subject to macerated states, and were more susceptible to trichophytosis. There were also those soldiers who continued to rise the sequelae of cold injury as an illegitimate basis for release from forward duty. Finally, there was the smaller number of cases resulting from some soldiers’ neglect of their cold injury during the past winter. These were stout soldiers who had resisted evacuation during the strenuous fighting of the Bulge but whose painful feet had finally led them to seek medical attention. They showed extreme vascular changes and, usually, had cold, clammy, blue feet with or without edema.122

Homologous Serum Jaundice

In late autumn of 1944, Capt. (later Maj.) Harold S. Ginsberg, MC, 7th General Hospital, called Colonel Kneeland’s attention to 14 jaundice cases occurring at that hospital. Each patient had received plasma some months prior to the development of jaundice, and some had received whole blood as well. Since the incidence of infectious hepatitis was low at the time, Captain

121 Annual Report, 188th General hospital, 1 Jan. 1945-31 May 1945.

122 Essential Technical Medical Data, Headquarters. ETOUSA, for April 1945.


Ginsberg suggested that the condition under scrutiny might be homologous serum jaundice. Accordingly, Colonel Kneeland requested that the hospital center consultants collect data concerning jaundice cases in the United Kingdom. 123

At the 30 December 1944 meeting of the Chief Surgeon’s Consultant Committee, Colonel Kneeland reported there had been nine cases of severe hepatitis at the 3l6th Station Hospital. Four of the patients had died. All the patients had received plasma, and seven of them had received blood transfusions.

Lt. Col. John B. McKee, MC, the Ninth U.S. Army medical consultant, at a meeting of the Medical Subcommittee held on 21 February 1945, expressed the opinion that transfusion reactions were more common than was supposed. He thought that not all cases were being reported, particularly those occurring in field hospitals. There was growing suspicion that these transfusion reactions tended to occur when the blood used was over 14 days old. Colonel McKee said that investigation was continuing.

By 1 March 1945, 49 hospitals had reported to Colonel Kneeland. Nine hospitals reported no cases; the remaining hospitals reported a total of 281 cases of jaundhce. These cases were surgical patients in whom the jaundiced condition had developed from 45 to 100 days after they had received blood or plasma. Twenty-one of these patients had died. Unfortunately, there were complete records on only 146 of these 281 cases. An analysis of these 146 revealed that 14 had died, a mortality of about 10 percent. Fatal cases invariably had a duration of only from 4 to 10 days after onset. The data strongly indicated that plasma was the source of infection. Accordingly, Colonel Kneeland conferred with Colonel Muckenfuss and Doctor Bradley, British Ministry of Health and a member of the Jaundice Committee of the Medical Research Council.

Doctor Bradley brought forth statistics on the occurrence of homologous serum jaundice in British troops confirming Colonel Kneeland’s findings which implicated plasma as the carrier of the icterogenic agent. Both Colonel Muckenfuss and Doctor Bradley believed that detailed study of the problem required tracing the plasma to its source. Admittedly, this was an impossibility in ETOUSA. The only recourse was to continue to gather more data so that the facts could not be questioned.

When General Morgan visited the theater in February and March 1945, he was apprised of the situation. The disease suggested a serious problem for the Zone of Interior hospitals in view of the excessively long incubation period. The medical officers who were concerned in the investigation of homologous serum jaundice in the European theater thought that the subsequent recognition of the disease in Zone of Interior hospitals and the studies made there were done in part to their early identification of the widespread incidence of the disease.

123 (1) Letter, Office of the Surgeon, United Kingdom Base, to Chief Surgeon, ETOUSA, 1 Apr. 1945, subject: Study of Homologous Serum Jaundice. (2) See footnotes 119 (1). p.440, and 1l6, p.438.


At about this time, there was a precipitous rise in the incidence of infectious hepatitis. Approximately 1,000 cases occurred in February. For the weeks ending on 23 and 30 March, there were 952 and 892 cases, respectively. In the first two weeks of April, 965 cases occurred the first week and 979 cases occurred the second.124 Some medical officers thought there was a direct relationship between presumptive homologous serum jaundice and naturally occurring infectious hepatitis. These officers pointed to the closely corresponding curves of incidence. Colonel Kneeland found that not only the curve of incidence but the gravity of jaundice among wounded patients was much greater than for any other group.125


Throughout most of the period of continuous heavy fighting, the incidence of tuberculosis in the U.S. Army in Europe continued to remain low. Hospital admission rates for tuberculosis for all troops were, in fact, at their lowest since the activation of the theater, although the incidence of tuberculosis among nurses showed a persistent increase. In the last months of the war, however, this picture was to change dramatically.

Colonel Badger had an opportunity to confer with Col. Esmond R. Long at the Office of the Surgeon General in October 1944 on policies of the European theater as expressed in Administrative Memorandum No. 22 and Circular Letter No. 100, pertaining to the evacuation of tuberculosis patients from the European theater to the Zone of Interior (pp. 412 and 431). Colonel Long considered these directives well adapted to the needs of the European theater and thought that, through them, diagnosis, treatment, disposition, and evacuation were 110th simplified and expedited.126

In addition, Colonel Badger looked into the possibility of obtaining mobile miniature X-ray units for use in the theater. After conferences with X-ray and supply personnel in the Office of the Surgeon General, it was apparent that these units were impractical for use in the United Kingdom or on the Continent for a variety of reasons. The British 35-mm. mobile unit was, by comparison, a more workable outfit with value in spot-survey work its contemplated for the European theater. 127

Just previous to Colonel Badger’s departure for temporary duty in the Zone of Interior, there came to light eight cases of active pulmonary tuberculosis in the 56th Fighter Group, Eighth Air Force, between August 1943 and September 1944. There was also one acute case in the 78th Fighter Group, Eighth Air Force. This brought the suggestion from Colonel Badger that all personnel of these and associated units be examined by X-ray. This suggestion was executed by Colonel Kneeland in Colonel Badger’s absence by authority of Col. Joseph H. McNinch, MC, Deputy Surgeon, United Kingdom Base.128

124 See footnote 122, p. 441.

125 Essential Technical Medical Data, Headquarters, ETOUSA, for March 1945.

126 Annual Report, Senior Consultant in Tuberculosis, ETOUSA, 1944.

127 ibid.

128 Letter, Office of the Surgeon, Headquarters, United Kingdom Base, to Commanding Officer, 163d General Hospital, 6 Oct. 1944, subject: Survey of Tuberculosis in the Eighth Air Force.


The chest X-ray surveys of the 78th and 56th Fighter Groups were carried out at the 163d General Hospital near Cambridge, England. 129 In the survey of the 78th Fighter Group conducted by Capt. (later Lt. Col.) James S. Mansfield, MC, with Capt. (later Maj.) James P. Palmer, MC, seven cases of active tuberculosis were discovered and boarded for return to the Zone of Interior. Captain Mansfield and Capt. (later Lt. Col.) Peter Zanca, MC, carried out the survey of the 56th Fighter Group, and found one case of active tuberculosis with positive sputum. Over 3,600 chest films were taken and read at the 163d General Hospital during October and November 1944.

It was concluded from these two surveys by Captain Mansfield and his associates, that no common source of infection could be found for the total of 17 cases of pulmonary tuberculosis discovered in these two fighter groups, 9 cases prior to the surveys and 8 cases as a result of the surveys. All of the cases were regarded as reactivation of previously existing pulmonary

tuberculosis. 130

Shortly after his return to the theater, Colonel Badger was assigned as Consultant in Medicine, Normandy Base Section, while still retainimig his position as theater senior consultant in tuberculosis. In February 1945, he submitted, for study by the Chief Surgeon’s staff, recommendations for a tuberculosis survey at the end of hostilities of all personnel who had been in the theater for longer than 8 months. Next, he prepared a circular letter to formalize procedures for the followup of contacts with active cases of tuberculosis.

This circular letter was published on 8 April 1945 by the Office of the Chief Surgeon, Headquarter’s, ETOUSA, as Circular Letter No. 38. It required the first hospital in the chain of evacuation making the diagnosis of tuberculosis to notify both the patient’s unit and the Chief Surgeon, ETOUSA, of the fact. The European theater Follow-up Card (medical) (p. 251) was to be used for this purpose. The tactical situation permitting, the circular letter required examinations of all contacts, that is, persons who had been in frequent close association with the afflicted individual. This circular letter assured proper followup examination and provided a simple and efficient method of noting cases and trends of active pulmommary tuberculosis as they occurred.

Recovered Soviet prisoners of war. - Meanwhile, the Third U.S. Army had recovered a group of Soviet prisoners of war at Sarreguemines in December 1944 (fig. 149). These Soviet soldiers had been captured by the Germans between May 1941 and May 1943 in the Black Sea area and in the Ukraine. After being shifted around from camp to camp in Germany as labor battalions, they had finally been sent to the mines in the Metz, Bitche, and Sarreguemines areas. Here, they had worked 12 or more hours daily with 1 day off a month when the coal-mining quota was filled. The men had been worked to the point

129 (1) Report, 163d General hospital, 22 Oct. 1944, subject: Tuberculosis Survey of 78th Fighter Group, 8th Air Force, and Attached Units. (2) Report, 163d General Hospital, 16 Nov. 1944, subject: Tuberculosis Survey of the 56th Fighter Group, 8th Air Force, and Attached Units.

130 Letter, T. L. Badger, to Col. J. B. Coates, Jr., 8 July 1956, subject: Corrections and Additions to Manuscript.


FIGURE 149.- Soviet soldiers, prisoners of Gernmans freed by Third U.S. Army, partaking of emergency rations rushed to them by liberating U.S. forces, Sarreguemines area, France.

of collapse, and, if they collapsed or relaxed their strenuous labors, they had been beaten and whipped. They had worked and slept without change of clothing. Sanitary conditions had been most primitive. Food had consisted of a steady diet of bread and tea for breakfast, thin turnip soup for dinner, and turnip soup for supper, with no bread at dinner or supper time. Potatoes had been given once a week on Sundays, and only once monthly had a small piece of horsemeat been included for dinner. In some camps or sections, there had been only two meals a day. 131

Shortly before being overrun by the Third U.S. Army, the Germans had gathered together all the sick in a hospital near Sarreguemines. Here, these patients were found by the Third U.S. Army and evacuated to the 50th General Hospital, Commercy, France, arriving there on 18 December 1944, and totaling, eventually, 325. Before capture by the Germans, the men were said to have been in excellent physical condition. Some had been in the Soviet Army for only a few months before capture. When they arrived at the 50th General Hospital, 307 were in a moribund or seriously ill condition, 16 were in fair condition, and only 2 were in a relatively good physical state. They were dirty, malnourished, and covered with all types of lice. There were severe pyoderma, emaciation in marked degree, and all stages of avitaminosis. There

131 Annual Report, 50th General hospital, 1 Jan. 1945-30 June 1945.


was generalized edema, and, in many, starvation bellies. Of the total 325, there were 136 who were diagnosed as having terminal pulmonary tuberculosis with severe malnutrition and marked avitaminosis; 78 had far-advanced pulmonary tuberculosis with severe malnutrition; 40 had minimal, moderately advanced and extrapulmonary tuberculosis, malnutrition, and avitaminosis; and 71 had injuries and diseases other than tuberculosis with malnutrition and avitaminosis 132

    The hospital initiated immediate measures to save life. Copious amounts of blood, plasma, glucose, and saline solutions were given. There were 170 pneumothorax treatments in 25 cases with hemoptysis, and there were 34 thoracenteces with aspiration in 15 cases with empyema or effusion. In spite of these measures, 28 patients died within a week after arrival, and 4 had expired en route to the hospital.

Most of these patients remained at the 50th General Hospital throughout the first half of 1945. This was an isolated incident which was not to be repeated for another 3 months but which remained a local problem until March 1945. These Soviet prisoners had been recovered in a precariously held bridgehead across the Saar at the very apex of the Third U.S. Army’s advance. While they were being evacuated to the 50th General Hospital, the main effort of the German winter offensive had struck some 100 miles to the northwest, stopping further advance by the Allies in this area during most of the approaching winter. Had the German counteroffensive struck a few days earlier, these prisoners might not have been recovered at this time. This unique problem which presented itself at the 50th General Hospital was greatly overshadowed by the more pressing medical problems of the winter.

In March, however, when the Allies were once again sending the reeling German Army behind the protective banks of the Rhine, there was a sudden influx of recovered Allied military personnel and displaced persons (fig. 150). The brunt of the evacuation fell on the 28th and 57th Field Hospitals and the 180th and 35th Station Hospitals, mostly in the Continental Advance Section and Oise Base Section of the Communications Zone. Col. Richard M. McKean, MC, medical consultant for Oise Base Section, reported that the 35th Station Hospital had found 123 cases of active tuberculosis and 80 suspects in 373 dislocated nationals.133 The immediate concern was for the protection of American personnel in the receiving hospitals. Colonel Badger thought that the European theater Medical Bulletin would be the most appropriate medium to warn the greatest number of medical personnel of the existing dangers. His article, published in the April 1945 edition, read in part, as follows:

German prisoners of war, allied nationals, especially the Russians subjected to years of forced labor, are coming to us as patients with advanced tuberculosis presenting very strongly positive sputa. These individuals are significant sources of contagion and all hospital personnel having responsibility for their care need adequate protection from these virulent forms of tuberculosis.

132 See footnote 131, p. 445.

133 Minutes, Chief Surgeon’s Consultant Committee Meeting, 22 Mar.1945.


FIGURE 150.-Recovered French personnel flying the Tricolor as elements of U.S. Army prepare them for return to France.

It is the task of every medical officer and nurse to leave no stone unturned in efforts to control tuberculosis. Spread of the disease by airborne routes as well as by contact sets the pattern of control. Surely no one would dry-sweep or dust a floor where tubercle bacilli wait impatiently to be spread around. No one would associate with the tuberculosis patient without closing off the very source of infection itself by a mask to baffle the bacillus. No one would be so casual as to infect “clean” areas of a ward with objects contaminated from contact with these highly contagious cases. No unit medical officer would wish to remain in ignorance of tuberculosis diagnosed along the line of evacuation in one of his men; for only by notification of such cases is he alerted to the special danger for the protection of others. Patients not trained in the art of safeguarding others need indoctrination in the technique. The education of the tuberculosis individual concerning the nature of his disease begins early. The vigilance of the medical officer in its early diagnosis and prevention never ceases.

On 1 March 1945, orders were received at the 46th General Hospital, Besancon, France, to prepare to admit 1,200 newly liberated Soviet patients, who were to arrive at the rate of one train load per day for 4 days. No other information was available except that they were to be predominantly medical cases. The 46th General Hospital (fig. 151) summarized its experiences with these patients in its annual report for 1 January through 30 June 1945, as follows:

The patients arrived by trainloads, and it was discovered that there were not only Russian soldiers and civilians but personnel from most of the countries of Europe * * *. Also, the Russians came from all parts of that country: the large cities of Moscow, Leningrad,


FIGURE 151.-Care of recovered Allied personnel at 46th General Hospital. A. Patients arriving by trainloads. B. X-ray screening.


FIGURE 151 -Continued. C. Patient seriously ill with tuberculosis. D. Pneumothorax treatment.


and Stalingrad; the Ural Mountains; Turkestan; Siberia; and even Mongolia * * *, All these had to be helped and treated without the medium of language. Signs were the only help, and in many circumstances these were misunderstood.

    During the months of March and April, 2,472 Russians, 41 Poles, and 128 Yugoslavs were admitted * * *, Of the civilians, some were boys of 15 and others were old men of 65 * * * The hospital Staff was aghast at the terrible physical condition of these people.

Because a great number of these patients had infectious diseases, it was necessary to practice isolation techniques and maintain proper sanitary conditions in the area. This was a problem equalling or surpassing that of language. Our conceptions of modern sanitation were unknown to them * * *, Then, because of their starvation experiences, the patients would hoard any food they could lay hands on * * *

The majority of these patients arrived with either 110 medical records or with records so incomplete as to be practically valueless. (One complete train arrived with E.M.T.’s marked F.U.O. in all cases.) Names had to he spelled phonetically, and on 16 March, with the last trainload, rosters of patients who had been sent to this unit before arrived. Since the patients had been previously reported under the name listed on the roster, it was felt that our records should be brought into agreement. This required hours of careful checking and correcting of records.

With the arrival of the 78th Russian Citizen Regroupment Center (18 officers and 43 enlisted men) every effort was made to work through them * * * , Patients ready for duty were evacuated weekly through the Provost Marshal or G-5 channels. On 5 June, two U.S. Hospital Trains evacuated over 500 long-term hospitalization cases.

Hundreds of lives have been saved by the care given them; many have doubled their weight, and have changed from listless hungry animals to almost child-like, playful human beings. Discipline, which was such a great problem at first because of the restrictions necessary for their proper care, is greatly improved because of understanding through constant education. It is felt that as these patients leave the 46th General hospital and return no their native land, there will go with them a spirit of thankfulness anid appreciation for the work done for them.

By the end of March 1945, Colonel Badger had inspected the 57th Field Hospital and the 46th and 50th General Hospitals, and had made recommendations concerning changes in treatment and tightening up of general control measures. He commended the 50th General Hospital for its excellent handling of a very difficult and dangerous situation and noted particularly the good progress which had been made at this hospital in the treatment of recovered Soviet prisoners of war.134

The patients at the 46th General Hospital had only recently arrived and that hospital was still in the throes of establishing routine measures for handling the problem (fig. 152) when, in addition to the treatment and control measures described elsewhere, Colonel Badger also made the following specific recommendations for contacts:

1. It is felt that the seriousness of contact with this group of cases of far advanced tuberculosis is such that personnel of the hospitals who have been associated with their evacuation to the 46th General hospital should be X-rayed at the present time and reX-rayed every three months a year.

2. Personnel of the 46th General Hospital have all been X-rayed and it is recommended that they should be re-X-rayed on a three-monthly basis as a routine or more often if they present signs or symptoms suggestive of underlying tuberculous pathology.

134 Letter, Senior Consultant in Tuberculosis, ETOUSA, to Office of the Chief Surgeon, headquarters, ETOUSA, attention: Chief Medical Consultant, 3 Apr. 1945, subject: Tuberculosis Among Russian RAMP’s at 50th General hospital.


FIGURE l52.-Routine control measures at 46th General Hospital. Aseptic setup in isolation wards.

3. It is recommended that every measure be undertaken which will diminish the spread of infection from these highly contagious patients. Further, personnel of this sort will undoubtedly be recovered and it is recommended that they be transferred at the earliest moment by the shortest route, entailing the least number of contacts, to their final hospitalization place.

4. Groups of recovered personnel present a serious tuberculosis problem and should not be sent to any institution without adequate warning of their arrival in order that resources may be assembled for the institution of proper measures of prevention and a technique which will prevent as much spread of the disease as possible.135

On 19 April 1945, Colonel Long arrived in the European theater. With Colonel Badger, he reviewed the procedures which had, by now, been fairly well stabilized in all installations where tuberculous patients were being treated. The two officers visited the 50th General Hospital on 6 May 1945 and the 46th General Hospital on 10 May 1945. At these two hospitals, where the great majority of these cases had been assembled, Colonel Badger noted that the patients had made remarkable progress and, except for those seriously ill with advancing disease, their physical condition was excellent. Previously recommended control measures were being carried out meticulously, although discipline still presented a problem at the 46th General Hospital.136

135 Letter, Senior Consultant in Tuberculosis, ETOUSA, to Chief Surgeon, ETOUSA, attention: Col. W. S. Middleton and Surgeon, 0ise Section, 30 Mar. 1945, subject: Tuberculosis in Russian RAMP at the 46th General Hospital.

136 (1) Letter, Senior Consultant in Tuberculosis, ETOUSA, to Office of the Chief Surgeon, Headquarters, ETOUSA, attention: Chief Medical Consultant, 13 May 1945, subject: Report of Survey of 46th General hospital Concerning the Care of Tuberculosis. (2) Letter, Senior Consultant in Tuberculosis, ETOUSA, to Office of the Chief Surgeon, Headquarters, ETOUSA, attention: Chief Medical Commsultant, 19 May 1945, subject: Survey of Russian RAMP’s 50th General hospital.


Soon, a similar problem of equal proportions came to light. In early April, the Third U.S. Army uncovered a notorious concentration camp, Buchenwald. This was only the first of such camps the Third U.S. Army was to uncover in rapid succession during its dash across central Germany into Austria and Czechoslovakia. Approximately 21,000 persons were in the camp when it was overrun. They were living under most horrible conditions, and it was estimated that the ill numbered 5,000. The l20th Evacuation Hospital, newly arrived in the army area, was dispatched on 15 April to provide medical service for them. This unit, plus a clearing platoon, operated for about 10 days until relieved by units of the First U.S. Army.137

The 45th Evacuation Hospital, under command of Col. Abner Zehm, MC, took over where the 628th Clearing Company and the l20th Evacuation Hospital were forced to leave off. Under the able direction of its commanding officer, this hospital rapidly established aseptic techniques for processing large numbers of tuberculous patients that would have been a credit to any sanatorium in the United States.138 Neither the limitations of space nor the scope of this chapter permit a discussion of the appalling conditions that were found at this and other concentration camps, nor would a few words do justice to the exemplary manner in which the problem was managed (fig. 153). Suffice it to say that, from the administrative point of view, it was initially a job for the armies, then a charge to the forward echelons of the Communications Zone, and later a longer’ term responsibility of military government. In the final analysis, it was a problem for the German people themselves who had permitted the situation to exist and to whom rightfully belonged the obligation to rectify this afront to civilization and humanity. Although it was a great problem in its early stages to the medical service of the U.S. Army, every effort was made to have German facilities accept this obligation at the earliest opportunity.

Recovered United States prisoners of war. - To complicate further the patient-load problems that beset each army on the front as a result of great numbers of prisoners of war, recovered Allied personnel, displaced persons, and refugees suddenly becoming their wards, there was also the happy reunion of advancing U.S. forces with their fellow soldiers who had been held captive by the Germans (fig. 154). As the Allies struck deeper into Germany, U.S. prisoners of war were recovered, sometimes by the thousands. Most of them were eventually evacuated through the Normandy Base Section. This base section had designated Camp Lucky Strike as the reception center for these returned prisoners. Here, the 77th Field Hospital was opened on 8 April 1945 with an initial 350-bed capacity. Patients came in such great numbers, however, that its capacity had to be enlarged to 1,000 beds by augmenting the 77th Field Hospital with the 306th General Hospital (operating during this period

137 Annual Report, Third U.S. Army, 1 Jan. 1945-30 June 1945.

138 (1) See footnote 136, p.451. (2) The Annual Report, 45th Evacuation Hospital, 1 Jan. 1945-30 June 1945, contains a full and detailed description of the unit’s activities at Buchenwald camp.


FIGURE 153 -Notorious Buchenwald. A. The so-called “hospital” as found by liberating forces. B. One of the piles of dead awaiting cremation found upon liberation of Buchenwald.


FIGURE 154.-American and British prisoners recovered at a German brick factory. A. Exterior of factory. B. Living conditions.


FIGURE 154.-Continued. C. Opening rations brought in to them by liberating forces

as a convalescent annex). Approximately 18 percent of the first 12,000 recovered personnel to arrive had to be hospitalized, but in May this rate dropped to 3 1/2 percent of those coming through the camp. Nevertheless, the hospital capacity had to be expanded to 1,500 beds. The primary cause for hospitalization, in the early groups of returnees, was malnutrition, primary or complicated. 139

Routine roentgenograms were made only in cases requiring hospitalization. The preliminary data, complicated as they were by many unknown factors, indicated that the incidence of tuberculosis was nearly 8 times that of U.S. troops in 1943.140 A more detailed discussion of tuberculosis as observed in recovered U.S. prisoners of war may be found elsewhere.141

Colonel Badger, in his role as medical consultant in Normandy Base Section, called the attention of General Hawley and his consultant staff to serious protein-deficient states occurring in patients, particularly in those with maxillofacial and other traumatic injuries preventing normal ingestion of food (fig. 155). He indicated that the intravenous use of plasma in large doses (at least 4 units daily) could overcome these deficiencies but that there was a

139 Annual Report, Normandy Base Section, 1 Jan. 1945-30 June 1945.

140 Annual Report, Senior Consultant in Tuberculosis, ETOUSA, 1 Jan. 1945-30 June 1945.

141 (1) See footnote 72 (2), p.403. (2) Cohen, B. M., and Cooper, M. Z.: A Follow-Up Study of World War II Prisoners of War. Washington U.S. Government printing Office, 1954. (3) Medical Department, United States Army. Preventive Medicine in World War II. Volume IV. Communicable Diseases Transmitted Chiefly Through Respiratory and Alimentary Tracts. Washingtons: U.S. Government Printing Office, 1958. (4) Medical Department, United States Army. Internal Medicine in World War II. Volume II. Infectious Diseases. [In preparation.]


FIGURE 155.-Malnutrition in a recovered Allied soldier.

common tendency to use inadequate supplies of plasma. He also noted the scarcity of intravenous protein solutions. In fact, Colonel Badger stated, at the March meeting of the Chief Surgeon’s Consultant Committee, that the 60 bottles of intravenous protein in his possession represented all there was in the theater. Circular Letter No. 36, dated 19 April 1945, Office of the Chief Surgeon, Headquarters, ETOUSA, outlined the program for the nutritional management of malnourished recovered Allied military personnel and provided for the intravenous administration of 4 units of plasma and 500 cc. of whole blood in 24 hours to patients with edema who could not tolerate food by mouth.

When the first groups of recovered U.S. prisoners of war came into Camp Lucky Strike, their nutritional management was already well planned. The ragged, dishevelled, and emaciated men responded well to treatment. Severely ill patients unable to take nourishment by mouth showed remarkable response to slowly increasing quantities of plasma administered intravenously. The very slow administration by the constant drip technique of a high-protein diet in liquid form by nasal catheter through the stomach also gave excellent results.


The proportion of primary nutritional deficiencies was greatly diminished in those arriving during May 1945, and respiratory infections and minor injuries predominated as causes for admission.142


The war in Europe ended when emissaries of the German Right Command signed a document of unconditional surrender in the early morning hours of 8 May 1945. In anticipation of this memorable event, a number of changes had taken place as regards medicine. General Hawley’s office announced, in late April, that, effective 1 May 1945, the evacuation policy for the European theater would be 60 days. Immediately after V-E Day, evacuation from the Continent to the United Kingdom was curtailed. The plan called for the evacuation out of Europe of all patients requiring over 60 days of hospitalization by the end of July 1945.143 Staging of units for combat had halted, and planning and organizing units for redeployment to other active theaters had begun. So rapid was the closing out of activities in the United Kingdom that the occupied beds in hospitals fell from 129,289 on 90 days before V-E Day to 28,153 by the end of May and to a mere 8,664 on 30 June 1945.144

    The activity that now demanded by far the greatest attention from the theater chief consultant in medicine down to regional consultants in hospital centers was the formation of units for direct redeployment to other still active theaters. At least the following variables had to be considered for each individual before he could be assigned to a unit scheduled for redeployment: His adjusted service rating;145 physical profile; specialty, if any; professional competence; age; and grade. These factors then had to be considered in relation to requirements of the table-of-organization position to which the individual was being assigned; that is, grade, military occupational specialty number, and index of professional competence. Above and beyond the need to weigh these specific items, there was always the desire to form compatible groups of medical officers who could work together and who, collectively, could supplement each other to provide the wide range of skills called for by the table of organization. The magnitude and complexity of the problem caused considerable confusion and many a headache. As stated earlier, many questions resolved themselves into a matter of supply and demand (p. 278).

The medical problem still outstanding at this time was the question of a mass radiographic survey for tuberculosis proposed in the earliest days of the theater. It had been deferred on numerous occasions as a result of Colonel Badger’s spot surveys which indicated that there was no dangerous increase in the incidence of tuberculosis. The X-ray examination of all inductees commencing in early 1943 further mitigated the need for a mass survey. 0n the

142 See footnote 139, p.455

143 Essential Technical Medical Data, Headquarters, ETOUSA, for May 1945.

144 See footnote 116, p.438.

145 The adjusted service rating was an arbitrary criterion for retention in service calculated on the basis of number of dependents and service in the Zone of Interior, overseas, and in combat.


other hand, certain desired radiographic surveys could not be carried out during the peak of hostilities. Now there were more data available as a result of the Air Force surveys and other limited surveys carried out in processing officer candidates and recovered prisoners of war. More recently, there was the important factor of greatly increased opportunities for contact with tuberculosis by healthy personnel in the management of large numbers of prisoners of war, displaced persons, and refugees. Although physical examinations were being conducted at assembly areas in conjunction with the physical profiling of troops to be redeployed, the possibility was remote that any significant numbers of tuberculosis cases would be uncovered by this method.

All these factors, taken collectively, indicated that a reevaluation of the problem was necessary. Fortunately, Colonel Long was in the European theater at this time. His counsel and advice were most welcome. The problem narrowed down to one salient fact: The immediate need was to detect and screen out cases of tuberculosis from units being redeployed to other theaters. Each such case transferred to another theater presented a serious liability involving future hospitalization and transportation in addition to jeopardizing the individual’s life. If no screening by X-ray was conducted, it was estimated that some 200 cases of potential or active tuberculosis would be redeployed.146

    In consultation with Colonel Long and in coordination with Colonel Allen, the theater senior consultant in radiology, Colonel Badger formulated a plan to effect this screening with the equipment available and under expected assembly area conditions. Furthermore, in order to save the and X-ray film, it was thought desirable to limit the screening to those among whom the probability of tuberculosis was the greatest. Accordingly, the consultants decided upon screening all personnel who had been in the theater over 18 months and all Medical Department personnel regardless of length of service in the European theater. X-ray examination was to be carried out by field units of hospitals located at the assembly areas. The plan was simple and yet deemed adequate to meet the current needs. Moreover, there was a surplus of some 1,700,000 sheets of X-ray film, 14 x 17 inches, in depot stocks, although it was realized that there was an overall shortage of X-ray film worldwide. This inventory of available X-ray film excluded those in hospital stocks. The number of personnel and the criteria for redeployment indicated that there would be no more than 50,000 persons to be thus examined (fig. 156) 147

    The plan was quickly approved within the theater headquarters, a radio message was dispatched from ETOUSA on 29 May 1945 to the War Department, and a reply was received on 31 May 1945. The plan was not favorably considered because of the worldwide shortage of X-ray film.

General Hawley, however, heeded the oft-repeated remonstrances of Colonel Badger and approved the X-ray examination of all nurses to be directly

146 (1) Letter, Col. E. R. Long, to The Surgeon General, 28 May 1945, subject: Visit of Tuberculosis Consultant in European Theater of Operations, United States Army. (2) See footnote 140, p.455. (3) Essential Technical Medical Data, Headquarters, ETOUSA, for June 1945, dated August 1945.

147 Ibid.


FIGURE 156.-Typical assembly area conditions, Le Havre, France.

redeployed--a measure that Colonel Long had also strongly recommended, informing General Hawley that the rate for nurses as a whole in the European theater, as determined by the Medical Statistics Division, Office of the Surgeon General, was twice the average rate for the Army as a whole. Colonel Long also emphasized the fact that lesions still in the incipient stage did not cause symptoms and could be detected only by X-ray examination. Circular Letter No. 57, dated 27 June 1945, Office of the Chief Surgeon, Headquarters, ETOUSA, was published implementing General Hawley’s decision and directing that the results of such surveys, with the films, be forwarded to the theater senior consultant in tuberculosis.

In the interim following the unfavorable response by the War Department, consideration was given to the employment of captured German 35-mm. equipment, which, could be brought into use within from 1 to 2 months. This idea was not pursued further because it was estimated that a substantial number of the 50,000 persons considered as most in need of X-ray examination would have been redeployed by the time the project could be set into operation. Apparently, there was no alternative but to forego any plans for even a limited chest survey, except for nurses being redeployed (fig. 157). However, a War Department message, dated 28 June 1945, that was brought to Colonel Badger’s attention on 2 July 1945 changed the picture completely. Upon reconsideration, the War Department now--a month later–approved the original request from the European theater, provided 14 x 17 inch film used for this purpose had an expiration date prior to 1 October 1945.

Approximately 400,000 films of this type were available in theater depots. Arrangements were made to centralize these stocks at points in proximity


FIGURE 157.- Nurses undergoing medical processing for redeployment, Camp Carlisle, Mourmelon, France, 6 July 1945.

to the Assembly Area Command and the two staging areas. Other necessary action was immediately taken to effect the survey as originally planned, but valuable time had been lost, and the opportunity for a complete survey of the most susceptible group had also vanished. Before leaving the theater, Colonel Badger completed all the necessary recommendations for a circular letter on specific measures to be followed.

Circular Letter No. 60, Office of the Chief Surgeon, U.S. Forces, European Theater, 2 August 1945, section III, subject: Chest Sumrvey of Directly Redeployed Persoimmiel, was promulgated after Colomuel Badger’s departure from the theater. It required an X-ray of the chest for all medical officers, nurses, and hospital aidmen assigned to ward duty who were scheduled for direct redeployment to another theater of operations. A similar requirement was made for all officers and enlisted men, male and female, who had been overseas for more than 1½ years and who were scheduled for direct redeployment. Such examinations were to be interpreted by the roentgenologist of the responsible hospital with proper notation of the results on the personnel records of the individuals concerned. Implementation of the plan at the local level was made a responsibility of the base section surgeon in the areas affected.

Soon after the plan was placed into full effect, the Assembly Area Command protested that the roentgenography of directly redeployed personnel was delaying the movement of some units. Accordingly, the appropriate section of Circular Letter No. 60 was rescinded by Circular Letter No. 61, Office of the Chief Surgeon, U.S. Forces, European Theater, 8 August 1945, section 1,


subject: Chest Survey of Directly Redeployed Personnel; section II, subject: Chest Survey of Redeployed Nurses. Only the requirement that a chest survey be completed on all directly redeployed nurses was continued. The Japanese capitulation followed soon thereafter with the resultant curtailment of direct redeployment. This automatically ended the last of Colonel Badger’s wartime tuberculosis projects in the European theater.

As Col. Osceola C. McEwen, MC, assumed the position of theater chief consultant in medicine, to help guide the transition of the U.S. Army in Europe from a wartime to occupation status, the incidence of respiratory and infectious diseases was very low. The hepatitis epidemic had well passed its peak. There was only one significant problem, diphtheria. To Colonel McEwen it appeared inevitable that with the high incidence of diphtheria among German civilians and the increasing fraternization between Americans and the German population, there would be a distinct increase in the disease among American troops during the coming winter. Furthermore, death from diphtheria continued to occur, and patients appeared in hospitals with obvious complications of diphtheria in which the diagnosis had not previously been made. Colonel McEwen enlisted the help of the War Department investigators of the disease, Lt. Col. Aims C. McGuinness, MC, and Dr. Howard J. Mueller, in, the preparation of a directive. The directive was published on 28 September 1945 as section I, Circular Letter No. 69, Office of the Chief Surgeon, U.S. Forces, European Theater. It was a comprehensive summary of general principles to be followed in the diagnosis, treatment, and control of diphtheria, with particular reference to conditions prevailing in the theater.

By the time V-J Day was celebrated, the wartime theater chief consultant in medicine, Colonel Middleton, and his complete staff of senior consultants had returned to the United States, their task completed.


Yale Kneeland, Jr., M.D.

The writer was consultant in medicine for 6 months in a base section in the European theater from which a very large amphibious operation was launched. Following this, his sphere of activities was enlarged to include what had originally been two additional base sections, and, at one time, the hospital bed occupancy of the area was over 129,000. He served in this capacity for 10 months.

    During each period, the office of professional services consisted of two individuals-the writer and his colleague in surgery. They were under the command of, and responsible to, the base surgeon; but there was an additional responsibility, of a professional character, to the Chief Consultants in Medicine and Surgery, Office of the Chief Surgeon, Headquarters, ETOUSA. This idea of a dual allegiance is contrary to the traditional Army theory of command. Thus, their relationship to the theater chief consultants, although intimate, was in a sense unofficial. The base surgeons, to their great credit,


did not appear to object to this type of short circuit in spite of its unconventional character.

In any complex situation, the man at the top pitches the key, so to speak; his myriad subordinates try (with varying success) to sing in tune. Be it said that General Hawley, Chief Surgeon, ETOUSA, was on the side of the angels. He wanted the American soldiers to have the best possible medical care. He believed that professional services had a great deal to offer toward this objective. He respected his consultants and lent their opinions a critical, but invariably courteous, ear. He often implemented their advice against the wishes of his administrative subordinates. The prestige the consultants ultimately obtained was in large measure due to his influence. But for him, the whole of professional services might have been reduced to impotence.

Roughly, the first 6 months of the writer’s service was what a bacteriologist might call the “phase of logarithmic growth.” At its beginnimmg, before the invasion, the number of hospitals in the base section was small. In the course of 6 months, new general hospitals arrived by the score. The second period was a plateau phase, where the volume of professional work was very great but the situation in regard to hospital units and personnel, fairly stable. The two periods also differed in that, during the first, the writer had free and ready access to the theater chief consultant and could submit his decisions for approval. During the second, the theater chief consultant was on a separate continent, and communication was infrequent and difficult.

To begin with, the base section consultant found himself on a medical staff that was unused to the luxury of professional services and somewhat suspicious at first of the innovation. It was necessary for him to gain the confidence of his chief and his colleagues in other sections. It was also necessary for him to orient himself in a bewildering new world. He had to visit the hospitals already set up and working, meet and appraise their medical personnel, ingratiate himself (if possible) with the commanding officers, and prepare lists of qualified individuals who might be used later on to bolster the weaker units as they arrived. Many of the “old” units were affiliated with and had been derived from teaching hospitals. These units were staffed by outstanding men.

The consultant had very little time to achieve orientation before the new units began arriving, and he experienced a sense of bewilderment which never quite left him. Here, if ever, was the moment when one needed an orderly mind, a long memory, and a flair for indices and files. Not all the good men were in the affiliated units. They turned up in field hospitals and were often tucked off in very odd corners. This particular consultant has a bad memory and a disorderly mind. Much of the time he felt as if he were looking into a kaleidoscope. He struggled and tried to overcome his deficiencies. The work had to be done and done rapidly. The new units arrived pellmell, tumbled into staging areas, and then proceeded to hospital sites that might or might not be completed. These new units were deliberately sent out from the Zone of Interior minus most of the pivotal professional men; that is, the chiefs of


services and sections. Occupants for these positions were to be provided after the unit had arrived. It was the job of the consultant to determine the needs of units and then try to supply them.

Thus, the newly arrived hospital units had to be “vetted” as soon as possible. In a 10-minute conversation, the consultant was supposed to determine each officer’s educational accomplishments, experience, and character. It required considerable effrontery to do this, or to do it with any sense of infallibility. The consultant was aware of the superficiality of his judgments, but there was no time for more searching investigation.

One fell back, inevitably, upon the record of formal education, together with hospital and teaching appointments, and it was remarkable how accurate these indices were, within, obvious units. Almost invariably, the man with the best education turned in a good performance. It was true, of course, that some individuals were much better than their rather mediocre background would suggest. To some of these, injustice may have been done. But in general the modern system of internships, residencies, and board certification made a quick appraisal far easier and more accurate than it would have been in the past.

At first, an attempt was made to strengthen these new hospitals in all positions. Soon, however, it became apparent that the supply of qualified men in the theater would run out unless this strengthening were kept at a bare minimum. On the medica! service, there had to be a really first-rate chief of service, one other really good younger man, a qualified neuropsychiatrist, and, if possible, someone with a working knowledge of communicable disease. (Fortunately there were a good many certified pediatricians available for this purpose.) It was desirable that one of the two internists be familiar with electrocardiographic interpretation. Also, an endeavor was made to provide someone with at least Army experience in dermatology. It was impossible to supply each hospital with a qualified dermatologist, and the deficiency was cared for by the establishment of a local consulting system in this specialty. The rest of the service could be made up of general duty officers. No attempt was made to provide an allergist or a gastroenterologist. (In an oversea theater, allergic disorders can be appraised by an internist; it is impractical to attempt any special studies. As to gastroenterologists, the average general hospital gets on better without one. The soldier with organic disease of the gut goes home; the soldier with functional dyspepsia is better off without too much study and treatment.)

Thus, the bare minimum was bare indeed, and yet it became increasingly difficult to satisfy. One did not want to reduce the affiliated units to mediocrity by too heavy withdrawals from their personnel, and yet they had to be the principal source. The consultant’s dilemma was increased by the fact that many of the incoming hospitals had on their rosters professionally inadequate men of higher military rank than those whom one proposed to send in to be chiefs of services. Moreover, once the necessary shifts of personnel had been decided on, it was the duty of the consultant to coordinate the transfers.


This required convincing a given individual that he wanted to leave his unit for a more responsible post, persuading his commanding officer to let him go, and inducing the new commanding officer to accept him. A considerable amount of tact was necessary, and although it was always possible to invoke the authority of the base surgeon and order the transfers to be effected, the velvet glove was greatly preferable to the iron hand within it. Thus, coordinating took time as well as patience, and it added to the existing congestion of a badly overworked long-distance telephone system.

Once the new men had been installed in a hospital, it was necessary to visit them in order to find out how things were working out-if they had, in fact, been given the jobs for which they were sent, and what problems in general confronted them. With these men, who had been assigned to a job on the consultant’s recommendation, the consultant thereafter enjoyed a rather special relation. In a sense he stood in loco parentis to them, and they tended, for the most part, to consult him when difficulties arose. It was a happy arrangement.

All this activity in regard to personnel occupied the greater part of the consultant’s waking hours during the first period of his service. Nevertheless, he had other occupations. He felt it incumbent on himself to brief hospital medical services on the medical problems of the invasion-or at least on what he thought the medical problems were likely to be. He discussed the management of the various infectious diseases, the function of the disposition board, and in general attempted to impart what knowledge he had gained in nearly two years overseas. Furthermore, he served as a channel by which information in the possession of the chief consultants might be directed to its destination. Lastly, he did a certain amount of actual consultation where time and distance permitted. It is possible that some of these consultations were of value, if not to the patient, at least to his physician. Always, they were of value to the consultant, and he learned from them. Occasionally, frantic calls for information came in by telephone, usually on such subjects as viper bites, wood alcohol poisoning, or botulism with which the consultant had the barest nodding acquaintance. On the whole, however, he did not regard seeing cases during his hospital visits as the ill spent. If nothing else, it gave medical officers a chance to present their choicest wares, which was always a source of pleasure.

There was routine office work, too. Disposition board proceedings were reviewed until their volume became so great that it had to be abandoned. Recommendations for promotion of medical officers were also passed on, a function that gave the consultant some opportunity, at least in a negative sense, to see that credit went where credit was due. Lastly, there were moments when his opinion was sought by other sections of the office. Altogether, during this period, he was not idle and, throughout it, received most valuable advice and cooperation from the theater chief consultant in medicine.

The last 10 months of his service as a consultant formed the second or plateau phase. The groundwork had been done, the hospitals were set up and working, and it now remained for them to give the very best care in their


power to the vast throng of sick and wounded which passed through them. For the consultant, it was a period of intense interest, although one in which he felt distressingly remote from the hospital wards. His area had been much enlarged, the hospitals were numerous, and the number of patients astronomical. He was forced to institute a system of local medical consulting based on hospital groups. (By this time, the hospitals had been divided into seven groups, each with a center headquarters.) With one exception, each of the group consultants in medicine was also chief of the medical service in a general hospital within the group. They did their consultation in addition to other duties, and very valuable service they rendered. The consultant at base headquarters worked through these men and would have been quite helpless without them.

This was a period when the need for hospital beds became pressing. Policies in regard to disposition were constantly changing, and these changes had to be implemented. At times, the administrators placed different constructions on various directives from what was intended. The consultant. through his local consultants, worked for uniformity in policy and harmony in the various agencies. One problem which can be taken as a concrete example is trenchfoot. Whether the high command expected a winter campaign is irrelevant to this discussion. Certainly, the medical consultant had not, and his knowledge of cold injuries was very slight. Moreover, the available circulars on the subject left, to his mind, much to be desired, dealing, as they did, with a more severe variety of injury. Many thousands of cases were seen, but they were mild. Only 1 in 10 had any lesion of the skin. The specific problems that faced the ward officer were not answered in the circulars--what to do with the 90 percent mild injuries? The individual soldier lay on his back with 10 toes pointing heavenward, and, in general, they were pretty normal toes. How to treat him? How long will he be laid up? Should he be boarded home immediately-for his bed was needed badly-or kept on the chance of his being able to perform useful duty again in this theater? These were important questions for several reasons: Hospital beds were short, manpower was short (these patients were mostly combat troops), and the numbers involved were equivalent to several divisions. The ward surgeons clamored for advice. What was the medical consultant to tell them?

Unfortunately, he didn’t know, but in the shortest space of time it was necessary to find out. This is not the place for a detailed discussion of trenchfoot. Let it suffice to say that many willing workers helped the medical consultant. They set up trenchfoot wards where practical clinical research was carried out. Within a few weeks, it became clear that patients in whom active muscular rehabilitation was started early did better than those who were permitted to remain idle. The sooner a man was made to walk, the better. The results of sympathetic block and the like were equivocal, but the results of an earnest program of physical rehabilitation were clear. Certain criteria were established by which the immediate prognosis for return to limited duty, at least, might be guessed at. (The medical consultant did not know what the ultimate prognosis was.) In any case, some order was developed out of the


original chaos in his mind, and thereupon he could proceed-tentatively, and with no massive assurance-to disseminate a program on trenchfoot.

There was another general category of affairs that occupied the consultant. The country in which his base was located happened to be that of a very highly civilized ally and contained many learned men in many fields, who had much of great value to impart to the American medical officer. In fact, there was much of value to both sides in the mutual exchange of information. Thus, various meetings were arranged, and, in the arrangement for such programs, the consultant found himself acting as a sort of liaison officer. Moreover, he had access to all the newest medical information in the hands of his ally; he was graciously invited to attend all relevant committee meetings and, as a consequence, acquired a larger stock of knowledge to disseminate during his visits to the hospitals. Eminent medical tourists from the United States usually paid a ceremonial call at his office, and he endeavored on such occasions to pick their brains. Altogether, the office took on the character of a nerve center and, had the medical consultant himself been of greater intellectual capacity, this function would no doubt have been better performed.

The consultant frequently found himself engaged with problems in human relations, arising from the fact that most civilian doctors are not happy in military service, particularly overseas. It has already been remarked that relations between the civilians and the regulars were not easy. The typical product of the university clinic is idealistic, sensitive, and very individualistic. Often, he felt himself to be operating in an unfriendly, almost a hostile, atmosphere. One such remarked to the writer: “We all felt like June brides when we joined the Army, but I never expected the groom would turn out to be a gorilla.” Strong words, no doubt, but expressive of a point of view. Often, the professional man in the hospitals felt lonely and forlorn. Frequently, he was conscious of hostility, real or imagined, on the part of the administration, usually in the person of his commanding officer.

The hospital commanders, generally, were not drawn from the top of the basket, professionally speaking. Some were regulars. Many were reservists who practiced general medicine in private life. Some were excellent. Some were not. For the perfect hospital commander, many qualities are necessary. He should have, to begin with, a firsthand acquaintance with good medicine. He should be a first-rate soldier. Add to these qualities the guile of the serpent, the softness of the dove, and a working knowledge of electricity, plumbing, landscape architecture, and international relations. Above all, he must be a housekeeper and a leader of men. To say that some hospital commanders fell short of this ideal is an understatement.

Even with good commanding officers, the professional men could become restless and unhappy. The consultant was the one individuual who was in a position to apply some balm to their wounds. He stood, as has been said, in loco parentis to many of the professional men. They had direct access to him. They felt him to be on their side. At the same time, a little of the reflected


glory of headquarters hung about him, and he had, therefore, some influence with some commanding officers. The consultant’s position was thus unique; he could, and possibly did, bring a little light into the gloom of some provincial hospitals. At any rate, he tried.

It was also possible for the consultant to interest himself in research, not fundamental research, but clinical investigation of the journeyman type. Under conditions of an active military compaign, definitive studies were very difficult to accomplish, but some useful information could be compiled. In this particular base, the consultant aided in the inauguration of certain studies. Specifically, these were homologous serum jaundice (in the wounded after D-day), some physiologic aspects of trenchfoot, sulfadiazine prophylaxis of common diseases of the upper respiratory tract, the local use of penicillin in infections of the mouth and throat, and antibody formation in nephritis amongst Germans.

At the end of his tour of duty, with victory in that theater won, the consultant was faced with the task of redeployment. The writer prefers to touch on this unhappy subject very lightly. It is not for him to criticize the basic theory of redeployment or to suggest that planning was insufficiently far advanced when the cease-fire sounded. The personnel problems of redeployment were uppermost in his mind, and there was little he could do about them. Many factors were involved, such as theater needs, about which the consultant knew nothing. All he knew was that his advice was sought in regard to personnel changes in the redeploying hospitals. The game had to be played according to a set of rules that he had no part in creating. There were tables of organization calling for certain specialty ratings (of which he did not approve), there was the adjusted service rating score, and there were physical profiles. All of these played a part in determining the immediate future of the individual officer. The consultant endeavored to temper justice with mercy but to little avail. He is not proud of his role during redeployment, and he gladly relinquished his post to his unfortunate successor when the moment came for him to return home.

The other hat which he wore during this whole period was labeled “senior consultant in infectious diseases.” He has very little comment to make on this subject for the reason that infectious diseases never presented a major problem. There was no situation comparable to malaria in the Pacific or the unfamiliar and often exotic diseases encountered in tropical areas generally. The incidence of streptococcal, meningococcal, and pneumococcal infections was lower than in the Zone of Interior. Gastrointestinal infections were infrequent, and the incidence of childhood communicable diseases is always low in seasoned troops. The epidemic of influenza A in the late autumn of 1943 was the only major respiratory outbreak, and it presented no special problems.

So it is that as this particular consultant looks back on the war years, it is his experience as a base section consultant that overshadows all other activities.



Theodore L. Badger, M.D,

Reviewing, some 12 to 15 years later, the World War II experiences of the writer as chief of the medical service of the 5th General Hospital, senior consumlant in tuberculosis of the European theater, and medical consultant to the Normandy Base Section after the invasion, there are several events that have emerged from the chaos of war experiences that are exciting and important and even glamorous.

The “Fifth General,” first general hospital of the U.S. Army to arrive in Europe during World War II, landed in Northern Ireland in May of 1942. Ironically enough for a group of Harvard men, it was housed in a rather gloomy institution for delinquent boys in Balmoral, Belfast.

The hospital arrived in Ireland in the same convoy with the crack 1st Armored Division, a former cavalry division converted to armor and tanks. This proud offensive fighting unit of the U.S. Army was so riddled with homologous serum hepatitis from yellow fever vaccinations, that if it had engaged immediately in combat its effectiveness would have been seriously impaired. Up to 600 jaundiced patients were on the wards of the 5th General Hospital at one time, and a total of some 1,600 patients with hepatitis was admitted in a period of 4 months. Colonel Gordon later traced this jaundice to its association with certain specific lot numbers of contaminated yellow fever vaccine.

The 5th General Hospital staff, particularly Maj. (later Lt. Col.) Charles D. May, MC, Maj. (later Lt. Col.) Charles P. Emerson, Jr., MC, and Maj. (later Lt. Col.) Richard V. Ebert, MC, handled the medical casualties of this epidemic until later aided by the arrival of the 2d General Hospital, the Presbyterian Hospital unit from New York, with medical services under the direction of Colonel Kneeland.

The epidemic of jaundice was hardly over when the first wave of primary atypical pneumonia struck in August 1942. Two hundred and twenty carefully studied and documented cases, with a total of close to five hundred admissions, showed clearly its nonfatal course in this age group of young soldiers as well as the ineffectiveness of penicillin and sulfadiazine on the course of even the most severe miliary forms of the disease. It was at this time that a chest X-ray survey of the entire 5th General Hospital personnel revealed more than 50 instances of ambulatory “atypical” pneumonitis similar to that seen in those hospitalized for “typical” atypical pneumonia.

It was approximately June 1942, a month after arrival of the 5th General Hospital, when the writer met Colonels Middleton, Cutler, and Gordon. This was the beginnming of a close association with all three of these men but especially with Colonel Middleton, since the writer was soon to be appointed as his senior consultant in tuberculosis for the remainder of the war “in addition to his other duties.”

In December 1942, the 5th General Hospital was transferred from Belfast, Ireland, to Salisbury, Wiltshire, in southern England. The personnel and


small equipment went by plane in the course of a day, while vehicles and heavy equipment went by motor and boat.

    It was during this sojourn in southern England that the mobile X-ray unit was organized. This unit, with the efficient medical aidmen of the 5th General Hospital and Colonel Smedal, the roentgenologist, proved to be a most adaptable outfit. It produced excellent chest roentgenograms with rapid efficiency in survey work and made it possible to keep track of the situation in tuberculosis with little or no dislocation of training schedules.

It was also during this long period in England, from December of 1942 to the invasion in June 1944-a period of relative inactivity while waiting for the transchannel crossing--that the basic medical program for the invasion matured. New medical units not indoctrinated in the needs of an active t theater of war and variably equipped in medical talent swarmed into Britain. It was in this period that Colonels Middleton and Cutler built up the consultation services of the theater and initiated the reassignment of medical personnel from one unit to another in such a way that each general and station hospital had chiefs of services of sufficient ability and experience to assure U.S. troops the best medical and surgical care. At first, many, the writer included, objected to being “robbed” of some of their best medical talent. But it soon became apparent that this distribution of medical officers with real professional ability was not only assurance for maintaining the highest standards of medicine, but it was also an opportunity for promoting younger officers of accomplishment. Colonel Middleton in, medicine and Colonel Cutler in surgery performed an extraordinary service in the equitable distribution of medical care to U. S. soldiers in the European theater.

It is to Colonel Middleton’s credit that he encouraged deviations from the routine in clinical investigation, teaching, and research as long as this did not upset the military mission of building up for winning the war.

General Hawley’s meetings of the professional consulting staff at the theater headquarters will always remain memorable as an exhibition of the power of persuasion when actual benefits to the health of the military command could he shown. General Hawley was a hard bargainer but gave wise and judicial council in decisions concerning the military and the medical, and he required as much of his subordinates. It was a truly superb medical service that was established in the European theater. In retrospect, it still appears that top military authorities failed to give full credit to the theater chief consultants in medicine and surgery in timely promotions and appropriate rank. For example, the theater chief consultants were frequently, if not always, of inferior rank as compared to the corresponding British consultants. The Chief Surgeon, ETOUSA, likewise, was late in receiving the rank of major general, long overdue for the service and duty he was rendering his country in the medical operations of the theater.

The special problems of the theater senior consultant in tuberculosis have been well documented in the body of this report, but two or three things may be added. The British consultants were seriously bothered that no one in the


U.S. Army was allowed to touch any British milk products because of contamination with tuberculosis. At the London County Council in 1943, it was revealed that, while only 30 percent of British milk was infested with tubercle bacillus, milk in London was felt to be 100 percent contaminated. It was collected each day by train in huge containers into which the milk supply from each station was dumped on its way to the big city. Thus, both clean and dirty milk were well mixed. Furthermore, it was believed by many eminent English physicians that this condition might be beneficial in building up individual immunity to the disease itself. Pasteurization, if used at all, was done by the flash method, which was known to be imperfect being in inexperienced hands as a result of the war’s drain on skilled manpower.

Most remarkable, however, was the plight of the Soviet prisoners of war evacuated to the 46th General Hospital. These starved, emaciated men presented tuberculosis in its most acute and fulminating forms. Rarely was a problem in prevention and isolation of tuberculosis more difficult than in these men with little or no knowledge of modern vehicles of hygiene and sanitation and with whom there was a complete language barrier. Furthermore, their primitive practices of hygiene and sanitation had further degenerated under years of bestial treatment by their German captors. Protection of U.S. nurses and medical aidmen was the matter of greatest concern. To make matters more difficult, a Soviet medical delegation, sent ostensibly to help, disagreed with American methods of treating tuberculosis and did its best to assume control of all plans for treatment. It quickly became apparent to the senior consultant in tuberculosis that the sooner the Soviet command sent a train to evacuate these patients to their own “beautiful santoria” in the mountains near the Black Sea, the better it would be for international relations, if not for the tuberculous patients.

Most disappointing was the refusal by the War Department of the request for permission to survey by chest films all military personnel to be redeployed to the Far East theaters. When the request was finally approved, it was too late to be of much use. The ultimate, although late, acceptance of the plan by the War Department was due to the strong support given by General Hawley and Colonel Middleton.

The additional assignment of the writer as medical consultant to Normandy Base Section deserves two comments.

First was the enormous amount of cold injury or trenchfoot that was seen in the winter of 1944-45. In December 1942, the British invited representatives from the U.S. Army to a conference on cold injury in London. There, they discussed the types and varieties of clothing that wide experience had taught them were good in the prevention of cold injury. During the winter of 1944-45, the British in the European theater lost only a handful of men from trenchfoot and other cold injury as compared to U.S. losses due to cold injury. U.S. troops were ill equipped, having improper footgear and socks for use in cold weather. Whether it was improper logistics or unwillingness to accept


the experience of others is not clear, but, in retrospect, it was an error, not only of judgment but of improper clothing and shoes.

The second item to be noted concerns recovered U.S. prisoners of war. April 1945, with the end of the war in sight, brought many thousand recovered American prisoners of war to Camp Lucky Strike in the Normandy Base Section. These recovered prisoners swarmed into the camp far in excess of its medical and military resources. The early emergency care of these emaciated men was, at first, an exploration into the conservative renovation of these released prisoners who were starved from a diet deficient in proteins, vitamins, and total calories. Too enthusiastic feedings precipitated acute and serious avitaminosis. Too rapid use of intravenous plasma in those unable to eat brought acute pulmonary edema and circulatory collapse. Earlier, in the Normandy campaign, the value and ease of transnasal gastric feedings of high protein content in those depleted by injury and infection had been learned. A high negative nitrogen balance could be readily remedied by this means, a lesson learned from the Cocoanut Grove Disaster studies in Boston. 148 This technique again proved useful at Camp Lucky Strike in the cautious, selective feeding of these starved and injured prisoners of war.

Colonel Long, the consultant in tuberculosis in the Office of the Surgeon General, visited the European theater on 19 April 1945. It was the writer’s privilege to review with him the principal problems of interest in tuberculosis control and disposition throughout the theater. The diagnosis and treatment of the recovered Soviet prisoners of war at Besancon, France, and of the Americans at Camp Lucky Strike in Normandy constituted the major acute problems of epidemic tuberculosis. To these situations, Colonel Long contributed greatly from his long experience in tuberculosis work and with his calm wisdom in evaluating what was best for the tuberculous soldier and most expedient for the Armed Forces. He had a forceful but pleasant and friendly way of getting timings done, and it was helpful to the European theater senior consultant in tuberculosis to have his backing from a higher echelon in problems vital to health but difficult of execution in the excitement of the last months of the war.

The last day of the war was memorable to the writer along with a small party of medical officers and nurses who had gone on 7 May 1945 with Colonel Long by ambulance train from Strassburg to Mannheim, Germany, to pick up a trainboad of wounded soldiers.

Shortly after arriving at the Mannheim railroad station, the morning of 8 May 1945, whistles and sirens and air maneuvers announced the end of the European war. Colonel Long assembled the small group on the battered platforms of the almost destroyed station of that war-ravaged city and with impressive dignity and sincerity of feeling paid deep tribute to that solemn moment when the hostilities were over at last.


148 The Cocoanut Grove, a nightclub in Boston, Mass., filled by a crowd of some one thousand persons celebrating a college football victory, was swept by fire at approximately 2015 hours on Saturday, 28 November 1942. By shortly after midnight victims of the holocaust had been evacuated to Boston City Hospital and Massachusetts General hospital. The official count on 6 December 1942 showed 498 dead. Source: A Preliminary Report on the Cocoanut Grove Disaster, Massachusetts General hospital, 6 Dec. 1942.


    No reconstruction of the medical work in the European theater in World War II is possible without an expression of thanks to the many individuals of every rank in the Medical Department who through their loyalty and devotion contributed to the extraordinary record of medical care that was practiced throughout the theater. Among the nurses, the medical officers, and midmen are the records of unsung heroism, whether in the combat or Communications Zone. One looks back years later with some nostalgia for the experiences in the care of the sick and wounded. Medically, the wide variety of diseases and the vast number of cases was unparalleled in civilian practice. Preventive medicine was as important as curative treatment. The somewhat harassing brushes with Army procedures were temporarily frustrating, but they never dimmed the extraordinary medical experiences of the war.

It was a privilege to have been in the consulting service of the Medical Department of the U.S. Army with a chief surgeon who combined the understanding and iron determination that was General Hawley’s and under a chief medical consultant with the insight, brilliant leadership, and friendliness of Colonel Middleton. Considering the writer’s 39 months in the European theater, as long as this had to be spent in military duty away from home and the practice of medicine, they could hardly have been richer in medical experience throughout the whole course of the war.

Time heals many ills as well as the personality problems that arise from the close and unnatural associations of war, perhaps because it is more pheasant to remember the brighter experiences or perhaps because distance lends enchantment and the rough places look more smooth. Perhaps, it is just the mellowing process of age that makes the best stand out in silhouette-the writer cannot say. But it is to be hoped that the lessons, other than medical, learned from World War II will make it unnecessary for the rising generation to repeat the experience of another similar or probably more devastating war sometime in the future.