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This volume on communicable diseases transmitted through contact or through unknown means is the second volume dealing with communicable diseases, the fourth volume to be published in the preventive medicine series, and the sixteenth volume to be published in the total series dealing with the history of the United States Army Medical Department in World War II. The third volume on communicable diseases, now in preparation, deals with arthropodborne diseases. The highly important diseases transmitted through the respiratory and alimentary tracts have been treated in Volume IV of this series published in 1958.

It was wise selection as well as fortunate chance that placed the late Brig. Gen. James S. Simmons, USA, at the head of the Advisory Editorial Board on the history of Preventive Medicine in World War II. It was equally wise selection and equally fortunate chance that made Brig. Gen. Stanhope Bayne-Jones, USA (Ret.), his successor. Under their sound and inspiring guidance, the entire Editorial Board has worked with interest, enthusiasm, and real efficiency, particularly in the selection of the contributors to the series. The 17 chapters in this book were written by 27 authors, all highly qualified, all with medicomilitary experience during World War II, and all of whom speak with authority in their special fields.

This is a record of past wartime experience, but it has in it the basis of the prevention and control of these special diseases in future wars. To look ahead, as many historians have pointed out, one must first look back. This volume also has in it much of value for civilian preventive medicine in peacetime.

Wars are primarily won or lost by skill at arms, but they may also be won or lost by the success or failure of the methods used to prevent and control disease. It is the ultimate result of the concepts and practices initiated by Maj. Gen. George M. Sternberg, USA, Surgeon General from 1893 to 1902, that the ratio of deaths from disease to deaths from combat injuries fell progressively from 5:1 in the Spanish-American War to 1 :1 in World War I and to 0.07:1 in World War II.

In World War II, as in all wars, communicable diseases provided special problems. Some which were no longer of great significance in civilian life became, in effect, occupational diseases in military circumstances. Some diseases which had long been adequately controlled in civilian life in the United States took on new significance when they were encountered in wartime in other parts of the world. Some familiar diseases seemed strangely unfamiliar when they were encountered in foreign lands. Diseases in populations with which Army personnel were in inevitable contact furnished problems in these populations as well as in the Army.

Most of the diseases described in this and other volumes in this series carried a certain mortality, which often was minimal. Even the mildest of them, however, was also associated with what has been well described as "a steady erosion of manpower." Fungus infections furnish an excellent illustration of a group of conditions which, though seldom serious, accounted for a heavy loss of man-days. They existed, in both active and latent forms, in many soldiers when they were inducted. All the wartime circumstances were favorable to recurrence. Numerous fresh infections developed. Methods of prevention which had been regarded as reliable were found to be not only ineffective but potentially harmful. The best methods of treatment were not really satisfactory. The care of these conditions, if only by the sheer weight of their numbers, took up much of the time of medical officers and added to the burden of outpatient clinics and sometimes of hospital services. Slight as these infections usually seemed in civilian life, they incapacitated the soldiers who suffered from them quite as truly as if they had been combat casualties.

Epidemic keratoconjunctivitis is another condition which produced an incredible amount of noneffectiveness. It had incapacitated many thousands of essential skilled workers in war plants before its risks were appreciated, and it became evident that the clue to its management was prevention, since there was no really satisfactory treatment. Once its infectiousness was realized, it was rapidly brought under control in affected Army units.

As one turns the pages of this book, certain facts seem to call for mention:

The first, and in many respects the most important, is the homogeneous, cordial, and productive working relation between medical officers responsible for preventive medicine in the Army and their counterparts in civilian practice and the U.S. Public Health Service. One has only to recollect, for instance, the impressive civilian cooperation through the Army Epidemiological Board to realize what this relationship meant. Without it, many of the diseases described in this and other volumes of the preventive medicine series would have presented even more serious problems than they did, and their solutions would have been much longer in coming.

Although a great deal of new and useful information was secured during the war about a number of diseases, some of them still remain mysteries.
Geographic areas were added, for instance, to the known distribution of Q fever, but the source of infection and the method of transmission are still
to be clarified. On the other hand, because of sound clinical and epidemiological practices employed during the war, light has been shed upon some diseases
long after the war. It was 10 years after the 1943 epidemic of Fort Bragg (pretibial) fever that the leptospiral origin of this disease was established by
serologic and bacteriologic investigations based upon the wartime practices.

All outbreaks of poliomyelitis during the war were isolated and sporadic, but it is disconcerting as well as surprising to find that the residua of this

disease accounted for the rejection of 1 percent of the men found by induction boards to be unfit for service.

The control of some diseases was not primarily a medical problem but, instead, a command problem. Scabies, for instance, paralleled venereal disease in that its incidence depended upon the incidence in the civilian population and the opportunities for contact and fraternization. Schistosomiasis, of which there were more than 2,500 cases, was originally believed by some line officers, and by a few medical officers, to be of only academic significance. Some soldiers from Puerto Rico with the disease were inducted before the necessity for screening inductees from this area was realized. In the Philippines, the prevention of schistosomiasis was entirely a matter of discipline, which involved keeping the men, their clothing, and anything else connected with them, including their vehicles, out of infected waters.

Yaws was an unimportant disease in the U.S. Army but an extremely important civilian disease in Haiti. A cooperative study showed that it responded promptly to penicillin, which was effective even when the patients were treated on an ambulatory basis. This is but one of the wartime discoveries which has proved of great value in peacetime.

In March 1941, venereal disease was the greatest single cause of non-effectiveness in the U.S. Army, an ironical situation indeed, because it could readily have been prevented and controlled by the means then available. It never ceased to be a problem, and it was often an embarrassing problem. Army philosophy was based on a frank recognition of the fact that an effective fighting force had to be maintained, regardless of moral implications. Prophylactic measures were therefore employed, and policies were varied to suit the conditions encountered in various theaters. This philosophy was in direct conflict with that of certain civilian agencies which were cooperating-and most cordially and effectively-with the Army. No one was completely satisfied either with the policies employed in World War II or with their results, but, in retrospect, it seems unlikely that anything much better could have been done.

Hepatitis furnished the most unexpected, and perhaps the most serious, problem of all the diseases discussed in this volume. Although this was an "old and ugly camp follower," neither its enormous incidence nor its serious potentialities had been foreseen by any medical authorities before the war. Then, 4 months after Pearl Harbor, came the "bombshell" of epidemic serum hepatitis, caused by the use of icterogenic human serum in certain lots of yellow fever vaccine. During 1943, in the midst of hard combat in the North African theater, medical officers were suddenly confronted with another type of hepatitis, the infectious variety, whose victims filled to overflowing the hospitals just to the rear of the combat area. Up to 1942, there had been no general realization of the possible dual character of hepatitis. How the disease was spreading in this epidemic was not understood. No methods of

prevention were known. No specific therapy was available. The experience was both colored and confused by the recent experience with serum hepatitis. A previous attack of that variety of hepatitis apparently furnished no immunity at all. This epidemic in North Africa was an outstanding example of what can happen when susceptible troops, during the summer, occupy an endemic area, as the eastern half of the Mediterranean littoral proved to be. There were later epidemics of infectious hepatitis in the Mediterranean theater, in the Middle East, in the European theater, and in the Pacific, but none so devastating from every standpoint as this first outbreak of serum hepatitis in 1942.

Three commissions working under the auspices of the Army Epidemiological Board took up the investigation, with the main objective of determining methods of spread and devising methods of control. The knowledge gained was sparse, in view of the magnitude of the problem, and there are many questions about infectious hepatitis which still require answers.

The responsibility for the history of the United States Army Medical Department in World War II was assumed by The Surgeon General of the Army in 1944. It is an important phase of his overall responsibility. In writing the foreword for this volume, the first to appear during my tour of duty, I gladly assume the task, and I pay tribute to all of those who have written and produced this volume and the other published volumes in the series, and who are at work on the volumes still to be published.

Lieutenant General,
The Surgeon General.