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This volume, the twenty-first to be published in the total series relating the history of the United States Army Medical Department in World War II, is the second volume to be published in the internal medicine group. The first volume, published in 1961, dealt with the activities of consultants in medicine in all parts of the world. This second volume deals with some of the infectious diseases encountered in a global war. The third and final volume in this group, now in preparation, will deal further with the infectious diseases and with general medicine.

Of necessity, as the editor of the internal medicine group points out in his preface, some of the material in this volume overlaps some of the material in the first internal medicine volume. It also overlaps certain of the material in the preventive medicine series. There has been, deliberately, no effort to alter the situation. To do so would have resulted in rigid and artificial distinctions and would also have deprived the reader of the benefit, in certain instances, of presentation of material on the same subject from more than one point of view.

As I read this book in manuscript, I was impressed with a number of considerations, some peculiar to this volume, some shared by the other volumes. Let me list some of them:

1. The wisdom of our policy of utilizing the personal experiences of present and former medical officers, who, as has been repeatedly pointed out, not only helped to create but also to record the data upon which this whole history is based. The authors of the various chapters in this volume were selected to write them not only because of their eminence in their particular fields but also because they had had wartime experiences in these fields. More valid sources could scarcely be imagined.

2. The expansion of knowledge of the etiology, clinical picture, control, and management of certain diseases about which little-in some instances nothing-was known before the war. The list is incomplete but, as examples, one might mention sandfly fever; Q fever; scrub typhus; Brill's disease; primary atypical pneumonia; and cutaneous diphtheria.

3. The remarkable utilization of opportunities for investigation and the amazing amount of valuable data that emerged from these studies, which were often made under almost intolerable conditions, both in and out of combat. In addition to studies involving United States military personnel, including released prisoners of war, were the studies involving Recovered Allied Military Personnel; enemy prisoners of war; and, civilians.

In this connection one is impressed with the importance and value of the work done by the various boards, commissions, and subcommissions appointed to investigate, and recommend action upon, certain aspects of infectious diseases. Their investigations included acute respiratory disease; influenza and other epidemic diseases; typhus; neurotropic virus diseases; hemolytic streptococcal infections; airborne infections; tuberculosis; and malaria. When one realizes that some 15,000 drugs for the suppression and treatment of malaria were investigated, some cursorily and some definitively, during the course of the war, one can also realize the fruitless activities and actual chaos which might have resulted without the guidance of the Board for the Coordination of Malarial Studies.

4. The changing concepts of certain diseases and their management. In 1941, for example, no one would have dreamed that one of the most significant chapters in a volume in the internal medicine series of the history would concern venereal disease. In December 1943, the treatment of patients hospitalized with venereal disease ceased to be a responsibility of the genitourinary service and became a responsibility of the medical service in Army hospitals. Hospitalization then gave way to ambulatory treatment. In the case of syphilis, therapy evolved from the time-honored but cumbersome and hazardous methods with arsenicals and bismuth-impractical even under relatively static conditions of training and completely impractical in combat-to the resolute decision to use penicillin for this purpose. This decision, made by The Surgeon General and applied Army-wide even at a time when last-minute preparations for D-day in Europe were being made, solved a serious problem with greatest effectiveness. Trained manpower was conserved; channels of evacuation were not clogged by this type of patient; and, many hospital beds were freed for more urgent purposes. Further, the use of penicillin simplified the treatment of gonorrhea and reduced the complications arising from that disease from 25 percent in 1937 to 1 percent in 1944.

The spread of knowledge of all these diseases required almost "evangelical efforts" on the part of the medical consultants and others responsible for the training and indoctrination of medical officers. As to the troops, control of disease was a matter of individual indoctrination and to be effective required firm command support. Education concerning malaria and its suppressive management did not succeed until Atabrine discipline became an actuality. Then malaria rates fell from as high as 1,500 to 2,000 per thousand per annum, or higher, to negligible figures.

A careful reading of this book makes clear that if these diseases had not been controlled, the United States could have suffered a great military disaster without regard to enemy capabilities. Some of the authors frankly acknowledge that luck played a part in the happy outcome, and so it did. The epidemic of encephalitis did not occur on Okinawa until the island had been occupied, though sporadic fighting was still going on and troops were staging for the invasion of Japan. On the other hand, the Medical Corps can justifiably assume credit for its brilliant work in a number of these dif-

ferent diseases. Epidemic typhus was rampant in civilian populations with which many troops were in close contact, but there were only 104 cases in the United States Army and not a single death.

One or two comparisons with World War I figures are further proof of the improvement of medical management of infectious diseases in World War II: In World War I, 46,640 deaths, 73 percent of all deaths from disease, were caused by influenza, lobar pneumonia, bronchopneumonia, bronchitis, and measles. In World War II, in an Army over twice the size of the World War I Army and mobilized over a longer period, there were only 1,285 deaths from these causes. In World War I, tuberculosis was the leading cause of disability separations; it accounted for 11.1 percent of all separations and for 13.5 percent of all separations from disease. In World War II, tuberculosis was thirteenth in the list of disability separations and it was responsible for only 1.9 percent of separations for disease.

The primary mission of the Army Medical Service is to conserve and maintain the fighting strength of the Army. After the difficult struggle for Buna-Sanananda in the New Guinea campaign, largely because of the ravages of disease, the 32d Infantry Division had to be taken out of the line for rest and rehabilitation and it was ineffective for many months. Extrapolation of these facts and others makes clear what might have happened had such situations continued. It is to the everlasting credit of the Medical Department-supported by understanding line commanders-that they did not.

In retrospect, the Medical Department seems to have accomplished an almost impossible task. It made its mistakes, and, to speak bluntly, some of them should not have been made. What one of the authors of this book said of malaria might well be said of a number of other diseases, that the stages of education in it were painfully alike in all theaters and areas. Nonetheless, medical personnel conquered and held in check diseases that were bewildering in both kind and number; that offered multiple difficulties of diagnosis and differential diagnosis, particularly in their very early stages; and that sometimes were completely unknown and sometimes had been modified by environment and by the changes in the clinical picture that occurred when non-immune persons entered areas of endemicity.

As a surgeon, I, as well as many of my surgical confreres, have had to concentrate on the essential character of our specialty in dealing with combat casualties. In my role as The Surgeon General of the Army, my outlook is necessarily wider and my appreciation of this book is therefore much deeper. 

Quite properly, since our task is the preparation of a history of the Army Medical Department in World War II, the chief emphasis in this book is upon the enormous clinical military experience with infectious diseases in all parts of the world. That does not make the volume less valuable as a text on these diseases for medical students, general practitioners, and specialists in internal medicine. I recommend it to them, as well as to medical officers of the Army and other armed services, as a compilation of data not readily come by elsewhere.

The nineteen authors of this volume deserve the grateful thanks of the Army Medical Service and of the medical profession in general. For a variety of reasons, some beyond our competence, some due to our own culpability, the preparation of these and other volumes of the history has been long delayed. It is a tribute to the sense of professional duty and the patriotism of these former medical officers that in the midst of their busy civilian lives they have added to their wartime service by taking the time to set down this record, and to carry out the task with real enthusiasm. That is evident on every page.

It is therefore my pleasure to express my gratitude to the authors of this volume and to its editor, Dr. W. Paul Havens, Jr., and to the Advisory Editorial Board of which Dr. Garfield G. Duncan is Chairman, for a mission well accomplished. It is my equal pleasure to express my appreciation to the personnel in my own office who are doing the prodigious work of producing these volumes.

Lieutenant General, 
The Surgeon General.