Military medicine, 175, 8: 118, 2010 118 military medicine

LESSONS UNLEARNED 
As General MacArthur went on the offensive in the Southwest 
Pacifi c area following the Battle of Midway in summer 1942, 
the power of the malaria parasite was given low priority. The 
capture of Dutch Indonesia in 1942 gave Japan control of the 
world’s largest supplies of chinchona. The U.S. armed forces 
reserved quinine for treatment only, but had no appropriate 
dosing schedule for Atabrine and no malaria discipline on 
the fi ghting line. On Guadalcanal, 12–23% of the 1st Marine 
Division was ineffective from malaria between August and 
November.
22
At the same time on New Guinea, the inade-
quately trained, poorly supplied, and poorly led 32nd Infantry 
Division was being pummeled by mosquitoes, the Japanese, 
and dysentery until LTG Robert Eichelberger assumed com-
mand. Eichelberger instilled leadership and discipline, straight-
ened out logistics problems, and by January 1943 had helped 
the Australians beat the Japanese. However, the heavy toll of 
Plasmodium falciparum and vivax malaria on Allied forces 
had to stop.
23
In March 1943, MacArthur put tropical disease 
control on his agenda by establishing a combined advisory 
committee, which reported directly to him, under the direc-
tion of COL Neil Fairly. Their recommendations received 
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Military Hygiene Enters the 21st Century
122 MILITARY 
MEDICINE, Vol. 175, August Supplement 2010
not only MacArthur’s support but also that of Army Chief of 
Staff George C. Marshall. Antimalarial education, research, 
and development became energized. Army schools of mala-
riology were established. Educational programs defi ning the 
dangers of mosquito exposure and methods of protection were 
intensifi ed. New repellents and a new pyrethrum bug bomb 
began making their way to the South Pacifi c in mid 1943, 
and by early 1944 a new and versatile insecticide called DDT 
was also going to the front. Vector control teams expanded 
their operations as more territory was secured. Through COL 
Fairley’s research, Atabrine doses were standardized and 
issued under supervision to troops weekly. Malaria control in 
the Pacifi c, however, did not really begin until mid 1944. A 
lack of American campaign experience with malaria provides 
a comforting alibi for these misadventures; not so for fi ghting 
in the cold. 
The army gained valuable experience in cold weather oper-
ations during the Indian Wars and it learned of the debilitat-
ing effect of wet and cold on feet encased in leather boots 
from the British in World War I. But in March 1943 the 7th 
Infantry Division began the Attu Island Campaign without 
properly insulated, wind-proofed, and water-proofed clothing 
or footgear. In 3 weeks of combat, the 7th sustained 3,829 
casualties, 31% of which were due to the cold, a rate identi-
cal to the rate of wounded in action. Commanders had ignored 
the quartermaster recommendations to wear special clothing 
and footgear and offi cers and enlisted were poorly trained to 
fi ght in cold, wet climates. Foot hygiene was not enforced 
and often wet clothing was discarded rather than dried out. 
Colonel Dunham’s book had not discussed cold injuries or 
their prevention for medical offi cers. The Medical Department 
Soldier’s Handbook did not mention trench foot and The Guide 
to Therapy for Medical Offi cers not only excluded trench foot 
but advised troops to lace shoes snugly, which only decreased 
distal circulation. It would take two more severely cold, wet 
winters in Italy and France to convince the U.S. army to pay 
attention to the problem. 
The soldier’s load went unaddressed by line or medical 
offi cers as well. In the 1920s, a British commission studied 
how soldiers were loaded down over the centuries. They con-
cluded that on a training road march the soldier’s load should 
not be in excess of 40–45 pounds, roughly one-third of the 
soldier’s body weight, and noted a soldier cannot be trained 
to effi ciently carry more than this weight.
24
However, on June 
6, 1944, American infantrymen struggled ashore carrying 80 
pounds. Some became slow moving targets on the beach, oth-
ers did not make it out of the surf. 
Psychiatrists and psychiatry were also ignored early in 
the war. Some offi cers still contended that a psychiatric diag-
nosis was the coward’s ticket to the rear. But as psych casu-
alty rates rose after the battles of Faid and Kasserine Pass, in 
mid February 1943, the interwar neglect of military psychi-
atry was highlighted, and the notion that proper leadership, 
high morale, and appropriate soldier selection could prevent 
such injuries was proven untrue. This led to Captain Frederick 
Hanson being deployed to Major General George S. Patton’s 
II Corps in late February. Hanson re-educated both line and 
medical offi cers of the value of proximity, immediacy, and 
expediency in treating traumatic psychiatric injury. Hanson 
returned 30% of cases to duty in 30 hours and during the bat-
tles of Maknassy and El Guettar, 70% of the 494 casualties 
were back in combat within 48 hours.
25
In the generation after World War II the explosion of oral 
medications—antibiotics, antihypertensives, and psychotropic 
agents, as well as newer and better vaccines—only marginal-
ized the importance of military hygiene. The idea of pill as 
cure all and medical offi cer as scientist only widened the intel-
lectual gap between line and medical offi cers. The Department 
of Military Hygiene at the U.S. Military Academy went away 
and in the late 1960s military physicians were replaced by 
medical service corps offi cers at the U.S. Command and 
General Staff Course. 
In Vietnam, we had to relearn lessons from the trenches of 
the First World War. 
Wet feet wrapped in wet socks and boots for a prolonged 
period could destroy the combat effectiveness of a unit. 
Granted it was warm water and called paddy foot, but the 
result was the same and so was the prevention. Malaria was a 
major problem for the First Air Cavalry early on in the north-
ern jungle highlands. The unit experienced the same rates that 
so concerned General MacArthur a generation earlier, about 
1,000 cases/1,000 soldiers/year and it was worse in the battal-
ions, the real population at risk. (R. J. T. Joy, personal commu-
nication) It was Guadalcanal all over again because malaria 
discipline was not enforced. 
And battle fatigue? Well, a 1-year rotation policy, the 
intermittent nature of guerilla warfare, and the rapid ramp-
ing up of division psychiatric assets combined to keep rates 
low. That same rotation policy, however, took soldiers home 
as individuals not units. Furthermore, they could be home in 
hours to days not weeks as in earlier wars and, therefore, the 
therapeutic catharsis achieved through informal group ther-
apy with one’s combat buddies was never obtained. By the 
late 1970s, post-Vietnam syndrome was a diagnosis and the 
rates were burgeoning. In the early 1980s, the concept of 
chronic post-traumatic stress disorder
26
became accepted, and 
it took only 20 more years to deploy combat stress teams to 
the battlefi eld.