Back to the Beginning for the Eighth Evacuation Hospital in Morocco During World War II 70 Years Ago

PREPARATION AND GETTING STARTED

Many innovations and improvements in health care have occurred during unsettling times of warfare when necessity and creativity are summoned to confront immediate threats to well being. Later these new approaches become the accepted treatment norm or these health threats continue to be issues. Our family has been fascinated to observe where some of these wartime changes in health care occurred and to unite them with the description, personal observations, and pictures that Dr Byrd S. Leavell captured in his book (1) about the Eighth Evacuation Hospital during World War II.

In 1941, Winston Churchill and others began planning a strategy for obtaining victory in the Western Desert of North Africa (2) as it did not seem feasible to attempt a direct invasion of France or Northern Europe. This did not occur for 3 more years (June 6, 1944). Gaining control of North Africa might accomplish several things: confront the Axis Afrika Korps advance by General Erwin Rommel from Egypt, force Spain to remain neutral, forestall Italy's alliance with Germany to head into North Africa, maintain control of Gibraltar thus retaining entrance into the Mediterranean Sea, preserve Mediterranean bases, and with control of Casablanca, gain an Atlantic Ocean port in North Africa (3, 4). The United States, although remaining out of the war in Europe, was giving substantial aid to Great Britain and was gradually being drawn into this part of the conflict. However, President Franklin Roosevelt ended the United States foreign policy of neutrality in June 1940 and the United States joined the conflict (5). Churchill elaborated further that “a campaign must be fought in 1942 to gain possession of, or conquer, the whole of the North African shore, including the Atlantic ports of Morocco” (6, 7). This approach was agreed upon at the Arcadia Conference (8, 9) held the end of July 1942, and became Operation TORCH.

The Eighth Evacuation Hospital was authorized on March 2, 1942, organized, and then dispatched in July 1942 to attend the largely medical problems that arose from army troops themselves beginning training for combat involvement. This was not a new or unknown activity for the University of Virginia, for in World War I it had sponsored Base Hospital 41 which was sent to Paris, France in July 1918, remaining there until the Armistice was signed on November 11, 1918 (10). When the hospital first began receiving patients in Pageland, South Carolina (July 14, 1942), and later at Fort Benning, Georgia (August 23, 1942, until September 16, 1942), the patients had mostly common minor disorders (respiratory infections, diarrhea, skin infections, infectious hepatitis, duodenal ulcer, etc) and more serious problems such as diabetic acidosis, amebic dysentery, nephritis, and cardiovascular problems that occurred in ostensibly healthy soldiers. Surgical services were needed for bone fractures, sprains, burns, lacerations, or for an emergency such as appendicitis (11). All of these diagnoses were well within the expertise of competent academic-clinical physicians serving the hospital. It then departed on September 16, 1942, for Camp Kilmer near Stelton, New Jersey, to join later on November 1, 1942, Operation TORCH which was the Anglo-American troop invasion planned for North Africa (9). The enormous convoy of ships was awesome to view as it sailed from nearby Jersey City, as described by members of the Eighth Evacuation Hospital unit on board the Santa Paula, a former Grace Lines luxury cruise ship that had been converted to a troopship carrying 3000 soldiers; it joined “the greatest armada that the world had seen up to that time” (12). Operation TORCH planned to take troops to three destination points: Casablanca in French Morocco, and to Oran and Algiers in Algeria (9, 13).

For the assault on the Casablanca area, the Western Task Force, composed entirely of American military units and comprised of 34,000 soldiers, landed on November 8, 1942, at Fedala with 20,000 troops which was close to Casablanca, at Port Lyautey, 80 miles north, and at Safi, 130 miles south (13, 14). The capture of Casablanca occurred on November 8–11, 1942 (13). But much of the convoy still remained out at sea, as the Casablanca harbor was damaged with sunken ships from the naval battle (14). Finally, on November 18, 1942, the Santa Paula slipped into the harbor at Casablanca; 2 days later on November 20th the Eighth Evacuation Hospital unit went ashore (15), and the hospital staff marched along the streets to the Italian consulate and school on Rue Mangin and Rue Jacques Bainville which was the destination for setting up the hospital (15). “The unit found its first obstacle; it couldn't get into the building … (it) was already jammed with American medics … all of whom had arrived on the same convoy” (15). Thus, in the beginning there was an initial faux pas which is reflected in Atkinson's title of his history, An Army at Dawn—War in North Africa (4). But, despite some space logistics (rather than set up a hospital in the confines of a building, using groups of tents was preferable) and disagreeable cold rainy weather, the Eighth Evacuation Hospital began to set up a hospital, then designated as a Provisional Hospital, and it received its first patient on November 22nd (15). The hospital would remain here until March 14, 1943, and would admit 5657 patients. The staff of the hospital included 47 officers (most were physicians), 52 nurses, and 318 enlisted men in the medical detachment (16).

As this was “dawn” and the beginning, what were the adaptations and some organizational issues that occurred to make this hospital's medical work special, and which affected military healthcare? First, procurement tactics and provisional support-supply functions needed to be reorganized (17) and critiqued for every new military encounter. The experience of a delay in delivery of military supplies and their distribution had occurred during World War I; this had resulted in the creation of the National Defense Act of 1920, which was charged with planning better procurement of military supplies, including medical supplies and their distribution. The Act needed major reorganization. Considerable effort was devoted to this program during the 1930s as tensions were increasing in Europe and the Far East, and the possibility of extensive military mobilizations seemed likely for a global war that might develop. The Medical Supply Service, organized in the Surgeon General's office, went into effect on July 1, 1942 (17). This organization had been recommended by Mr Edward Reynolds, former President of the Columbia Gas and Electric Corporation of New York, who then was a Special Assistant to the Surgeon General. Mr Reynolds became Acting Chief of the Supply Service and later appointed Chief; he served in this capacity during 1943–1946 (17).

To illustrate the issue of having timely availability of medical supplies and how this affected care in military support hospitals, two examples were immediately important for the Eighth Evacuation Hospital and likely for other hospitals in the North African campaign: having human blood plasma for transfusion use, and the availability of a new antibiotic, penicillin.

BLOOD PRODUCTS TO TREAT TRAUMA

For context, there are multiple clinical conditions causing shock from an appreciable reduction in the volume of circulating blood leading to peripheral circulatory failure and low blood pressure. A form of shock, defined as a traumatic form, is applicable to warfare inflicted injury and would reflect acute hemorrhage from extensive contused wounds and severe burns. Prolonged dehydration which may lead to serious reduction in the volume of circulating blood might be encountered, but under wartime circumstances, this would be treated with replacement of water and electrolytes. Blood replacement or therapy with plasma was the battlefield strategy anticipated for the wounded.

In 1935, Flosdorf and Mudd (18) provided a method for preserving blood plasma (and also serum) through dehydration of it in a frozen state which could be dried, preserved, and reconstituted. Interesting research followed (19, 20) about shock, plasma loss, and therapy with intravenous infusion of plasma. Also, it was noted that from burns, plasma in effect was lost, so plasma replacement was given. Medical interest in the use of plasma therapy had been of particular interest at the University of Virginia's Medical Center in Charlottesville, Virginia, and the availability of an especially fine blood bank there made transfusion therapy of special interest for the clinicians in the Eighth Evacuation Hospital unit (21).

However, the availability of human blood plasma for transfusion therapy for the anticipated injured in the North African war theater became a last-minute issue, just as the supply ship convoy was preparing to leave the Norfolk, Virginia area. During final loading of supplies and preparation to deploy, anarchy apparently ruled the docks and loading plans changed frequently (22). As described: “At the eleventh hour, medical officers abruptly realized that Task Force 34 collecting supplies had stockpiled only a small fraction of the blood plasma required. Recent experience had shown that plasma … was highly effective in keeping wounded soldiers alive, and when it dried out it could be stored without refrigeration for weeks. With authority from the War Department, the port surgeon by day's end had requisitioned virtually all of the plasma east of the Mississippi River and had organized three Air Force bombers to pick up and deliver it. When bad weather closed in on Norfolk, ground crews lit flares to guide the pilots home. Trucks raced from the airfield to the port with a thousand precious units of plasma just before the fleet weighed anchor” (22). The plasma procurement program was considered to be of great significance by the Supply Service, and the production of 700,000 units of dried plasma (250 cc unit size) occurred in fiscal year 1942 (23).

A NEW ANTIBIOTIC: PENICILLIN

Another supply issue that became of special concern was the availability of the new antibiotic, penicillin. Stemming from the observations of Sir Alexander Fleming in 1928 (24) that Staphylococcus aureus on a plate did not grow in areas of the plate that had been accidentally contaminated with a green mold, named Peniicillium notatum, researchers in about 1940 were spurred to create an injectable agent for treatment. Focusing on the research of H.W. Florey (25) whose work helped demonstrate the therapeutic powers of penicillin, as found in early experimental rodent models of infection, and also coupled an American-English liaison (known as a Rockefeller Foundation–Oxford University), stimulated interest in the preparation of sufficient amounts of penicillin to assess its clinical value further, and to pursue clinical trials in 1941 (26) and to study treatment of war wounds in North Africa (27).

Further investigation in North Africa began in the summer of 1942 (28) in which 15 battle casualty-sustained wounds in a Scottish General Hospital near Cairo, Egypt (29), were given local irrigation with penicillin (and 9 of 15 cases also included sulphonamide or sulphanilamide). This route rather than systemic administration was performed because of the limited amounts of penicillin available. The first dose of penicillin given to a patient in the United States was at the Yale-New Haven Hospital in March, 1942 (30). However, penicillin development and production were vigorously underway by the Army Medical Supply; no other new item among medical supplies attracted as much attention. Initial experimentation in the United States began in April 1943. Penicillin was first purchased under contracts in May 1943, and clinical experiments were underway in Army Hospitals in the summer and fall of 1943. Production soared and good amounts were shipped to Army Hospitals in the United States and to those in all theaters of military operations, as described (31). A thorough review of the testing and effective use of penicillin was authored by P. Neushul (29).

In retrospect (32), the combined efforts to develop penicillin in sufficient quantity by having an industry-government collaboration with open scientific interchange, and then conducting thorough clinical trials to prove its usefulness in military medicine, all accomplished by mid-1944, created a precedent for how new antibiotic research might need to be done at present. With the increase of bacteria and other pathogens resistant to present antibiotics, prompting an urgent need to find newly effective therapies to confront the “superbugs,” this prior government-pharmaceutical collaboration, so effective before, now needs attention (33).

WHAT WAS THE EIGHTH EVACUATION HOSPITAL COPING WITH IN CASABLANCA IN 1942–1943, AND LATER IN ITALY?

As mentioned (15, 34), the Eighth Evacuation Hospital set up and began receiving patients toward the end of November 1942 and operated as a 400-bed provisional general hospital at the Italian consulate and school until March 10, 1943. Although the initial battle to retake Casablanca had concluded on November 11, there were still 61 battle casualties to care for resulting from the initial invasion which involved 34,000 American troops; more injuries occurred after an air raid on Casablanca on December 31, 1942. But most of the 5657 patients (35) during this initial 3½-month interval had a variety of usual medical diseases or non-battle types of injuries. However, among the troops was an unexpected number of infections, especially venereal diseases (chancroid, syphilis, and gonorrhea) (34). In fact, a special stockade at the hospital, consisting of 10 patient tents, was formed on December 17, 1942; 602 (10.7% of admissions) infections were for venereal disease during this initial interval (35). This venereal disease treatment center was named “Bousbir” after “the largest brothel in the world” (36) that had 500 workers on duty each day. A description of this venereal disease unit was provided by Dr Staige Davis Blackford, who organized the Eighth Evacuation Hospital, in a letter he wrote (36). But patients came from other places as well. Some of the patient traffic for this venereal disease unit was said to reflect the bustling, liberal, Bohemian, cosmopolitan atmosphere of Tangier in Spanish Morocco, a city approximately 200 miles north of Casablanca at the Straits of Gibraltar that linked Europe and Africa. Residents of North Africa and Europe visited there. A question that cannot be answered is, “Was any of the new antibiotic, penicillin, which was being used for irrigation of wound infections perhaps being tried in any refractory cases of venereal disease?” Penicillin therapy would be used successfully in men, presumably military personnel, with sulfonamide-resistant gonorrhea, as reported from the US Marine Hospital, Staten Island, NY (37).

From March 18, 1943, until June 19, 1943, the Eighth Evacuation Hospital moved its location in Casablanca to Anfa Hill, a suburb just outside the main city. There the hospital functioned as a provisional convalescent hospital and admitted and cared for 1459 patients during this interval (35). Among these patients, 706 were classified as having medical diseases, 433 were injuries, and 320 were wounds. Injuries were not military battle suffered injuries. The Casablanca Conference occurred in the Anfa Hotel (38–40), and those in attendance included Winston Churchill, Franklin Roosevelt, and many other prominent people and military officers, such as Dwight Eisenhower, George Patton, Lord Montgomery, Charles DeGaulle, et al. The conference, which lasted for 2 weeks, was to decide what to do after the defeat of the Axis forces in North Africa, and to chart the next course. This plan led to the invasion of Sicily and design of the subsequent Italian Campaign (40). It must have been an exciting location on Anfa Hill, and Dr Leavell recorded the special places in several of his water color paintings that depicted the Anfa Hotel and the villas where Churchill and Roosevelt and their entourages stayed.

As the Allied forces moved across Morocco, Algeria, and Tunisia with difficult fighting, so well described by Rick Atkinson (4), the military skills of the troops improved and success occurred. Thus, at the end of the “beginning” there was a positive assessment for Operation TORCH at this point (39). Keeping pace were the support services, including military hospitals that had to move and relocate often. The Eighth Evacuation Hospital had to partially split up on June 19, 1943, when a small detachment was sent from Casablanca to Bizerte, Tunisia, and it participated in caring for the wounded from the invasion of Sicily. The remainder of the Eighth Evacuation unit left Anfa Hill and Casablanca on July 21, l943, and travelled by train to Algiers, Algeria (40). The trip along the Mediterranean coast took the staff through a picturesque part of the continent, including through the Atlas Mountains, which reminded some staff of the Shenandoah Valley of Virginia (40)—nostalgic thoughts no doubt for those from the Charlottesville, Virginia, area. The Eighth Evacuation unit did not deploy to Sicily, but readied for going to the Italian mainland. The unit landed at Salerno, Italy, on September 21, l943, but in doing so a considerable amount of its basic equipment was lost that was on board a transport supply ship that had sunk (41); re-equipping the hospital was quite a challenge. In October, the hospital moved past Naples to Caserta. But because much of its equipment, especially surgical items, had not been replaced, most of the patients that arrived at the Eighth Evacuation Hospital were admitted to the medical service (42). From October 16, 1943, until December 10th, a total of 3915 patients were admitted. In Caserta, the hospital was re-equipped and became designated as a field hospital for the first time; soon it would move near Teano and for the first time function in a combat operational area. The Eighth Evacuation Hospital supporting troops from the US Fifth Army had 2 more years of service to face, which proved to be the most arduous time of its deployment in the war as the Italian Campaign continued.

The late autumn and winter of 1943–1944 was a tough period. “Probably the worst casualties that the Hospital received during the entire war were those suffered in crossing the Rapido River during the latter part of January” (43). The taking of Rome was the objective. The fighting near Cassino was grueling and the Allied forces could not dislodge the well-entrenched German forces. Finally, in late February, the Allies ceased their attack. The hospital had had 6597 admissions. Yet the hospital's operation at Teano gave the personnel of the Eighth Evacuation unit a feeling of confidence and satisfaction, it was believed (44). “In fact the winter of 1943–1944 saw important advances in the care of the sick and wounded in the 5th Army; … the use of penicillin, which became (readily) available in early 1944, and the establishment of a blood bank in Naples in February 1944 practically revolutionized the care of the wounded. Tetanus was not seen and with radical debridement of wounds and use of penicillin, gas gangrene practically ceased.” (43). Preventive measures, using lyophilized human serums as passive immunization against many infectious diseases (45) was now established and had a favorable impact.

The difficult fighting in Italy continued, as was so well described (38), and Rome was finally “liberated” on June 4, 1944; but there was still another long year of battle as the Allies kept pushing up into Italy. During the winter of 1944–1945, places such as Pietramala (October 13, 1944, to April 29, 1945, which was the longest time for any combat hospital to stay positioned in the Italian Campaign), and at Verona for 2 months after, were continued as locations for the hospital before it relocated near Florence, Italy. Finally, the Eighth Evacuation Hospital was inactivated on September 30, 1945. Of course, the Eighth Evacuation Hospital was not the only hospital supporting the Allied troops in the Italian Campaign and four others are listed by unit numbers (46). But the Eighth Evacuation Hospital received some special distinctions which included having been the second hospital to land in North Africa (November 18, 1942) and to have served in North Africa and Italy longer than any other American hospital (46).

After reviewing the prior 2 years of arduous battle in Italy, what were some of the implications for health care in the broadest sense—surgical, medical, neuropsychiatric, etc.—that permit a few generalizations which have been gleaned from various background sources, and are indicative of how treatment had been affected?

HINDSIGHT

Astute clinicians observing diseases have always been interested in defining the patient's presentation, selecting laboratory tests that help diagnostically in assessing disease activity, and trying to understand pathophysiology and the host's response. When the hospital was not overcrowded with large numbers of battle casualties, there was time and interest to initiate clinical investigation. Prophylactic care under wartime circumstances can be very important, and the widespread use of preventive measures (45) to combat common but devastating infections, using mosquito control to suppress malaria, immunization against thypus, use of tetanus toxoid, and penicillin use, overall had a significant impact. As stated, World War II was the first great conflict in which fewer American troops died from infectious disease than from their wounds and injuries (46). Several examples of clinical research will be presented.

When patients were admitted with a fever and a presumed acute infectious disease to the Eighth Evacuation Hospital's medical service during 1944 and early in 1945, quick identification of the infectious site and establishing a differential diagnosis might be clarified by having the total white blood count and differential cell count. Among two infections so studied were primary atypical pneumonia of unknown etiology (100 cases) and acute infectious hepatitis with jaundice (n = 162 cases). Results were not especially different from other such reports about leukocyte counts in these diseases, but a manuscript was written (47) and submitted to the Archives of Internal Medicine. Apparently it was not accepted nor was it published in another journal, as a reference for this research cannot be found in the authors' bibliographic listings. But research interest in infectious hepatitis was very appropriate as more soldiers died from this disease (a death rate of about 3 per 1000 cases) than any other medical disorder, or they lost at least 50 days from duty (48). Other research had a better outcome that was conducted during the winter of 1944–1945. A group that included 100 patients with tertian malaria treated at the Eighth Evacuation Hospital was studied to assess the effect of spontaneous and artificially induced fever on liver function as determined by the rate of bromsulfalein clearance. The initial manuscript of this work (49) was submitted to the Journal of the American Medical Association for publication, but must have needed a bit more investigation. Some additional research was completed back in Charlottesville after returning home (50). Subsequently, the research was published in the Journal of Clinical Investigation (51). A list of other clinical research papers, including surgical topics, was given (52).

Bitter winter fighting occurred in Italy during the winters of 1943–1944 and 1944–1945 against a well-entrenched and experienced enemy. It seems that the intensity of weaponry and ammunition had increased, making battle injuries more severe; the likelihood of encountering a planted land mine and experiencing explosive trauma was increased. The rugged terrain and inclement winter weather complicated the retrieval of the injured, especially in Teano during mid-December 1943 through March 25, 1944, making evacuation back to the hospital slower. From a time-lag study that began at the time of wounding until arrival at the Eighth Evacuation Hospital, which was located about 18 miles behind the place of departure for the injured soldier took approximately 10 hours (35). Thus, the seriousness of the injury and a longer period to be taken back to a hospital for care became more significant factors.

Blast injury, encountered during World War I and known to cause a syndrome of shocked lung, was again apparent. Dr Leavell recognized this problem in his publication (53) about three American soldiers who developed what seemed to be acute heart failure after being wounded with a highly explosive shell. Each of these soldiers got appropriate initial care for multiple injuries and seemed somewhat stabilized, but on days 3, 5, and 4, respectively, after wounding and operative care, each became acutely dyspneic, had moist rales heard throughout both lungs, and seemed to have heart failure. Two of the three died, and at autopsy the two hearts seemed normal in appearance, but the lungs had areas of hemorrhage and extensive pulmonary edema. Subsequently, 20 other soldiers with blast injury were identified and followed until they succumbed. Unfortunately, their patient data were not complete for analysis, as these patient records were lost when the hospital next moved; only 15 of the electrocardiograms of the 20 patients were retained and analyzed in the paper (53).

I wish we knew more about these young soldiers whose ages ranged from 20–31 years for the 17 whose age was given; 12 of these had stepped on a land mine and 8 were injured by a highly explosive shell. Had they developed shock and been given plasma initially to stabilize them? What would the lung tissue have revealed on histologic examination? Dr Leavell, when he knew of my developing interest in the field of pulmonary medicine, told me about this scenario of acute respiratory decompensation occurring later in soldiers who had experienced blast injury, but had been treated for injuries and seemingly stabilized, and how serious this complication was. About this time in the late 1960s (1967–1970) when I was a Clinical Associate in the US Public Health Service and assigned to the National Institutes of Health (NIH) in Bethesda, Maryland (in the Laboratory of Clinical Investigation of the National Institute of Allergy and Infectious Diseases in the Clinical Center), we did infectious disease consultations at the National Naval Center Hospital just across Wisconsin Avenue from the NIH Clinical Center. Soldiers had infectious problems that we advised on, but some had serious respiratory ones. It was known that battle injury had occurred only a couple of days before, and after initial stabilization, the patients were air evacuated from the Da Nang Air Force Base in South Vietnam to Andrews Air Force base outside Washington, DC; the patients were sent to Walter Reed Hospital and to the National Naval Hospital for continued care. “Da Nang Lung” was the diagnosis used for these injured with late onset of respiratory difficulty. During this time, an important description (54) was provided for 12 adult cases of acute respiratory distress that occurred; seven of these patients had experienced multi -trauma and lung contusion. The onset of acute respiratory distress occurred on average 46 hours after illness (range reported, 1 to 96 hours). Shock of varying degree was present in 5 patients; 7 of the 12 patients died. This was a variable kind of presentation but related to a shock lung scenario, as discussed by Dr Fishman in his publication, “Shock Lung: A distinctive nonentity ” (55). The diagnosis of acute respiratory distress syndrome (ARDS) has persisted since 1967, but it is likely that shock lung with respiratory failure was encountered and described in World War II, also.

The effects of blast trauma continue to plague injured soldiers (56) in present day combat areas such as Iraq and Afghanistan. Now central body and chest areas have better protective covering, or body armor, so there may be less direct chest and lung contusion after encountering a mine device, but the traumatic injury to limbs often results in traumatic amputation, and head and brain concussion injury are major warfare injury concerns. However, the consequences of post-traumatic stress are not limited to military problems and are now considered in many sporting events during which participants incur repeated head trauma. The serious effects of explosive trauma occurring in crowds, as occurred for runners and spectators near the finish area of the Boston Marathon in April 15, 2013 (57), continue to make patient evacuation and emergency care of those who are seriously injured a challenge (58).

WHY RETRACE SOME OF THE EIGHTH EVACUATION HOSPITAL'S TREK?

Our family has known a lot about the Eighth Evacuation Hospital's activities during World War II and has been curious to see where some of these occurred. Anne B. Leavell Reynolds remembers peeking out from behind a curtain as a young girl saying “just who is he” at seeing her father, Dr Byrd S. Leavell, return home more than 3 years after his departure with the Eighth Evacuation Hospital. Dr Leavell wrote a book about the experiences while he was away from his family using many details from his daily diary (1). There were water color pictures and some pen drawings he had made of the hospital tents and layout of village scenes from nearby. We wanted to see and retrace some of the actual locations he described; a trip to Morocco was a first phase to see and relive some of the events that occurred 70 years ago when the Eighth Evacuation Hospital members arrived in Casablanca. They went ashore on November 18, 1942, and we toured the city on November 15, 2012.

The appearances of some things in Casablanca were different but also much the same as Dr Leavell had described them. We found becoming familiar with the Moroccans and assimilating their history and culture difficult during our visit, just as he had described (59). The French feeling and flavor did permeate the city and was very much still in evidence at many places in the country. On our tour of the city, we had a view of the ocean seaside and the city port that we imagined may have looked quite different when the Eighth Evacuation Hospital members were being kept at sea and not allowed to land until the residual of the naval warfare was sufficiently cleared to permit it safely. We did ride along the road the hospital unit took to reach the Italian consulate; however, we did not get to actually see the Consulate building until later that evening when our tour guide led us by foot through the nearby streets and we faced it across an intersection. It was evening, but the area was well lit. Having the picture from Dr Leavell's book of the exact same view of the consulate (60), it outwardly appeared exactly the same now as it had 70 years ago! Amazing.

Along a street we passed by buildings that would have been part of the school that was close by the consulate, but it was unclear what they might be used for now. Just a bit further on would be the area of Anfa and where the Anfa Hotel had been when the famous Casablanca Conference was held in December 1942. Apparently, the Anfa Hotel no longer exists, but it was uncertain if the prior hotel building still existed for another use. Morocco is changing and the country's people are much more interested in their historical background; they are focusing more on the many various groups of people who have migrated from lower African states or have come from the Middle East and gone into Southern Europe (61). There is an inherent fascination with some of the cities in Morocco, especially Casablanca which is similar for many Americans who have travelled to visit and live awhile in Paris, France (62). Casablanca has a flavor of interesting life and intrigues, certainly reinforced by the captivating movie of 1942, Casablanca, with Humphrey Bogart, who played the expatriate cabaret proprietor Rick Blaine, and Ingrid Bergman. “As time goes by,” this movie remains one of the all-time great movies. And we did have an evening dinner at Rick's Restaurant (a modern creation).

While members of the Eighth Evacuation group were in Casablanca and Morocco, in a strange land under uncertain and unnerving wartime conditions, they did have some “down time” and boredom may have set in. To counter this, the Eighth Evacuation Hospital staff made trips to downtown Casablanca to the Medina, a walled native Arab section, for shopping and went on sightseeing trips to cities such as Rabat and Marrakech, as described (59). Our planned trip made a tour of major cities, travelling to Rabat, the country's capital city, Meknes, Fez in northern Morocco, then moving south through the Atlas Mountains to Erfoud and the Sahara Desert, then westward to Ouarzazate, where motion pictures are often produced, to Marrakech, and then up to Casablanca.

While in the city's Medina area of Fez, Morocco's oldest imperial city, labeled as the “Athens of Africa,” we viewed Al Karaouine University, a medieval theological university that dates to the ninth century (founded in 859 AD) and is the oldest degree-granting university in the world (63). What a surprise in looking into the interior of an entrance to read on a sign that Moses Maimonides, the Jewish philosopher, jurist, and physician, had studied at this university when he and his family lived in Fez; he was there from ages 24 to 30 years. Maimonides, born March 30, 1135, in Cordova, Spain, and his family were confronted in 1148 with the Almohads, a fanatical Islamic sect that had taken over the area. As the Jewish community was being forced to submit to Islam, and their Judaism had to be kept private, this was a trying situation to lead in a sense a double life and proved to be difficult. The Maimonides family left Cordova for Fez, Morocco, in 1159; they remained until 1165, and then moved to Palestine and later to Egypt. Maimonides, a multi-dimensional intellectual person who encompassed many disciplines and wrote with authority about so many things, was a major and prolific contributor to medieval scholarship (64–66). He bridged the early Hippocratic-Galen knowledge of medicine to the Middle Ages period and synthesized much of medical history and its practice for the medical community. In Egypt, he was a physician in the court of Sultan Saladin (67). Maimonides' Treatise on Asthma, the manuscript dating to 1211 (64), was created for educational use by the Sultan's nephew and perhaps his oldest son who had asthma. The Treatise, 10 chapters in length, is comprehensive, insightful about things that provoke attacks of asthma, and how to cope. The information is still useful. Recent interest in the effect of dietary products, especially grains and the effect of gluten on respiratory symptoms, particularly asthma and on bowel symptoms, is very current. Its message is very worthwhile for us modern-day clinicians to review. He died in 1204 and was buried in Tiberias.

CONCLUSION

In times of strife and physical uncertainty, the care of vulnerable and injured people is a medical mission requiring ingenuity to use and adapt existing therapeutic methods, but these unsettling periods can also stimulate innovative approaches in medicine. The Eighth Evacuation Hospital's staff did these things well, and the efforts of all those involved are to be appreciated still. For family members of their staff to have the opportunity to review personalized written and pictorial descriptions and to visit locations where some of this care was delivered and new approaches tried was inspirational and will be treasured.

DISCUSSION

Barondess, New York: Two brief comments. One is that shortly after forces landed in the North African invasion they experienced an enormous outbreak in hepatitis, which was later proven to be related to the yellow fever immunization that they had received before they embarked. It was a vaccine that had been stabilized with a small amount of obviously contaminated human serum. That outbreak was instrumental in differentiating long-incubation-period hepatitis—hepatitis B—from infectious, or at the time, short-incubation-period hepatitis; a distinction that was established by experiments in human volunteers. The other comment is, if I may just make this appeal, to refer to the name of this organization as ACCA achieves in efficiency what it loses in euphony.

Reynolds, Hershey: Dr Barondess, thank you very much, and I appreciate you elaborating on the infectious hepatitis, which all through, remained a tremendous problem for them to deal with.