SFMCR | |
Rm 28266, X-73489

5 March 1946.
MEMORANDUM TO THE SURGEON GENERAL,
Room 2E288 (Extension 4469)
The Pentagon.
Subject: Establishment of a Long-Term Follow-Up Clinical Research Program

on Army Material.

1. During the period beginning with the mobilization of the Army in 1940
and continuing to date an enormous amount of material of great clinical value
has accumulated in the records kept in Army hospitals and dispensaries and in
medical installations of other branches of the Armed Forces, It can fairly be
said that no similar amount of material has ever been accumulated, and it is
doubtful whether a similar amount will ever again be available,
2. Furthermore, the rigidly controlled Army system of personnel and
records has made this material unusually complete, This is particularly true
of records of patients who had to appear before boards for disposition and who
for that reason were usually studied very intensively.
3. It is suggested that this accumulation of material should be turned to
practical use by the establishment of a clinical research program, including a
follow-up system to determine the natural and post-treatment history of such
diseases and conditions as might be selected for the study. Failure to estab-
lish such a system would result in an incalculable loss to clinical medicine,
as well as to the Armed Forces, From the standpoint of military medicine, the
findings would furnish a rational basis for the development of professional pro-
cedures and operational policies and would indicate the wisdom of inducting men
with certain disabilities because factiial data would be available as to their
usefulness while in service and as to their pension rights after their separa-
tion from the service. . :

4. A recollection of the manpower shortages and other difficulties which
frequently occurred in World War II will make clear the usefulness of such data.
The military value of follow-up studies was repeatedly proved during the course
of that war. Follow-up studies on pilonidal sinus in 1944 showed that existing
policies as to surgical treatment were wasteful of manpower and that a change
toward a more conservative polity would save over 435,000 man-days per year. A
similar study on herniated nucleus pulposus radically altered the management of
that condition, and other studies had equally valuable results,

5e Peptic ulcer is an illustration of a condition which has not been, but
could be, investigated with value both to clinical medicine and to the estab-
lishment of policies in the Armed Forces, A follow-up study of cases identified
in military personnel #ould establish the incidence of the disease in certain
age groups and the proportion of cases which might be expected to go on to per-
foration, hemorrhage, cicatrization and other complications over given periods
of time, It would probably settle the disputed question as to whether or not
benign peptic ulcers undergo malignant changes. It would undoubtedly establish
the results of various forms of treatment in respect to mortality, morbidity,
recurrence and long-term disability. These and other data, departing from a
given base line and followed up over long periods of time dispassionately and
in the absence of special pleading, have never been available,

6. Similar studies could be made of numerous other conditions such as in-
ternal derangements of the knee, chronic osteomyelitis, bone defects, head in-
juries, pulmonary suppuration, bronchiectasis, foreign bodies in the lung,
beripheral vascular insufficiency, malignancies of certain types and in certain
barts of the body, and peripheral nerve injuries, At the present time the only
©ne of these conditions in which follow-up studies are being conducted is peri-
Pheral nerve injuries, The valuable information gathered from the Peripheral
Nerve Registry established in 1944 emphasizes the potential importance of the
Program proposed, At the clinical research level it furnishes an opportunity
to provide an investigative program in which the entire medical profession would
Participate and from which all would profit.
7. ‘In general, the following plan might be followed:

a. The project would ‘preferably be a joint undertaking of the Army and
Veterans Administration.

b. It covld perhaps be set up as a project under the National Research
Couneil and assigned to various sub-committees, as was done with such success in
other undertakings in World War II. Whether or not this was done, however, a
most important consideration would be the appointment of a carefully selected
committee to initiate the project, determine its extent, establish methods of
procedure, and exercise a general supervisory function,

c. It could be financed by grants from the proposed National Research
Foundation, legislation for which is now pending, or by a Federal subsidy, de-
pending upon the set-up. - ob : a

d. An adequate sample of the mass of material available in each cate-
gory selected for study would be made from the available material. The records
would be photostated and the original records returned to storage for use as
other needs for them arose.

e. The length of the follow-up would be determined upon for fixed.
periods of time, and in some instances for life, according to the nature of the -
condition to be studied. :

f. Contacts would immediately be made with the patients in each cate-
gory through the Veterans Administration, the Army, civilian hospitals, social
agencies, and civilian physicians. The mechanism now exists for follow-up studies -
on patients in the Army hospital system or returned to duty, though it has not.
been fully utilized for a variety of reasons and it is obviously self-limited.

8. Other details of procedure could be worked out by a survey of the prob-
lem and the formulation of detailed objectives. It is suggested, howeyer, that,
if such a project is initiated, there should be no delay in setting it-in motion,
while clinieal material to be used in the program is still readily available.

{sf MIGHAEL E. DeBAKEY
Colenel, Medical Corps
Surgical Consultants Division. .