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HISTORY OF THE OFFICE OF MEDICAL HISTORY
India-Burma Theater of Operations
Herrman L. Blumgart, M.D., and George M. Pike, M.D.
The problems confronting the U.S. Army Medical Department in USAFIBT (U.S. Army Forces, India-Burma Theater) can be understood only in relation to the environment in which the personnel of this theater worked. The climate, the lack of modern sanitation, the wild and primitive regions of the Stilwell Road (formerly Ledo Road) country in which some units operated, and the close proximity of the native Indian population in other areas created peculiar, if not unique, medical problems. Few, if any regions excel India and Burma in the variety and profusion of disease. One million persons die annually of malaria while a hundred million suffer clinical attacks yearly, and 250,000 die of pulmonary tuberculosis, according to the most reliable estimates available. Endemic foci of the three major plagues--smallpox, cholera, and plague--constantly smolder in India and are among its principal medical exports. Each and every one of these factors posed particular medical problems or influenced professional policies and must be appreciated in any review of medical problems in this theater.
The China-Burma-India theater was established on 15 March 1942, and U.S. troops on the Asiatic mainland were designated USAFCBI (U.S. Army Forces in China-Burma-India). Lt. Gen. (later General) Joseph W. Stilwell, USA, and Col. (later Brig. Gen.) Robert P. Williams, MC, were assigned as Commanding General and Surgeon, USAFCBI, respectively. At that time, only 3,000 U.S. military personnel, chiefly Army Air Forces, were stationed in the theater, which included, generally, China, French Indochina, Thailand, Burma, and eastern India. The theater expanded rapidly. In October 1944, it was divided into the USAFCT (U.S. Army Forces, China Theater) and USAFIBT. While, of necessity, this chapter includes observations concerning activities in the USAFCBI theater, it deals primarily with USAFIBT.
When Lt. Col. (later Col.) Herrman L. Blumgart, MC (fig. 239) arrived as Consultant in Medicine, USAFIBT, on 28 January 1945, the total bed capacity of the general, station, field, and evacuation hospitals (maps 6 and 7) in the theater was 19,772, and 512 medical officers were assigned the care of 9,819 patients. From a humble organization in 1942, the Medical Department in the theater had expanded to an organization of approximately 14,000 officers and men.1
1 Report, Headquarters, USAFIBT, subject: Operational Data; Medical Department Facilities, IBT, 4-Week Period Ending 26 Jan. 1945.
FIGURE 239.-Consultant in medicine, China, Burma, and India. Col. Herrman L. Blumgart, MC, Consultant in Medicine, Office of the Surgeon, Second Service Command; Consultant in Medicine, Office of the Surgeon, USAFIBT; and Consultant in Medicine, Office of the Surgeon, USAFCT.
SCOPE OF CONSULTANT ACTIVITIES
The primary mission of Colonel Blumgart in this already established headquarters team can be simply stated. It was to improve the quality of professional medical care by recommendations to the Surgeon, USAFIBT. Generally speaking, this mission was carried out by activities that fell into the following four groups: (1) Formulation for the Surgeon's approval of general overall policies affecting medical care, (2) formulation of specific recommendations to the Surgeon to correct defects in medical care common to various installations visited, (3) on-the-spot correction of irregularities and deficiencies observed during visits to hospitals, and (4) consultation regarding local professional problems. These four activities hardly ever existed separately, one being almost always influenced by another. In the matter of assignment of personnel, for instance, the overall distribution of medical officers necessarily conformed to the existing tables of organization and the total number of officers in various categories available in the theater. On the other hand, the individual assignment of such officers, and reassignments from one hospital to another when necessary, were frequently determined by observations, made during the med-
ical consultant's visits, on the qualifications of each officer and the needs of each hospital.
Activities at Headquarters
Colonel Blumgart spent somewhat less than half of his time in the Office of the Surgeon, Headquarters, USAFIBT. Here, many activities claimed his attention as a member of the Surgeon's staff. Diseases cannot be compartmentalized; formulation of many policies and action on many problems
required coordination of the neuropsychiatric, surgical, and medical consultants' opinions. Many matters primarily the concern of the Preventive Medicine Section or of the Personnel Section in the office were referred to Colonel Blumgart for comment and coordination. The preparation of the section on medicine in the ETMD (Essential Technical Medical Data) reports; the review of all publications on medical subjects submitted to the Surgeon, USAFIBT; the preparation of material on current medical problems for the Surgeon's monthly Field Medical Bulletin; the preparation of theater circulars, Surgeon's circulars, and memorandums on professional medical subjects; the review of clinical records and post mortem findings in all deaths due to medical disease--these activities claimed most of Colonel Blumgart's time while at headquarters.
Coordination with neuropsychiatric consultant. - The professional problems that concerned the neuropsychiatric and the medical consultants were particularly closely-related. In all medical conditions for instance, the significance of the symtoms to the patient is important; a "stitch" in the chest if it occurs near the heart may lead to invalidism and days lost solely because of the patient's fear of heart disease or of pulmonary tuberculosis. In other conditions, such as dyspepsia with its manifold manifestations, the symptomatology may represent "body language" expressing the patient's emotional difficulties. Prolonged duty in this noncombat theater under the hardships of
the extremely variable climate of India proved to be emotionally wearing. Because medical officers themselves were not immune to these stresses and strains, they frequently were resentful of such reactions in their patients and their ability to deal with them sympathetically was reduced.
The proposal to have simultaneous visits by the neuropsychiatric and medical consultants to the various installations in the theater in order to emphasize the dual approach met with approval by the Surgeon, USAFIBT, and proved to be of inestimable value in proper treatment and salvage of many patients. The educational value of joint ward rounds, to the members of the hospital staff inculcating on them the significance of psychosomatic medicine and the importance of immediate therapy, was evidenced by the lively discussions that were almost always evoked. The major amount of each consultant's time was spent on the more specific medical and neuropsychiatric problems. At most of the installations, conferences with the staff were held jointly by the two consultants to delineate the fundamental concepts of diagnosis and therapy in psychosomatic medicine, always using as a text specific cases seen during ward rounds.
This arrangement was found to he highly effective. It worked well because the neuropsychiatric consultant was firmly grounded in the field of internal medicine and the medical consultant had some knowledge of psychiatry. To eliminate loss of time and energy on controversial points during conferences, the two consultants had achieved a common approach and general agreement. In addition, the medical consultant, interested in the more purely medical aspects of disease, actively participated in the conferences, and the neuropsychiatric consultant utilized his extensive specialized experience in answering questions at issue. All these factors helped to demonstrate to advantage the interrelationship between the two fields.
Coordination with preventive medicine officers. - Many of the preventive medicine activities in the theater were closely related to internal medicine problems. Almost daily, informal conferences were held between Colonel Blumgart and various officers in the Preventive Medicine Section, Office of the Surgeon, Headquarters, USAFIBT. The statistical accuracy of the incidence of diseases depends in the first instance on the accuracy of clinical diagnosis. In a theater in which constant watchfulness had to be exercised for diseases such as smallpox, cholera, schistosomiasis, filiariasis, and kala-azar, particular caution in differential diagnosis was essential. Accordingly, Colonel Blumgart reviewed numerous case records and rendered many opinions. The initiation of Atabrine (quinacrine hydrochloride) suppressive treatment for malaria likewise raised medical problems in respect to various manifestations of Atabrine toxicity and to the incidence, treatment, and administrative disposition of the affected individuals. One of the most pressing problems in the theater was the high incidence of diarrheal and dysenteric diseases, particularly amebic dysentery. As will be shown later, an integrated approach to this entire problem was accomplished only by the closely coordinated efforts of the preventive medicine officers and the medical consultant.
management. - Basic to all other considerations in achieving a
high standard of
medical care was the question of personnel. U.S. Army medical
as a group represent a
cross section of the Nation's medical profession. The number of
trained specialists was
decidedly limited, as well as the number of general internists
qualified to be chiefs of medical
services or heads of sections. The personnel records of
training and postgraduate
medical experience are not a sure index of proficiency. For
certain medical officers
with a wide range of medical knowledge, some of whom had been qualified
by an American
specialty board, lacked sound, conservative, clinical judgment; others
lacked necessary qualities
of leadership. Conversely, other medical officers with little
postgraduate training, who
nevertheless had maintained an active interest in scientific matters
during years of general
practice, were found fully qualified to be chiefs of medical services
at 250 or 500 bed station
hospitals. Appraisal of the intrinsic qualifications of the
officers could be made only on
the basis of personal observation during actual ward rounds.
Blumgart spent at least one
or more hours with each officer on the wards reviewing in detail
physical findings, clinical
records, and treatment and administrative disposition of
Informal discussions of related
general subjects such as infectious hepatitis, dengue, chemotherapy,
and the significance of
various laboratory procedures formed part of such visits. This
evaluation by Colonel
Blumgart and a review of each medical officer's personal records served
as the basis for the
proper assignment to each officer of a classification number and rating
and made possible a full
utilization of each officer's capabilities. In some instances,
personality clashes rendered an officer's services ineffective at a
particular installation and could
be obviated by his assignment
elsewhere. The Surgeon, USAFIBT, emphasized the importance of a
personal evaluation of each
medical officer by Colonel Blumgart and directed that the personnel
officer consider Colonel Blumgart's opinion before effecting transfers
and assignments. This
appraisal of officers by the
consultant proved helpful to the personnel officer, who was confronted
constantly with shifting
needs consequent to the departure or arrival of medical officers.
Colonel Blumgart was also responsible for articles or comments on current medical problems in the Field Medical Bulletin. Medical officers were encour-
aged to submit reports on their studies, and many of these were published. The Field Medical Bulletin also provided a valuable means of conveying information regarding recent advances in medicine. Various irregularities or deficiencies, such as failure to comply with certain directives or misunderstandings regarding the intent or meaning of others, were corrected by appropriate brief notes. In some instances, where no suitable official guides or directives were available, appropriate circulars or memorandums were submitted to the Surgeon, USAFIBT, for approval and then distributed. A more detailed account of such directives is included later in this chapter in discussions of the various diseases of particular interest in this theater.
Review of clinical records and post mortem findings - Soon after Colonel Blumgart's arrival in the theater, the Surgeon, USAFIBT, approved the request that complete clinical records and results of post mortem examinations for nonbattle casualties be submitted to headquarters for review. This proved to be an exceptionally valuable procedure. By this means, theater headquarters was kept informed of some of the most interesting cases, medical care of the most seriously ill was reviewed, and occasional suggestions or deficiencies were noted. These facts were made the subject of correspondence, or, more often, a conference with the hospital staff was held on Colonel Blumgart's next visit to the installation. It is believed that this procedure also had anticipatory value as it was generally understood by medical officers that the clinical record of any seriously ill patient would eventually be scrutinized in the theater Surgeon's Office.
Other activities. - In addition to the main duties just outlined, many miscellaneous activities occupied Colonel Blumgart's time while he was at headquarters. Many communications were received regarding medical practice and procedure that required reply. In addition, the available current periodicals, ETMD reports from other theaters, and other reports were constantly scanned in order to maintain professional medical standards abreast of current advances.
Activities in the Field
Colonel Blumgart's activities in the field have been indicated as ramifying from his activities and relationships at headquarters and will be described in more detail here.
During the 9 months he spent in the India-Burma and China theaters, the author spent somewhat more than half his time in traveling more than 40,000 miles in field visits to the various installations, although, as much as possible, the visits were grouped to conserve time. Many dispensaries were visited, but only a few of those of the Army Air Forces could be seen during his period of duty.
The isolation arising from the wide dispersion of units and the poor lines of communication made it the more important for Colonel Blumgart to be regarded as a two-way ambassador between the theater surgeon and the installations, interpreting theater policy locally and acquainting theater
headquarters with the problems confronting the officers in the field. For the most part, medical officers had had no opportunity to discuss professional matters with anyone other than their immediate associates and had but little information regarding experience with comparable problems at other installations. The opportunity to display their own accomplishments was an important morale factor. Colonel Blumgart himself had had little specialized training or experience in the field of tropical medicine, but the clinical experience gained during initial visits to some of the large installations together with collateral reading remedied this deficiency. At many installations, the experience and ingenuity of the medical officers provided constructive suggestions that could be transmitted to the officers at other installations. This function of Colonel Blumgart as a medium for exchange of ideas was probably one of his chief contributions. The confidence of hospital personnel in his helpful intent having been established, Colonel Blumgart's suggestions were accepted without resentment. In some installations, there was a surplus of medical talent; 2 or 3 highly able internists were serving in a 200-bed hospital. In others, no internist with extensive knowledge and sound, conservative, clinical judgment had been assigned. These instances were, however, few and were readily rectified by personnel reassignments.
Training and education. - The scarcity of medical officers sufficiently skilled and personally qualified for positions of responsibility and leadership made it imperative that hospitals be considered as training centers. Thus, pivotal personnel lost through illness or rotation could be replaced. It was found that many young medical officers who were products of the emergency accelerated program of civilian medical education had considerable innate ability but meager clinical knowledge or experience. Whenever possible, such officers were assigned to duties under the immediate supervision of mature, seasoned clinicians and, after varying periods of time, were qualified to be chiefs of small station hospitals or heads of sections at general hospitals.
The criteria for diagnosis of disease and the therapeutic regimes that were employed varied greatly from hospital to hospital and indeed from ward to ward. This was due to the fact that the medical officers--men with widely different types of training, experience, and personal views--had not received the fundamental directives and guides issued by the Surgeon General's Office. Few, if any, TB MED's (War Department technical bulletins, medical), had been received, and but few overall professional policies had been established in the theater. To raise the quality of medical care to the highest possible level, each installation was directed to prepare a list of the TB MED's it lacked, and adequate distribution was effected. It was further directed that a complete file of such bulletins as well as theater surgeon's circulars, be maintained by the commanding officer and by the chiefs of medical and surgical services. In the instance of some diseases such as amebiasis, which constituted one of the major problems in the area, a theater directive was issued, since none had been made available by the Surgeon General's Office. Every effort was made to encourage faithful adherence to all directives.
The consultant attempted to stimulate professional interest by recommending the establishment of a suitable reading and conference room in each installation, even when a tent had to be erected for that purpose. Steps were undertaken to supply each installation with its authorized allowance of books and periodicals. Through the generosity of the Josiah Macy, Jr. Foundation, New York, N.Y., reprints of outstanding articles appearing in current medical periodicals were distributed to the medical officers in this theater. By informal communication between the Surgeon, USAFIBT, and the medical director of the foundation, Dr. Frank Fremont-Smith, material particularly relevant to the medical problems in India and Burma was made available. By this means, medical officers were encouraged to keep abreast of advancing medical knowledge.
In addition, medical officers were urged to review series of cases at their own installations and to prepare reports summarizing their experiences. In some instances, these reports were used solely as the basis for a talk at one of the medical conferences; at other times, they were found suitable for publication in the Field Medical Bulletin or even in current leading periodicals in the United States. A schedule of at least one medical conference a week and one grand ward round for the discussion of the most interesting and perplexing cases was established at the various hospitals. The value of such an educational program in improving medical care, in heightening the professional interest of the medical officers, and consequently in raising morale was gratifyingly evident. The numerous reports received from these installations were of invaluable assistance in obtaining a comprehensive knowledge of diseases peculiar to this theater.
Visits to hospitals. - The major portion of the time spent at each hospital by Colonel Blumgart was utilized in a careful review of medical practice on each of the wards. In the smaller installations, each patient was examined, the clinical records reviewed, and the clinical management discussed. In the larger installations, with a census of approximately a thousand patients, this was manifestly impossible. On each of the wards, however, at least five cases were spot checked; all patients with a fever of 101o F. or more were reviewed; and the seriously ill were examined, as well as any additional ones requested by the medical officers.
In addition to the visits on the medical wards, an hour or more was usually spent in the laboratories. In some installations, the monthly report of the laboratory substantiated the impression on ward rounds that an excessive amount of laboratory data had been requested. This practice tended toward poor quality of laboratory work with occasionally misleading inaccuracies. In other instances, laboratory tests necessary for diagnostic purposes were omitted. General criticisms of such deficiencies were never expressed, however, until the indications and contraindications for such tests in the individual patient were pointed out at the bedside. Visits to the laboratories of the hospitals by Lt. Col. (later Col.) Howard A. Van Auken, MC, Commanding
Officer, 9th Medical Laboratory, were of great value in heightening the quality of laboratory work performed.
The inspection of the X-ray department properly fell within the province of the surgical consultant, but Colonel Blumgart always made a visit in order to coordinate the activities of this department with those of the medical service. (During World War II, the radiology service in an Army hospital was frequently under time overall jurisdiction of the chief of surgery.)
At a few installations, it was observed that there were too many consultation requests from one service to another, particularly at some of the general hospitals where, at times, such complaints as headache led to a request for neurological consultation, backache for orthopedic consultation, and precordial ache for a cardiac consultation. It was emphasized that such practice results in but little benefit to the patient when required of a specialist deluged by impossible demands on his time. Time and effort were conserved by the proper use of consultation forms. The necessity for explaining on such forms the purpose of a consultation prevented the expenditure of much fruitless effort by Colonel Blumgart. The presence of the ward officer in charge of the patient at the time of consultation was urged so that the medical consultant could confine himself to the pertinent issues and resolve any differences of opinion with the medical officer in immediate change
Clinical research. - The promotion of clinical investigation was considered an important function of Colonel Blumgart. A study of disease may appear at first somewhat remote from the primary mission of improving the quality of medical care, but the novel medical problems peculiar to wartime, particularly in a theater such as India-Burma, raised many issues concerning which there were no guideposts from prior experience. Clinical investigation had to be undertaken to answer such questions in order to provide the best medical care. The type of investigation that could be fostered was limited by certain definite factors but was favored by the rich clinical opportunities that were available. Any study had to be relatively simple and conform to the exigencies of time available to the medical officer from his immediate compelling clinical responsibilities. Observations had to be made by means of techniques readily at hand. The possibility of transfer of officers to another assignment made it imperative that any investigation should be undertaken by a group whenever possible. Some of the time, Colonel Blumgart acted as instigator in these research projects, while at other times he merely facilitated the progress of the study. Some investigations were initiated at the bedside when, during discussions on ward rounds, a question arose that required research to provide the answer.
It was important that fruitless energy should riot be dispelled in clinical investigations. To this end, it was emphasized that no research project should be undertaken without approval of the proper authority, that a definite protocol of the proposed study should be submitted to the chief of service, and that the advice and assistance of the office of the theater surgeon should be utilized.
Assisting to establish contacts between officers at the different installations, making available technical assistance from the theater laboratories and other sources, and guiding the progress of investigations were functions that the medical consultant found interesting and gratifying.
Reports to headquarters. - At the conclusion of each field trip, Colonel Blumgart submitted a report to the theater surgeon summarizing the conditions at each installation and making recommendations for improvement. The procurement of basic statistical and personnel data was facilitated by the use of a form which was given to the commanding officer of each hospital on Colonel Blumgart's arrival and was returned completed to Colonel Blumgart within from 24 to 48 hours. The form provided space for information on the number of medical personnel, by corps, on each service in the hospital; the number of patients in the hospital's reconditioning program, the number sent to the Zone of Interior in a specified period of time, the number on the medical service and the length of hospitalization, the number acted on by the disposition board, transferred to other hospitals, and being retained in the hospital for other dispositions; the name, duties, and patient responsibility of each officer on the medical service; the number of admissions to the hospital and the medical service for a specified period, including breakdowns for admissions for diarrhea diseases, fevers of undetermined origin, and venereal diseases; and finally, the number of deaths on the medical service for a specified period, with a breakdown by date, diagnosis, and race (United States or Chinese).
CONSIDERATIONS IN DIAGNOSIS OF DISEASE
Medical practice in a tropical and subtropical theater such as India-Burma requires not only new knowledge but also a reorientation in processes of reasoning in arriving at a diagnosis and presents novel considerations in respect to treatment.
1.. Effects of climate. - The consistently high temperatures prevailing in many parts of this theater, together with the meager recreational facilities and the isolation of many of the posts, had a profound effect on medical personnel (fig. 240). Even in the relatively brief experience of Colonel Blumgart-- somewhat less than 1 year--it was striking to witness alert, energetic, enthusiastic medical officers gradually "flatten out" during the second monsoon of their stay. The same influences were apparent in many of the patients hospitalized for psychosomatic complaints, such as headache, backache, and dyspepsia.
Heat exhaustion and heat stroke were not prevalent and constituted a relatively minor problem. During the hot humid months of the monsoon season, oral afternoon temperatures as high as 100oF. in apparently healthy males and as high as 100.4o F. in females were observed in nonhospitalized personnel engaged in routine activities. The subjects had been in the area 4 months and therefore had had ample opportunity for acclimatization. Similar
elevations, in the absence of any explanation other than the climate, were observed in the wards of hospitals.
The widespread use of
particularly sulfadiazine, led to occasional renal
complications during the hot season. Every effort was made to impress
medical personnel with the necessity of maintaining an adequate
urinary output rather than emphasizing fluid intake, and,
on 2 April 1945, Circular No. 8 was published to this effect by the
Office of the Surgeon, Headquarters, USAFIBT. Ingestion of even
as 3 or 4 liters of fluid a day, even with only
moderate doses of sulfonamides, under certain circumstances led to such
conditions as oliguria,
hematuria, and loin pain. The loss of water and electrolytes due
saline purgatives or to
intercurrent vomiting and diarrhea at times assumed considerable
stages of the war was presumptive evidence of amebiasis in patients with gastrointestinal symptoms.
The prevalence of acute febrile diseases posed particularly perplexing problems in patients entering hospitals with fever. At the onset, one commonly was unable to make a diagnosis unless the blood smear was positive for malaria. A patient with malaise, fever, and symptoms similar to influenza in the United States might turn out to have anything from malaria to infectious hepatitis, scrub typhus, or kala-azar. The problem was not made easier by the great variety of clinical manifestations of dengue and sandfly fever.
In the Zone of Interior, one is usually more accurate in ascribing all of the patient's signs and symptoms to a single disease entity. In the India-Burma theater, however, a multiplicity of diagnoses was frequently indicated. A patient with any febrile illness could suddenly develop chills and fever representing the activation of subclinical malarial infection. Vague gastrointestinal complaints, not a prominent part of the clinical picture, might represent chronic amebiasis. Laboratory diagnostic procedures were an indispensable aid and placed a premium on a well-staffed laboratory department.
The challenging aspect of internal medicine in the India-Burma theater was well described in the following extract from a personal communication from Lt. Col. James E. Cottrell, MC, Chief, Medical Service, 142d General Hospital, Calcutta, India:
We are always taught, in the United States, to hunt for a single diagnosis which will explain all the features of the case. On the other hand, in this country, we must always consider the possibility that the patient has two or more diseases, and be on watch to find the others that we have not yet diagnosed. I have myself seen a man brought in from the Burma jungle with the following combination: malaria, scrub typhus, amoebiasis, bacillary dysentery, and uncinariasis. Equally impressive combinations of diseases are not uncommon in Chinese soldiers.
MILITARY IMPORTANCE OF DISEASES ENCOUNTERED
The extremely high
the diarrheal and dysenteric diseases and malaria contributed
heavily to the theater's noneffective rate. Scrub typhus and
diphtheria, though less
important statistically, hampered military operations because of their
occurrence in combat areas
and the serious disability they occasioned. Some diseases, such
infectious hepatitis, dengue,
and sandfly fever, were under constant scrutiny because of their
possible epidemicity, while
others, such as poliomyelitis, filariasis, and kala-azar, had a
deleterious effect on morale. Certain
diseases with considerable incidence in the native population were
never encountered in the
personnel of the U.S.
Army forces in the theater but constituted a serious potential threat. Thus, not a single authentic case of cholera, yellow fever, plague, or the more unusual parasitic infections was reported; medical personnel were, however, constantly alerted to their possible appearance. In regions where morbidity and mortality from smallpox and typhoid fever were extremely high, the incidence in U.S. Army troops was extremely low.
Diarrheal and Dysenteric Diseases
The prevalence of the diarrheal and dysenteric diseases among the indigenous Indian population made serious infection inevitable among military personnel unless they were properly insulated by appropriate public health measures (fig. 241). The incidence of diarrheal and dysenteric diseases in India is largely due to some of the following factors: The water supply is frequently polluted; the habits of the native population are grossly insanitary; night soil is frequently used as fertilizer; contamination of food by flies and other insects is likely to occur; the high temperatures prevailing during most of the year favor food spoilage because refrigeration facilities are meager; and, even in installations where ice is manufactured, the ice itself is frequently polluted by fecal discharges. The long supply line to the troops in this theater
and the necessary reliance on canned articles led to a monotonous diet and increased tendency of soldiers to frequent civilian establishments. Although the low-caste Indians employed in Army messes often lived in fairly favorable sanitary surroundings adjacent to the military area, most of their insanitary habits were unaffected by contact with U.S. Army personnel. The Indians had spent their lives in an environment in which defecation was promiscuous, usually taking place near bodies of water and wells. The use of toiler paper is objectionable to them, for they consider it an insanitary method of cleansing. They perform anal ablution after defecation, washing themselves with the left hand and then rinsing the hand with any available water. Soap is rarely used, not only because it is frequently out of their economic reach but also because it is often made from animal fat, with which they avoid all contact for religious reasons. Even those that can afford knives, spoons, and forks do not use them, preferring to eat with their fingers. The entire family eats from one or two central dishes, all using their hands in place of tableware. The low-caste Indian regards the presence of flies as inevitable as the monsoon rains; swarms frequently can be seen resting on prepared food, which may be only a short fly hop from excrement on ground near their dwellings.
The urgent military necessity of sending military personnel into this part of the world did not permit the inauguration of adequate preventive measures from the outset, and it was almost inevitable that diarrheal diseases would constitute one of the most serious medical problems (charts 5, 6, 7, 8, and 9). The noneffective rate caused by the diarrheal diseases in 1944 was very similar
to that caused by malaria (chart 9). Many patients with gastrointestinal disorders undoubtedly continued to serve on active duty, and consequently the actual incidence was probably even greater than the statistics would indicate.
Of the diarrheal and dysenteric diseases, amebiasis presented the most serious problem (chart 8). It was so regarded not only because of its high incidence but also because of its insidious character, the necessity for early diagnosis and thorough treatment to prevent infection from spreading, the difficulties of laboratory diagnosis, and the seriousness of the late complications.
The solution to this problem was along two distinct lines: Prophylaxis and early vigorous action in identifying and treating already infected individuals. The protection of military personnel from infection with Endamoeba histolytica was the responsibility of the preventive medicine section of the theater surgeon's office. The measures undertaken are described elsewhere. In brief, these consisted of providing a clean supply of water (fig. 242), fly control, elimination of native food handlers from Army messes as far as practicable, periodic examination of all food handlers at suitable intervals, inspection of civilian eating establishments and placing unsatisfactory ones out of bounds, surveys of various units to detect carriers, and the supervision of laboratory
teams engaged in special studies of the pathogens responsible for the diarrheal diseases.
The importance of some of these factors was illustrated by the experience of various medical units in which the incidence of amebic infection soon after arrival in this theater was alarmingly high. For instance, in observations on 833 cases of amebiasis by Maj. (later Lt. Col.) Max Ellenberg, MC, and his associates at the 24th Station Hospital at Jorhat, India, it was found that approximately 45 percent of the military personnel of the hospital suffered from amebiasis soon after the installation began operations. To curb this high rate, all drinking water was boiled, fresh vegetables were scrupulously prepared under constant supervision, and natives were not allowed to enter the kitchens nor permitted to handle any utensils after sterilization. The entire personnel of the installation was surveyed, and all infected persons were treated. Instructions in regard to preventive measures were issued and enforced. The incidence of amebiasis showed a striking decrease, and finally not a single case occurred in the personnel of this installation in a period of more than 6 months.
Treatment was the province of the medical consultant. At the time Colonel Blumgart was assigned to USAFIBT, the available evidence indicated that more than 25 percent of diarrhea in the region was due to amebic infection. Visits to the hospitals revealed that its manifold clinical manifestations were not appreciated. Brief episodes of watery stools were being diagnosed as
simple diarrhea, cases of chronic hepatitis were being diagnosed as psychoneurosis, and the stools of such patients usually were not being examined. It was not recognized that "Delhi Belly" and food poisoning were frequently amebic dysentery. The importance of securing proper stool specimens, the technique to be employed in detecting E. histolytica in the stools, and the distinguishing characteristic of E. histolytica from E. coli and other nonpathogenic endamoeba were not always clearly understood. The therapeutic regime employed in treating the patients varied not only from hospital to hospital but from ward to ward, according to the medical officer in charge. Appropriate tests of cure were frequently neglected at the conclusion of treatment, and the followup of patients was woefully inadequate. The medical condition of many patients was not evaluated after a single course of treatment had been completed. Some patients entered other installations because of recurrence or reinfection, and records of previous hospitalization were not available.
The professional medical attack on these problems was along the following three main approaches: (1) Increased accuracy in the detection of cases of
clinical amebiasis and the identification of all carriers who entered the hospital because of other diseases, (2) improved treatment in order to eliminate the disease in the individual patient and prevent his becoming a carrier, and (3) followup observation of all patients in order to be certain that repeated tests of cure would be made and therapy instituted in the event of recurrence. By encouraging reports of the results of the various measures undertaken, improved methods of practice were hoped for.
The initial step in this program was the preparation of Circular No. 9, which was issued on 2 April 1945 by the Office of the Surgeon, Headquarters,
USAFIBT. This directive outlined the salient clinical diagnostic criteria for the various forms of amebic infection. The pathology of amebiasis and the technique of stool examinations were briefly reviewed. A section on preventive measures was included. The various complications and sequelae of amebic dysentery were delineated. To achieve greater effectiveness and uniformity in treatment, a conservative basic scheme of therapy was recommended for amebiasis in each of its various manifestations including complications and sequelae. This circular was the foundation of the entire program. The following paragraphs elaborate on each of the three phases of the clinical problem.
Diagnosis of the disease group. - The first main approach to the problem was by increased accuracy in the detection of cases of clinical amehiasis and of all carriers who entered the hospital because of other diseases. The onset of amebic dysentery is frequently insidious and may be characterized by only vague symptomatology with but slight constitutional reaction. Consequently, the disease was often not diagnosed. It was essential, therefore,
to increase the index of suspicion of all medical officers. The prevalence of diarrhea in military personnel, even in the absence of amebic infection, only added to the difficulty of diagnosis. For example, Capt. Albert Ehrhich, SnC, in a study at the 20th General Hospital, Assam, India (fig. 243), of the carrier rate in 506 apparently healthy United States soldiers who had spent 23 months in India, found that of 47 E. histolytica carriers only 11 (23 percent) gave a past history of diarrhea. In the 459 found free from infection, 12. 6 percent gave a past history of diarrhea. This experience was similar to that observed elsewhere in the theater.
Major Ellenberg and his associates in their study likewise observed that of 486 patients who entered the hospital for complaints directly or indirectly related to amebic infection, diarrhea was by no means a uniformly characteristic diagnostic symptom. Abdominal pains were by far the most frequent complaint (70 percent); actual diarrhea was only half as common. Moreover, the patients with diarrhea rarely had marked frequency of bowel movements. The high incidence of nausea and vomiting (29 percent) and anorexia (26 percent) often led to an erroneous diagnosis of gastritis or of peptic ulcer, as shown in a study on pneumoperitoneum in the diagnosis of deformities of the liver by Clark, Bercovitz, and Jones at the 69th General Hospital, 5 miles northeast of Ledo, Assam, India. In their opinion, examination of the abdomen elicited characteristic physical signs, leading to a high percentage of correct clinical diagnoses prior to the receipt of the laboratory report. In
this study, abdominal examination typically revealed a tender, squashy cecum; a less tender, palpable, ropy sigmoid; right upper quadrant tenderness; and shock tenderness over the hepatic area.
Prominence of some of these symptoms and signs was not uncommonly due to amebic colitis simulating acute appendicitis. The combination of abdominal pain, vomiting, and tenderness of the right lower quadrant frequently resulted in the admission of such patients to the surgical service. The surgeon alert to amebiasis was not readily deceived, for a history of diarrhea, abdominal tenderness over other portions of the large bowel as well, and indurated, tender segments of the large intestine indicated the advisability of stool examinations, proctoscopy, and other diagnostic tests. The presence of amebic colitis was, however, no guaranty that the patient did not also have acute appendicitis and require surgical intervention: The general clinical impression was, indeed, that amebic colitis predisposed the patient to acute appendicitis. It was therefore advised that, when any patients showed convincing signs of acute appendicitis, delay in surgical intervention was not to be countenanced. When, however, the evidence was equivocal, symptoms and signs vague, and continued observation considered safe, a short course of antiamebic therapy often resolved the dilemma.
In the general experience of most observers, physical examination was entirely negative in from one-third to one-half of the patients hospitalized for amebiasis. When physical signs were present, they were frequently not striking and were confined to the abdomen. Increased reliance on stool examinations was, therefore, necessary.
To insure accurate laboratory diagnosis, it was essential to have well-trained personnel and to maintain close liaison between the medical ward officers and the laboratory. Few well-trained laboratory technicians were available, and as a consequence there were missed diagnoses or, equally deplorable, falsely positive diagnoses. This situation was corrected in time by visits of Colonel Van Auken of the 9th Medical Laboratory to the laboratories of the hospitals in this theater. Laboratory technicians were sent to the 9th Medical Laboratory for a refresher course of several weeks. Steps were taken to supply dispensaries with microscopes and necessary equipment to perform suitable stool examinations.
In the larger station and general hospitals dysentery wards were organized, if this had not already been done. A part of the ward was partitioned off and equipped for laboratory studies of stool specimens and sigmoidoscopy. This arrangement favored prompt delivery of specimens; increased the interest and proficiency of the medical officers in the management of the various dysenteric diseases; familiarized the fixed ward personnel with routine techniques, which were consequently carried out with greater dispatch and efficiency; and facilitated employment of the necessary precautions against infection (fig. 244). Such an arrangement had been in operation at the 20th General hospital and was fully described by 1st Lt. (later Capt.) Arthur
M. Rogers, MC, and Capt. (later Lt. Col.) Kendall A. Elsom, MC, in a report on amebiasis as seen in a general hospital in Assam (fig. 245).
Certain details essential for accurate diagnosis, although generally known, required special emphasis. Particularly stressed were the importance of repeated examinations of fresh stools after saline purgatives if the patient was passing formed stools, the value of zinc flotation-concentration method, the importance of selecting proper portions of the stool containing flecks of bloody mucus for examination, and the invaluable information gained by proctoscopy. Proctoscopy was not recommended unless adequately skilled medical officers were available. Whenever practicable, however, examination of material taken directly from the lesions with a 1-cc. pipette with a small aspirator attached often led to more rapid diagnosis and at times revealed amebas despite repeatedly negative stool examinations.
Laboratory examinations of the blood generally revealed normal findings, except in cases of hepatitis and liver abscess when the white count usually was elevated.
The diagnosis of amebic hepatitis or liver abscess was frequently missed by newcomers to this theater. Patients with these conditions at times were hospitalized with vague symptoms and a diagnosis of psychoneurosis. In other instances, amebic hepatitis with or without abscess presented an acute,
severe, clinical syndrome characterized by intense pain in the right lower chest or right upper quadrant, frequently intensified by breathing and occasionally referred to the right shoulder. Chills and fever were common. Physical examination usually revealed a tender enlarged liver with rectus muscle spasm, compression or percussion tenderness, leukocytosis of from 14,000 to 24,000, and limitation of motion of the diaphragm revealed by X-ray. Physical signs of pneumonitis were not uncommon. A prior history of dysentery was frequently unobtainable, and stool examinations were often negative for E. histolytica. Some patients complained solely of epigastric pain and other symptoms not usually associated with hepatic pathology. Simulation of peptic ulcer, gall bladder disease, bronchopneumonia, or pleurisy was not rare.
During his visits to the various installations, Colonel Blumgart emphasized that a presumptive diagnosis of acute amebic hepatitis may be made on the basis of any three of the four following features: (1) History of diarrhea, (2) pain and tenderness over the liver, (3) fever, or (4) leukocytosis. He also emphasized that, of these four features, the second is the most constant and occasionally may be represented only by referred pain to the shoulder. The diagnostic importance of pain and tenderness over the liver made it essential that percussion or compression tenderness be sought generally in every patient as part of the physical examination.
Many of these considerations were discussed by Maj. (later Lt. Col.) G. Klatskin, MC, in a review of his experience with classification, diagnosis,
and treatment of amebiasis. In analyzing 62 of his cases, he found they fell into four distinct groups, which were readily differentiated clinically, as follows: Acute amebic liver abscess, acute amebic hepatitis, subacute amebic hepatitis, and chronic amebic hepatitis. Major Klatskin stated:
The acute abscess cases were characterized by liver pain, high fever arid frequently by cough. A definite mass was demonstrable in the liver either by palpation or by X-ray examination in every instance. The right lobe of the liver was generally enlarged and exhibited compression tenderness. Abnormal pulmonary findings were frequent. Marked leukocytosis with only slight increase in the percentage of polymorphonuclears was the rule.
The acute hepatitis cases resembled the abscess cases except that no mass could be demonstrated in the liver, liver pain and cough were less common, diarrhea and cramps were more common and leukocytosis was less marked.
The subacute hepatitis cases differed markedly from the others. Only half of them complained of liver pain. Many were admitted because of diarrhea and cramps and were found to have enlarged tender livers. Fever was inconstant and when present was low grade in character and intermittent. Cough and abnormal pulmonary findings were unusual. Leukocytosis occurred infrequently and when present was usually mild.
In contrast to the first three groups of cases, in which symptoms were usually present for less than ten days, the chronic hepatitis cases were admitted with liver pain of long duration, ranging from two to twelve months. As in the case of subacute hepatitis, fever and leukocytosis were inconsistent. Diarrhea was fairly common and cough and abnormal pulmonary findings occurred occasionally. * * * It must be remembered that cases in one group may advance or regress to another, either as a result of treatment or spontaneously under the influence of factors already discussed.
In this series of cases, the most characteristic symptom common to all groups was liver pain. This pain had a number of distinct features. It was usually localized in the right upper quadrant of the abdomen beneath the costal margin and less commonly in the left upper quadrant, in the epigastrium, and in the right lower chest. It was usually described as a constant ache or an intermittent sharp pain and, as a rule, was only moderate in severity. Major Klatskin noted:
Aggravation of the pain by movements and change in position was a prominent feature and was of great diagnostic significance. The principal aggravating factors were deep breathing and cough, bending and twisting, lying on either or both sides in bed and jarring. Frequently the patient spontaneously offered the information that these produced or aggravated his pain, but in many instances it was necessary to inquire specifically about their effect. The effect of jarring, especially on riding over rough terrain, probably occurred more frequently than indicated, as many of our patients were not asked about it.
Radiation of the pain was very common, especially on movement or change in position. In several instances, the first complaint was pain at the site of radiation, and only later was pain noted in the liver. This led to a number of diagnostic errors, especially when radiation was to the chest. The common sites of radiation were the shoulder, chest and lumbar region. On one occasion, it radiated to the neck. Radiation was always to the right, except in the three patients with involvement of the left lobe of the liver in whom radiation occurred to the left.
The compression test proved to be of great help in differential diagnosis. It clearly demonstrated the hepatic origin of the pain and differentiated it from that arising in other structures above and below the diaphragm. The test was tried in a great variety of conditions including pneumonia, pleurisy, renal colic, pyelitis, acute dysentery, peptic ulcer and malaria with enlargment of the liver and was invariably negative. It was also of some value
in differentiating amoebic from infectious hepatitis. In a large series of infectious hepatitis cases, in which the test was tried, it was negative in all but a few. The only other condition in which the test was invariably positive was acute cholecystitis. No doubt there are other conditions, such as subphrenic abscess, in which the test may be positive.
Compression tenderness is by no means to be considered pathognomonic of hepatic amoebiasis, but it has proved its worth as a confirmatory finding, and in a few instances it has made an early diagnosis possible in the absence of other findings.
Therapy. - The second main approach in clinical attack was by improved treatment in order to eliminate the disease in the individual patients and prevent their becoming carriers. The importance of early adequate treatment of amebic dysentery, well recognized by those familiar with the disease, was not fully appreciated by most U.S. Army medical officers. In the absence of prior directives, the therapy of the various clinical manifestations was variable and characterized at times by practically sole reliance on carbarsone or one of the iodine compounds. The treatment outlined in the theater directive on amebiasis (Circular No. 9, April 1945) was similar to that advocated in paragraph 7 of Circular Letter No. 33, 2 February 1943, Office of the Surgeon General, United States Army, entitled "Treatment and Control of Certain Tropical Diseases." This therapeutic regime will be evaluated when the results of treatment as recorded in the amebiasis registers are finally available and analyzed.
It is of interest that a similar regime was employed independently by Major Ellenberg and his associates and by Captain Rogers and Colonel Elsom with apparent success. In their study of 833 cases, Major Ellenberg employed three types of treatment, all of which were similar in that emetine and carbarsone were administered during the first 10 days, one of the oxyquinoline derivatives such as chiniofon, Vioform (iodochlorohydroxyquinoline), or Diodoquin (diiodohydroxyquinohine) from the 11th to the 19th day, with either carbarsone or chiniofon enemas on alternate days during this latter period. The average time of disappearance of signs and symptoms was 8 days. The investigators described a not infrequent reaction to treatment on or about the 4th day, which closely simulated the original symptoms and usually consisted of cramps, diarrhea, a moderate rise in temperature, and general malaise. They stated: "* * * one must consider the possibility of this representing a 'Herxheimer' type of therapeutic response and not necessarily a toxic reaction* * * . "At the conclusion of treatment, a proctosigmoidoscopic examination was performed in every case and was followed by stool examinations after a saline purge. Of the 833 cases, the stools were found to be negative in all but 10; these responded to a second course of treatment. The results did not indicate the relative superiority of any of the three oxyquinoline drugs used. There were 9 recurrences in the series of 833 cases. Of the 9, 3 recurred within 3 months following completion of therapy. The other six recurred from 3 to 6 months after completion of treatment and may have been reinfections. Thus, there was an overall cure rate of 99 percent. These successful results may be attributed in part to early diagnosis and treatment of the cases; approximately 75 percent had had symptoms for less than 1 month and only 7 percent longer than 3 months.
Toxic effects from the drugs in the dosages recommended were infrequent and never serious. Subcutaneous instead of intramuscular administration of emetine was less painful and had no ill effects. In a few patients, two injections of 34 grain daily, instead of the customary single injection of 1 grain, obviated the attendant nausea.
Major Klatskin analyzed the effectiveness of treatment in 69 cases of amebic abscess and hepatitis. He employed the following criteria for cure: (1) Complete absence of pain and fever, (2) absence of liver enlargement, (3) absence of subcostal and compression tenderness, (4) normal white blood cell count and sedimentation rate, and (5) absence of E. histolytica from the stools. The treatment consisted of repeated courses of emetine until the criteria of cure were observed. Thereafter, emetine was supplemented with one or more courses of Diodoquin or chiniofon, followed by carbarsone, to eradicate the associated colonic amebiasis presumed to exist in all cases. The schedule of treatment consisted of a first course of 12 grains of emetine given over a 15-day period; then a course of 1 grain daily, given with a 3-day rest period after the 6th or 9th dose, depending on the patient's reaction to the drug. Most patients tolerated 9 grains, but occasionally patients complained of weakness and exhibited a fall in blood pressure after 6 grains. After a 3-day rest period, Major Klatskin found they were able to complete the 12-grain course with no ill effects. He wrote:
The first course is followed by a two-week rest period, at the end of which emetine therapy is resumed. Courses of six grains each are then alternated with two-week rest periods until the criteria of cure are met. A rest period of two weeks was chosen because it proved to be sufficiently long to prevent the cumulative toxic effects of the drug. Also it was noted that considerable improvement often occurred up to two weeks after the drug was stopped, so that the total dosage of emetine could be kept down to a minimum. Where the rest periods were prolonged beyond two weeks in the face of liver tenderness, leukocytosis or an increased sedimentation rate, a clinical recrudescence frequently occurred. In a few of the more acute cases the second and third courses of emetine were given at eight to ten day intervals with no untoward effects. It may be necessary to shorten the rest periods in this manner if a recrudescence with fever occurs.
Except for the occasional weakness and fall in blood pressure during the first course of emetine, no toxic effects were seen.
The total emetine dose required to effect cure varied with the type of hepatic amoebiasis. The abscess cases required the largest doses (average 21.9 grains in 47.6 days), the acute hepatitis somewhat less (average 14.4 grains in 33.4 days), and the subacute and chronic cases the least (average 11.2 and 12.4 grains respectively in 16.1 days).The largest dose of emetine administered to any patient was 27 grains, the smallest 6 grains.
The response to emetine usually was so dramatic that it was considered diagnostic of the disease. Of the 69 patients treated, 68 were cured. One patient, though afebrile and greatly improved clinically, had a persistently enlarged and tender liver.
Relatively few cases of hepatic abscess requiring aspiration or drainage were seen in the theater. Captain Rogers and Colonel Elsom, in their study of 444 cases of amebiasis, at the 20th General Hospital, observed only 4 patients
with liver abscess. In time localization of such lesions, the possible usefulness of pneumoperitoneum was studied by Colonel Bercovitz and his associates at the 69th General Hospital. Their observations were not conclusive but indicated the possible value of this technique as a diagnostic adjunct. In the theater ETMD for August 1945, Col. Harry C. Hull, MC, and his associates at the 142d General Hospital reported a contribution, of considerable merit, to therapy of hepatic abscesses. These officers treated two patients with amebic abscess of the liver by closed drainage after visualization with diodrast. Both patients were gravely ill despite employment of all accepted measures, including repeated aspiration. Under local anesthesia, a catheter was inserted into the abscess cavity, closed drainage with suction was instituted, and penicillin injected daily into the abscess cavity and also intravenously. Both patients made full recovery.
To appraise the plan of treatment in use and to elaborate improved methods of therapy, a program of clinical investigation of the diarrheal diseases was planned and put into operation at the 142d General Hospital. The relative value of the oxyquinoline drugs, the evaluation of emetine and the possibility of either omitting it from the treatment of acute dysentery or substituting an oral preparation, the efficacy of the oxyquinoline derivatives in treatment of asymptomatic carriers, and the possible value of chemotherapy, such as use of the sulfonamides and/or penicillin, in affecting the secondary bacterial invaders in the bowel were some of the problems that were proposed for investigation. The end of hostilities interfered with the complete fulfillment of this program.
Followup observations. - The third medical approach was through followup observations of all patients in order to be certain that repeated tests of cure be made and therapy instituted in event of recurrences. Posttreatment examinations must be viewed as part of the management of the patient as well as part of the control of the spread of these diseases. The necessary transfer of personnel within the theater led to unsatisfactory followup of patients with amebiasis. Tests of patients' stools on return to duty after hospitalization usually were not performed. When patients reported to dispensaries or were readmitted to hospitals because of gastrointestinal complaints, records of previous hospitalization were not available. Results of previous clinical findings, the prior diagnoses and response to treatment were unknown. It was believed in the Office of the Surgeon, moreover, that the inadequately treated military personnel might, on their return to the Zone of Interior, present a public health problem as carriers. To remedy this situation, it was decided that an amebiasis register analogous to the syphilis register, should be initiated for each patient. This register contained a summary of all pertinent clinical data, results of examinations, and a summary of the treatment previously employed. The register was begun by the medical officer making the original diagnosis, was maintained by the medical officers currently in charge of treatment of the case, and was forwarded to the surgeon of the patient's new station or command. When a satisfactory result had been attained or when the patient was transferred out
of the theater, the register was forwarded to the Office of the Surgeon, Headquarters, USAFIBT. Besides the purposes of this register just mentioned, evaluation of the therapeutic regimes employed was made possible. When the registers were forwarded to the Surgeon General's Office at the conclusion of the war, they were studied and were made available on subsequent hospitalization of the patient in the Zone of Interior.
Only meager information was generally available regarding followup of patients hospitalized for amebiasis. Major Ellenberg and his associates, however, performed a 1-month followup stool examination in each of their 833 cases, a 3-month followup examination in 60 percent, and some were followed for varying periods up to 11 months.
Of particular interest were the results of their followup in 101 cases in the personnel of their own unit whom they were able to study with especial care. Twenty-six had been hospitalized because of clinical manifestations; the remaining 75 were asymptomatic carriers. All had a minimum followup period of 6 months, and 81 were followed monthly for 11 months. There were only 2 recurrences in this group of 101 cases; one a symptomatic and the other an asymptomatic case. As previously stated, the remarkable cure rate of 99 percent in the entire series is to be attributed in part to early diagnosis and effective treatment.
Of the 444 patients with amebic dysentery studied by Rogers and Elsom at the 20th General Hospital, 162 followups were requested and 84 (35 acute, 20 subacute, and 29 chronic) were obtained. The total followup period was from 3 to 6 months for 25 patients, 6 to 12 months for 24, and 12 to 23 months for 35. A summary of the findings in the 84 patients follows.
At the various hospitals, readmission for amebiasis was not uncommon. In a theater where repeated exposure to infection was inevitable, one could not
confidently distinguish between recurrence and reinfection. Disposition to the Zone of Interior of patients with persistent disability despite therapy and of patients with persistent organic intestinal damage limited clinical experience with this important group of cases.
BACILLARY AND OTHER FORMS OF DYSENTERY
The numerous cases of dysentery prevailing in the India-Burma theater and the limited laboratory facilities generally prohibited detailed laboratory diagnostic study except in special instances. However, the Sub-Commission on Dysentery of the Army Epidemiological Board reported in November 1944 that, of 369 cases admitted to the 20th General Hospital because of diarrhea and of 175 cases seen in dispensaries, stools were positive for bacillary dysentery in 24 percent and 16 percent, respectively. As Colonel Blumgart advocated examination of stools for E. histolytica in every case and recommended equipment of the smaller installations and dispensaries with microscopes and the necessary laboratory supplies, this was done to an increasing extent. Except in field, station, evacuation, and general hospitals, mild cases of diarrhea usually were treated symptomatically and the more severe or protracted cases with chemotherapy. Patients treated on an ambulatory basis usually were given sulfaguanidine, which, although therapeutically inferior to sulfadiazine, was not attended by the dangers inherent in sulfadiazine. The hot climate in this theater during much of the year predisposed patients to dehydration and renal complications, particularly those patients with diarrhea whose fluid intake could not be supervised. Under the more favorable conditions of hospitalization, sulfadiazine was administered with excellent results in accord with TB MED 119, November 1944, entitled "Bacillary Dysentery." Most cases of "Delhi Belly" cleared rapidly regardless of the regime employed. Even in proved acute bacillary dysentery, the efficiency of chemotherapy was not always evident. Thus, in 300 Chinese patients studied by Major Elson, Maj. (later Lt. Col.) Dickinson S. Pepper, MC, and Lt. Col. (later Col.) James S. Forrester, MC, neither sulfaguanidine nor sulfadiazine shortened the course of disease or ameliorated the symptoms in comparison with the group of controls. However, the value of chemotherapy in the treatment of bacillary dysentery and in the prevention of the carrier state was generally impressive.
The differential diagnosis of the diarrheal and dysenteric diseases in the India-Burma theater presented no unique or peculiar problems. As in other tropical and subtropical regions, the following possible diagnoses required consideration: Amebic dysentery; bacillary dysentery; simple diarrhea, including food poisoning; and parasitic infestations, such as hookworm and strongyloidiasis. The acute form of amebic dysentery could not be distinguished from bacillary dysentery with absolute confidence on clinical grounds alone. Concurrent bacillary and amebic infection was frequent: indeed,
according to various estimates, from 10 to 25 percent of patients with bacillary dysentery had amebiasis as well. In general, however, certain diagnostic considerations served as guides for differentiation. In amebic dysentery, the onset was usually less violent, the symptoms were apt to have existed for weeks rather than for hours, and the maximum number of bowel movements per day was characteristically from 5 to 10 rather than from 15 to 20 as in bacillary dysentery. High fever, prostration, and intense abdominal pain were less frequent in amebic dysentery; the leukocyte count was more likely to be normal or only slightly elevated; and the stools consisted primarily of feces containing blood, whereas in bacillary dysentery they often consisted only of a very small amount of odorless bloody mucus. Bacillary dysentery tended to subside even when not treated with sulfonamides, whereas amebic dysentery continued unabated or improved only slightly until specific treatment was instituted.
Simple diarrhea could be distinguished in the majority of cases by its more explosive onset, by its tendency to affect simultaneously a number of men in the same organization, by the absence of blood in the stools, and by its rapid subsidence within from 24 to 48 hours. Malaria was occasionally associated with bloody dysentery, but the abrupt onset of chills, a remittent type of fever of 104o F. or above, headache, and generalized bone, joint, and muscle pains were so highly characteristic of it and so atypical of amebic or bacillary dysentery that the differentiation was usually not difficult. Hookworm disease and strongyloidiasis frequently gave rise to low-grade, generalized abdominal pains and diarrhea. The two diseases did not cause bloody stools, and the abdominal symptoms produced by them were usually less clearly colonic in origin, consisting rather of generalized or upper abdominal discomfort with indigestion. Finally, an important diagnostic consideration was the fact that certain localities in India and Burma were known to be highly endemic centers of amebic infection, and personnel from these areas were always to be suspected.
The effective treatment of patients by preventing their becoming carriers and by detecting and eliminating the carrier state in others undoubtedly was partly responsible for the reduced noneffective rate for the diarrheal and dysenteric diseases in 1945 (chart 8). Of equal if not greater importance was the improved sanitation throughout the theater.
In a lecture on the importance of malaria in India, Lt. Col. (later Maj. Gen. Sir) Gordon Covell, Director, Malaria Institute of India, stated: "Although * * * the case mortality from malaria is probably less than one per cent, it has been estimated that in India alone the disease is directly responsible for more than one million deaths per annum in a normal year, whilst in years of great epidemics this figure may be greatly exceeded." 3
3 Covell, G.: Lectures on Malaria. Health Bull. No. 5, New Delhi: Government of India Press, 1941.
This indicated the occurrence of malaria in approximately 100 million people in India each year, or in 1 of every 4 of the population. Into this situation U.S. Army troops were sent in 1942, many of them going to the Province of Assam, which was described in the 1943 annual report of the 20th General Hospital, as follows:
* * * a malaria infested area, one that is continually epidemic, as bad as any in the world * * *. From the best statistics available, the malaria infection rates of the native population were as high as 3,000 per 1,000 per annum, or 300 percent during the rnalarious season. The rate dropped to about 70 percent during the winter months or the so-called "non-malarious" season.
Lest it be thought that malaria was confined to the jungle regions such as Assam, one of the very first letters in the medical files may be cited, reporting an outbreak of malaria in a detachment of 20 men who traveled by rail from Karachi to Dinjan.4 Of the 20 men, 7 (35 percent) contracted malaria on the trip. This report was only the first of many to come to the theater surgeon's office. Any train trip that involved night travel, and all but the very shortest did, almost invariably resulted in new cases of malaria. In spite of control efforts, this situation still prevailed as late as August 1944. The 843d AAA Automatic Weapons Battalion, mobile, left Bombay for Teok on 7 August, arriving on 18 August. Of the 726 men in the battalion, 98 developed malaria within a month of arrival; as far as could be ascertained, 85 of the 98 contracted the malaria on that trip. 5
Malaria control was grossly inadequate in most areas. Occasionally, as in New Delhi, moderately effective measures had been initiated; in August of 1942, only 12 cases occurred in U.S. military personnel stationed there.
However, during 1943 and 1944, most of the troops were in the parts of India where the malarial rate was highest and where there had been no control prior to their arrival. A highly effective malaria control program was immediately instituted by the Preventive Medicine Section, Office of the Surgeon, Headquarters, USAFCBT, in areas where United States troops were stationed (fig. 246). A description of the control program is available elsewhere. The following pages are concerned with the disease as encountered by the medical officers of the India-Burma theater.
In all, 39,906 cases of malaria among U.S. troops were treated in time several years of the theater's existence. Knowledge of the disease was furthered, and valuable contributions to therapy were made. The great majority of the cases were seen in the 20th General and in the 48th and 73d Evacuation Hospitals in the Assam-Burma region along the beginning of the Ledo Road. Later, the 69th General Hospital and the 14th Evacuation Hospital also came into the Ledo area. Many reports and scientific papers were submitted from these
4 Letter, Col. John M. Tamraz, MC, Surgeon, U.S. Army Forces in India, Burma, and China, to Chief of Staff, Services of Supply, 30 July 1942, subject: Malaria Contracted by Troops Traveling on Railways.
5 Letter, Maj. Mason Trupp, MC, Assistant Surgeon, Headquarters, 10th Air Force, to Commanding General, 10th Air Force, 21 Oct. 1944, subject: Report of Excessive Number of Malaria Cases Within the 843d AAA AW Battalion.
installations, all stemming from the thousands of cases seen during the monsoon seasons of 1943 and 1944.
The material available for this review did not lend itself to a chronologic study in the sense that a day-by-day development of the malaria problem and its solution in the theater could easily be presented. Ideas conceived in 1943 frequently could not he completely developed until 1944, and in many instances the final report did not reach the theater surgeon until late in 1944 on early 1945. Consequently, it seemed best to present the material by subject, including under each heading all the ideas that were developed in sequence as nearly chronologically as the material permitted.
U.S. soldiers. - From 1 September 1942 to 30 June 1945, a total of 39,906 cases of malaria were reported in this theater. This figure included recurrences as well as original cases. Table 5 shows the total number of cases and the rates for each year. Chart 10 shows the attack rate by month for January 1943 through August 1945.
Table 6 shows the malaria statistics of the two most active hospitals in the Assam-Burma area for the part of 1943 that these hospitals were functioning. The 20th General Hospital received patients beginning 3 April 1943 and the 73d Evacuation Hospital beginning 26 April 1943. The figures for the 73d Evacuation Hospital are incomplete in that the breakdown for the month of November was not available. However, these figures suffice to show that in a period less than the full year these two hospitals alone treated approximately 45 percent of all the cases of malaria in U.S. soldiers seen in 1943. The figures for the Chinese soldiers are of interest; cases were not included in the U.S. Army statistics, but are shown in table 6, as they formed a part of the experience of these hospitals.
FIGURE 246.-Malaria control. A. Civilian contractor mosquito proofing army installation with hessian cloth and mosquito netting. B. Native teams organized to DDT spray villages in vicinity of army installations.
Deaths from malaria among U.S. personnel were uncommon, and in each death that did occur cerebral malaria was the cause.
Chinese soldiers. - The prevalence of malaria in the Chinese was due to many factors, the chief of which was the almost complete lack of interest in antimalaria precautions on the part of the Chinese. This was only another manifestation of the general lack of concern about health principles of any sort, and, indeed, lack of concern for life itself. It was also thought by some medical officers that the Chinese were inherently more susceptible to malaria, but whether this was a matter of racial susceptibility or a secondary result of the poor physical condition of all the Chinese troops flown to India from China was questionable. In any event, in the Chinese the incidence of infection from Plasmodium falciparum was much higher than in the Americans, the condition of patients on admission usually much worse, and deaths more frequent.
TYPES OF INFECTION
In U.S. personnel at the 2Oth General Hospital, during the period April 1943 through March 1944, there were approximately as many infections from P. vivax as from P. falciparum, whereas infections from P. malariae were uncom-
mon. Figures differed somewhat in the following year, when there was no appreciable change in the number of infections from P. vivax but a pronounced decrease in the number of infections from P. falciparum (table 7). The decrease in the latter reflected the decreased malaria rate; the high figure for malaria caused by P. vivax represented its tendency to recur. Infections with P. malariae remained relatively rare.
Mixed infections were considered much more common than the figures indicated. Under the pressure of a caseload so great that surgeons as well as internists were caring for malaria patients, a laboratory could do very little more than a single malaria smear, and, once a parasite was seen and the diagnosis established, the luxury of a continued search for other forms was not always possible. Mixed infections always showed P. falciparum; P. vivax was usually the other parasite. As far as can be determined from the available material, a mixed infection did not necessarily present added difficulties in treatment.
The unclassified group included all cases in which parasites were seen but the specific type not identified. It will be seen from table 6 that in 1943 approximately 25 percent of all the malaria cases seen at the 20th General Hospital and 21 percent of the cases seen at the 73d Evacuation Hospital fell into the unclassified group. Table 7 shows a pronounced drop in this figure at the 20th General Hospital in the following year: This difference represented a change in laboratory conditions. In 1943, with limited time and laboratory facilities, prolonged efforts to make an absolute identification were not justified. In 1944, with better laboratory facilities and more time, it was possible to make a reduction in the unclassified group. Capt. (later Maj.) Calvin F. Kay, MC, of the 20th General Hospital, reported on primary infections, reinfections, and relapses in the highly malarious district of Assam. In the unclassified infections in this study, Captain Kay reported that, when further smears were obtained and identification was possible, almost without exception the previously unidentified parasite proved to be P. vivax. From this finding and from the similarity of the relapse rates in this group to those in patients with malaria caused by P. vivax, Captain Kay was of the opinion that infections caused by P. vivax constituted the bulk of unclassified infections. in discussing this question, Captain Kay made the following statement:
"We had at first expected the reverse to be the case inasmuch as the later forms of P. vivax are more easily identified than those of P. falciparum. However, with the thick blood smears employed, in many instances large numbers of P. vivax trophozoites were present with none of the readily distinguishable later forms in evidence."
On the other hand, this opinion apparently was not universally held at that hospital, because Lt. Col. (later Col.) Thomas Fitz-Hugh, Jr., MC, Maj. (later Lt. Col.) Henry U. Hopkins, MC, and Major Pepper, in their report on cerebral malaria, stated: "We have also good grounds for believing that the majority of the 'Type Undetermined' and 'Clinical Only' groups are actually caused by P. falciparum infection." The medical officers at the 73d Evacuation Hospital were of the opinion that a large proportion of the unclassified cases were caused by P. falciparum, since this was the more commonly seen parasite in that region. They also felt that, inasmuch as an unclassified case signified insufficient parasites in the peripheral blood for a definite diagnosis and since the finding of few parasites in the peripheral blood was usually an indication of an infection from P. falciparum this was further evidence that the unclassified group largely represented infections from P. falciparum.
The last subgroup in table 6 included patients in whom the diagnosis was made solely on clinical evidence without laboratory confirmation. In many instances, treatment had been started before the patient reached the hospital. Although some of these cases undoubtedly were not malaria, the subsequent course and response to treatment of most of them and the known fact that several factors contributed to the difficulty of obtaining positive smears made it evident that in the large majority the diagnosis was correct. Captain Kay, basing his opinion on recurrence rates and later rechecks on smears, concluded that 66 percent of his group of unclassified cases were due to infections from P. vivax and 33 percent to infections from P. falciparum.
Malaria relapses gave rise to the same problems in the India-Burma theater as elsewhere. Major Kay studied three Organizations and calculated relapse rates in 499 individuals, of whom 407 were followed for at least 4 months. In individuals with one previous clinical attack of malaria, the relapse rate was 25 percent for the entire group, including patients with unclassified infections and those with infections caused by P. vivax and P. falciparum. Those patients who had malaria caused by infection from P. falciparum showed less than 5-percent relapse rate, and those with infections caused by P. vivax showed 34-percent relapse rate. In individuals who had already had one relapse, the rate rose to 75 percent. The figure of 34 percent, appreciably lower than the usually accepted figures for malaria relapse in other parts of the world, might have been greater had the cases been studied longer. The studies of the 73d Evacuation Hospital in a 6-month period showed a relapse rate of 9.7 percent following the initial attack.
The well-known fact that trauma, operations, and acute illnesses can produce a recurrence of a latent malaria infection was adequately demonstrated in the experience of this theater and led to the use of suppressive Atabrine therapy in patients hospitalized for any medical or surgical reason who gave a history of having had a previous attack of malaria.
The word "protean" has often been used in describing malaria manifestations; however, its frequent use does not make it any the less applicable. Medical officers who came to this theater from the United States had had very little experience with malaria before their arrival. Though textbooks and courses on tropical medicine have always emphasized that this disease, like syphilis, can be a great imitator, a doctor whose training and experience have always associated diarrhea with bacillary or amebic infection is not likely to consider malaria as a cause of watery stools. The difficulties in diagnosis are well described in the following extract from a personal communication from Col. Francis C. Wood, MC, Chief, Medical Service, 20th General Hospital:
We saw the abdominal malarias, often indistinguishable from acute appendicitis, the dysenteric malarias, that looked somewhat like bacillary dysentery except that the patients were more apt to have chills and a higher fever. We saw the post operative and post traumatic malarias; any fever was malaria till proved otherwise. We saw some very queer malaria pictures; our Chaplain had a typical attack of acute cholecystitis that turned out to be malaria.
Cerebral malaria. - Cerebral malaria was the major clinical problem. In the early days, when malaria cases were pouring in, filling both medical and surgical wards, the various manifestations of cerebral malaria were not fully appreciated.
The figures for incidence were somewhat variable, largely because of the varied opinion as to what constituted cerebral malaria. Whereas at first only those cases with convulsions, coma, or other severe cerebral symptoms were included in the classification, it later became apparent that drowsiness or mild behavior changes were early manifestations and such patients had to be treated accordingly. Colonel Wood, whose letter was just referred to, described the situation in these words: "At first we didn't know what to look for. We didn't know how drowsy a patient had to be to be suspected of early cerebral malaria. Eventually we found out that if, when awakened, a patient was not fully awake and able to tell you his name promptly, that patient needed careful watching."
At the three hospitals that saw practically all the cases of cerebral malaria, the average incidence of this manifestation in relation to the total number of malaria cases was 2.3 percent at the 20th General Hospital, 2.3 percent at the 48th Evacuation Hospital, and 1.1 percent at the 73d Evacuation Hospital (fig. 247), with an overall average of 1.9 percent. These figures included Chinese as well as U.S. troops. For U.S. personnel alone, the incidence at
the 20th General Hospital was 2.2 percent. Although the figure was not strikingly high, it is significant that most of the malaria deaths came from this group. Included in the annual report for 1943 of the 73d Evacuation Hospital was a special report on malaria by Lt. Col. (later Col.) Edward R. Ware, MC, and his associates. In this study, which covered a 6-month period, there were 57 cases of cerebral malaria with 27 deaths, a mortality of 46 percent. Only one of the 27 deaths occurred in an American. From the 20th General Hospital, Colonel Fitz-Hugh and his coworkers reported a mortality of 33 percent in Chinese patients and 5 percent in Americans. The 48th Evacuation Hospital, which treated chiefly Chinese troops, reported a 43 percent mortality in them and no deaths in U.S. personnel for the period from 1 April 1944 to 16 March 1945.6 The 14th Evacuation Hospital, reporting on all its cerebral malaria cases from its opening in September 1943 to May 1945, had a total of 121 cases with 33 deaths, a rate of 27.3 percent; all deaths occurred in Chinese soldiers.7 Although these figures do not all cover the same period and better methods for diagnosis and treatment were available as time went on, it was apparent that the mortality for cerebral malaria made this a disease that required alertness in diagnosis and prompt action in starting treatment.
6 Essential Technical Medical Data, USA FIBT, dated 1 July 1945.
7 Essential Technical Medical Data, USA FIBT, dated 1 Sept. 1945.
The etiologic agent in cerebral malaria has generally been accepted as P. falciparum and in rare instances as P. vivax. Practically all the data that were collected supported this conception. Although Colonel Fitz-Hugh and associates made the statement that "cerebral malaria is chiefly if not exclusively a result of P. falciparum infestation * * *, " a table in their paper reveals 5 cases of cerebral malaria attributed to P. vivax-1 case in an American and 4 in Chinese. The 14th Evacuation Hospital staff emphasized the fact that P. vivax can be a cause of cerebral malaria. Although the possibility of a double infection in which P. falciparum was overlooked must be considered, the clinical impressions of these men together with laboratory findings cannot be disregarded.
The clinical picture of cerebral malaria has been described by many authors and has been particularly well presented by Colonel Fitz-Hugh and his associates. All variations of cerebral manifestations were seen, from mild dizziness or slight drowsiness to severe headache, coma, and convulsions. Temperature charts showed no constant pattern, and a normal or slightly elevated temperature did not necessarily indicate improvement. Some cases that were admitted as ordinary malaria and seemed to be responding properly to treatment showed severe cerebral symptoms several days after admission. No adequate explanation for this was found, but it was observed that hypo-glycemia was occasionally a factor on prolonging cerebral symptomatology.
An interesting clinical observation, made at the 20th General Hospital in June 1945, was brought to the attention of this author by Colonel Wood. When a group of Chinese patients with malaria received no treatment for a period of several days preparatory to the use of a new drug, fraxine, all the patients with infection due to P. vivax became symptom free in 4 days without therapy, but the infections from P. falciparum did not subside spontaneously. Colonel Wood believed that this experience suggested why more infections from P. vivax were seen in American and more infections from P. falciparum in Chinese patients; the Chinese with infections from P. vivax recovered spontaneously and did not come to the hospital, leaving a relatively high proportion of patients with malaria due to P. falciparum to be hospitalized.
The CBI theater was established in March 1942. As far as can be determined, the first publication on the subject of treatment of malaria appeared in first theater Field Medical Bulletin, published in August 1942, and was a summary of a pamphlet issued by the British War Office. The treatment recommended was different from that recommended by Circular Letter No. 56, Office of the Surgeon General, U.S. Army, 9 June 1941, entitled "Notes on the Treatment and Control of Certain Tropical Diseases," which was still in effect. In the November 1942 issue of the CBI Field Medical Bulletin, another article on therapy appeared by Maj. (later Lt. Col.) Sydney P. Wand, MC, and Maj. (later Lt. Col.) Robert S. Crew, MC, of the 159th Station Hospital. These authors mentioned that the article in the August issue recommended a
treatment not in line with Circular Letter No. 56, and they went on to present several changes in the treatment of malaria gleaned from the School of Tropical Medicine in Calcutta, India. These also were different from the recommendations of The Surgeon General.
Finally, in the January 1943 issue of the theater Field Medical Bulletin, The Surgeon General's authority was recognized by reprinting Circular Letter No. 135, Office of the Surgeon General, U.S. Army, 21 October 1942, subject: The Treatment and Clinical Prophylaxis of Malaria. By January 1943, Circular Letter No. 135 had received complete distribution in the theater, and in the February 1943 issue of the Field Medical Bulletin, Lt. Col. Gordon S. Seagrave, MC, expressed doubts regarding the efficacy of Atabrine. He also presented his own views on the therapy of malaria, which included the use of liquor arsenicalis and neoarsphenamine.
The theater as a whole continued to use the plan of treatment outlined in Circular Letter No. 135 (October 1942) and in Circular Letter No. 33 (Office of the Surgeon General, February 1943), changing to Circular Letter No. 153, Office of the Surgeon General, U.S. Army, 19 August 1943, subject: The Drug Treatment of Malaria, Suppressive and Clinical, when this was received. By the end of 1943, installations in the heavily infested areas had sufficient experience to reach their own conclusions about the efficacy of the different methods of treatment. In the special report on malaria by Colonel Ware and his associates at the 73d Evacuation Hospital, it was concluded that all methods currently in use at that hospital were equally effective insofar as end results were concerned but that the treatment recommended by Circular Letter No. 153 did not reduce the temperature as rapidly as methods employing quinine and Atabrine in combination. This was very nicely demonstrated by a graph which accompanied the special report. The same conclusion was reached by the 20th General Hospital in the monthly sanitary report, dated December 1943, which states:
In accordance with instructions
The Surgeon General (Circular Letter #153)
quinine was withheld from all patients save those particularly ill, and
the entire treatment carried
on with Atabrine. The results have not been statistically
there seems no doubt that
the patients thus treated have a longer and more severe course and
several cases of cerebral malaria have developed after some days of
The 48th Evacuation Hospital evidently was also somewhat concerned about the effectiveness of the therapy recommended by The Surgeon General, because, in addition to the recommended plan of treatment, Lt. Col. (later Col.) Herman A. Lawson, MC, and Capt. (later Maj.) John A. Dillon, MC, treated a group of Chinese patients with a somewhat larger total dose. They reported the results in the April 1944 issue of the Field Medical Bulletin. The conclusion was that the treatment recommended by Circular Letter No. 153 was satisfactory and no clear-cut advantage was demonstrated in the use of larger doses of Atabrine. The experience of the theater with Circular Letter No. 153 was summarized in the theater ETMD dated 30 July 1944. The general opinion was that the results were satisfactory and that only in the
very sick patients was it necessary to supplement Atabrine treatment with quinine, usually intravenously. This will be taken up later under the treatment of cerebral malaria.
STUDIES WITH VARIOUS DRUGS AND COMBINATIONS
During this period when Circular Letters No. 135 (for 1942) and No. 33 and No. 153 (for 1943) were in effect, which included all of 1943 and most of the malaria season of 1944, occasional investigations were carried on, particularly at the 20th General Hospital, to determine the effectiveness of other drugs or combinations other than those recommended in Circular Letter No. 153. Observations were also made on the usefulness and side effects of the commonly used drugs. The following paragraphs summarize these observations.
Plasmoquin (pamaquine naphthoate). - The hospitals in the Assam-Burma region, in which Negro troops were stationed, soon discovered that Plasmoquin, always recognized as a moderately toxic drug, was particularly dangerous in Negroes, producing a severe hemolytic reaction. Because of the frequency and severity of the reaction, this drug was eliminated from the therapy program in all the hospitals in that area and eventually in the theater.
Fraxine.-This drug, of unknown composition, was tried at the 20th General Hospital on Chinese troops and reported on in that hospital's sanitary report, dated December 1943. It had been sent by the Chinese for testing as an antimalaria agent. It was completely ineffective in malignant tertian malaria, and its value in benign tertian malaria was open to question, since it was during this study that it was found that Chinese with malaria caused by P. vivax recovered spontaneously if untreated.
had long been recommended in the treatment of malaria. Although
had already been established that alone they had no effect in
preventing relapse or, for that
matter, in preventing initial infection by the malaria parasites, Major
Kay, at the 20th General
Hospital, undertook a study of the treatment of benign tertian relapses
with a combination of
Atabrine and Mapharsen (oxophenarsine hydrochloride). No
effects were observed in
the use of the combination of drugs; relapses occurred with the same
frequency in the Atabrine-Mapharsen group as they did in the group
treated with Atabrine alone.
and T/3 L. J. Kimmelman, of the 20th General
Hospital, worked. out a plan to give almost the
complete week?s dose of Atabrine in the first 24 hours of
was felt that, if this
method proved to be safe and effective, it would insure adequate dosage
and at the same time
shorten the hospital stay legitimately. The dosage used was 0.3
of Atabrine every 3 hours
for 8 doses. Patients so treated were compared with other groups
treated on different schedules.
The final result compared favorably with other plans of
fact, the duration of fever
and of parasitemia was less than usually observed in patients treated
according to Circular Letter
No. 153. Because 2 of 80 patients developed signs of stimulation of the
central nervous system,
the authors reduced the dosage to 0.2 grams every 3 hours for 8
This seemed to be as
effective as the original dose.
Major Machella, with 2d Lt. David F. Burgoon, SnC, and T/3 R. Fine, also studied the effects of the two drugs on the liver. Concerned primarily with the effect of a single intravenous dose of Atabrine or SN 6911, Major Machella limited the study to determination of Bromsulphalein (sulfobromophthalein sodium) excretion before, during, and after an attack of malaria. He found a definite impairment of the ability of the liver to excrete the dye during the period of fever; this impairment disappeared in the majority of cases within 96 hours after the institution of therapy and usually within from 48 to 72 hours after subsidence of fever. In general, the more prolonged the fever, the greater the dye retention; but in all but four cases the retention was only temporary. Those four cases all showed slight jaundice on admission. That the dye retention was related to the fever rather than to the disease per se was demonstrated by normal controls with artificially induced fever (typhoid vaccine) showing a similar degree of dye retention. It was impossible to demonstrate any effect of Atabrine or SN 6911 on the ability of the liver to excrete Bromsulphalein.
Failure to respond to oral administration of Atabrine was not common but did occur on a few occasions. Lt. Col. Frank B. Cutts, MC, and Capt. (later Maj.) Irving A. Beck, MC, of the 48th Evacuation Hospital reported in the April 1945 India-Burma theater Field Medical Bulletin on 8 cases, out of approximately 4,500, that did not show a typical response to oral administration of Atabrine. In 3 of the 8, the therapeutic response was delayed but eventually appeared. In the remaining five cases, there was no response. Atabrine was not found in the urine of any of these patients, and, since it was believed that they were taking the tablets, it was concluded that there was no absorption of the drug. Intramuscular Atabrine produced a prompt response and the appearance of the drug in the urine.
Plasmoquin. - All three drugs used in the treatment of malaria produced reactions. Plasmoquin had always been known as a toxic drug and proved to be particularly toxic in Negro soldiers. Both the 73d Evacuation Hospital and the 20th General Hospital had occasion to treat Negro troops since many Negro units were working along the Ledo Road. A severe type of hemolytic reaction was the most serious difficulty associated with Plasmoquin therapy. The 20th General Hospital, in its annual report for 1943, reported on approximately 20 instances of this reaction, all in Negro troops. The 73d Evacuation Hospital witnessed 10 such reactions--9 in Negroes and 1 in a Chinese soldier. All patients developed a moderately severe anemia; in 6 of the 10 patients at the 73d Evacuation Hospital the red blood cell count fell below two million. Because of the severity of these reactions, Plasmoquin was omitted from routine antimalaria therapy. There were also lesser reactions to Plasmoquin, such as gastrointestinal disturbances, cyanosis, hepatitis, and drug fever.
Quinine. - This drug had long been known to produce toxic effects, but, because the value of the drug as an antimalaria agent outweighed the disadvantages of its toxic reactions, its use was continued. It was administered intravenously in all cases of cerebral malaria prior to the availability of parenteral Atabrine and was generally considered to be a life-saving procedure. On the other hand, in the experience of the 48th Evacuation Hospital, as reported in the theater ETMD for June 1945, intravenous administration of quinine was very dangerous. Eight Chinese patients died in convulsions very shortly after the injection of quinine. Although it was admitted that a definite cause and effect relationship could not be proved, the clinical impression was so strong that the investigators at this hospital felt that any reasonable alternative was preferable to intravenous injection of quinine.
Whereas Atabrine given orally practically always produced good results in the usual case, it was frequently ineffective in cerebral malaria, and other measures had to be instituted. This was largely owing to the fact that patients with cerebral malaria were unable to take oral medication and required more intensive treatment. Patients with cerebral malaria who were responding favorably to oral treatment frequently suffered relapse after 3 or 4 days. In the early days of the theater when parenteral Atabrine was not available, practically all installations used intravenous quinine. Later, intramuscular and intravenous injections of Atabrine were used with excellent results.
In the ETMD for June 1945, Major Machella summarized the results in five cases of cerebral malaria treated with a single intravenous infusion of Atabrine. The dose varied from 0.6 gram to 1.0 gram, administered in 1,000 cc. of physiologic saline. One patient, in coma on admission, expired in 31 hours; he had received 0.8 gram of Atabrine intravenously. Two patients who received the infusion too rapidly had brief psychotic episodes which lasted less than 24 hours. When the infusion was given slowly, no toxic manifestations were noted. No conclusions regarding the relative merits of parenteral quinine and Atabrine were drawn from this very small series of cases; however, Major Machella felt that Atabrine was at least as effective as quinine and that 0.8 gram of Atabrine administered in a slow intravenous drip provided an effective method of clearing the blood of parasites. Aside from the specific drug therapy of cerebral malaria, certain general measures were tried. Some appeared to be of benefit; others were discarded. They were as follows:
1. Spinal tap. - There were no consistent results from this procedure. The group at the 20th General Hospital found it extremely useful and felt that an initial spinal tap was always advisable, whereas at the 73d Evacuation Hospital only in occasional cases did lumbar puncture, with reduction of the spinal-fluid pressure, have any appreciable effects. In most cases, it was of no avail.
2. Transfusion of whole blood. - The medical officers at the 20th General Hospital felt that whole blood transfusion was, at times, a life-saving procedure, particularly in cases with pulmonary edema.
3.Intravenous Adrenalin (epinephrine). - This drug was used by the 20th General Hospital and the 73d Evacuation Hospital. It was considered to be of value in some cases; however, because of untoward reactions, its routine use was not advised.
4. Sedation. - This measure was used universally in excited or convulsive cases. Intravenous Sodium Amytal (amobarbital sodium) and intravenous paraldehyde were used most often.
injection, and also nitroglycerin into the carotid. No striking results were obtained from these measures. A suggestion that resulted in much correspondence was submitted by Capt. (later Maj.) Mason Trupp, MC, an Army Air Force surgeon. He recommended the combined use of nicotinic acid and oxygen, the nicotinic acid to increase the cerebral blood flow and the oxygen to relieve the anoxemia produced by the plugging of the cerebral capillaries by parasites and pigment. For some reason, the suggestion received only a limited trial. A few cases were treated at the 234th General Hospital in Chabua, India, and occasional cases elsewhere, but no adequate clinical trial was ever given.
In general, the results of malaria treatment recommended in the directives from The Surgeon General were excellent, and very few patients, mostly cases of blackwater fever and several cerebral cases, required evacuation to the Zone of Interior.
At least since 1932, typhus fever--louseborne, tickborne, fleaborne, and miteborne--has been known to exist in Burma. Interestingly enough, however, the first reported case of scrub typhus in the India-Burma theater came not from Burma but from India where a civilian technical representative had been admitted to the 100th Station Hospital at Delhi, India, on 2 October 1943, with fever and mild meningeal signs. Agglutination of OXK strain of Proteus to 1/2500 was found on the 10th day of hospitalization, and complement-fixation tests done later in Washington likewise indicated that the disease was scrub typhus. The history in this case revealed that the patient had just returned from Kunming, China, where several other cases of typhus had been reported. The other cases were proved later to be of the epidemic variety; only the one case was proved to be scrub typhus.
The chief focus of scrub typhus in the India-Burma theater was Burma. In November 1943, Chinese troops, stationed in Chinglow and Shingbwiyang, in Burma, began to develop a disease that at first was thought to be measles but later was diagnosed as a form of typhus fever.8 In one company of the 114th Infantry, 28 cases occurred with 4 deaths. At the end of November1943, two U.S. soldiers suspected of having this disease were hospitalized at the 20th General Hospital, and shortly afterwards Maj. Walter S. Jones, MC, who had been assigned to the Chinese as liaison officer and had also made a trip to Shingbwiyang, developed an acute illness which, following the appearance of a rash on the fifth day, was diagnosed as mite typhus. His own subjective reactions to this disease are described in detail in his 1 August 1945 report to the theater surgeon on his activities with the Chinese.
In December 1943, Major Pepper studied all the cases then at the 20th General Hospital and in addition traveled down the Ledo Road to investigate the focus of infection around Shingbwiyang (fig. 248). He discussed his findings with Maj. (later Lt. Col.) William L. Jellison of the U.S. Public Health Service, who was of the opinion that a mite was the most likely vector because, if fleas, ticks, or lice were the vectors, not only would there be a history and signs of bites but the insects themselves would be found. Mites, on the other hand, would be practically impossible to find and would not leave visible bites.
Consequently, in his report on his investigations which he submitted on 9 December 1943 to the Surgeon, Base Section No. 3, Major Pepper concluded:
"The disease seen both in the Ledo Road section of Assam and in the region of Shingbwiyang is a form of miteborne rickettsial disease which closely resembles the mite typhus, tropical typhus, rural typhus of Malaya or Sumatra, scrub typhus etc. of the literature."
Captured Japanese medical reports indicated that the enemy was encountering the same disease among their troops. The reports show that there was some doubt in the minds of Japanese medical officers regarding its proper classification. They called it eruptive fever, found that it was caused by rickettsial bodies, and felt that it was closely related to Japanese
river fever. (Tsutsugamushi disease). Their reluctance to identify it specifically as Tsutsugamushi disease was apparently due to their failure to find the typical ulcer in most of the cases. In one group of 29 patients, only 2 showed the characteristic eschar. The descriptions presented in the captured reports leave no doubt that this was the same disease that was then appearing in Chinese and U.S. troops.
The British were having their own difficulties with this infection. Report No. 433 of the Joint Intelligence Collecting Agency, China-Burma-India theater, dated 24 February 1944, described an outbreak in the 1st Devon Regiment, which occurred between 21 October and 17 November 1943. Of particular interest in this report is a graph showing the number of cases that developed day by day and their relationship to the time the group entered and left the infected focus.
The initial outbreak of mite typhus among U.S. troops was of relatively brief duration. The first cases appeared in November 1943 and a considerable number in December 1943, but by January 1944 the incidence had fallen sharply. Col. Elias E. Cooley, MC, Medical Inspector, USAFCBI, submitted a preliminary report on scrub typhus among U.S. and Chinese troops in India-Burma, in which he included a report on the clinical aspects of the disease by Major Pepper and a report on possible vectors by Capt. (later Maj.) Virgil. Miles, SnC, entomologist of the 18th Malaria Survey Unit. Maj. (later Lt. Col.) John T. Smiley, MC, Surgeon, Base Section No. 3, then prepared a final report, dated 20 April 1944, summarizing the situation. His findings confirmed those already arrived at by Major Pepper. In addition, Major Smiley came to the following conclusions: "It is highly likely that sporadic cases occurred throughout the year; however, these have been recorded as fever of unknown origin inasmuch as no serologic studies were done, but there seems to be a definite seasonal increase in the disease during November and December." The concept of seasonal incidence developed support as time passed. However, there was good reason to believe that this factor was more apparent than real (p. 746).
A second outbreak of the disease began in April 1944 and lasted through July 1944. These cases were limited almost entirely to troops taking part in the battle around Myitkyina, Burma, chiefly to the group known as Merrill?s Marauders (5307th Composite Unit (Prov.)) (fig. 249). There were 148 cases with 17 deaths. Writing about this outbreak to the Surgeon, USAFCBI, on 23 August 1944, Maj. (later Lt. Col.) Kirk T. Mosley, the theater epidemiologist, said:
The outbreak of scrub typhus fever occurred while this force was engaged on a combat mission to clear the enemy out of North Burma, especially in the general region of the route of the Ledo Road. The area covered by the 5307th Composite Unit (Prov) during this period was in the lower ranges and foothills of the North Burma mountains where the head-waters and tributaries of the Mogaung, Tinai, and Irrawaddy rivers are located. These streams or their tributaries were crossed a number of times and sites along their banks
were frequently used as bivouac areas. The establishment of bivouacs on the banks of these streams may be an important feature in the epidemiology of the outbreak and offers a reasonable explanation of the occurrence and distribution of cases among the three (3) battalions and also the distribution within the component elements of each battalion (fig. 250).
Cases continued to appear during August and September but not in
excessive numbers. In
October, November, and December of 1944 and in January 1945, the number
of cases rose
sharply. There was a lower death rate in the third outbreak, and
the disease was in general not so
severe as in the previous epidemics. These cases came largely
from troops stationed at Camp
Landis who had taken part in the last stages of the Burma campaign.
Incidence. - Chart 11 shows the number of cases per month of scrub typhus in U.S. troops from December 1943 to July 1945. Deaths are also indicated. Although at first glance one might suspect a seasonal incidence, with peaks in late fall and spring, this distribution in all probability was related to the movement of the troops into infected areas during those months rather than the season of the year per se. There was a total of 726 cases and 52 deaths in U.S. Army personnel.
Mortality. - The overall case fatality ratio in U.S. troops was approximately 7 percent, although in the first two outbreaks it was almost 12 percent. The chief factor in producing the higher mortality may well have been the poor physical condition of the troops on arrival at the hospital. Many of the men in the Myitkyina campaign, already acutely ill, were forced to march for several days to reach an evacuation point. On 28 May 1944, in a preliminary report to the Commanding Officer, 20th General hospital, Lieutenant Sayen, officer in charge of the typhus investigation at that hospital, made the following comment on the epidemiology of the second outbreak:
The mortality of the present Scrub Typhus Epidemic is considerably higher; and the individual patients are more severely and prolongedly ill than was the case in the outbreak which occurred late in 1943. This seems directly caused by the physical condition of the
troops when they acquired the infection. The 1943 American victims were supply or liaison troops in relative sound health. The present group is composed of exhausted, malnourished men; often not evacuated from the battle front until several days after the onset of typhus. Not infrequently the patients suffer from simultaneous diseases, particularly amoebiasis and malaria. The importance of early evacuation, institution of bed-rest, nursing care and proper nutrition, as well as the treatment of concomitant diseases for which specific therapy is available cannot be overestimated.
There is nothing characteristic of the early symptoms that distinguishes this disease from any other acute infectious process.
Incubation period. - The incubation period is always difficult to determine in diseases with gradual onset and indefinite time of exposure. In two medical officers, who were in a known typhus focus for only 4 days, it was from 9 to 13 days in one and from 10 to 14 days in the other. One had a typical skin lesion 2 days, the other 4 days, before the onset of fever. The incubation period for the fever in these two cases corresponded closely with the one determined by the British, which was from 9 to 17 days for 121 cases.
Signs. - Three physical findings were found sufficiently characteristic to make them of considerable diagnostic importance. These were the typical eschar, generalized lymphadenitis, and the rash.
The following tabulation shows the incidence of these signs in the series of 600 cases reported on by Colonel Wood and Captains Sayen and Pond from
the 20th General Hospital and in the 86 cases reported on by Captains Agress and Evans from the 73d Evacuation Hospital:
Incidence of Clinical Signs (in percent)
The eschar, shown in figure 251, was the most pathognomonic physical finding, although it was seen less frequently than lymphadenitis. Although the lesion was found on all parts of the body, in most cases it occurred on the trunk or in the axillae. Unusual sites were the eyelids, the penis, and the perianal region. More than one eschar was very rare; Colonel Wood and Captains Sayen and Pond mention one case. The importance of the eschar as a diagnostic sign lay in the fact that usually this primary lesion was present for several days before the actual onset of symptoms. If the lesions had been discovered and the significance recognized, the affected individuals might have started their arduous trip back to a hospital 2 or 3 days before the onset of the disease instead of moving deeper into the jungle, as they unquestionably did in groups such as Merrill's Marauders. The best descriptions of the eschar
were found in Lieutenant Sayen's preliminary report of 28 May 1944 and in the article on 616 cases of Captains Sayen and Pond and Colonels Forrester and Wood, the latter containing the following comment:
A typical primary ulcer, or eschar, of Scrub Typhus begins as an inflamed, painless papule which soon ulcerates, forming a central crater over which a dark, reddish-black scab forms. In moist areas, or when the scab is pulled off a deep ulcer with raised edges and thin yellowish-white exudate is seen. An essential characteristic is that it does not heal, possibly not until many days after the patient has recovered from his systemic symptoms. Although resembling other types of bites in its early phase, the mite ulcer shortly becomes so distinctive that it can scarcely fail to be recognized if seen. It is a raised lesion about the size of a dime with a black scab at the center (2 to 8 mm. in diameter) and a red, angry flare surrounding it for a distance of a centimeter or more. One or more regional lymph nodes soon become enlarged and tender and it is these rather than the symptomless ulcer which may attract the attention of the soldier. Since the eschar may occur anywhere on the body, commonly in moist, protected areas such as the axillae and the genital or perianal regions, a thorough search must be made of every suspected case. Medical corpsmen and line officers could probably be taught to recognize such lesions in addition to members of the Medical Corps.
Lesions on moist intertriginous surfaces (axillae, scrotum, perianal region) appeared as shallow, yellow-based ulcers without much surrounding hyperemia and without the black crust; consequently they were easy to overlook. Lesions on the hands and those below the popliteal space were often indistinguishable from the many cutaneous erosions and leech bites sustained by troops traversing the jungle * * *. The vast majority of patients did not report feeling any "bite." Secondary infection was rare * * *. The presence or character of the ulcer appeared to have no relation to any other manifestation of the disease, including the OXK titer and the severity.
The lymphadenopathy was the most frequent single physical finding. Generalized lymphadenitis was the rule, but it was common to find enlarged tender lymph nodes draining the site of the primary ulcer a day or two previous to the appearance of the generalized adenopathy. Because of the wide variability in the site of the eschar, careful search was necessary in order not to overlook the regional lymph nodes. The nodes were usually large and rubbery but at times small and firm.
Fever. - An irregular spiking type of temperature curve with double daily rises was regarded as characteristic of scrub typhus by Captain Sayen and his associates. It was exhibited by 70 percent of the patients at some time during the course of the disease. This characteristic type of curve was usually not persistent but was supplanted by long or short periods of remittent or sustained fever.
Agglutinations of the Proteus OXK antigen were found to be of the greatest diagnostic value. A detectable titer was not usually found until the 10th day of the disease or later. Opinions varied as to what constituted a diagnostic titer. Observers at the 20th General Hospital, using 1/100 as the diagnostic dilution, found only 55 percent of their 600 cases with this titer or a higher one. At the 73d Evacuation Hospital, observers considered a titer of 1/50 as strong evidence of scrub typhus; 70 percent of their 86 cases showed this or higher.
The rash in most instances was a nonpruritic maculopapular eruption (fig. 252), which usually appeared between the 3d and 7th day of the disease and lasted from 5 to 7 days. It involved the trunk always and the extremities in about a third of the patients. The face was involved in 15 percent. It never involved the palms or the soles. There was no correlation between the appearance, character, or persistence of the rash and the severity of the disease. When florid or typical, the rash was diagnostic, but this occurred in only half the patients.
In time first week of the disease, there were no unusual features that distinguished scrub typhus from any other severe generalized infection associated with marked toxemia. However, the average patient continued to have fever for approximately 3 weeks, and it was during the 2d and 3d week that such manifestations as typhus pneumonia, major involvement of the central nervous system with coma or convulsions, cardiovascular involvement, and hemorrhagic phenomena appeared. These complications were described in detail by the observers at the 20th General Hospital. They were the most
serious diagnostic and therapeutic problems; there were other less significant features, such as tender toes, conjunctivitis, deafness, visual disturbances, and edema of the face, hands, and feet.
Respiratory manifestations. -
of the respiratory system was very common; almost
every patient had bronchitis, and pneumonia was seen frequently.
Colonel Wood and Captains
Sayen and Pond concluded that the following points were most important
in establishing the
diagnosis of typhus pneumonia:
c. The ordinary roentgenologic signs of pulmonary consolidation are rarely seen. The chest film often shows nothing but prominent hilum and trunk shadows in a patient with extensive typhus pneumonia. Occasionally there is diffuse mottling. Typhus pneumonia is a lesion which is not adequately demonstrated by x-ray of the chest. When abnormalities are found they usually fail to indicate the true extent of the lesion. The occasional case will die with extensive typhus pneumonia without having had the degree of tachypnea indicated in (a), but this is rare. In conclusion, then, the most important clinical indicator of the condition of the lungs in scrub typhus is the respirator rate chart. It rarely fails to show a rate above 35 per minute for at least 2 days when the lesion is extensive enough to be of major clinical significance.
Cardiovascular findings. - In the cases observed at the 20th General Hospital, cardiovascular findings were summarized by Colonel Wood in the theater ETMD for March 1945. In 500 cases, no true congestive heart failure was seen. Cardiac enlargement determined by percussion and the position of time apical impulse was found in 28 percent of 200 cases; however, Colonel Wood questioned whether X-ray findings would corroborate such a high percentage. In the same 200 cases, 24 percent had a gallop rhythm and 33 percent a soft first heart sound. Electrocardiographic tracings were taken on 42 patients in the 2d and 3d week of the disease. In 30 of this group, the tracing was taken because a cardiac complication was suspected; 8 showed P-R interval prolongation of 0.22 seconds or more, 18 showed minor and 3 showed definite abnormalities of the Q.R.S. and/or T segments. In the remaining 12 cases, the tracings were taken merely to determine the incidence in unselected cases of scrub typhus. Although the series was too small for conclusions, 3 cases showed P-R intervals prolonged to 0.22 seconds or longer, and 2 showed marked RST segment deflections and/or T wave inversion.
Colonel Wood concluded his report on the cardiovascular findings, as follows:
These cardiac phenomena rarely occur in the first week. They appear from the 7th to the 16th day. We do not as yet have the figures for the duration of enlargement, gallop, etc. Moreover the correlation between pathologic and clinical findings is not yet available. The patients with the largest hearts did not all die, by any means. In fact most of them recovered. As they got well, their hearts returned to normal size. None of them showed congestive failure. A few patients who died showed mild to moderate degrees of right sided cardiac dilatation at autopsy. Pericardial effusion was not seen.
* * * * * * * * * * * *
e. Conclusion. - Although our data are as yet incomplete, it is our impression that these cardiac signs all disappear during convalescence, and that the "effort syndrome" picture seen in some convalescent typhus patients is not due to heart disease per se.
Ocular changes. - Maj. Harold G. Scheie, MC, studied the eyes of the patients at the 20th General Hospital at weekly intervals during the course of the disease, consolidating the results of his studies in a brief but comprehensive report. He stated as follows:
* * * The first and most uniform change found in the fundi of the patients with scrub typhus was progressive venous engorgement with onset late in the first or during the second week, continuing until the veins are two to two and one half times the diameter of the arteries. Accompanying this change the veins become more tortuous, irregular and sausage like in caliber, most marked near the disc. The outlines of the venous walls become indistinct while the arteries remain well defined. Apparent compression of the veins occurs at the arteriovenous crossings where the veins frequently appear interrupted by the arteries, which at these points have a diffuse veil along their walls. As these latter changes progress, the disc and retina become edematous and the posterior pole of the eye appears somewhat veiled particularly in the region of the disc. The disc and surrounding retina appear pale and more opaque than normal. In a few cases retinal hemorrhages and cotton wool exudates occur when the retinal changes are at their height.
Conjunctival injection occurred in 38 percent; subconjunctival hemorrhages in 6.5 percent. Retinopathy, when present, was of diagnostic significance inasmuch as lesions of this type were not seen in other febrile diseases. Edema of the disc and retina was noted in 36 percent, was always bilateral, and was preceded by engorgement of the veins. Retinal hemorrhages occurred in 6.6 percent. They were usually superficial and flame shaped but occasionally deep and punctate. Retinal exudates, usually of the cotton-wool type, occurred in 4.9 percent. Major Scheie failed to find evidence in the retinal vessels of the perivasculitis mentioned in TB MED 31; he felt that the changes were rather those of a true vasculitis.
Neurological manifestations. - Involvement of the central nervous system was evident in practically all cases. A nerve type of deafness was seen in the majority of patients during the 2d or 3d week. Tinnitus was usually an accompaniment. Peripheral nerve symptomatology, such as paresthesias, numbness, and weakness, was seen in a few. These phenomena generally disappeared with defervescence. Meningoencephalitis was evident at post mortem examination in all fatal cases. Clinically, involvement of the central nervous system was reflected by apathy and drowsiness in the early stages of the illness and, in the 2d and 3d week, by confusion, delirium, restlessness, convulsions, and coma. Captains Sayen and Pond and Colonels Forrester and Wood described the restlessness in their 616 cases as follows:
Twenty-six patients developed a peculiar, persistent restlessness. Such individuals would not lie quietly, but constantly thrashed about, sat up, or tried to get out of bed. They would not tolerate an oxygen mask, or an intravenous infusion. They required constant nursing supervision and sedation. They were all gravely ill and wore themselves out at a time when their physical reserves were precariously low.
Malignant restlessness or convulsions were among the most ominous developments, and coma was usually followed by exitus. In 200 cases at the 20th
General Hospital, only 12 patients had convulsions; coma occurred in 14 cases.
Hemorrhagic phenomena. - To a variable extent, hemorrhagic phenomena were seen at the different hospitals. In the theater ETMD for June 1945, the 73d Evacuation Hospital reported that at that hospital relatively few patients showed a bleeding tendency except as a terminal event; whereas, in the theater ETMD for April 1945, Capt. (later Maj.) Horace H. Hodges, MC, at the 20th General Hospital, found the reverse to be true, as follows:
It was concluded that, in a considerable proportion of patients with scrub typhus, there is an abnormality of the clotting mechanism. A lowered prothrombin content seems to be frequently associated with prolonged clotting. An actual purpura, with platelet deficiency, was encountered twice with long clotting and low prothrombin. The significance or cause of this is unknown. In itself, prothrombin in the range of 50 percent normal is not enough to prolong clotting. Other unknown factors must be operating.
Also in the June ETMD, the 14th Evacuation Hospital in reporting on a gross pathologic study revealed the following incidence of vascular or hemorrhagic manifestations:
1. Of 16 autopsies performed on U.S. soldiers, there was 1 case of acute infarction of liver, 2 cases of acute infarction of spleen, 1 case of acute military myocardial infarction with perirenal hemorrhage, 2 cases of adrenal medullary hemorrhage, 1 case of massive hemorrhage into psoas muscles and retroperitoneal tissue, 1 case of massive hemorrhage into small and large intestines, and 1 case of acute infarction of kidney.
2. Of 7 autopsies performed on Chinese soldiers, there were 3 cases of massive hemorrhage into psoas muscles and retroperitoneal tissues; 1 case of massive hemorrhage from nasopharynyx; 1 case of acute infarction of kidney; and 1 case of massive aspiration of blood into lungs, source undetermined.
These were all post mortem findings. No mention was made in the report of the incidence of hemorrhagic phenomena in nonfatal cases.
Therapy was primarily supportive and
symptomatic. Strict bed rest
was essential, and it was
generally agreed that nursing care was of the utmost importance.
At the 20th General Hospital, it
was the consensus that the care a patient received in the first week of
the disease might be
decisive in determining ultimate survival.
which in other illnesses would be expected to beneficially affect dehydration, will most frequently be found to fail in this condition and at times is obviously deleterious.
Only one patient was seen at the 20th General Hospital in whom the slow administration of fluids intravenously produced an adverse effect.
Blood transfusions were routine for patients with anemia and hypoproteinemia. Sedation, in adequate doses, was essential for restless patients; narcotics, rectal paraldehyde, and intravenous barbiturates were used. Oxygen was administered for cyanosis. Sulfonamides and penicillin were employed by all installations. It was agreed by all that these drugs had no effect on the typhus itself and that they were of questionable value in complications such as pneumonia.
The installation of air conditioning (fig. 253) in the typhus wards of the 20th General Hospital in June 1944 was followed by a prompt drop in mortality from 17 percent to 3 percent. However, although it was reasonable to believe that air conditioning made the patient feel more comfortable and generally improved his subjective feelings, there was no proof that the drop in death rate was a consequence of the air conditioning, in view of the additional fact that the patients admitted to the hospital at that time were in better physical condition than those who came in during the early weeks of the Myitkyina campaign.
In the treatment of the complications, vitamins E and K were used to control bleeding tendencies. Digitalis was not used in the cardiovascular complications at the 20th General Hospital because of the impression of the staff that the drug was not helpful in acute febrile diseases. On the other hand, the 14th Evacuation Hospital staff made the following statement: "Digitalis has proven a most valuable drug when used in cases with any manifestations of cardiovascular impairment or dysfunction, as well as in cases with obvious cardiac failure." The 48th Evacuation Hospital was also of the opinion that digitalis was beneficial.
Prolonged convalescent care was the rule. The majority of patients with scrub typhus were returned to duty within a period of from 3 to 4 months. A complete program for reconditioning of such patients, based on the program in use at the 20th General Hospital, was published in Circular No. 11, Office of the Surgeon, Headquarters, USAFIBT, 23 December 1944, subject: Scrub Typhus Reconditioning. The convalescent period required from 3 to 4 months for patients who were to return to combat duty. Because of the severity of the illness and the prolonged convalescence, there was a tendency for patients to develop an effort syndrome if the physical reconditioning was pushed too hard. Patients who had been severely ill, usually with a complication such as pneumonia, myocarditis, meningoencephalitis, or severe hemorrhage, were evacuated to the Zone of Interior.
Chronic ulcerative skin lesions originating in unhealed, infected abrasions or bites are common during the monsoon season in the Assam-Burma jungle. They are generally called tropical ulcers or, particularly in this region, Naga sores (fig. 254). Consequently, when in June and July 1944, U.S. soldiers in the neighborhood of Myitkyina developed sluggish, necrotic ulcers on their extremities, the lesions were considered to be a form of tropical ulcer. Under the pressure of combat conditions, many men continued to remain on duty and received little or no treatment. Soldiers given local treatment usually showed some degree of healing of the ulcers; their return to duty, however, resulted in almost immediate relapse.
The more severe and persistent cases were evacuated back to general hospitals. When some of the patients on the dermatology service at the 20th General Hospital developed neuritis and cardiac symptoms in August and early September 1944, Colonel Wood, chief of the medical service, and Maj. (later Lt. Col.) Clarence S. Livingood, MC, of the dermatology service, both submitted reports on 15 September 1944 to the commanding officer of the hospital, suggesting that these skin ulcers were cutaneous diphtheria.
As a result of these reports, Maj. (later Lt. Col.) John L. Arbogast, MC, of the 9th Medical Laboratory, made an epidemiologic and bacteriologic survey of the Myitkyina area, sending in a preliminary report to the commanding officer of the laboratory on 16 October 1944 and a more complete report on
16 November 1944. Thie survey showed that the units involved in the outbreak were exposed to living conditions that were severe even for combat. In addition to the hardships of foxhole fighting, these men suffered from numerous minor abrasions from the thick jungle undergrowth, from leech and insect bites, and from the intense heat and humidity of the Burma monsoon season. Poor personal hygiene was unavoidable; bathing facilities were rarely available. Clothing and equipment were always damp, and, since much of the fighting took place through rice fields, it was impossible for the men to keep their feet dry.
The source of the infecting micro-organism was a matter of great interest and was intensively studied. The 9th Medical Laboratory studies included cultures from the rice paddies; these were uniformly negative. Rare cases of faucial diphtheria were reported among the troops from time to time, but 129 nose and throat cultures from a group of the 475th Infantry showed only one positive for Corynebacterium diphtheriae; it proved to be avirulent. No definite relationship could be traced between faucial diphtheria and cutaneous diphtheria. It is of interest that the Joint Intelligence Collecting Agency, in its report No. 2078, dated 14 November 1944, observed that during the same months the British hospitals in India were also seeing a number of cases of cutaneous diphtheria.
Cutaneous diphtheria was not reported until September when the diagnosis was first established at the 20th General Hospital in a group of patients with myocardial and neuritic complications. Earlier cases undoubtedly had occurred. One soldier, admitted to another hospital because of ulcers of the leg, developed myocarditis and died in congestive heart failure 12 days after admission. No electrocardiograms or cultures were made. At post
mortem examination, inflammatory changes consistent with diphtheritic rnyocarditis were evident.
Once cutaneous diphtheria became established as a disease entity, patients were diagnosed early and hospitalized. A more complete report on 9 October 1944 from Major Livingood of the 20th General Hospital to his commanding officer followed the original brief reports, and in October the 69th General Hospital reported on 30 cases. Additional reports were submitted in 1945. In the theater ETMD for April 1945, Capt. (later Maj.) Harvey Blank, MC, of the 69th General Hospital, reported on another 40 cases from that hospital, and Maj. Herbert S. Gaskill, MC, of time 20th General Hospital, reported on neurological complications. In the May 11945 ETMD, Captain Blank reported on 3 cases from time 69th Genera] Hospital enlisted detachment. Major Kay of the 20th General Hospital submitted a report on the cardiac complications.
The clinical findings have been described in many textbooks and in TB MED's on the subject. It was apparent from the histories of these cases that, like tropical ulcers, time diphtheritic ulcers arose from minor cuts, abrasions, and mosquito bites which failed to heal. Multiple ulcers were the rule, in most cases located on the lower extremities, usually below the knees. The hands and the forearms were the next most frequent sites; other parts of the body, such as the scalp, trunk, axillae, and perianal regions, were less commonly involved.
Major Livingood, in his preliminary report of 15 September 1944, stressed the following three diagnostic features:
1. An ulcer with a black adherent crust; this was the most important clinical finding.
2. A greyish, yellowish, or brownish-grey membrane in a superficial or deep ulcer.
3. An ulcer surrounded by an inflammatory reaction out of proportion to that usually seen in eczematous ulcers of a similar size.
Captain Blank, in his analysis of 40 cases at time 69th General Hospital, described the lesion as punched-out ulcers with a black or brownish-black eschar or, in the absence of an eschar, a greyish membrane. The scars were "deep, very destructive, and atrophic, with a volaceous tan color." Darkening of the skin around the ulcers was described by all observers, and anesthesia of the skin immediately surrounding the ulcer was common. Pain was not a prominent feature except when an attempt was made to remove the eschar or membrane.
Under local treatment, the ulcers healed slowly from the periphery towards the center. The scar did not contract when healing was complete, and the final scar was an atrophic circular spot the size of the original ulcer.
The healed ulcers frequently broke down. The process was usually preceded by the formation of a bulla or vesicle in time center of the healed scar.
When this ruptured, the rest of the ulcer soon broke down completely. Healing generally took place fairly rapidly after such a breakdown, but because of the frequency of such occurrences hospitalization was usually prolonged. In a final report on the cases seen at the 20th General Hospital, Capt. Daniel J. Perry, MC, of the dermatology and syphilology section, wrote to the consultant in dermatology in the Surgeon General?s Office, as follows:
This tendency of diphtheritic ulcers to break down is perhaps explained by the microscopic picture which shows massive fibrous tissue formation enclosing small vessels and capillaries surrounded by a round cell exudate. The process extends peripherally into the normal skin beyond the ulcer and also downward into the subcutaneous fat. The histologic picture suggests that a local toxic agent has produced severe cutaneous and subcutaneous changes. The destruction of nerve endings probably accounts for anesthesia present in the scars of cutaneous diphtheritic lesions.
Cultures from the recurrent ulcers did not show virulent C. diphtheriae.
The 7 cases with cardiac complications (in the 141 cases reported on by Major Kay of the 20th General Hospital) constituted only 5 percent of time total group. Only 4 of the 7 cases had definite myocarditis; the others were listed as probable. One of the four died. There was no -"typical picture" of cardiovascular complications. The one fairly consistent finding was an inversion of the T wave in lead CR3 this was present in all cases of myocarditis except the one with fatal termination. Interestingly, no instances of intraventricular conduction defects were noted in the cutaneous diphtheria group, although two patients with faucial diphtheria who developed myocarditis showed this type of lesion. Cardiac manifestations usually developed between the 3d and the 7th weeks. At the 69th General Hospital, only two cases with cardiac involvement were seen.
Neurological complications were much more common. At the 20th General Hospital, 43.5 percent of the cases showed neuritic involvement. At the 69th General Hospital, in a group of 40 cases, 48 percent developed neuritis. The important neurological complications seen at the 20th General Hospital were summarized in the theater ETMD, dated 10 May 1945. These complications were discussed, in general, as follows:
Neuritis appeared in the average case 70 days after the onset of cutaneous diphtheria (the extremes were from 23 to 158 days). The clinical course of the neuritis proceeded in regular sequence through certain definite steps, which were in some cases partially superimposed and in others quite separate. The steps in order of their appearance were (1) cranial-nerve involvement, (2) peripheral-nerve involvement (sensory), and (3) peripheral-nerve involvement (motor). In the majority of cases, cranial-nerve involvement failed to appear, but the stated sequence in peripheral-nerve involvement was maintained. In many cases, the peripheral motor symptoms did not occur, the patient showing only sensory phenomena.
The manifestations of these three types were as follows:
1. Cranial nerve involvement (duration from 10
to 30 days) . - The
most common symptom was
blurred vision due to loss of accommodation. Other less frequent signs
were weakness of the
pharynx and palate, loss of taste, and numbness of the lips and tongue.
began with paresthesia (numbness and tingling of hands or feet or both). Later, there was a diminution in perception of light touch and pain.
3.Peripheral nerve involvement, motor (duration from 60 to 90 days) . - This always began with the subjective symptom of weakness of arms or legs, accompanied by diminished or lost tendon reflexes. In severe cases, atrophy occurred. A very few individuals showed posterior column signs, loss of position and vibration plus mild ataxia.
Cranial nerve involvement was usually followed by moderate or very severe neuritis. Consequently, it seemed to be a prognostic indication. The duration of neuritis was directly related to its severity. The average case lasted 100 days (extremes from 21 to 184 days). The site of the cutaneous lesion bore no relation to the location of the neurological involvement. Severity of cutaneous lesions could not be correlated with severity of neuritis, but it did correlate with frequency of neuritis. The spinal fluid proteins were found to be elevated in nearly every case of neuritis. In general, the elevation was proportional to the severity of the neuritis and persisted until the neurological phenomena disappeared. Complete recovery from neuritis occurred eventually, even in the most severe cases.
Antitoxin, in doses of from 20,000 to 40,000 units intranmuscularly as early in the course of the disease as possible, was the most important measure. Injection of the antitoxin in the neighborhood of the lesion had no apparent advantage over intramuscular injection into the buttocks.
Nonspecific therapy consisted of pressure dressings after cleansing with various antiseptics, such as penicillin solutions, potassium permanganate, mercury bichloride, and sulfonamides. Cod liver oil ointment under a firm dressing was used effectively in several instances, and zinc peroxide also was used with beneficial results. Parenteral penicillin was ineffective.
The ulcers of twelve cases at the 20th General Hospital were treated surgically, and reported on by Maj. (later Lt. Col.) Henry P. Royster, MC. It was the opinion of Major Royster that more frequent use of surgery would have resulted in a larger proportion of men returned to duty and would have reduced the length of hospitalization. He concluded that surgery should. be considered in every case when the lesion fails to heal after from 60 to 70 days; excision of the ulcer during the acute stage is contraindicated. Excision of the ulcer and a small cuff of skin followed by application of a split skin graft apparently yielded the best results. The nutritional state of the patient seemed to exert a profound influence on the healing process. In a patient with anemia and hypoproteinemia associated with hookworm infestation, the wound failed to heal until these factors were taken into account and corrected. Adequate feeding of protein and transfusion of blood and plasma were necessary in some cases. No manifestations of vitamin C deficiency were apparent.
The first intensive bacteriologic studies were begun by the 9th Medical Laboratory in October 1944 and reported on to the commanding officer of the laboratory by 1st Lt. (later Capt.) Charles Cox, SnC, on 14 November 1944. In addition to cultures from the ulcers, the study also included cultures from the soldiers of one of the organizations located near Myitkyina. Nose and throat cultures from the 475th Infantry, one of the units most affected, showed
128 negative cultures and 1 morphologically positive, but avirulent, culture. Cultures from the rice paddies, considered a possible source of infection, were uniformly negative.
Of 53 cultures taken from leg ulcers, 10 showed morphologic characteristics typical of C. Diphtheriae - 9 were avirulent, and 1 was positive to virulence test. Later cases showed a higher percentage of virulent cultures. Of the 10 positives, the single virulent culture came from a patient whose ulcers were only of 6 days? duration and who had a Schick positive reaction, whereas in the other 9 patients the lesions were from 23 to 110 days old and the Schick reactions were negative.
Schick negativity, however, did not mean protection against the disease. In Major Livingood's report of 9 October 1944, one patient, a medical officer treated at the 20th General Hospital, had definite knowledge of having a negative Schick reaction for 6 years. This individual not only developed clinical cutaneous diphtheria but also neurological complications. A soldier in the 69th General Hospital enlisted detachment, reported on by Captain Blank, developed typical clinical cutaneous diphtheria 3 weeks after a negative Schick test had been found in the course of a routine survey of his unit. 9 Although no cultures were taken in this case, it resembled in every respect the other cases of cutaneous diphtheria. A second case at the 69th General Hospital developed typical skin diphtheria with a positive virulent culture for C. diphtheriae in March 1945; this patient also had had a Schick negative reaction in October 1944 when the unit was surveyed.
Cutaneous diphtheria proved serious in many respects. Two deaths were directly attributable to it. A tremendous number of man-days were lost to the Army because of the slow healing of the ulcers and the high incidence of neurologic complications requiring prolonged hospitalization and convalescence. The total number of hospital days of 140 patients at the 20th General Hospital was 18,783. Many of the patients lost a total of 5 months from duty, and several lost as much as 7 months. The average healing time of the ulcers for the whole group at the 20th General Hospital was approximately 42 days, with extremes of from 12 to 128 days. Sixty percent of the patients at the 20th General Hospital returned to full duty after an average period of hospitalization of 85 days, and 18 percent returned to limited type of duty.
The most important lesson learned from this epidemic was that these patients had to be recognized in the early stages by the forward medical units and evacuated immediately. The earlier specific treatment was instituted, the shorter was the stay in the hospital and the lower the incidence of complications.
9 The question of the potency of the testing materials may be raised in these last two cases, or for that matter in almost any case tested with Schick material and found negative, unless it is known whether others tested from the same vial were Schick positive. The diphtheria toxin is heat labile, and, with the high temperatures reached in India, it is conceivable that the testing material may have been rendered useless.
Fever of Undetermined Origin
The medical officer arriving in India or Burma from the temperate zone of the United States is startled by the omnipresent diagnostic problem of the patient who presents himself at dispensary or hospital solely because of fever with attendant malaise, headache, and generalized pains and aches. A careful physical examination soon after the onset fails to reveal army diagnostic findings. The medical officer soon learns that repeated careful physical examinations and laboratory studies during the succeeding days may reveal findings that will declare the diagnosis of malaria, dengue, sandfly fever, infectious hepatitis, kala-azar, smallpox, typhoid fever, poliomyelitis, typhus fever (louseborne, tickborne, fleaborne, or miteborne), amebic hepatitis, or one of the dysenteries. Then, too, many patients will reveal the presence of diseases more usual in the previous professional experience of the medical officer, such as nasopharyngitis, primary atypical pneumonia, or infectious mononucleosis. The fact that the patients were mainly a young vigorous group from which the sickly had been screened, accounted for the few instances of metabolic or degenerative diseases, such as diabetes, nephritis, tuberculosis, or chronic rheumatic heart disease.
The incidence rate per 1,000 per annum of patients with undiagnosed fevers, or FUO (fever of undetermined origin), in the India-Burma theater was not equaled in any other theater of operations. It is unfortunate that the term "fever of unknown origin" as used in the statistical reports carries the connotation that such patients manifested fever that could not be diagnosed by the medical officers. In point of fact, this applied as a rule only when the patie nt first presented himself at the dispensary or other local installation soon after the onset when there were no characteristic diagnostic findings. These installations were not always equipped with the laboratory facilities to make the requisite diagnostic studies. The majority of such patients, when observed during their clinical course, revealed some definite disease or syndrome entity and were appropriately reported. Such an individual appeared twice in the statistical reports, initially under FUO and, later, under dengue, sandfly fever, malaria, or whatever diagnosis was finally made. The extent to which the official FUO rate of this theater reflected the initial perplexity of the medical officer rather than the final diagnosis is not ascertainable. Chart 12 shows the theater rnonthly incidence rate from January 1943 through 1 July 1945.
Dengue and sandfly fever group. - Many patients exhibited a febrile course of from 1 to 10 days with clinical characteristics consistent with either sandfly fever or dengue. Certain patients, to be sure, showed a rash, blood findings, or temperature curve wholly characteristic of the one or the other. For the most part, however, clinical observation permitted no such differentiation. The fact that sandflies are prevalent in Karachi, India, and the Aedes
aegypti in Calcutta, India, led to diagnoses of sandfly fever in the former and dengue in the latter on epidemniologic grounds, although the clinical findings might be identical. Elsewhere in Burma and India, knowledge of insect vectors is rather incomplete.
Throughout the India-Burma theater generally, the problem of diagnosis of these two diseases was confused by several factors. There is no conclusive evidence that Phlebotomus papatasii is the only competent vector of sandfly or that A. aegypti is the only insect that can transmit dengue in India or Burma. Moreover, no accurate entomologic surveys of India or Burma had come to the attention of the U.S. Army Medical Department. The medical officer was caught in a further dilemma. Only the following three official diagnoses were permissible under the reporting procedures in effect: Dengue, sandfly fever, or fever of undetermined origin. Unable to make a definite diagnosis of either of the first two, he retreated to the comparative safety of the third classification. This problem of diagnoses was not peculiar to the Medical Department of the U.S. Army stationed in this theater. Outbreaks of febrile
illness of short duration with practically no mortality are rather extensively referred to in the Indian and British medical literature by such vague terms as "Madras fever," "Bombay fever," or "Assam fever."
It was not unusual at the time of visit of the medical consultant to encounter groups of patients from a particular unit with surprisingly uniform characteristics such as fever lasting from 5 to 6 days, severe moderate prostration, pains and aches in the muscles, photophobia, headache, moderate lymphadenopathy but no rash, leukopenia, or secondary rise of temperature. Such groups of cases were frequently given such diagnoses as "1880th Engineer fever," "610 Ordnance Ammunition Co. fever, and "Signal Corps Construction Battalion fever." This phenomenon of a disease exhibiting striking uniformity during temporary outbreaks is similar to that witnessed in many other conditions. Even the common cold at certain times may affect almost all victims with sinusitis, or gastrointestinal symptoms may assume striking prominence.
On occasion, this predominance of a single feature of the illness was perplexing. At several installations in this theater during the spring months of 1945, interesting groups of cases were observed with symptoms and signs consistent with either dengue or sandfly fever but, in addition, striking evidence of meningeal inflammation. From the 18th General Hospital, Myitkyina, Burma, Capt. Frank W. Kibbe, MC, reported 22 cases. He summarized his observations as follows:
These 22 patients were admitted to the 18th General Hospital during the month of June 1945. It is noteworthy that the patients are not all from a single group or outfit, but that four of the patients are from one group, and that three others not only came from the same outfit, but lived in the same tent. Their fourth tentmate was not admitted to the hospital, but had mild symptoms for one day at the company. Questioning of patients in an effort to discover a mode of infection common to all has thus far proved unsuccessful.
The patients were admitted to the hospital with a variety of symptoms, the most constant of which was severe frontal headache. This was nearly always accompanied by pains in the eyes. Six of the twenty-two patients had definite prodromal symptoms of a mild head cold or slightly sore throat. Four others had mild diarrhea, one severe enough to simulate an acute dysentery. There was no history of bite in anyone and no local papules or wheals as described in pappataci fever. At the height of the disease, the single striking symptom was the intense frontal headache over and in the eyes. On physical examination they showed no sinus tenderness, but marked eyeball tenderness both on pressure and with motion. Every patient had small cervical nodes along the posterior chain. Only three of the group showed even moderate nuchal rigidity and in nearly half the cases it was absent altogether. All the patients had mild fever ranging from 100o to 103o. The elevation lasted from two to five days and did not recur in any instance.
Every patient had a routine examination of the hemoglobin, white blood-cell count, differential, and urine. The white counts varied from about 5,000 to 12,000 with normal differentials while other laboratory studies were negative. The spinal fluids showed varied reactions, the white cell counts ranging from 0 cells up to 490, almost all of which were lymphocytes in all cases. The protein concentration ranged from normal to 70 mgms. per 100 c.c. In three of the reported cases, only the elevated protein was present with no increase over normal of the white cell count. Up to the present time various other studies have been negative including occasional proteus and heterophile agglutinations, Kahns and spinal fluid chlorides. No late studies have been completed as the disease is not suffi-
ciently long lasting. Throat cultures, where indicated, showed no diphtheria (K-L) organisms.
Because of the suspicion of lymphocytic choriomeningitis, ten mice were given intracerebral inoculations. Our limited supply of animals did not allow us to do this procedure on all patients so characteristic ones were picked, some from the high cell count group, others from the increased protein group, etc. Three of the mice were injected with the patient?s blood, 3/100ths c.c.'s I.C.) taken at the height of the illness. The other seven were all injected with spinal fluid. None of the mice showed the typical leg symptoms and convulsions of lymphocytic choriomeningitis. Two of the mice died violently (crushed by the case) on the eighth day, while all the rest survived showing no symptoms at all at any time. The two crushed mice were autopsied and showed no evidence of disease.
The majority of the patients were over their acute symptoms by the end of six days, and were discharged from the hospital by their fourth week. At the time of discharge none of the patients showed any gross abnormalities. No residua were noted at this time.
Similar cases were observed at the 234th General Hospital in Chabua, 100th Station Hospital in Delhi, and the 99th Station Hospital in Gaya. Appropriate tests of the sera in two of the cases at the 234th General Hospital were negative for lymphocytic choriomeningitis. Occurring at the time when instances of poliomyehtis and of lymphocytic choriomeningitis were encountered, these cases raised an important clinical problem. Were medical officers dealing with lymphocytic choriomeningitis, abortive poliomyelitis, or were the findings merely expressions of the inflammatory reaction of the meninges to a virus similar to or identical with that which causes dengue or sandfly fever? None of these patients gave evidence of other diseases in which meningeal irritation is recognized; namely, acute infectious mononucleosis, mumps, acute infectious hepatitis, primary atypical pneumonia; bacterial pneumonia, or influenza. It was believed that, although further virus studies would be helpful and additional complement-fixation studies for lymphocytic choriomeningitis would be desirable, the clinical evidence permitted a diagnosis of the dengue-sandfly group of fevers, probably pappataci fever, it was of considerable interest to note that in the extensive experience of the Mediterranean (formerly North African) theater, sandfly fever with a similar benign, lymphocytic meningitis was observed.10 Napier, likewise, states that sandfly fever may simulate benign lymphocytic meningitis.11
Although hookworm infestation was prevalent in the native population of India and Burma, it was not a problem of great moment in U.S. troops except in certain areas under particular circumstances. In a survey on the incidence of intestinal parasitism in Assam, by Capt. (later Maj.) Franklin Carter, MC, of the 9th Medical Laboratory, single stool examinations were done in 6,422 U.S. soldiers; only 13 were positive for ancylostomiasis. Similarly, only 9 hookworm infestations were found in a survey by Captain Ehrhich
10 Circular Letter No. 40,
the Surgeon, Headquarters, North African Theater of Operations,
29 July 1944, subject Sandfly Fever (Pappataci Fever).
of 506 personnel of the medical detachment of the 20th General Hospital. This is in contrast with the finding of 280 positive stools from 1,000 Indian civilians. These studies, although not highly accurate because of the inevitable handicaps incident to wartime conditions, nevertheless, provided a general estimate of the incidence of infestation.
The extent to which hookworm disease was responsible for hospitalization is not known since report of the disease was not required on Form 82 ab, Statistical Health Report. The experience of the medical consultant on his visits to the various installations was in general accord with the low incidence of infestation found in the surveys just mentioned, except, however, that the disease was far more common than had been suspected in the patients hospitalized in Ledo and along the Stilwell Road. These patients had worked in maintenance and construction units, had bathed in streams, occasionally had walked barefooted along river banks or in fields, and had had ample opportunity for infection. Similarly, early in the war, combat units were not infrequently affected. It is probable that almost all of these patients contracted hookworm infestation in this theater. Only about 20 percent had lived in the hookworm belt in the United States, and Ancylostoma duodenale, a species encountered in the United States, was recovered in a high percentage.
The experience with hookworm infestation in combat troops was excellently described by Captain Rogers and Lt. Col. Gustave J. Dammin, MC, in their report based on 50 consecutive cases admitted or transferred to the gastrointestinal and dysentery wards of the 20th General Hospital. Several hundred additional cases both with and without symptoms were seen on the general medical wards during the same period of time. The authors, stressing particularly the syndrome of acute onset of moderately severe gastrointestinal symptoms associated with eosinophilic leukocytosis, and stated:
It differs from the traditional clinical picture of hookworm disease chiefly in the abruptness of onset, the prominence of acute and sometimes disabling digestive symptoms and the lack of anemia * * *. In many, a sudden onset of nausea, vomiting, abdominal pain and diarrhea occurred. In others, a more gradual onset of cramping and burning abdominal pains after meals was the initial manifestation. The nausea, vomiting and diarrhea tended to subside and to become intermittent.
These authors described pain as the most prominent and persistent of the gastrointestinal symptoms. It was usually epigastric but sometimes periumbilical, and it tended to be diffuse. In many patients, the pain appeared immediately after meals. The frequency of time various symptoms of the hookworm infestation found in the patients in this study is shown in table 8.
Physical findings were not striking except for the almost universal loss of from 10 to 40 lbs. in weight. The definite diagnosis of hookworm infestation depended on the. demonstration of the ova in time stools. In accord with extensive experience elsewhere, Captain Rogers and Colonel Dammin found that direct examination of the stools, even when repeated several times, was not a satisfactory procedure. Repeated examinations by the direct method established the diagnosis in only approximately 60 percent of the patients;
only 20 percent had positive stools on the initial examination. On the other hand, when the zinc sulfate flotation method was utilized, hookworm ova were consistently found after not more than 3 stool examinations, and in 85 percent of the patients they were demonstrated on the initial examination. In accord with general experience, one of the most striking features was the prevalence of eosinophilia.
TABLE 8.- Symptoms
observed among consecutive cases of hookworm infestation at the 20th
Hospital, U.S. Army troops, 1945
centration techniques. Not a few diagnostic mysteries, temporarily residing under the designation of dyspepsia or psychoneurosis, were classified by carrying out these simple measures.
Occasional cases of filariasis contracted elsewhere were seen in the India-Burma theater from time to time, but no outbreaks occurred in U.S. Army personnel. Nevertheless, the presence of endemic foci of infection among the congested native population in close proximity to some of the Army encampments and the prevalence of one of the chief vectors of the disease, Culex fatigans, raised important problems.
During May 1945, three cases of filariasis were reported from the Hastings Air Base near Calcutta. They were referred for study to the 142d General Hospital in Calcutta. Eighteen additional cases were under observation at this time at the Hastings air station.
An epidemiologic survey of the problem was made by preventive medicine personnel of the theater surgeon's office and reported in the theater ETMD for August 1945. The Hastings Air Base was adjacent to the community of Rishra, a slum district, in which there were many cases of elephantiasis. No factual data regarding the epidemiology of filariasis in this community were available. It was clear, however, that transmission of the disease occurred in this population and that living conditions and sanitation at the air base during the first few months after opening of the stations were such that it would have been possible for transmission of filariasis to occur. A well-organized and vigorous mosquito-control program plus a successful sanitary cleanup program resulted in the control of the chief vector. It was believed that these measures greatly reduced or eliminated the possibility of contracting the disease at Hastings Air Base.
When seen at the 142d General Hospital, the three cases referred from the air base showed no positive evidence of filariasis. Orchitis had completely subsided, and, in the opinion of the chief of the genitourinary section, little or no residual changes were present. The chief of the surgical service, who had extensive experience in the Southwest Pacific Area in an endemic area of filariasis, was of the same opinion. The chief of the medical service, who had seen many cases of filariasis returned to the Zone of Interior, was in agreement. It was acknowledged that many infections remain asymptomatic for years, or even for their duration, and that the cases examined might have been filariasis. It was believed, therefore, that the three patients should be classified as suspects, their clinical status checked monthly, and, if further evidence of filariasis appeared, they should be returned to the Zone of Interior.
A conference was held in Calcutta attended by the Surgeon, Base 2; by representatives of the Air Forces and of the 142d General Hospital; by a member of the Preventive Medicine Section, Office of the Surgeon, Headquarters, USAFIBT, and by the consultant in medicine. This conference concerned itself mainly with the development of a common policy in respect to the dispo-
sition of patients suspected of harboring the infection. It was generally agreed that patients with a definite diagnosis of filariasis should be evacuated to the Zone of Interior. The chief differences of opinion revolved about the disposition of the filariasis suspect, in whom there was insufficient evidence to warrant a definite diagnosis but in whom, on the other hand, the possibility of harboring infection could not be confidently excluded. The various views were reduced to writing and communicated to the theater surgeon. After careful study, the theater policy was laid down in Circular No. 21, 29 July 1945, Office of the Surgeon, Headquarters, USAFIBT, on the diagnosis and disposition of cases of filariasis. It was recommended that any patient in whom the diagnosis was seriously entertained should be transferred early while still showing acute manifestations. It was further stated that:
It is imperative that a definite diagnosis of filariasis be made only when reasonal clinical evidence exists. This is particularly important because of the serious emotional impact on the individual concerned, and the adverse effect on the morale of troops in the area, as demonstrated by experience with the disease in the Pacific theater. The impossibility of making an absolute diagnosis early in the course of the disease by detection of microfilaria in the blood or by biopsy of affected regional lymph nodes makes reliance on sound, conservative clinical judgment essential. If a reasonable basis for the diagnosis is established in a general hospital by a thorough and careful review of the case, the patient is to be evacuated to the Zone of the Interior in accord with War Department policy.
The criteria which must be exercised in establishing the clinical diagnosis in the early stages of the disease are outlined in paragraphs 3 and 4, TB Med 142. In some patients the available evidence will not justify a clinical diagnosis of filariasis; on the other hand, its possible presence cannot be confidently excluded. Such suspects should be returned to their organization and the unit medical officer be informed of the status of the case so he can make periodic examinations at monthly intervals or oftener if considered necessary, for at least four months.
Particular caution must be exercised in basing the diagnosis on a single finding, particularly when such a finding frequently occurs unrelated to filariasis. A single recurrence of epididymitis or orchitis, without other evidenc of filariasis and with only equivocal residual changes, is not considered to be sufficient basis for the diagnosis of filariasis. The diagnosis should, however, be suspected. In the physical examination of the scrotal contents, it should be remembered that there is a considerable range of normal variation. In order to evaluate correctly the earliest changes in the scrotal contents extensive experience in the palpation of the normal and abnormal is necessary.
If an individual is a noneffective repeatedly because of unexplained recurring inflammation of the scrotal contents which cannot be arrested or cured by appropriate medical or surgical management, he should be evacuated to the Zone of Interior because of inability to render consistent and effective service in the theater. Such cases, without any other evidence of filariasis however, should not be evacuated as filariasis, although the clinical records should indicate that such a diagnosis has been considered.
The diversity of clinical problems encountered in the India-Burm theater is illustrated by the occurrence of lead poisoning in petrolatum pipeline companies. One of the major missions of this theater was the construction and maintenance of the pipelines to China. Jungle and mountainous terrain presented
construction difficulties such as have been rarely encountered in a project of this nature and necessitated a great number of pumping stations (fig. 255). The operation of the pipeline was begun in December 1943. The first case of suspected lead poisoning appeared in December 1944 in a patient admitted to the 20th General Hospital because of moderate anemia. A survey was then made by 1st Lt. (later Capt.) Benjamin S. Golub, MC, of all exposed personnel in the company to which this patient belonged; 16 men, or approximately 11 percent of all exposed personnel, were found to show a significant degree of basophilic stippling. These men were admitted to the hospital for further study. The majority had suffered from headaches, and all showed an abnormal degree of basophilic stippling with an increased urinary excretion of lead. Except for one patient with a red count of 4.15 million, the red blood cell count in all patients was 4.5 million or more. A field survey revealed that the pumping-station operators and maintenance crew were, exposed to leaded gasoline from the following:
1. Normal leakage of gasoline from pumps into drip pans. Men constantly watched gauges on pumps and were continually exposed to fumes.
2. Water laden with fumes drawn off from storage tanks into adjacent ditches for evaporation.
3. Frequent failure to wash hands before eating.
4. Pumping-unit exhaust fumes.
5. Frequent washing of hands with gasoline.
6. Pumping units washed with gasoline every 12 hours.
7. Pumping units refuelled every 6 hours with gasoline carried over
from storage tanks in 5
9. Common practice of standing in pool of gasoline either barelegged or with legs covered with grease.
The following measures were put into effect to minimize exposure:
1. Construction of an observation and control tower 50 ft. from the pumps to afford adequate supervision and minimize exposure.
2. Use of nonleaded gasoline for washing hands and for cleaning pumping units.
3. Frequent showers.
4. Change of clothing after work.
5. Periodic rotation of personnel.
6. Careful washing of hands before eating.
7. Use of high rubber boots and rubber gloves.
8. Prompt washing with soap and water after exposure of skin to liquid gasoline.
All personnel with signs of lead absorption were rotated and removed from exposure for a minimum of 6 months. Pipeline-company personnel who were exposed to gasoline were required to have blood-smear examinations every 3 months. During the entire survey, 475 exposed individuals were examined; 14 (2.9 percent) showed basophilic stippling of erythrocytes.
The incidence of diseases of the skin in the India-Burma theater, as in all tropical climates, was high. The 20th General Hospital reported that skin diseases constituted 10 percent of all dispositions from the hospital in the first year of operation and 8.6 percent in the second, approximately the same as the figures for diarrheal diseases. In addition to the patients that required hospitalization, many were seen as outpatients.
of the skin, more than any other group of diseases, reflected the
effects of the climate
of India and Burma on U.S. military personnel. Capt. Neal Phillips, MC,
of the 18th General
Hospital, writing on skin diseases in Burma, made the following
observation on the climate and
its relation to the various dermatologic manifestations; the remarks
apply equally to India:
Dermatologically, then, it is obvious that the monsoon period with its dampness encourages the growth of molds, yeasts and fungi while the hot dry season promotes disturbances in the coil glands and pilosebaceous system. * * * with the body continuously bathed in sweat, such diseases as contact dermatitis, eczematous dermatitis, miliaria,
folliculitis, infectious eczematoid dermatitis and possibly dermatophytids are the problem confronting the dermatologist during the hotter period, while during the monsoons, fungus diseases flourish.
Not only were fungus infections and eczematous and infectious eczematoid skin conditions more frequent and more severe than in the United States but there were also skin disorders peculiar to the tropics though not due to the climate per se. These included tropical ulcer, dhobie-mark dermatitis, and sensitivity to exotic plants. Atypical lichen planus also was of importance in this theater and was studied extensively, particularly at the 20th General Hospital.
Prickly heat. - In India, prickly heat, also known as miliaria, miliaria rubra, and sudamina, was undoubtedly the most prevalent skin disorder, and it affected the vast majority of U.S. Army personnel. Discomfort and interference with sleep frequently lowered efficiency in military personnel. Although rarely disabling, extensive cases occasionally became secondarily infected and required hospitalization. The characteristic features of small red papules or vesicles, which appeared principally on the trunk and upper extremities and were associated with intense itching, presented rio diagnostic difficulties. A powder containing sulfur, boric acid, starch, and zinc oxide was the most commonly used therapeutic agent, but there were almost as many other methods of treatment as there were doctors treating patients with prickly heat. Some advised a deep tan; others advised staying out of the sun. Both tanned and untanned individuals had prickly heat. Very little effect was noticed with any of the methods recommended; when the weather cooled, the prickly heat disappeared.
Dhobie-mark dermatitis.12 - This was one of the surprising medical experiences of U.S. troops in this theater. The dhobie, the Indian laundryman, marked clothes with the intensely irritating juice of the bichi nut.13 When these marks came in contact with a sensitive skin, a localized contact dermatitis resulted. When the source of irritation was removed, the dermatitis disappeared in a few days. Colonel Fitz-Hugh, Major Livingood, and Lieutenant Rogers, as well as Major Waud and Capt. Henry Fein, MC, published reports on this type of dermatitis in the Field Medical Bulletin for June 1943.
Tropical ulcer. - Necrotic, sluggish skin ulcers are found in most tropical countries and are known by different names in each country where they occur. In India, particularly in the Province of Assam, and in Burma, they were referred to as tropical ulcer, Naga sore, or Assam ulcer. They were commonly seen during the monsoon season and frequently found in individuals suffering from some systemic disease or chronic malnutrition. The ulcers originated in infected cuts, abrasions, or insect bites and usually developed into rapidly progressive, painful lesions with a necrotic base, undermined necrotic edges, and a blue-grey border. In time, the lesions became chronic,
12 Not to be confused with dhobie itch, which is a fungus infection.
13 Much confusion exists regarding the exact identification of the nut used in the process. The term "bichi nut" seems to be the most generally employed.
pain disappeared, and progress was slower; the base of the ulcer then generally showed some granulations, and the border was raised, indurated, and red. Bacteriologic examinations showed fusiform bacilli and spirochetes.
Except among Merrill's Marauders, there were very few instances of tropical ulcer among U.S. personnel. Merrill's unit, fighting during the monsoon season under highly insanitary and exhausting conditions in the country where Naga sore was endemic, inevitably developed cases of tropical ulcer. The major part of the experience of U.S. hospitals with this disease came through care of the Chinese troops who, malnourished and insanitary, were fertile soil for this type of lesion. Several reports on treatment were published; these were largely based on the experience with Chinese troops.
Lt. Col. Clarence J. Berne, MC, of the 73d Evacuation Hospital appended a preliminary report on therapy of tropical ulcers to the annual report of the hospital for 1942. He was of the following opinion: "Treatment of tropical ulcer should consist of two phases; an initial phase during which the septic factor is eliminated, utilizing chemotherapy, if helpful, and a secondary phase initiated when the ulcer becomes free of significant infection." Skin grafting was not done in his series, which was in its initial stages at the time of the report. No definite conclusions were drawn.
In the Field Medical Bulletin for October 1943, Maj. (later Lt. Col.) James M. Beardsley, MC, of the 48th Evacuation Hospital reported on the treatment of 21 cases of tropical ulcer by a more radical surgical approach. This group showed large ulcers with a sloughing necrotic base. He concluded that the best treatment for such large tropical ulcers was immediate excision followed by skin grafting and that prolonged conservative therapy resulted in a loss of valuable time. Small ulcers were treated conservatively with sulfanilamide powder and pressure bandage.
Maj. (Later Lt. Col.) John H. Grindlay, MC, who had been in Colonel Seagrave's unit 14 and who had had occasion to treat many tropical ulcers in the men forced out of Burma in 1942, published his experiences with this condition in the January 1944 issue of the Field Medical Bulletin (fig. 256). He recommended, in the early stages of the ulcer, excision of necrotic tissue and use of magnesium sulfate and glycerine dressings daily. In cases where the ulcer had progressed to deep tissue involvement, complete excision of the ulcer and all necrotic material was recommended. After the application of sulfanilamide crystals to the tissues, the cavity was packed with petrolatum-impregnated gauze and the entire limb placed in a cast. In 3 weeks, the cast was removed, revealing fresh granulation tissue. A fresh cast was applied and again removed in 3 weeks. The procedure was repeated until the crater was filled with granulating tissue, at which time pinch grafts were applied.
Contact dermatitis. - Major Livingood of the 20th General Hospital made an extensive study of a type of contact dermatitis seen in the Assam-
14 A hospital of the American Baptist Mission at Namkham, Burman, at the start of World War II; later served with the British Army in Burma and the United States, British, and Chinese Armies in India, Burma, and China. Its commander was Lt. Col. Gordon S. Seagrave, MC, who had been in Burma since 1922.
Burma region (fig. 257). The etiologic factor was ultimately shown to be the sap of certain species of trees.15 This skin condition was seen chiefly in engineer and other organizations working along the Ledo Road between Ledo and Shingbwiyang. It was acquired by contact with the sap of these trees and, in unusually sensitive individuals, by contact with the leaves. It was also suspected that smoke of burning wood from these trees could produce the dermatitis.
The skin manifestations were not severe. The eruption was characterized by "finely vesicular erythematous, rather ill-defined patches with varying degrees of edema. Excoriations, crusting and oozing follows scratching and in some instances secondary pyogenic infection takes place, in which case a relatively chronic impetiginous eczema may ensue." The symptoms of itching and burning were severe and out of proportion to the extent of the other manifestations.
Major Livingood believed that the trees belonged to the Anacardiaceae family and that at least two genera were capable of producing the irritating sap. These were Drimycarpus and Semecarpus. The most characteristic feature of the sap was its change in color from milky white, yellow, or light red to black on exposure to the air.
15 Letter, Maj. Clarence S. Livingood, MC, Chief, Section of Dermatology and Syphilology, 20th General Hospital to Base Surgeon, Base Section 3, 27 May 1944, subject: Contact Dermatitis in Base Section No. 3 (Tree Sap Dermatitis).
Hypohidrosis syndrome. - Eighteen cases of an unusual syndrome peculiar to hot climates and not described in most textbooks were seen at the 20th General Hospital and reported by Major Livingood in the Field Medical Bulletin for May 1945. These cases were very similar to those reported by Wolkin, Goodman, and Kelley.16 In his report, Major Livingood quoted the clinical description of the syndrome described by these three authors. Because features described by them are so characteristic, the quotation used by Major Livingood is presented here, as follows:
In general they all presented a typical history, viz. a rather sudden onset of generalized weakness, subjective warmth and discomfort, dizziness "all-in" feeling, headache and shakiness. These symptoms occurred during exposure to sunlight, either with or without physical exertion. The onset of the symptoms was associated with or preceded by a cessation of sweating in each case. This was in turn often preceded by a distinct period of profuse outpouring of sweat from a few days up to several weeks' duration. The loss of sweating was limited uniformly to the body region below the neck in pronounced contrast to the outpouring of sweat from the face and neck. The objective findings were characterized most of all by a warm, dry skin from the neck down, whereas the fact and neck showed
16 Wolkin, J., Goodman, J. I., and Kelley, W.E.: Failure
profuse droplets of sweat. The skin of the entire body below the level of the neck had the appearance of goose flesh. However, this fine papular eruption did not appear and disappear in a matter of minutes like goose flesh. The papular eruption was diffuse and uniform, each papule being about the size of a large pinhead. In cases of longer standing there was a fine, branny desquamation. As this condition improved, the fine papular eruption disappeared and the skin resumed its normal appearance.
Major Livingood's group included both white and Negro soldiers; 6 of the patients had atypical lichen planus and 3 were recovering from typhus fever when the symptoms appeared. All cases gave a history of excessive sweating and generalized pruritus prior to onset of the syndrome; most of the patients "tended towards a seborrhoeic habitus." As in the cases previously described, failure of the sweating mechanism was noted most frequently on the trunk and limbs, with a dry skin and a "fine branny desquamation" in the involved areas. The parts of the body usually not affected by the disturbance were the face, palms, soles, and axillae; those regions generally showed hyperhidrosis. Asthenia and weakness were a constant feature; hyperpyrexia did not occur.
Seven of the group improved spontaneously, and their sweating function returned to normal in from 2 weeks to 4 months. The remainder continued to show hypohidrosis, and at the time of the report 4 months had elapsed without evidence of improvement. In this respect, Major Livingood?s cases differed from similar cases described by other authors who found that sweating returned to normal in practically all cases within a few weeks. 17 Another point of difference was the gradual onset in Major Livingood's patients as compared with the rapid onset with evidence of heat exhaustion reported by the other authors.
Although the number of cases showing hypohidrosis was small, the syndrome was of considerable interest and of some military significance; in several instances, evacuation to the Zone of Interior was contemplated because a deficiency in normal sweating constituted a serious hazard in this theater.
Atypical lichen planis. - In a letter dated 30 October 1944 to the Surgeon, USAFCBI, The Surgeon General requested a résumé of the experience in the theater with the clinical syndrome known as atypical lichen planus (fig. 258). The letter included a brief description of the syndrome and stated that it was seen with striking frequency in the Southwest Pacific Area. A copy of the letter was forwarded to all medical installations.
As far as can be determined, the diagnosis of atypical lichen planus was not made in this theater prior to November 1944. On 15 November 1944 in a letter to the Commanding Officer, 20th General Hospital, Major Livingood, in reply to The Surgeon General's request, reported three cases and made the following statement:
About five weeks ago, I received a personal letter from a dermatologist of my acquaintance informing me that he had seen a group of cases from the Southwest Pacific Area
17 (1) See footnote 15, p. 774. (2) Allen, S. D., and O?Brien, J. P.: Tropical Anidrotic Asthenia: A Preliminary Report. Med. J.. Australia 2: 335-336, 23 Sept. 1944.
presenting signs and symptoms suggesting an atypical form of Hypertrophic Lichen Planus-he did not include a detailed description of the syndrome. At that time I reviewed all of my cases of Hypertrophic Lichen Planus as well as other chronic recurrent dermatoses and came to the conclusion that I had not seen the syndrome in this hospital. Therefore, it seemed an amazing coincidence to see three cases which probably fall into this group in the past four weeks, one of them a General Officer. We forwarded biopsy specimens to the Army Medical Museum on one case about 10/26/44 and on the other two cases a few days ago. In the clinical protocol, I referred to the fact that I thought that these patients had an atypical form of Hypertrophic Lichen Planus which had been seen in the Southwest Pacific Area and asked for information on the pathology of the lesions as it had been noted in those cases.
In his comments on the disease, Major Livingood said: "I have found no clues as to etiology except in two patients particularly there seemed to be a questionable light sensitivity factor. All three of these patients had been living under field conditions at the time of onset."
The 234th General Hospital reported a single case that was thought to fit the description in The Surgeon General's letter.18 Although the description
18 Letter, Col. Bennett G. Owens, MC, Commanding Officer, 234th General Hospital, to Surgeon, Headquarters, Services of Supply, USAFIBT, 2 Dec. 1944, subject: Information on Occurrence of an Unusual Skin Disease.
strongly suggested atypical lichen planus, the history revealed that the disease had its onset 18 months earlier, while the patient was still in the United States. In January 1945, a communication from the 18th General Hospital reported two cases of a skin disorder considered to be atypical lichen planus.19 Both patients had been taking suppressive Atabrine; patch tests with this drug were negative. One of the two patients was found sensitive to SKAT, developing a positive patch test with this mosquito repellent but with no other.
On 23 February 1945, Major Livingood submitted a followup report on the 3 original cases and in addition reported 6 more full-blown cases of the disease; 3 others were mentioned in which the diagnosis was not definitely established. This report was very comprehensive, and the findings may be summarized as follows:
These cases were characterized by: Combination of eczematoid dermatitis, eczematous plaques, and violaceous lesions of various morphes identical with those seen in atypical lichen planus; generalized distribution with predilection for certain sites; severe pruritus; long course; marked residual changes in the skin including loss of hair and marked disturbance of sweating function.
All patients who were seen with the disease had had intimate contact with the jungle. All patients except one had been on suppressive Atabrine prior to onset. Most patients had antecedent eczematous lesions.
The probable multiple etiologic background was possibly a combination of exposure to jungle and a drug allergen - Atabrine in the majority of cases. One patient had never taken Atabrine at any time but had had arsenicals for early syphilis. Light sensitivity was a possible predisposing factor. Exacerbation was seen after the following: Atabrine therapy for malaria, sulfathiazol, typhoid vaccine, ultraviolet light, sunlight, and possibly food allergens.
It was suggested that men who work and/or live in the jungle might acquire a contact sensitization dermatitis from the sap and leaves of trees and shrubs which occur only in tropical and semitropical zones of the world and that these sensitized individuals might develop the atypical-lichen-planus syndrome when an endogenous allergen (Atabrine in most instances) is administered.
There was evidence that the patients in this series had disturbances of glucose metabolism, and of gastrointestinal and liver function, manifested by flat glucose-tolerance curves, X-ray changes in the gastrointestinal tract, and decreased liver function with Bromsulphalein excretion test.
report, dated 19 March 1945, by Major Livingood, brought the total
number of cases seen
at the 20th General Hospital to 15. In this report, he emphasized
the possibility that exposure to
the irritant black sap of certain tropical trees might be an etiologic
factor. Major Livingood wrote:
19 Letter, Lt. Col. Alexander J. Schoffer, MC, Chief, Medical Service, 18th General Hospital, to Deputy Theater Surgeon, headquarters, USAFIBT, 10 Jan. 1945, subject: Report of Two Cases of Atypical Hypertrophic Lichen Planus.
patients with this disease had been in contact with the jungle with exposure to potentially allergenic contact agents-tree-sap, various plants, etc. I consider this a possible important predisposing factor; also dietary deficiencies, and multiple insect bites are possible predisposing factors.
To facilitate study, it was decided to concentrate all cases of this disease in a few hospitals. The 20th General Hospital was designated as the center in the Advance Section, the 234th General Hospital in the Intermediate Section, and the 142d General Hospital in the Base Section. The 20th General Hospital prepared a form for the study of the cases, and, in July, Maj. (later Lt. Col.) James M. Flood, MC, who succeeded Major Livingood at the 20th General Hospital, submitted a report on 19 cases seen between 14 March and 1 July 1945. The report opened: The experience in this theater leaves little doubt that atabrine is the main causative factor of atypical lichen planus as seen in this area. Whether there is an associated factor still remains a question, but it must now be assumed that atabrine is the principal etiologic agent."
This report was accompanied by a paper by Major Machella and coworkers on liver-function studies. Although the studies suggested the possibility of hepatic damage, no patients with atypical lichen planus showed any clinical evidence of liver disturbance.
The 234th General Hospital reported that 11 patients with the disease were being observed but no data were submitted in this preliminary report. 20
Other cutaneous eruptions. - In addition to atypical lichen planus, there were other skin eruptions that were attributed to Atabrine. Major Livingood reported a number of skin reactions seen at the 20th General Hospital. These included an extensive maculopapular eruption with a violent systemic reaction in a dental officer and a pruritic maculopapular toxic erythema in two nurses, 14 days and 4 days after the suppressive Atabrine program had been initiated. The eruption reappeared in both nurses when the drug was again administered at a later date. Two individuals developed a flareup of an old eczematoid dermatitis shortly after the Atabrine regime was instituted.
In the theater ETMD for August 1945, Captain Blank of the 69th General Hospital reported on 12 cases of an urticaria-like syndrome that he attributed to Atabrine sensitivity, and in a communication dated 23 July 1945 to the theater surgeon's office, he later reported 2 additional cases. In 12 patients, who gave no previous history of Atabrine ingestion, the eruption did not appear until 2 or 3 weeks after the institution of the suppressive Atabrine program. In 2 patients, both of whom had previously taken Atabrine, the eruption appeared within 3 days; in both, the symptoms disappeared spontaneously without discontinuance of the drug. In the other patients, the urticaria disappeared when the drug was stopped and reappeared briefly in 4 patients when Atabrine was again administered. All 14 patients eventually were able to take suppressive Atabrine treatment without difficulty. Skin tests with pure
20 Letter, Capt. Joseph A. J. Farrington, Chief of Dermatology Section, 234th General hospital, to Office of the Surgeon, headquarters USAFIBT, 6 July 1945, subject: Atypical Lichen Planus.
powdered Atabrine were done in six cases, with results negative to both patch and intradermal tests.
One case of urticaria thought to be due to Atabrine was reported from the 234th General Hospital.21 A patch test in this case was strongly positive.
Upper respiratory infections
The newcomer to India, particularly if he had recently endured the snow and sleet of northern United States and had arrived in India during the sunny months of March through June, with daily temperatures of 80o-100o F., was startled by the prevalence of upper respiratory infections. This fact is reflected in the high incidence rate for this condition in the India-Burma theater (chart 13 and table 9). The actual incidence was much higher since only the
21 Letter, Capt. Joseph A. J. Farrington, MC, Chief of Dermatology and Syphilology Section, 234 th General Hospital, to Office of the Surgeon, Headquarters, USAFIBT, subject: Suppressive Atabrine as a Possible Cause of Urticaria.
disabled were admitted to hospitals or kept in quarters. The extent to which these infections contributed to the total noneffective rate was, however, small (charts 13 and 14 and table 9).
The clinical characteristics of nasopharyngitis in India were astonishingly similar to those seen in the United States; the complications of chronic sinusitis, middle ear infections, and the not infrequent association of tonsillitis and bronchopneumonia were apparently as frequent. Bacterial pneumonia was relatively uncommon, and but few deaths occurred.
Primary atypical pneumonia
With the onset of warm weather in this theater, the increased prevalence of respiratory infections was striking. This increased incidence was particularly noticeable in Delhi and occurred during uninterrupted sunshine and equable temperature. Actual observation of many of these cases by the consultant in medicine revealed that the clinical characteristics and X-ray and laboratory findings were in the main identical with those observed during epidemics in the United States. The increased incidence could not be ascribed to any discernible factors. Among other possibilities, ornithosis was considered since, at the time of increased prevalence of primary atypical pneumonia, swarms of migratory birds made their appearance - a single tree, for instance, often being occupied by at least several hundred parakeets. Inquiry by the consultant in medicine, however; failed to uncover any supporting evidence for this possibility. Attention was directed to this condition by the publication of notes in the Field Medical Bulletin, discussions with the staffs of the various hospitals, and requests for reports from the representative group of hospitals. The subject was summarized in the theater ETMD report, dated 1 June 1945.
Incidence. - In general, there was an increased incidence of atypical pneumonia for the first 3 months of 1945 as compared with the corresponding period in 1944 (table 9 and chart 15). At the 100th Station Hospital, there were 96 cases in the first quarter of 1945, whereas only 14 cases were reported for the same period in 1944. The 234th General Hospital and the 73d Evacuation Hospital treated approximately twice as many cases of atypical pneumonia in 1945 as in 1944. In all instances, the hospital census was roughly the same
for both periods. Two reports indicated that the increase in respiratory infection was coincidental with movement of new troops into the area. The rotation of personnel, with the arrival of replacements from the United States, also began at the same time the increase in disease was noted.
Epidemiology. - Although atypical pneumonia is apparently transmitted by contact and is usually associated with an increase in upper respiratory infections, the disease was not highly communicable. Certain other factors were involved in addition to simple exposure. In this connection, the following paragraphs are quoted from an excellent comprehensive analysis of 96 cases prepared by Capt. Abraham Gootnick, MC, Chief, Medical Service, 100th Station Hospital:
In considering the epidemiology of this outbreak, it should be mentioned that the usual criterion for admitting a patient to the hospital was the finding of a temperature above100o at the dispensary. A great many of the milder cases of upper respiratory infection were thus screened out - at least as many as were hospitalized. But this screening did not apply to the more severe upper respiratory infections, and even less to the pneumonias. One check on the incidence of unrecognized pneumonia was provided by one organization, consisting of 34 personnel, 13 members of which were in the hospital with respiratory infections at one time. All remaining members were called in for mass x-ray check-up. All chests were clear.
The experience with this organization is also illustrative of the mode of transmission of the infection, which appeared to be by contact, contact with co-workers or barracks neighbors. From the few patients with atypical pneumonia, whose infective contact could be determined with some certainty, the incubation period ranged from 9 to 16 days. An incidental finding of interest was the apparent immunity of medical officers, nurses, and ward
attendants - personnel whose contact with respiratory infections was close; and the considerable susceptibility of hospital personnel whose contact with patients was tangential. Enlisted men working in the laboratory, in the x-ray department, and in the admitting office came down with respiratory infections of varying severity.
Clinical characteristics. - The clinical characteristics of primary atypical pneumonia in the India-Burma theater coincided closely with those reported in outbreaks of the disease in the United States. The majority of the cases were troubled initially with an apparent upper respiratory infection, which ranged from a mild nasopharyngitis to a severe bronchitis. A dry, hacking cough was a conspicuously disturbing symptom in many of the patients. Two symptoms frequently mentioned as rare in primary atypical pneumonia were found rather commonly in the patients in this theater. In Captain Gootnick's report just mentioned, he stated as follows: "(1) Repeated shaking chills lasting 15 to 45 minutes were recorded in 25 of the 96 patients. (2) Aching in the chest (apart from the usual substernal soreness), referred to the involved side, occurred in 19 patients. In nine of these, sharp stabbing pain in the chest on inspiration was the chief complaint leading to hospitalization."
Examination of the chest on admission often revealed inconstant physical signs of patch consolidation. X-ray of the chest, at this stage of the disease, frequently yielded diagnostic evidence of the characteristic changes of primary atypical pneumonia. The white blood counts and differential smears showed the usual findings, as did examination of the sputum. Blood cultures performed in representative patients were uniformly sterile. The 100th Station Hospital reported that: "A spot check for the presence of cold agglutinins was done in a total of nine cases. In 3, cold agglutinins were not present in the one sample of serum examined; in 6, the serumn was positive for cold agglutinins and showed an increasing titer after the second week of illness, reaching a titer of 256 in 2 at the end of the third week."
Reports from other hospitals were essentially in agreement with Captain Gootnick's observations. An interesting finding was the occurrence of pleural reactions, a feature considered by some observers to be rare in this disease. Captain Gootnick reported 4 cases with pleural rub. The 73d Evacuation Hospital reported 6 pleural reactions - 2 in Americans and 4 in Chinese. Of these, 1 American and 1 Chinese patient had small effusions. The 99th Station Hospital reported on 24 cases, of which 2 showed pleural rubs. Another feature noted in all reports and also observed in previous reports on atypical pneumonia was the high proportion of cases that were afebrile or showed only a low-grade temperature.
Sequelae. - Very few significant complications or sequelae were reported from this theater. The 99th Station Hospital observed one case of extension from one lung field to the other. The 234th General Hospital reported one mild case of purulent bronchitis following the pneumonia, and the 73d Evacuation Hospital found one case with suggestive findings of bronchiectasis. There was no followup report on these cases.
Little statistical information is available regarding the incidence of bronchial asthma in the India-Burma theater. The condition was more frequent than might be anticipated and was prone to recur even after hospitalization induced temporary improvement. If returned to duty, the patients contributed little of military value and were almost always finally sent to the Zone of Interior. Twenty-three such patients were sent to the United States during 1944 from the 142d General Hospital, 68 from the 181st General Hospital, Karachi, India, and 76 from the 20th General Hospital. In this connection, a personal communication from Colonel Contrell of the 142d General Hospital is of interest:
India is a bad county for allergic
conditions. Many persons who had had allergic symptoms find that they
worse than in the U.S., or that new manifestations appear-e.g. a person
who had hay-fever in childhood develops
asthma in India. Sometimes, one can return a mild asthmatic to duty for
time, but I have never seen one that lasted
long. In general, if a soldier has been seen to have an unequivocal,
moderately severe, asthmatic attack, it is useless
to return him to duty in this country. I suspect that mods are
important as allergens here, but I do not know.
The incidence of pulmonary tuberculosis among the military personnel in the theater was low (table 9). Among the Chinese, however, tuberculosis was prevalent. An ETMD report, dated 3 May 1945, from the 48th Evacuation Hospital stressed this high incidence of tuberculosis in Chinese patients who constituted the bulk of the hospital census. The average Chinese soldier neither understood the American interest in sanitation nor was he particularly interested in practicing its precepts. The Chinese used no precautions in the disposition of their sputum, the floor being most convenient for expectoration. The personnel of the 48th Evacuation Hospital were, therefore, extensively exposed to the disease. Frequent routine checks were made on the personnel and, up to the time of the report, no cases of tuberculosis were discovered that could be attributed to contact with the Chinese. The commanding officer of the hospital suggested that members of the hospital staff be observed carefully for some time after return to the United States.
Homologous Serum Jaundice and Infections Hepatitis
Infectious hepatitis was under continuous surveillance by the theater surgeon from the very beginning of the establishment of the USAFCBI
theater in March 1942. On 30 May 1942, a cable was received from the Surgeon General's Office alerting the theater to Jaundice of unknown etiology following administration of yellow fever vaccine. Among the first cases to be reported from the India-Burma theater were seven instances of jaundice following yellow fever vaccination in United States troops. General Stillwell himself developed jaundice on 3 June 1942, having received vaccine from lot No. 334 on 2 February 1942.
From the available scattered and incomplete reports, it is apparent that many cases of jaundice of unknown etiology were observed in 1942 and that a significant number of these patients had had vaccine from lot Nos. 334, 335, 338, and 367. In a report by the Surgeon, USAFCBI, 17 October 1942, to The Surgeon General, complete questionnaires on 80 cases of jaundice without known cause were transmitted. Thirty-six of this series had received yellow fever vaccine from lot Nos. 331, 335, and 371. Of the other cases, 19 had had contact with jaundiced patients. On 28 November 1942, another report of 35 patients was submitted, most of whom had received yellow fever vaccine from lots of the 300 series. Complete information regarding the number and distribution of the cases following yellow fever inoculation was not available, but it was apparent that the number constituted a serious problem.
The only available comprehensive report was submitted from the 73d Evacuation Hospital by Colonel Ware, Capt. (Later Maj.) Coleman B. Hendricks, MC, and Capt. Thomas H. Brem, MC. The 405 patients who constituted the basis of the study had all received yellow fever vaccine at approximately the same time. Information concerning the lot numbers and the exact date of inoculation was recorded in 305 cases. The report read, in part, as follows:
For all lots of yellow fever vaccine, the majority of patients became ill between 70 and 110 days after inoculation, the peak being reached between 90 and 100 days. Extreme variations were 46 and 170 days. Although 18 different lots of vaccine are included, two particular lots account for 222 of the 305 cases. In each of these two major lots of suggestive-lot No. 367 at 70 days and lot No. 338 at 100 days, while the peak of the aggregate of all cases falls at approximately 90 days.
The clinical course, including the symptomatology and physical signs, was that observed in the extensive series of cases observed elsewhere in the U.S. Army. No deaths occurred.
The energetic action initiated by The Surgeon General was effective in subduing the outbreaks of postvaccinal jaundice in the U.S.Army. In a letter dated 21 December 1942 from Col. (Later Brig. Gen.) Stanhope Bayne-Jones, MC, Office of the Surgeon General, to the Surgeon, the opinion was expressed that the cases reported from the China-Burma-India theater in the last months of 1942 were probably unrelated to the administration of yellow fever vaccine. The cases of infectious hepatitis occurring in 1943 and thereafter were consequently to be considered in a similar light.
The incidence of infectious hepatitis during 1943, 1944, and 1945 is graphically presented in chart 16 and table 10. In accordance with experience in the North African theater and in the Northern Hemisphere, a seasonal increase during the late summer months, particularly in September and October, was apparent. This increased incidence reflected an increased number of cases occurring sporadically throughout the theater and also occasional outbreaks. The clinical characteristics observed in these case of infectious hepatitis coincided with those witnessed elsewhere in the U.S. Army.
TABLE 10.- Incidence of infectious hepatitis in U.S. Army troops in India-Burma theater, by month and year, January 1943-July 1945 1
Occasional sporadic groups of cases were observed from time to time. During August 1944, 122 patients with infectious hepatitis were admitted to the 98th Station Hospital, Chakulia, India, from 14 units in the theater. As in other outbreaks, the source of infection was undetermined. These cases were considered to be unrelated to the administration of yellow fever vaccine. A similar increased incidence had been noted 1 year previously. The fact that a considerable proportion of these cases originated in two of the 14 units is of epidemiologic interest. It was evident that the increased incidence of infectious hepatitis in the two units was not related to troop strength.
No statistics concerning the incidence of poliomyelitis among the native population could be uncovered. Clinical observation on casual visits in the congested districts of Karachi, Delhi, and Calcutta impressed the visitor with the rather frequently observed residual flaccid paralyses. It is of interest, however, that experience in the British Army in India reveals a low incidence in Indian troops as compared with British troops.
Poliomyelitis was seen only sporadically in the military personnel of the India-Burma theater. The case fatality ratio, between 20 and 25 percent, the ever-present possibility of an epidemic, and the effect on morale when sporadic cases appeared made the disease one that commanded continuous consideration (table 11 and chart 17).
There were no major outbreaks of poliomyelitis; a focus of three cases, however, occurred in Agra, India, during September 1945, and this area was accordingly placed out of bounds to all personnel except those on official military business. In the British Army, a seasonal increased incidence was evident from March to October for the years 1942-44. The data of table 11 are too small to be statistical significance in this connection. The incidence of respiratory and/or bulbar involvement in U.S. military personnel was apparently high although no compilation of experience was available. In a group of 10 cases at the 263d General Hospital, Calcutta, India, in August and September 1944, there were 7 cases of respiratory paralysis or bulbar paralysis or both; 4 of the 10 patients died because of respiratory paralysis.
The clinical characteristics of poliomyelitis in the India-Burma theater were identical with those seen in the United States. The principal problem was the supply and maintenance of the respirators. With sporadic cases occurring at installations thousands of miles apart and often in relatively secluded places, it was imperative to maintain respirators at certain key points in usable condition ready for immediate air transport. One Drinker-Collins respirator was kept in readiness at Ledo and one at Karachi, and two were stationed in Calcutta. Arrangements were made with the British for the loan of mechanical respirators. Several of these were used but were unsatisfactory. They were subject to mechanical breakdown, and the bellows almost invariably developed leaks. By maintaining competent technicians constantly on duty, however, these respirators were invaluable in emergencies. "Savalife" respirators, employed at several installations, were useful in emergencies and during air transport of patients. They were found impracticable
for prolonged use, as indicated in a letter to the Surgeon General's Office from the Surgeon, USAFIBT:
Even with the best nursing care the machine was extremely uncomfortable with pressure from the metal and intense itching and maceration of the body tissues from constant contact with the rubber. As a result there were many macerated and blistered areas around the neck, trunk and arms.
The apparatus is sufficiently difficult to remove and replace as to make it impossible (because of the time element involved) 1st, to give the skin proper care and 2d, to allow the patient to have periods out of the machine so that he can begin using his own respiratory muscles as tolerated.
There were numerous mechanical difficulties. One death was attributed to mechanical failure of one of the British respirators, and on another occasion a hand bellow was used for 9 hours while the respirator was being repaired. In general, however, the use of the British respirators, with the splendid co-operation of the Air Transport Command in rushing a respirator to any installation immediately on call, proved adequate in the treatment of emergencies.
Typhoid and Paratyphoid Fevers
Although the statistics for typhoid and paratyphoid fever in the native population were grossly inaccurate, it was evident from the available information that enteric fever was widespread. Statistics in India always err on the low side because of the impossibility of obtaining accurate health reports. In one town, an epidemic was recognized by the medical staff of the local hospital only because of the unusual number of cases of fever that were being treated as outpatients at a time when malaria was not prevalent. In the 1940 annual report of the Health Commissioner of India, there were 1,738 deaths recorded in Delhi Province as due to enteric fever. Delhi City contributed 683 to this figure, and New Delhi, the capital of British India and certainly one of the best controlled cities in India from a public health standpoint, was responsible for 72. The rest came from the rural areas.
No epidemics occurred in U.S. Army personnel, but sporadic cases were reported throughout the 3 ˝ years of the theater's existence. Table 12 shows the number of cases of typhoid fever; table 13 shows the cases of para typhoid fever (A and B are not differentiated).
The first case of typhoid fever, reported in September 1942, was in a soldier stationed in Delhi. He was treated at the British Military Hospital, Delhi Cantonment, where the diagnosis was established by positive blood culture. One week later a case of paratyphoid A developed, which was also treated by the British. In October 1942, a soldier from the Delhi area was admitted to the 100th Station Hospital and proved to have typhoid fever; in the following month, a fourth patient was admitted and the case was diagnosed as typhoid fever. Three of these patients were from the headquarters squadron of the Tenth Air Force, but no common source of infection was found.
As a consequence of these cases, it was suspected that the antityphoid vaccine prepared in the United State was not highly effective against Indian strains, and it was directed that U.S. military personnel in China, Burma, and India be required to take a stimulating dose of Indian-type typhoid vaccine. This policy was also adopted by the British Army, whose experience was similar to that of the U.S. Army. Although this program was carried out for a brief period, it was later discontinued, apparently on advice from the Surgeon General's Office. It is impossible to say whether the incidence of typhoid and paratyphoid fever was affected.
No unusual clinical problems were encountered; in general, diagnoses were arrived at more slowly because of the lack of laboratory facilities. There
were only three deaths from typhoid fever. This low mortality rate in a country where the typhoid micro-organisms have lost none of their virulence, at least for the native population, demonstrates the efficacy of antityphoid immunization.
The 1939 annual report of the Public Health Commissioner of India on smallpox begins as follows: "The epidemiological statistics published by the League of Nations shows that British India ranks higher than all other countries in its rate of incidence of smallpox." The disease is endemic in India, with localized minor epidemics occurring at all times during the year with a seasonal peak around March, April, and May. A cyclic increase in incidence occurs every 5 or 6 years. This is attributed to the increased proportion of susceptible children, a result of the inefficient enforcement of vaccination. An epidemic year was expected in 1942 or 1943; actually it occurred in 1944 and 1945.
No cases of smallpox were reported in U.S. military personnel in 1942 and 1943. Table 14 shows the cases and deaths by months for 1944 and 1945. The first case was admitted to the 111th Station Hospital at Chabua and, as far as could be determined, was acquired from Chinese soldiers in the nearby staging area. Subsequent cases resulted from contacts with both the native Indian population and the Chinese troops.
Although the incidence of smallpox in U.S. Army troops was not high, the fact that it occurred at all was of great concern to the Preventive Medicine Section of the theater surgeon's office, and many investigations were carried out, as reported by that section. The essential finding that emerged from most of these studies was that either vaccination had not been accomplished recently or, if it had been, an immune reaction was recorded on the immunization register without sufficiently careful observation to distinguish between an immune reaction and an unsuccessful vaccination.
The disease was frequently severe and the case fatality ratio high. Sulfonamides and penicillin were used to combat secondary infection. The only unusual clinical problem that arose was the differentiation between generalized vaccinia and smallpox in 4 cases seen at the 18th Field Hospital and reported on by Major Mosley. These 4 cases, 1 or which was fatal, were originally reported as generalized vaccinia, because the patients had been vaccinated 5, 7, 3 and 4 days before the onset of their illness. However, investigations by the theater epidemiologist, Major Mosley, revealed exposure in each case to the native population at either Bombay or Calcutta at a time when smallpox was at its peak incidence. Major Mosley concluded that these cases of generalized vaccinia were actually instances of smallpox.
In view of the prevalence of smallpox, the theater policy was vaccination every 12 months; in addition, whenever a diagnosis of smallpox was made, all units in the vicinity of the suspected source were revaccinated. When the actual number of cases of smallpox among U.S. Army troops is considered in relation to the possibilities of exposure to this extremely virulent disease, the immunization program may be regarded as highly successful.
Cholera is endemic in India and constituted a constant potential threat to U.S. military personnel. Its prevalence in lower Bengal and other localities in close proximity to Army installations provoked energetic preventive measures, as described elsewhere.
Despite particulary heavy outbreaks in 1945, such as that in Calcutta, an area where many troops were stationed and were on leave, not a single case occurred in military personnel in the India-Burma theater from 1942 to October 1945. On 20 July 1945, the theater surgeon addressed a letter to the surgeons of the base, intermediate and advance sections, alerting all medical officers to the possible occurrence of cholera and advising certain modifications in the treatment outlined in TB Med 138, February 1945, subject: Cholera. One mild case was observed in a Red Cross worker who had been repeatedly vaccinated in accordance with theater policy. At the 181st General Hospital where she was hospitalized, Vibrio cholerae was isolated from the stools, and the finding was confirmed at the 9th Medical Laboratory. The patient made an uneventful recovery.
This remarkable record of no morbidity in military personnel in the theater is to be attributed to the close supervision of water supplies, the sanitation of the messes, the educational programs, the continued inspection of civilian restaurants, quarantine of native areas and establishments when indicated, and the strict enforcement of the cholera-vaccination program.
Cases of melioidosis are recorded, mostly from Burma, predominantly in males. Although only about 100 cases have been recorded in the past 30 years since the disease was first described, there is reason to believe it is more widespread than the diagnosis would indicate. In Rangoon, the estimated incidence is 4.5 per million. It is of interest that a case of this disease was diagnosed in a U.S. soldier and verified by recovery of the micro-organism from skin pustules and blood culture while the patient was alive and from post mortem abscesses from the lung, blood, liver, and spleen, by the 9th Medical Laboratory. Identification of the micro-organism of melioidosis was confirmed by the Army Medical School, Washington, D.C.
The disease is extremely varied in its manifestations and readily escapes diagnosis. The condition may simulate cholera, pneumonia pyemia, plague, or typhoid fever. The case reported in the April 1945 Field Medical Bulletin, by Lieutenant Cox and Major Arbogast, exhibited the pyemia syndrome. The patient had been ill 24 hours before admission with headache; fever and chills, accompanied by nausea and vomiting; and pain in the chest, the lower back, and the joints of the lower extremities. He had been a mule skinner, and some of his mules had died of the illness. During the 7 days in hospital before death, he developed scattered pustules over the entire body with a septic temperature ranging as high as 103o and 105o F. and the appearance of pneumonic consolidation of the base of the left lung. Laboratory studies revealed a white count of 7,000-9,000 and a red count of from 2.5 to 3.5 million; the causative micro-organism was recovered from cultures of the blood and contents of the skin pustules. During the last 2 days of the patient?s life, 40,000 units of penicillin were administered intramuscularly every 4 hours but without discernible effect. Post mortem examination revealed the characteristic findings of this disease.
The disease has been recorded as uniformly fatal, but with earlier diagnosis and newer modes of chemotherapy the course of the disease may be favorably affected.Schistosomiasis
No cases of schistosomiasis originated in the India-Burma theater. Twelve cases caused by Schistosoma haematobium were reported in a letter, dated 11 January 1945, from the Surgeon, 329th Air Service Group, to the Surgeon, U.S. Army Air Forces, IBT. In all of these cases, the disease was acquired when the group bathed in a pond while traveling across Africa. All the
patients had symptoms of pyelitis or cystitis and 60 percent had hematuria. Two patients were evacuated to the United States; the remainder eventually became free of symptoms following several courses of treatment with Fuadin (stibophen).
Cutaneous leishmaniasis or kala-azar was seen but rarely in this theater. Reliable statistics were not available, but it appears that only 1 case was reported in U.S. military personnel in the theater in 1944 and 13 cases in the first 5 months of 1945. Kala-azar is especially prevalent among the native population of Bengal and Assam, but relatively uncommon among the white people in those areas. The low incidence among those enjoying better living conditions and among military personnel is probably to be attributed in part to protective measures against insects, which are particularly effective against the Phlebotomus vector of the disease with its flight range of not more than a few hundred yards.
A few cases of kala-azar were seen at the 48th Evacuation Hospital and other installations caring for Chinese military personnel. Of the 14 cases reported among U.S. military personnel, 8 were studied at the 142d General Hospital. All had evidently contracted the disease in India, and Leishmania were demonstrated in 7 of the 8 cases; in the remaining 1 case, the diagnosis was established by the clinical course and response to treatment, in spite of 3 negative sternal punctures. The experience of the 142d General Hospital with these cases was summarized in the theater ETMD report dated 1 July 1945, which reads, in part, as follows:
The average time elapsing from apparent onset of illness until the diagnosis was established was about two months; the longest time was one hundred and twenty-one days and shortest (in a case diagnosed before transfer here) was twelve days. This wide variation suggests that Medical Officer's "index of suspicion" of kala-azar has been too low, and it is noteworthy that this index", in the staff of this Service, has risen sharply. The remittent and recurring nature of the fever has, in many cases, led to diagnoses such as typhoid fever, paratyphoid fever, brucellosis, amebic abscess of liver or spleen, malaria, and dengue at one time or another. The matter is further complicated by the not infrequent coincidental occurrence of malaria or amebiasis. One patient had had several hospitalizations for undiagnosed febrile illnesses which, in retrospect, were exacerbations and remissions of kala-azar.
The clinical findings and the course of the disease in these patients were in accord with common experience as described in TB MED 183, July 1945, subject: Visceral Leishrnaniasis-Kala-azar. The diagnosis was suspected by reason of unexplained fever for several weeks, comparative well-being of the patient, and gradual enlargement of the spleen and liver together with the characteristic blood changes. The definitive diagnosis was established by sternal puncture. Splenic puncture was not practiced. Since the cases were relatively recent in origin, the formol-gel reaction and the distilled-water tests were of little help.
Response to treatment was generally satisfactory. Fuadin (trivalent antimony) given to 2 patients appeared to be entirely ineffective and in 1 case was followed by an alarming febrile episode of several day's duration.
The ETMD report states:
The pentavalent antimony preparation Neostam was given to three of these patients, and Neostibosan to five. Both have proved effective, but Neostibosan appears to be distinctly the better of the two. The total dosage of Neostam has been from 4.0 to 4.7 gm., and of Neostibosan from 3.0 to 3.6 gm. One of the eight patients is now under treatment. The other seven have made apparently complete clinical recovery.
Every effort was made to emphasize the necessity of considering kala-azar in the differential diagnosis of fevers of undetermined origin. The increased number of cases reported in 1945 was possibly in part attributable to raising the level of suspicion in the medical officers of this theater. It is not improbable, however, that in some instances of this infection the diagnosis was missed.
EVALUATION OF CONSULTANT SYSTEM
Detailed descriptions of the educational and editorial activities of Colonel Blumgart, his role in furthering clinical research, and his relationships with other consultants have been delineated. Further comments have been made on these activities in relation to the problems posed by specific diseases. The following comments concern an evaluation of the consultant system as it operated in the theater.
On the basis of 3 years of experience as consultant in medicine (2 years in the Zone of Interior and 1 year in the India-Burma and the China theaters) the author considers the consultant system to be invaluable in enhancing the quality of medical care.
In the India-Burma theater, the role of the consultant as a two-way ambassador between the theater surgeon in Delhi and the installations in the field facilitated the interpretation of higher policy and directives of headquarters to those engaged in caring for the soldiers and conversely permitted bringing to the attention of higher authority some of the problems in the field. Important knowledge and experience gained in some of the installations could be transmitted to other installations having only fragmentary experience with certain diseases and conditions of medical practice.
The isolation in this theater arising from wide dispersion of units and poor lines of communication frequently resulted in medical officers having no opportunity to discuss professional matters with anyone other than their immediate associates. Colonel Blumgart's visits established a line of professional communication with theater headquarters. The improvement in morale was one of the most gratifying consequences of the consultant system.