U.S. Army Medical Department, Office of Medical History
Skip Navigation, go to content

HISTORY OF THE OFFICE OF MEDICAL HISTORY

AMEDD BIOGRAPHIES

AMEDD CORPS HISTORY

BOOKS AND DOCUMENTS

HISTORICAL ART WORK & IMAGES

MEDICAL MEMOIRS

AMEDD MEDAL OF HONOR RECIPIENTS External Link, Opens in New Window

ORGANIZATIONAL HISTORIES

THE SURGEONS GENERAL

ANNUAL REPORTS OF THE SURGEON GENERAL

AMEDD UNIT PATCHES AND LINEAGE

THE AMEDD HISTORIAN NEWSLETTER

Chapter 21 - Cholera

Contents

CHAPTER XXI

Cholera

Kirk T. Mosley, M. D.

HISTORICAL NOTE

The early history of Asiatic cholera in the United States Army is based upon the experience of the military forces with the disease when cholera pandemics originating in the endemic centers of the Far East invaded the North American Continent and gave rise to widespread epidemics within the United States on at least four different occasions in the 19th century.1 The disease entered the United States through seaports, particularly New York and New Orleans, being brought in by infected immigrants from cholerastricken areas of western Europe. In the first three epidemics, which swept this country in the fourth, sixth, and seventh decades of the 19th century, troops of the Army often suffered as severely as did the civilian population from outbreaks of the disease. In some instances, troops were responsible for the spread of the disease as infected units were moved from a station to a new post where the disease had not yet appeared. In many instances, the disease was introduced among the troops from civilian communities. One of the first experiences of American soldiers with cholera fully demonstrated its devastating character and showed how disastrous an outbreak can be to a military operation. During the Black Hawk Indian War in 1832, seven companies of infantry troops destined for this campaign embarked on the steamer Henry Clay at Buffalo, N. Y., on 1 July. Cholera broke out among the troops on 4 July. By 9 July, only 68 men of the 7 companies that departed from Buffalo were left. Many died of the disease on board ship; many others deserted in panic and died of cholera in the surrounding countryside.

Fortunately, cholera has not been a serious problem to military operations of the Army in any of the major conflicts involving the United States. The disease had not reached the North American Continent at the time of the Revolutionary War and the War of 1812.The Mexican War had just ended when the second American invasion by cholera began in 1849.Cholera was absent from the United States during the Civil War but entered shortly thereafter, in 1866, for the third major outbreak in this country. Cholera apparently played no role in the Spanish-American War, but in 1902 and 1903 the disease, broke out among American troops on duty in the Philippine Islands.

1 Wendt, Edmund C.: A Treatise on Asiatic Cholera. New York: W. Wood & Co., 1885.


452

The islands at that time were suffering from a severe epidemic of cholera which had spread from the Asiatic mainland.2 For the next 15 years, sporadic cases of Asiatic cholera appeared in American troops stationed in the Philippine Islands.During World War I, 11 admissions for cholera with 2 deaths occurred among American troops overseas; both deaths and 10 of the admissions were among American troops on duty in the Philippines and China.3 An additional 6 admissions for cholera, with 5 deaths, occurred among Philippine native troops.In World War II there were only 13 cases and 2 deaths from cholera among American troops, though large forces were involved in extensive military operations in the highly endemic centers of the disease on the Asiatic mainland. The remarkable achievement of the Army in cholera prevention in World War II is attributable to well-developed and well-executed disease-control measures by our military forces. Principles of sanitation effective in the prevention of infectious diseases transmitted by way of the gastrointestinal tract were particularly emphasized in the preventive measures against cholera.

ADMINISTRATIVE PREVENTIVE MEASURES

With the entry of the United States into the war, necessary revisions were made in Army regulations in order to take full advantage of the latest developments in the field of sanitation and preventive medicine for the protection of troops against infectious diseases, including cholera. Army Regulations No. 40-205, Military Hygiene and Sanitation, was revised and published on 31 December 1942. Army Regulations No. 40-210, Prevention and Control of Communicable Diseases of Man, was published on 15 September 1942 after extensive revision. This revision greatly simplified and condensed a large number of previous regulations and War Department circulars and represented a most valuable accomplishment in the administrative service of the Surgeon General's Office in communicable disease control.

Circular Letter No. 56, published by the Surgeon General's Office on 9 June 1941, provided technical guidance, on the prevention of cholera. This letter was revised and published as Circular Letter No. 33 on 2 February 1943. Ill each of these letters, a section was devoted to cholera. The cholera section in the latter publication was superseded by TB MED 138, published in February 1945. These publications provided medical officers with the latest knowledge concerning the epidemiology and clinical aspects of cholera. The facts that cholera was in the category of an exotic disease and was little more than a name to most medical officers enhanced to a great degree the value of the technical directives on cholera prepared by the Surgeon General's Office.

2 Annual Reports of The Surgeon General of the Army, 1902. 1903, 1904.Washington: Government Printing Office.

3 The Medical Department of the United States Army in the World War. Statistics. Washington: Government Printing Office, 1925, vol. Xv, pt. 2, pp. 86-89, 134-137.


453

Research

Although principles of sanitation for the prevention of cholera were well established and of proved value, there was a constant effort to increase the effectiveness of the known preventive measures against this disease and to develop new ones through research and investigation. This activity of the Surgeon General's Office may be divided into two general fields: Improvement and evaluation of the effectiveness of the cholera vaccine and investigation of drugs and chemicals which might be effective in the prophylactic treatment of individuals exposed to chlorea. Also, knowledge of the pandemic tendencies of cholera and its ability to reach major epidemic proportions under conditions of warfare made it necessary to forestall the menace of cholera even before our country became militarily involved in World War II.

The preliminary precautionary measures were chiefly directed at improving the effectiveness of cholera vaccine. In the spring of 1941, information regarding the use of vaccines for the prevention of cholera and the method of obtaining the best vaccine possible was sought from medical authorities. In the fall of 1941, direct approach was made to the National Research Council for aid and advice in solving the problems connected with the use of immunization procedures against certain infectious diseases, including cholera.4 Acting quickly on this request, the National Research Council assembled a conference of experts which met on 22 October 1941 and prepared resolutions proposing policies to be followed in the immunization of American troops against certain infectious diseases. These resolutions were submitted to The Surgeon General and were the basis of policies adopted by the Army in its immunization program against cholera.5 The chapter on immunization in another of the preventive medicine volumes gives details of the cholera immunization policies and practices adopted by the War Department.6

The establishment of policies governing cholera vaccine and its use did not lessen the interest of The Surgeon General in investigations to improve the effectiveness of vaccine as a protective measure. Arrangements were, made to obtain from East Indian and Egyptian sources new strains of Vibrio cholerae for the study of their immunizing properties and for possible use in preparation of vaccines.7 The Surgeon General made valuable use of the resources of the National Research Council to keep informed about progress in the studies on cholera vaccine, including the chemical aspects, various strains of cholera vibrios, and techniques used in controlling the production and testing the potency of vaccines against cholera. In the, summer of 1942, Col. (later Brig. Gen.) James S. Simmons, MC, recognizing the need for organized effort to

4 Memorandum, Surgeon General's Office (Col. J. S. Simmons), for Dr. L.H. Weed, National Research Council, 8 Sept. 1941, subject: Immunization Against Certain Infectious Diseases, Notably Plague, Cholera, and Typhus.

5 War Department Circular No. 4, 6 Jan. 1942, sec. 3, Vaccination Against Typhus Fever, Cholera, and Plague.

6 Long, Arthur P.: The Army Immunization Program. In Medical Department, United States Army, Preventive Medicine in World War II. Personal Health Measures and Immunization. Washington: U. S. Government Printing Office, 1955, vol. III, pp. 314-317, 347-348.

7Memorandum, Surgeon General's Office (Lt. Col. Rogers), for the Adjutant General's Office, 22 Dec. 1941.


454

further the Army's knowledge concerning protection against cholera, especially in respect to the value of vaccines, urged that the National Research Council establish a small committee to coordinate cholera research activities. A committee was appointed on 26 August 1942. The committee, in a report made a few weeks later, summarized the existing status of knowledge about cholera vaccines, with particular reference to research being done at the time.8 It was agreed, on the basis of this report, that the cholera vaccine in current use by the Armed Forces should be continued in its present form, though research was to be encouraged on the antigenic, chemical, and other aspects of the cholera organism, with the hope of improving the vaccine against the disease.

In the latter part of 1942, an informal suggestion was made concerning the advisability of establishing a cholera commission similar to the Typhus Commission. This suggestion, however, did not receive favorable consideration.

In a conference on cholera vaccine held by the National Research Council on 1.6 June 1943, it was decided that a field experiment in a cholera area was needed to determine the efficacy of the vaccine then being used by the Armed Forces and such other vaccines as might be selected in protecting a population against the disease. By a strange but fortunate coincidence, a very extensive field study on this same problem was actually in progress in India. A preliminary report of this study, conducted in Madras Province, India, under the direction of Dr. R. Adiseshan, Director of Public Health, Madras, with the assistance of Dr. C. G. Pandit and Dr. K. V. Venkatraman of the King Institute of Preventive Medicine, Guindy, Madras, and other scientists, was made available to the National Research Council by the end of the year and indicated that a considerable degree of protection was afforded by immunization.9According to the evidence presented in a final report, ail immunized population is at least 10 times less susceptible to the disease than an unimmunized population.

Research in the use of drugs in the treatment of cholera, though chiefly the concern of the Medical Consultants Division of the Surgeon General's Office, was of great interest to the Preventive Medicine Division. This interest was an outgrowth of the remarkable success in the use of drugs in small doses for prophylactic or suppressive effects in such diseases as malaria and meningococcal meningitis. Also, pressure for information about drugs effective against cholera developed when it became obvious that an increasingly larger number of troops would be exposed to cholera and that complete protection to exposed individuals is not assured by cholera inoculations. The logical place for studies on the therapeutic effectiveness of drugs is in an endemic area of the disease. Since India is such an area, the National Research Council was requested in February 1945 to consult with the Director General of the Indian Medical Service concerning plans of scientific groups of that country for investigating newer drugs in the therapy of cholera. The council was also re-

8 Minutes, Committee on Medical Research, National Research Council, 26 Sept. 1942, subject: Conference on Cholera Vaccine.

9 Minutes, Subcommittee on Tropical Diseases, Committee on Medical Research, National Research Council, 28 Jan. 1944.


455

quested to ascertain whether a representative of the United States would be welcomed to observe and participate in the investigations. Reports of investigations by Indian scientists conducted under the auspices of the Indian Research Fund Association had been the source of most of the information on the use of newer chemotherapeutic agents in the treatment of cholera. The close liaison of the International Health Division of the Rockefeller Foundation with scientific organizations and agencies of India was of great benefit in making available to The Surgeon General information on the results and progress of research being conducted in that country. While there were indications that Indian authorities and scientists would give favorable consideration to the proposals of the National Research Council, the termination of the war occurred before final arrangements were completed, and the project never materialized. However, the results of an investigation of the treatment of cholera, conducted in Calcutta by a Navy epidemiologic team, led to The Surgeon General's issuance of a letter suggesting certain modifications in the therapy of cholera as described in TB Med 138. These modifications were concerned chiefly with the use of penicillin and plasma in the treatment of acute cases. At the close of the war, no reliable information had been obtained on the use of drugs in the chemoprophylaxis of cholera.

ARMY EXPERIENCE IN THEATERS AND AREAS

India-Burma Theater

The greatest exposure of United States troops to cholera occurred in the China-Burma-India (later India-Burma) theater. Cholera was a constant menace to a large number of troops in this area, especially to those stationed in or near Calcutta or passing through or visiting this metropolis and its environs. In this section of India along the lower Ganges River, the disease is nearly always present with the danger of large epidemics occurring during the cholera season each year.

In spite of an ever-present possibility of cholera outbreaks and the occurrence of extensive epidemics among civilians in proximity to military installations, no cases of the disease were reported among United States Army troops stationed in this theater. This excellent record is even more unusual when compared with that of Indian and British troops (table 77) who were stationed in the same area and potentially subjected to the same. exposure as the United States troops. While cholera outbreaks were known to have occurred among Chinese troops stationed in India and Burma, reliable information could not be obtained on the number of cases and deaths from this disease among Chinese soldiers assigned to this theater.

Except for immunization directives requiring troops to be immunized against cholera and to receive stimulating doses of vaccine every 6 months, very few administrative actions at theater level were specifically directed against cholera, although a survey on the cholera situation in Assam and


456

TABLE. 77.-Cholera cases and dealths among enlisted personnel in British and Indian Armies, in India, 1940-46

Bengal Provinces was made by the theater surgeon's office in the latter part of 1943.10 The absence of theater action specifically dealing with cholera is made apparent in the official compilation of directives affecting the Medical Department which were in force as of 31 December 1944.11 In that section of the compilation arranged according to subject matter, the subject of cholera did not appear once, since no directives in force at that time pertained specifically to this disease. The explanation for this seeming failure to appreciate the hazard of cholera lies in the fact that, from the very beginning, other gastrointestinal infections, especially the diarrheas and dysenteries, presented the theater with a serious health problem and overshadowed cholera as a cause of concern to the Medical Department. 12 The increasingly high rates for the diarrheas and dysenteries approached a critical level in 1944 and were the basis of two extensive surveys, one by a subcommission of the Army Epidemiological Board 13 and a second by a special commission from the Office of the Surgeon General headed by Brig. Gen. Raymond A. Kelser.14 Each survey listed a great number of defects in sanitation which might readily account for a high incidence of gastrointestinal diseases, particularly in an environment which is heavily seeded with the infectious agents of these diseases. As a consequence, most of the administrative actions taken in regard to gastrointestinal diseases lead as their primary purpose the control and prevention of the diarrheas and dysenteries. In most instances, these measures were by their very nature equally effective against cholera.

10(1) Circular No. 50, Rear Echelon, Headquarters, U. S. Army Forces, China-Burma-India Theater, 17 Aug. 1943, subject: Immunization. (2) Circular No. 5, Headquarters, U. S. Army Forces, India-Burma Theater, 20 Jan. 1945, sec. V, Immunization. (3) Essential Technical Medical Data, Headquarters, China-Burma-India Theater, 13 Dec. 1943.

11 Circular Letter No. 1, office of the Surgeon, Headquarters, U. S. Army Forces, India-Burma Theater, 1 Jan. 1945, subject: Compilation of Directives Affecting the Medical Department, India-Burma Theater.

12 Van Auken, H. A.: A History of Preventive Medicine in the U. S. Army Forces of the India-Burma Theater, 1942-45. [Official record.]

13 (1) Monthly Report for July, Sub-Commission on Dysentery, Army Epidemiological Board, 8 Aug. 1944. (2) Progress and Final Report, Sub-Commission on Dysentery, Army Epidemiological Board, 20 Nov. 1944.

14 Letter, Headquarters, Services of Supply, U. S. Army Forces, India-Burma Theater; to Commanding General, U. S. Army Forces, India-Burma Theater, 9 Nov. 1944, subject: Report of :Medical Department Mission.


457

There were occasions, however, when the threat of cholera was particularly dangerous and received special attention from the Medical Department in specific commands and areas in the theater. The most serious threat of cholera to American troops in the India-Burma theater occurred in the Calcutta area in the spring of 1945 when a severe epidemic broke out among the civilian population in Calcutta and the surrounding territory, with as many as 100 cases and 35 deaths being reported daily. At the height of the outbreak, the epidemic spread to British troops billeted in the Grand Hotel, with 14 cases reported in this group. The 135 American officers also billeted in the hotel were immediately removed, and the dining quarters of the establishment was put out of bounds for American forces. To Lt. Col. K. R. Flamm, MC, the surgeon of this base section, can be attributed much of the success of the vigorous attack against this threat of cholera. The precautionary measures launched against the disease included: (1) An intensive educational campaign explaining to troops how cholera is spread and flow to avoid it; (2) special measures to insure that all troops stationed in the area or passing through were properly immunized against cholera; (3) rigorous inspection of civilian eating establishments in bounds to United States troops, with special attention given to water protection and sanitation, foodhandlers' hygiene, exclusion of serving of fresh raw fruits or vegetables to troops who were patrons, and other sanitation requirements essential for the prevention of cholera; and (4) enforcement of strict sanitary discipline in all the Army messes and other food-dispensing establishments on Army posts, with particular attention to native foodhandlers and their personal hygiene. The use of Indian labor for foodhandling lead been discouraged as far as possible, but utilization of cheap labor for this type of service was never completely abandoned by many units. These special measures taken by the commanding general of Base Section 2, which included Calcutta and the surrounding area, represented the only large-scale effort directed primarily at prevention and control of cholera in the India-Burma theater. Because of the strategic importance of Calcutta and the relatively large number of troops (24,500) stationed in the city and its immediate environs, as well as a great flow of Army personnel through this military center, an extensive epidemic of cholera among troops in the area would have gravely impaired the functions of this vital supply base and resulted in serious interference to the theater operations.

Other incidents involving cholera reported in the theater were of much less military significance but were of considerable medical interest. In the spring of 1943, a severe cholera outbreak occurred among the civilian population in several villages, including Pandaveswar, which were in the immediate vicinity of airbases of the 7th Bombardment Group. Special measures were taken by the local commanders to prevent the spread of the disease to personnel in these installations.15 In the spring of 1945, three suspected cases of cholera in American troops were reported by the 4th Combat Cargo Group stationed

15 Letter, Surgeon, 7th Bombardment Group, to the Commanding Officer, 7th Bombardment Group, 16 June 1943, subject: Cholera Epidemic Among Natives in Panda.


458

at Chittagong. These suspected cases and the circumstances surrounding their occurrence were thoroughly investigated by the theater epidemiologist, who was unable to find sufficient evidence to support the tentative diagnosis of cholera. Another incident later in the same year was the occurrence of a case of cholera in a Red Cross worker who was presumably infected in Calcutta but developed her illness in Karachi while she was waiting for passage to the United States. This case, though mild, was confirmed by positive stool cultures.16

It is very difficult to draw any satisfactory conclusions concerning the unique record of the India-Burma theater in regard to cholera. While there were no cases among Army personnel, reports of the two separate extensive surveys, which included observations on sanitary conditions in military units, indicate that there were certainly opportunities for exposures to the disease, particularly in those areas where the disease is known to be endemically present at all times. Thus, much of the protection against cholera might be attributed to the effectiveness of the cholera vaccine. While such an assumption seems reasonable, an excellent summary of the American forces' experience with cholera in India contained in a report from the theater, points out certain difficulties in determining the protective value of cholera inoculations as well as in evaluating the relative merits of immunization and sanitation as cholera preventive measures.

China Theater

American troops assigned to the China section of the China-Burma-India theater (later, October 1944, the China theater) faced essentially the same threat from cholera which troops faced in India. The disease was endemic throughout the area of Free China in which American troops were stationed, and epidemic outbreaks occurred periodically. During the war years, 1942-45, widespread outbreaks struck the civilian populations in many of these areas of Free China, in some instances in the immediate vicinity of Army installations. Because of the constant possibility of an explosive outbreak, routine immunization against cholera with stimulating doses at 6-month intervals was administered to all United States Army personnel.17 Sanitation was emphasized as an important measure for the prevention of cholera and similar enteric diseases. The Fourteenth Air Force published a memorandum which was ordered to be read to all members of that command at monthly intervals.18

American troops remained relatively safe from cholera until the summer of 1945, when outbreaks seriously threatened units in various parts of Free China. As a result of these outbreaks, a special cholera commission made up of civilian experts was sent to assist the Chinese National Relief and Rehabilitation Administration in controlling the disease among the civilian population. The first of these threats developed in Chungking, the provisional capital of Free

16 Essential Technical Medical Data, India-Burma Theater, 1 June 1945.

17 Annual Report, Office of the Surgeon, Headquarters, China Theater, 26 Oct.-31 Dec. 1944.

18 Fourteenth Air Force Memorandum 25-8, 10 May 1944, subject: Rules for Health in China.


459

China and also the headquarters of United States Army forces in China, with the occurrence of a severe epidemic among the civilian population. This outbreak was carefully investigated by the theater medical inspector, and his report is one of the remarkable documents on cholera during World War II. His investigation revealed that sanitary conditions in the American installations were in many instances very unsatisfactory, and of particular concern to him were the serious defects observed in sanitation and in protection of water supplies. Necessary corrective actions were taken in accordance with his recommendations and included the publication of directives on cholera control for troops in the Chungking area. The efforts to prevent cholera from spreading to American forces in the Chungking area were apparently successful, since no cases of the disease appeared in our troops in this area.19

However, only a few weeks later, two separate sharp outbreaks of cholera, the only outbreaks to involve American troops in World War II, appeared in units stationed in other sections of China.20 The first outbreak, which resulted in six cases with one death, occurred during the later part of July 1945 among the enlisted personnel of the 1836th Ordnance Company stationed at the Liangshan Air Base. This outbreak was attributed to the consumption of cakes and cookies which, against instructions, had been purchased from a bakery in the city of Liangshan, where a serious epidemic of cholera was raging. The cakes were served at a snackbar operating on the base. At the same time that these cases of cholera occurred, there was a sharp increase in the number of cases of diarrhea among troops of the 1836th Ordnance, Company which operated the snackbar where the questionable food was being served. The six cases of cholera were diagnosed on clinical grounds and treated in the station dispensary. The five who recovered responded well to therapy which included in some instances penicillin and sulfaguanidine in addition to parenteral fluids. According to the immunization records of these six cases, the initial immunizations against cholera were completed in August 1943 with American vaccine. All except one received a stimulating dose of Chinese vaccine in April and May 1944. Five cases received stimulating doses of Chinese vaccine in October 1944; the sixth received American vaccine in September 1944. In April 1945, five cases received American vaccine, and in May 1945 the remaining case received Chinese vaccine. Only two of the cases received another stimulating dose in July 1945.

The other outbreak occurred at Chihchiang during the first week of August 1945 and involved personnel of the 547th Quartermaster Depot Supply Company. In this outbreak, there were seven cases with one death. The vehicle of transmission in this outbreak apparently was contaminated water, since all of the patients were known to have, on one or more occasions, drunk

19 Essential Technical Medical Data, Headquarters, China Theater, 12 Aug. 1945, inclosure 2.

20 (1) Essential Technical Medical Data, U. S. Army Forces, Headquarters, China Theater, 2 Oct. 1945, pp. 4-5 and inclosures 2 and 3. (2) Annual Report, Office of the Surgeon, Headquarters, Fourteenth Air Force, 1945 , (2d and 3d quarters). (3) Annual Report, Headquarters, Army Air Forces, China Theater, 1945 (3d and 4th quarters), annex III, inclosure 4.


460

water, unboiled and unchlorinated, from a well at the Catholic Mission in the city of Chihchiang. Samples of water taken from this well on two separate occasions were submitted to the 1724 General Hospital for analysis and were found to be positive for colon-group organisms. One nun at the mission developed cholera from which she recovered.

In this outbreak, the patients were hospitalized and treated in the 21st Field Hospital. Stool specimens which were examined in the 172d General Hospital were positive for all seven cases. All patients received adequate amounts of parenteral fluids to combat dehydration and acidosis. Four patients also received penicillin, and, according to one source of information, there was no appreciable difference in response between the patients who received penicillin and those who did not. The patient who died received penicillin therapy. There is lack of information on the immunization histories of these cases, though it is known that one patient lead received a stimulating dose of American vaccine on 29 July 1945 and that the other six patients had received stimulating doses of Indian vaccine on 26 April 1945.

The seriousness of the cholera situation in the China theater was called to the attention of all troops in a theater circular dated 2 August 1945 in which the following measures were emphasized: Water sanitation, including purification and handling after treatment; precautions in the preparation and handling of food; avoidance of prepared food and drink from civilian sources; insect control measures; provision of adequate waste-disposal facilities for American personnel and for Chinese personnel working in American installations; and the maintenance of high immunity to cholera by administration of stimulating doses of vaccine at intervals of not more than 4 months. No further outbreaks occurred among United States forces in China. The, absence of additional cases is attributed to the combined effectiveness of sanitation and immunization.

Southwest Pacific Area

The medical history of the United States Army in the Southwest Pacific Area in respect to cholera is an excellent account of wise precautions and careful preparation for eventualities. Although during the initial stages the campaign in this area was far removed from endemic cholera areas, the disease spread far beyond the usual endemic centers, having been seeded by the movement of Japanese troops throughout Southeast Asia including Indo-China, Siam, Singapore, and islands to the south and east of the mainland including the Philippines, Java, Sumatra, Celebes (Makassar), Truk, and possibly New Britain (Rabaul). There were reports that the, disease had occurred in units of the Japanese Army in many of these areas, and it was believed that the spread of the disease was partly due to the movement of infected Japanese troops from endemic foci to previously uninfected areas.

The spread of cholera from the mainland of Asia toward areas which


461

were in the line of the offensive from Southwest Pacific bases, together with the possibility that troops at any time might encounter the disease in infected units of enemy troops, stimulated the development of a careful cholera-control program. Evidence of the careful planning designed to minimize any potential threat of cholera to the success of military operations in this area is contained in a letter from the Chief Surgeon to the Surgeon, Sixth U. S. Army, dated 3 April 1944, recommending (1) vaccination of all troops against cholera; (2) the establishment, in the supplying base of each operation, of a special stock of supplies (such as cresol, gowns, mosquito and fly netting, and salt solution infusion sets), earmarked for epidemic use; (3) equipment of forward laboratory sections for prompt bacteriologic diagnoses of cholera; (4) publication of a technical memorandum for all medical officers on the diagnosis and treatment of cholera and on special precautions to be taken in addition to usual sanitary measures; and (5) a report to the task force surgeon of any evidence discovered of epidemic disease among enemy troops. These measures were all implemented by the necessary official directives and letters.21In the planning of the specific preventive measures for cholera, full use was made of the counsel and advice of the Combined Advisory Committee on Tropical Medicine, Hygiene, and Sanitation. The Committee addressed a letter dated 22 June 1944 to the Commander in Chief, Southwest Pacific Area, giving full support to the cholera-control measures outlined in the letter of 3 April 1944 referred to.

Although no cholera cases or incidents occurred among United States troops in the Southwest Pacific, the planning in this area was well designed to meet any cholera situation which might be encountered under conditions of combat.

Cholera in Other Theaters and Areas

Cholera did not present a problem in other theaters and areas. However, each theater had regulations concerning the requirements for cholera immunizations, and, because of pandemic potentialities of cholera, especially under conditions of warfare, a careful watch was maintained in all theaters for any evidence indicating the spread of the disease from its endemic centers. From time to time, false alarms of spread in the Western Hemisphere were received; however, during World War II, the extension of the disease beyond the usual endemic centers occurred only in areas which came under the influence of Japanese military control.

21 (1) Technical Memorandum No. 1, Office of the Chief Surgeon, Headquarters, U. S. Army Forces in the Far East, 17 Apr. 1944, subject: Cholera. (2) Letter, General Headquarters, Southwest Pacific Area, to Commander, Allied Land Forces; Commander, Allied Air Forces; Commander, Allied Naval Forces; Commanding General, U. S. Army Forces in the Far East; Commanding General, U. S. Army Services of Supply, 24 Sept. 1944, subject: Cholera. (3) Letter, Headquarters, Advance U. S. Army Forces in the Far East, to Commanding General, Sixth Army; Commanding General, Eighth Army; Commanding General. Far East Air Forces; Commanding General, XIV Corps; Commanding General, U. S. Army Services of Supply; Commanding General, 14th Antiaircraft Command; Commanding General, Replacement Command, 12 Oct. 1944, subject: Cholera.


462

SUMMARY

The history of cholera in the United States Army is paradoxical in that this disease exacted a heavier toll among troops in times of peace than during periods of major military campaigns, when epidemic diseases such as cholera are usually most prevalent and destructive. Such a record owes much to the fortunate circumstance that peace prevailed on the North American Continent when cholera made its invasions of the Western Hemisphere in the 19th century. Also, there is the factor that military operations by United States troops in highly endemic areas in World War II did not include ground-combat activities to any significant degree. Most of the troops in the India-Burma and China theaters were primarily engaged in opening and maintaining communication and supply lines to Free China by way of India and northern Burma. Air Force personnel engaged in aerial warfare in these theaters were stationed in bases which were in most instances comparatively safe from enemy action, so that it was possible to maintain a high degree of sanitation in these military establishments.

Both sanitation and immunization were emphasized as preventive measures against cholera by the Medical Department of the Army. From the experience in World War II, it is impossible to evaluate the relative merits of each of these measures separately. Used together, they proved very effective under the conditions and circumstances faced by United States troops in the highly endemic areas of the disease.

While a creditable record was made in the prevention of cholera, very little was added to basic knowledge about the epidemiology of the disease. The opportunity for increasing understanding of basic factors influencing its peculiar restricted geographic distribution, epidemic and pandemic properties, and other unsolved problems was not pressed with the same intensity as were the investigations of other diseases of less catastrophic potentialities. Most of the investigative work centered around attempts to improve the cholera vaccine and a somewhat belated effort to discover a chemical prophylactic.