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Chapter 17.1 - Diarrhea and Dysentery
DISEASES TRANSMITTED CHIEFLY THROUGH ALIMENTARY TRACT
ARMY EXPERIENCE WITH DIARRHEAL DISORDERS BEFORE WORLD WAR II
Montgomery says the Eighth Army won, but Rommel claimed the victory for dysentery * * *. But, as the Germans learned at El Alamein, dysentery can still win battles, when hygiene discipline on one side is slack.-SIR SHELDON F. DUDLEY.
Throughout history, military populations have
experienced great morbidity by reason of the
diarrheas and dysenteries. As causes of illness and norneffectiveness,
these diseases have
plagued the United States Army since it was first organized. Until the
time of World War I, they
were important causes of mortality.
Diarrheal disease was rampant among troops during
the Revolution and apparently was
responsible for more deaths than were caused by enemy action. Available
figures for the Civil
War indicate the military significance of this disease in combat
troops; diarrheas and dysenteries
"occurred with more frequency and produced more sickness and mortality
than any other form of
disease." More than 1,755,889 patients were admitted to field medical
installations and hospitals. For diarrheas and dysenteries, including
gastroenteritis, the case rate was 741.2 per annum per
1,000 average strength.Deaths were 46,277, representing a mortality
rate of 18 per 1,000; 2.6
percent of the men admitted for these causes died. During the Civil
War, more than 1 death in
every 4 caused by disease was ascribed to diarrheas and dysenteries. In
the Union Army, of
every 1,000 men the following numbers succumbed to dysentery or
diarrhea during each year of
the war; Negro troops fared worse than white troops:1
1 Medical and Surgical History of the War of the Rebellion. Medical History. Washington: Government Printing Office, 1879, vol. 1, pt. II, pp. 1, 6, passim.
The dysenteric diseases are at their worst in
prisoner-of-war camps.The stockade for Union
prisoners of war at Andersonville, Ga., is an outstanding historical
example, to such extent that it
became known as the most fatal field in the War Between the States. At
least 16,772 cases of
diarrhea and dysentery occurred at this prison and represented an
estimated annual rate of 1,724
per 1,000 strength; 4,529 men died. More than one-half of all
fatalities were attributed to
diarrhea and dysentery.2
During the Spanish-American War, at the turn of the
20th century, the incidence of diarrheas and
dysenteries among United States Army troops was slightly lower than
that among troops during
the Revolutionary War and the Civil War. However, typhoid fever was
distinguished as a disease
problem because of a mortality far exceeding the more frequent but less
dysenteric illnesses. Indeed, diarrhea and dysentery seemed in this war
to have lost much of their
killing power. During the war years of 1898-1901, 204,040 admissions
representing a rate of 426 admissions per 1,000 troops. The number of
deaths was 1,595, a rate of
3.3 per 1,000. Case fatality dropped to 0.78 percent in this period.
Diarrheal disease occurred in
severe epidemic form in United States Army troops in the Philippines
shortly after the American
occupation in 1899-1900. Much of the excess incidence was doubtless due
dysentery, but typhoid fever was the more serious problem in terms of
resulting deaths. At the
time of the Spanish- American War, attention was focused upon typhoid
fever with a resultant
improvement in diagnosis of this enteric condition. Examination of data
of this and other wars
suggests that many, fatal intestinal infections of earlier wars were in
reality typhoid fever,
erroneously diagnosed as infections within the group of diarrheas and
gastroenteritis). Comparison of experience in World War II with that of
former wars must take
this into account.
During World War I, the Army benefited from the great improvements in environmental sanitation of the preceding two decades. During the period from April 1917 to December 1919, there occurred in the overseas Army 48,202 admissions for diarrheal disease, including gastroenteritis, a rate of 28.9 admissions per 1,000 troops. There were only 208 deaths (0.13 deaths per 1,000 troops) which represents the best record up to that time in any American war. Case fatality was 0.43 percent. The improvement in respect to typhoid fever was even more startling (table 82).This favorable downward trend of cases and deaths of typhoid fever continued throughout World War II, but the rate of 40 cases of reported dysenteries and diarrheas (excluding gastroenteritis) per 1,000 strength in total troops overseas certainly shows no appreciable improvement over World War I experience. However, a comparison of the Army in continental United States and in the European Theater______
2 Medical and Surgical History of the War of the Rebellion. Medical History. Washington: Government Printing Office, 1885, vol. 1, pt. 111, p. 35.
of Operations, with troops of World War I, is more justifiable and reveals that deaths from diarrheas and dysenteries followed a downward trend in World War II, reasonably reflecting the improved sanitation of America and Europe. During World War II, as contrasted with World War I, a greater proportion of combat troops were sent to tropical or semitropical regions with High endemicity for dysenteric diseases and a low standard of sanitation. The rate of 18 cases per 1,000 strength for the Zone of Interior in World War I is to be compared with 9 cases per 1,000 for World War II (table 54). The enteric disease rate among overseas troops in World War I, approximately 29 cases per 1,000 troops per annum, may properly be compared with the rate among troops in the European theater in World War 11, 14 cases per 1,000 troops per annum. The rates for World War II are about one-half those of World War I. By the same standards, the case rates for typhoid fever dropped in World War If to less than one-tenth of the rates for this disease in World War I for the total Army, and to approximately one-twentieth of the World War I rates for this disease among United States Army troops in Europe. Typhoid case rates among the United States Army at home became an almost insignificant 0.006 case per 1,000 troops per annum. Marked improvement also occurred in respect to the paratyphoid fevers.
In comparing current experience with past Army history of these diseases, due consideration must be given to the fact that earlier data often were based on hospital admissions alone, whereas World War II morbidity statistics include all patients, whether sick in quarters or admitted to hospital. Although reporting is still far from complete, the general level of reporting is better than in former wars. World War II data for common diarrheas are considerably increased by these factors, while the more severe illnesses such as the dysenteries (when diagnosed as such) and typhoid fever are probably little affected, since most patients with these diseases would have been admitted to hospital even in former wars. As a result, more mild cases of diarrheal disease probably have crept into statistical records of recent wars as compared with earlier wars. This factor must be considered in evaluating both incidence of disease and effectiveness of medical care. With the reporting of a larger number of mild cases and better medical care, case fatality rates fell to almost insignificant levels, despite the high morbidity reported in several theaters of operations in World War II. Nevertheless, control of the diarrhea's and dysenteries has not kept pace with that accomplished for typhoid fever.
For the purposes of this analysis, the diarrheas and dysenteries are classified as common diarrheas and dysenteries (protozoal, bacillary, and unclassified) according to the diagnostic. titles set forth in statistical health reports.
diseases distinguished etiologically as either bacillary or amebic dysentery. Diarrhea is the typical symptom, often of sudden onset: and brief duration, and is accompanied by varying degrees of tenesmus and abdominal pain and followed by rapid recovery. The common diarrheas are characterized by an extremely low fatality. The few deaths attributed to common diarrhea are presumably the result of failure to recognize a more serious infection such as bacillary or amebic dysentery. Specific etiologic agents are by definition undetermined.
There conditions doubtless played an important role in the World War II Army and will in the Army of the future. As more becomes known about them, they may become subject to separate statistical analysis, but during World War II their recognition and reporting was not specifically accomplished. Viral etiology was suspected in several theaters, and some attempts that were made to recover these agents are described in this chapter. Such entities during World War II were merely given one or another of the common diarrhea diagnoses or were considered to be cases of gastroenteritis or unclassified dysentery.
Factors Affecting Reporting of Specific Dysenteries
By regulation, the diagnosis of bacillary and amebic dysentery during World War II was contingent on recovery or identification of the bacillus or ameba, a practice that did not hold in former wars. Instances of clinical dysentery associated with pus, mucus, and possibly blood in the stools were designated "dysentery, unclassified," in the absence of microbiologic confirmation. In general, the frequency of etiologic diagnosis of bacillary or protozoal dysentery was a reflection of the amount and quality of laboratory work.
3 Gordon, J. E.: A History of Preventive Medicine in the European Theater of Operations, U. S. Army, 1941-45. [Official record.]
and others 4 as 9.8 percent for the United States and in excess of 50 percent for poorly sanitated regions of the Tropics and subtropics. An even larger number are carriers of protozoa closely resembling E. histolytica. The diagnosis of amebic dysentery was in all probability frequently made when the true infectious agent was an unsought Shigella. Persons without clinical symptoms are known to have been treated with a view to eliminating the Endamoeba, and some were given the diagnosis of amebic dysentery. For these reasons, the incorrect diagnosis of common diarrhea was made less frequently for cases of amebic dysentery than for cases of bacillary dysentery. Small numbers of patients with common diarrheal diseases and shigellosis were in all likelihood erroneously designated as suffering from amebic dysentery. The tendency was to over report amebic dysentery and to under report bacillary infections.
4 Mackie, Thomas T., Hunter, George W., III. and Worth, C. Brooke: Manual of Tropical Medicine. Philadelphia: W. B. Saunders Co., 1945, p. 191.
5 Gilmore, H. R.: Final Report of the Preventive Medicine Officer, Office of the Surgeon, Mediterranean Theater of Operations, U. S. Army, 1 January-31 October 1945. [Official record.]
The most useful approach appears to be a study of diarrheas and dysenteries as a single group of diseases and as they occurred in the several theaters of operations. In the following presentation of analyses, the practical purpose of the study-to provide a basis for future experience in the event that United States troops should again be deployed in the areas involved is kept constantly in view. Bacillary dysentery is given special consideration in this presentation: other specific; diarrheal diseases are presented in separate chapters. Individual attention is given the dysenteries so far as the data permit. Proved cases of bacillary dysentery are a part of this report; amebic dysentery, although given some general consideration here, is the subject of a separate chapter.
6 Fifth Army Medical Service History, 1944.
7 Progress and Final Report, Sub-Commission on Dysentery. Army Epidemiological Board, 20 Nov. 1944.
regularly on the statistical health report. They may not always reflect the changes in diagnosis which occurred during the course of hospitalization. Such data therefore do not tally identically with those derived from statistical tabulations of individual medical records. They do provide an excellent basis for epidemiologic description of the picture as it unfolded in the several theaters of operations during World War II. For such separate consideration as will be given to individual diagnostic entities comprising the group, especially bacillary dysentery (table 59), the major source of statistical data is various tabulations of individual medical records as compiled by the Office of the Surgeon General. In general, admissions data are used for the common diarrheas and incidence rates for the specific and unclassified dysenteries.
During the years from 1935 to 1939 inclusive, Army troops stationed within the United States were a relatively stable population, living under sanitary conditions reasonably comparable to those of better sanitated civilian communities. The incidence of diarrheal disease was low, and rates were remarkably uniform from year to year (table 55). For the decade of the 1930's, incidence rates were within the range of 5 or fewer cases per 1,000 men as illustrated in chart 27. During the latter half of the, period, annual
incidence varied from 2.5 to 3.6 cases per 1,000 per annum and the average was 3 cases.The highest rates were in summer, August being the peak month; winter rates were lowest, with a usual seasonal increase in late spring. Diarrheal disease presented a favorable and stabilized situation.
The incidence of diarrheal disease in troops in the continental United States rose rather sharply to 13 cases per 1,000 per annum for the 2 years 1940 and 1941 (chart 27). These were the years of preparation for war, with more than fourfold expansion of the Army. Raw recruits and untrained men were brought together from all parts of the Nation, and they engaged in active field training and maneuvers. In 1940 and 1941, diarrheal disease rates were 7 cases and 15 cases, respectively, per 1,000 troops (table 54). For the same years, rates for the total Army (both overseas and in continental United States) were also 7 and 15, which shows that the bulk of the problem was in the Zone of Interior rather than overseas. Overseas troops had slightly higher rates of 9 and 17, but less than 12 percent of the average strength of this expanding Army was stationed overseas, chiefly in the Philippines with rates of 27 and 28 cases, respectively, per 1,000 per annum and in the Antilles Department (Latin American area) with rates of 34 and 26 cases, respectively, per 1,000 per annum. The well-established program of sanitation and military preventive medicine in the Panama Canal Department proved its worth, for during these 2 years the rate was 3 cases per 1,000 per annum.
monthly rates were exceeded at one time or another in all tropical or subtropical areas of military operations, with the single exception of the Panama Canal Zone.