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Chapter 3, Part 4

Medical Science Publication No. 4, Volume II



Enteric infections, particularly bacillary dysentery, historically are diseases of major importance to confined population groups. Epidemics repeatedly occur aboard ships, in institutions for mentally defective and mentally ill, jails, orphanages, and prison camps. Experience with dysentery in the United Nations prisoner-of-war camp in Korea followed this historical pattern. After the landings at Inchon and the breakout of United Nations Forces from the Pusan perimeter had occurred, a large number of prisoners of war were gathered. During the winter of 1950-51 these people were concentrated under the care of the South Korean Army near Pusan, while a semi-permanent camp was being constructed on the island of Koje, 20 miles south of Pusan. During that winter epidemic disease was a major problem, and enteric infections including bacillary dysentery, amebic dysentery, and Salmonella infections were responsible for a high rate of morbidity and mortality

After the prisoners were transferred to the improved facilities of the prison camp at Koje, diarrheal disease continued to be one of the major problems confronting the medical authorities responsible for the care of the prisoner group. The ultimate care of the patients with diarrheal disease, particularly due to Shigella organisms, was complicated by the fact that the majority of the cases were caused by organisms which were sulfonamide-resistant. At that time salfonamides were the only specific anti-bacterial agents available to the clinical personnel. As a result, these diseases created a problem which required that an effort be made to determine the ways in which enteric diseases were transmitted through this specific camp, and to evaluate other antibiotic drugs so that the infections could be brought under control. The severity of the epidemic encountered presented an unusual opportunity to conduct these investigations.

The studies on the character of the acute enteric infections in the prison camps as well as those on diagnosis and treatment of bacillary and amebic dysentery were carried out by a unit known as the Joint

*Presented 27 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington,
D. C.


Dysentery Unit and were under the sponsorship of the Commission on Enteric Infections of the Armed Forces Epidemiological Board. The persons participating in this study came from the United States Army, the United States Navy, the United States Public Health Service and civilian laboratories. This unit operated in the facilities of the Sixty-fourth Field Hospital which was responsible for the care of the prisoners in the Koje Island Camp.

To understand why enteric disease was such a problem in the camp and to establish the pattern of its epidemiology several factors must be evaluated: (1) the physical characteristics of the camp itself; (2) patterns of routine living within the camp; (3) the prevalence of individuals who carried pathologic organisms in their stools.

The prisoner-of-war camp at Koje was composed of a number of enclosures within which was a series of compounds. Each compound was an autonomous unit unto itself, and was divided as a military unit into battalions and companies. The compounds varied in size; there were 1,000 to 10,000 men per unit. The men were housed in tents or adobe mud huts, and because of limited space crowding was a major problem. As many as 90 men were housed in a single squad tent and often 350 men lived in one adobe hut. They slept on straw mats. Each man was issued three or four woolen blankets which he alone used. These blankets were aired every day. Toilet facilities were crude. The usual method of disposing of excreta involved the use of large portable buckets which were emptied several times a day into the sea. Washing facilities also were inadequate, although the men attempted to improvise methods for bathing and hand washing. Some of these devices were both ingenious and workable. The majority of the prisoners in the compound, however, did not have the advantages of such improvements and hand washing following defecation was rare.

Food for the entire compound was prepared by a group of food handlers in a large central kitchen. The primary items of diet were boiled rice, a soup made of vegetables, meats and spices, and a fish sauce which was added to the rice. After being prepared in the central kitchen the food was taken in large 10-gallon cans to the various feeding lines. There it was ladled into each man's bowl or dish, which had previously been dipped into boiling water. Individual battalions had their own feeding lines. Therefore, there were as many as five or six different areas of food dispersal in each compound. The foodstuffs were supplied by the U. S. Army Quartermaster Department, except for some vegetables which were purchased from the local market. Water, brought to the compound in large cans and tanks, was obtained directly from the reservoirs, and was well chlorinated and filtered. The same reservoirs supplied the mili-


tary staff of the camp and little or no dysentery was seen in this group, although mild diarrhea was common.

An important contributing factor to the presence of enteric disease was the high endemic level of infection among the prisoners at the time of their capture. Routine studies of random groups of prisoners in the compound revealed that from 3 to 6 percent of them, most of whom were clinically well, harbored Shigellae in their stools. About 3 percent of them harbored the cysts of E. histolytica. One group of 1,000 Chinese prisoners was cultured immediately upon arrival at the prison camp. Eight percent were found to be infected with pathogenic Shigellae. Examinations of stools of men who were involved in the handling of food were also done. The incidence of E. histolytica cysts or pathogenic Shigellae in this group was comparable to that in the general population of the compound.

No one factor could be incriminated as the primary cause for the spread of enteric infections in this camp. The lack of proper toilet and bathing facilities was, of course, considered to be of importance. The open toilet cans were easily accessible to flies. However, the incidence of enteric disease was lowest during the summer when flies were most numerous and highest during the winter when they were most scarce. Accordingly, crowding was considered to play a more important role. It appeared likely that infected mucus from the hands, clothing or skin of infected persons could be easily passed to the hands of neighbors in the crowded bathing areas, tents and huts.

Numerous attempts were made to incriminate food as the source of infection, but no evidence could be obtained to substantiate this possibility. Studies made of the temperatures of the food at the various feeding lines, 3 to 4 hours after cooking, revealed that most of the food was maintained at temperatures well above those needed for pasteurization. Bacteriological examinations of food and of water were also consistently negative for pathogenic organisms. Epidemiological observations likewise seemed to eliminate food as the source of infection. Outbreaks within a compound tended to be localized to battalions or even to tents, suggesting local transmission rather than origin from a central source.

The clinical characteristics of the enteric diseases encountered were varied. The incidence of diarrhea was extraordinarily high. Dispensary statistics indicated as many as 5,000 to 10,000 cases per 1,000 individuals per year, and many men never reported to sick call. The majority seeking treatment complained of simple watery diarrhea associated with few abdominal cramps, mild tenesmus and the passage of small amounts of mucus in the stools. These patients were seen by the Korean physicians in the compound dispensaries, were treated with supportive measures, and were usually asymptomatic in 2 or 3


adays. Some, however, did not respond to this treatment. Their diarrhea tended to increase, as did the severity and frequency of their abdominal cramps. Fever appeared and was usually followed by the onset of bloody, purulent dysentery. Individuals with such symptoms were transferred to the Sixty-fourth Field Hospital for further diagnosis and specific therapy. The majority were found to have Shigella infections. About 10 percent had dysentery due to E. histolytica, and a smaller group were infected with Salmonella organisms.

Many of the patients with the milder form of diarrhea were also found to be suffering from bacillary dysentery. Cultures were taken from random patients who reported to the daily sick call in the compound complaining of diarrhea; 25 to 60 percent were positive for pathogenic Shigellae.The response of this group of patients, however, clearly indicated that mild bacillary dysentery is a self-limited disease. Only those patients with the more severe form of the disease required specific therapy. Because sulfonamides failed to control many of the most fulminating infections, a clinical study was undertaken to evaluate the effectiveness of the newer broad-spectrum antibiotics.