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Chapter VIII |
Activities of Medical Consultants CHAPTER VIII India-Burma Theater of Operations Herrman L. Blumgart, M.D., and George M. Pike, M.D.
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
Ending 26 Jan. 1945. 696 SCOPE OF CONSULTANT ACTIVITIES
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 698 MAP 7.-U.S. Army hospitals in Assain, India, and northern Burma. 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.
699 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.
Colonel Blumgart was also responsible for articles or comments on current medical problems in the Field Medical Bulletin. Medical officers were encour- 701 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
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
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
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
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.
communications were
received regarding medical practice and procedure that required
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
702 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.
703 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 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 704 Officer, 9th Medical Laboratory, were of great value in heightening the quality of laboratory work performed.
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. 705
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 706 FIGURE 240.-Recreation hall, 20th General Hospital. 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 much
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
importance. 707
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.
Epidemiologic factors 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 709 CHART 5.-Monthly
admission rates, all causes,
U.S. Army troops in India-Burma theater, January 1943-August 1945 1 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.
to that caused by malaria (chart 9).
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.
AMEBIASIS 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
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 711 FIGURE 242.-Water purification plant at 18th General Hospital constructed by hospital personnel 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.
712 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.
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.
CHART 9.-Noneffectiveness for
and dysentery and for malaria among U.S. Army troops in
the India-Burma theater, by month,
19441 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.
715 FIGURE 243.-20th General Hospital. 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.
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
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
abdomen elicited
characteristic physical signs, leading to a high percentage of correct
clinical diagnoses prior to
the receipt of the laboratory report. In 716 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
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.
717 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).
718 FIGURE 245.-Medical ward, 20th General
719 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:
720 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.
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
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. 721 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,
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,
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
Major Klatskin found they were
able to complete the 12-grain course with no ill effects. He wrote:
The largest dose of emetine administered to any patient was 27 grains, the smallest 6 grains.
722 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.
723 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.
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. Differential diagnosis 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, 725 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
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
gave rise to low-grade,
generalized abdominal pains and diarrhea. The two diseases did
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
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
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. Malaria 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. 726
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
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.
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,
Surgeon, Headquarters, 10th Air Force, to Commanding General, 10th
Air Force, 21 Oct. 1944, subject: Report of Excessive Number of
Cases Within the 843d AAA AW
Battalion. 727
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. INCIDENCE 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. 728 729
Deaths from malaria among U.S. personnel were uncommon, and in each death that did occur cerebral malaria was the cause. 730
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- 731 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.
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: 732 "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.
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
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. RELAPSE RATES 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. 733 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. Clinical aspects
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."
734 FIGURE 247.-73d Evacuation Hospital. A. Receiving office. B. American medical wards. 735 FIGURE 247.-Continued. C. Chinese medical wards. 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. 736 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
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
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.
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.
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
his own views on the
therapy of malaria, which included the use of liquor arsenicalis and
In accordance with instructions received from 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 analyzed, but 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 this therapy.
738 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.
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
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. Arsenicals.
- Arsenicals
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.
DRUG REACTIONS 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. 741 CEREBRAL MALARIA 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.
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.
4. Sedation. - This measure was used universally in excited or convulsive cases. Intravenous Sodium Amytal (amobarbital sodium) and intravenous paraldehyde were used most often. 742 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. Evacuation policy 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.
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. __________ 743 FIGURE 248.-Tick-infested jungle at 23-mile mark along the Ledo Road.
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:
744 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.
745 FIGURE 249.-Brig. Gen. Frank Merrill, USA, Commanding General, 5307th Composite Unit, Provisional, Merrill?s Marauders, with interpreters. 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. 746 FIGURE 250.-Bivouac area at 12-mile mark along Ledo Road. Statistics Incidence. -
11 shows the number of cases per month of scrub typhus in U.S. troops
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
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: 747
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. Clinical aspects 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.
748 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)
Laboratory findings 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. 750 FIGURE 252.-Scrub typhus (Tsutsugamushi disease). Macular eruption characteristic of the disease. 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 751 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
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:
* * * * * * * * * * * * 752 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:
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.
753 General
Hospital, only 12 patients had convulsions; coma occurred in 14 cases.
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.
755 FIGURE 253.-Continued. C. Interior view of an air-conditioned ward. which in other illnesses would be expected to
beneficially affect dehydration, will most frequently be found to fail
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. 756 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.
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.
757 FIGURE 254.-Typical tropical ulcer or Naga sores. 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
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.
758 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. Clinical manifestations
Complications 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.
760 began with paresthesia (numbness and tingling of hands or feet or both). Later, there was a diminution in perception of light touch and pain.
nerve involvement was usually followed by moderate or very severe
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.
761 128 negative cultures and 1 morphologically positive, but avirulent, culture. Cultures from the rice paddies, considered a possible source of infection, were uniformly 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.
_________ 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. 762 Fever of Undetermined Origin Diagnostic problem 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.
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
763 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.
764 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.
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.
765 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.
Hookworm Infestation 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 _______ 766
767 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.
768 centration techniques. Not a few diagnostic mysteries, temporarily residing under the designation of dyspepsia or psychoneurosis, were classified by carrying out these simple measures. Filariasis
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.
769 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.
Lead Poisoning 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 770 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:
771 7. Pumping units refuelled every 6 hours with gasoline carried over from storage tanks in 5 gallon cans.
Skin Diseases 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.
772 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
Dhobie-mark dermatitis.12 - This was one of the surprising
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.
_________ 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. 773 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.
______ 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. 774 FIGURE 256.-Burmese nurse bandaging infected leg of Chinese soldier. 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
_________ 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). 775 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:
__________ 16 Wolkin, J., Goodman, J. I., and Kelley, W.E.: Failure 776 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.
_________ 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. 777
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."
_________ 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. 778 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.
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. 779 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.
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. 780
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. Respiratory Diseases 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. 781 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. 782
Primary atypical pneumonia With the onset of warm
weather in this theater, the increased prevalence of respiratory
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. -
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 783 CHART 15.-Monthly
incidence rates for primary atypical pneumonia in U.S. Army troops in
India-Burma theater, January
1945 1
In considering the epidemiology of this
outbreak, it should be mentioned that the usual criterion for admitting
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
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 784 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."
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:
786 theater in March 1942. On 30 May 1942,
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
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 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. 788
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.
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 790 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.
TABLE 11.-Incidence of
poliomyelitis in
U.S. Army troops, India-Burma theater, by month and
year, 1942-45 1 791 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.
792 TABLE 13.-Incidence
of paratyphoid fever in U.S. Army troops in India-urma theater, by
month and year,
1942-45 1 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.
793 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. Smallpox The 1939 annual report of
the Public Health
Commissioner of India on smallpox begins as
follows: "The epidemiological statistics published by the League
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
children, a result of the
inefficient enforcement of vaccination. An epidemic year was
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
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
contacts with both the native
Indian population and the Chinese troops. 794 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.
Cholera 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
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
made an uneventful
recovery. 795
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. Melioidosis 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
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
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
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). Leishmaniasis 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.
797 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
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,
in some instances of this infection the diagnosis was missed.
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.