Activities of Medical Consultants
CHAPTER VIII
India-BurmaTheater of Operations
Herrman L.Blumgart, M.D., and George M. Pike, M.D.
The problems confronting the U.S. Army Medical Department in USAFIBT (U.S. Army Forces, India-Burma Theater) can be understood only in relation to the environment in which the personnel of this theater worked. The climate, the lack of modern sanitation, the wild and primitive regions of the Stilwell Road (formerly Ledo Road) country in which some units operated, and the close proximity of the native Indian population in other areas created peculiar, if not unique, medical problems. Few, if any regions excel India and Burma in the variety and profusion of disease. One million persons die annually of malaria while a hundred million suffer clinical attacks yearly, and 250,000 die of pulmonary tuberculosis, according to the most reliable estimates available. Endemic foci of the three major plagues--smallpox, cholera, and plague--constantly smolder in India and are among its principal medical exports. Each and every one of these factors posed particular medical problems or influenced professional policies and must be appreciated in any review of medical problems in this theater.
The China-Burma-Indiatheater was establishedon 15 March 1942, and U.S. troops on theAsiatic mainland were designated USAFCBI (U.S. Army Forces inChina-Burma-India). Lt. Gen.(later General) Joseph W. Stilwell, USA, and Col. (later Brig. Gen.)Robert P. Williams, MC,were assigned as Commanding General and Surgeon, USAFCBI,respectively. At that time, only3,000 U.S. military personnel, chiefly Army Air Forces, were stationedin the theater, whichincluded, generally, China, French Indochina, Thailand, Burma, andeastern India. The theaterexpanded rapidly. In October 1944, it was divided into the USAFCT(U.S.Army Forces, ChinaTheater) and USAFIBT. While, of necessity, this chapter includesobservations concerningactivities in the USAFCBI theater, it deals primarily with USAFIBT.
When Lt. Col. (later Col.)Herrman L.Blumgart, MC (fig. 239) arrived as Consultant inMedicine, USAFIBT, on 28 January 1945, the total bed capacity of thegeneral, station, field, andevacuation hospitals (maps 6 and 7) in the theater was 19,772, and 512medical officers wereassigned the care of 9,819 patients. From a humble organizationin1942, the Medical Department in the theater had expanded to anorganization of approximately 14,000 officers and men.1
1 Report,Headquarters, USAFIBT,subject: Operational Data; Medical Department Facilities, IBT, 4-WeekPeriodEnding 26 Jan. 1945.
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SCOPE OFCONSULTANT ACTIVITIES
The primary mission of Colonel Blumgart in this already established headquarters team can be simply stated. It was to improve the quality of professional medical care by recommendations to the Surgeon, USAFIBT. Generally speaking, this mission was carried out by activities that fell into the following four groups: (1) Formulation for the Surgeon's approval of general overall policies affecting medical care, (2) formulation of specific recommendations to the Surgeon to correct defects in medical care common to various installations visited, (3) on-the-spot correction of irregularities and deficiencies observed during visits to hospitals, and (4) consultation regarding local professional problems. These four activities hardly ever existed separately, one being almost always influenced by another. In the matter of assignment of personnel, for instance, the overall distribution of medical officers necessarily conformed to the existing tables of organization and the total number of officers in various categories available in the theater. On the other hand, the individual assignment of such officers, and reassignments from one hospital to another when necessary, were frequently determined by observations, made during the med-
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MAP 6.-U.S. Army hospitals in India.
ical consultant's visits, on thequalifications of each officer and the needs of each hospital.
Activitiesat Headquarters
Colonel Blumgart spentsomewhat less thanhalf of his time in the Office of the Surgeon,Headquarters, USAFIBT. Here, many activities claimed hisattention as amember of the Surgeon's staff. Diseases cannot becompartmentalized; formulation ofmany policies and actionon many problems
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MAP 7.-U.S. Army hospitals in Assain,India,and northern Burma.
required coordination of theneuropsychiatric, surgical, and medical consultants' opinions. Manymatters primarily the concern of the Preventive Medicine Section or ofthe Personnel Section inthe office were referred to Colonel Blumgart for comment andcoordination. The preparation ofthe section on medicine in the ETMD (Essential Technical Medical Data)reports; the review ofall publications on medical subjects submitted to the Surgeon, USAFIBT;the preparation ofmaterial on current medical problems for the Surgeon's monthly FieldMedical Bulletin; thepreparation of theater circulars, Surgeon's circulars, and memorandumson professional medicalsubjects; the review of clinical records and post mortem findings inall deaths due to medicaldisease--these activities claimed most of Colonel Blumgart's time whileat headquarters.???
Coordination with neuropsychiatric consultant. - The professional problems that concerned the neuropsychiatric and the medical consultants were particularly closely-related. In all medical conditions for instance, the significance of the symtoms to the patient is important; a 'stitch' in the chest if it occurs near the heart may lead to invalidism and days lost solely because of the patient's fear of heart disease or of pulmonary tuberculosis. In other conditions, such as dyspepsia with its manifold manifestations, the symptomatology may represent 'body language' expressing the patient's emotional difficulties. Prolonged duty in this noncombat theater under the hardships of
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the extremely variable climate of Indiaproved to be emotionally wearing. Because medicalofficers themselves were not immune to these stresses and strains, theyfrequently were resentfulof such reactions in their patients and their ability to deal with themsympathetically was reduced.
The proposal to havesimultaneous visits bythe neuropsychiatric and medical consultants to thevarious installations in the theater in order to emphasize the dualapproach met with approval bythe Surgeon, USAFIBT, and proved to be of inestimable value in propertreatment and salvage ofmany patients. The educational value of joint ward rounds, to themembers of the hospital staffinculcating on them the significance of psychosomatic medicine and theimportance ofimmediate therapy, was evidenced by the lively discussions that werealmost always evoked. The major amount of each consultant's timewasspent on the more specific medical andneuropsychiatric problems. At most of the installations,conferenceswith the staff were heldjointly by the two consultants to delineate the fundamental concepts ofdiagnosis and therapy inpsychosomatic medicine, always using as a text specific cases seenduring ward rounds.
???This arrangement was found to he highly effective. It worked well because the neuropsychiatric consultant was firmly grounded in the field of internal medicine and the medical consultant had some knowledge of psychiatry. To eliminate loss of time and energy on controversial points during conferences, the two consultants had achieved a common approach and general agreement. In addition, the medical consultant, interested in the more purely medical aspects of disease, actively participated in the conferences, and the neuropsychiatric consultant utilized his extensive specialized experience in answering questions at issue. All these factors helped to demonstrate to advantage the interrelationship between the two fields.
Coordinationwith preventive medicine officers. - Many of the preventivemedicine activities in the theater wereclosely related to internal medicine problems. Almostdaily, informal conferences were held between Colonel Blumgart andvarious officers in thePreventive Medicine Section, Office of the Surgeon, Headquarters,USAFIBT. The statisticalaccuracy of the incidence of diseases depends in the first instance onthe accuracy of clinicaldiagnosis. In a theater in which constant watchfulness had to beexercised for diseases such assmallpox, cholera, schistosomiasis, filiariasis, and kala-azar,particular caution in differentialdiagnosis was essential. Accordingly, Colonel Blumgart reviewednumerous case records andrendered many opinions. The initiation of Atabrine (quinacrinehydrochloride) suppressivetreatment for malaria likewise raised medical problems in respect tovarious manifestations ofAtabrine toxicity and to the incidence, treatment, and administrativedisposition of the affectedindividuals. One of the most pressing problems in the theater wasthehigh incidence of diarrhealand dysenteric diseases, particularly amebic dysentery. As willbeshown later, an integratedapproach to this entire problem was accomplished only by the closelycoordinated efforts of thepreventive medicine officers and the medical consultant.
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Personnel management. - Basic to all other considerations in achieving a high standard of medical care was the question of personnel. U.S. Army medical officers as a group represent a cross section of the Nation's medical profession. The number of highly trained specialists was decidedly limited, as well as the number of general internists qualified to be chiefs of medical services or heads of sections. The personnel records of educational training and postgraduate medical experience are not a sure index of proficiency. For instance, certain medical officers with a wide range of medical knowledge, some of whom had been qualified by an American specialty board, lacked sound, conservative, clinical judgment; others lacked necessary qualities of leadership. Conversely, other medical officers with little postgraduate training, who nevertheless had maintained an active interest in scientific matters during years of general practice, were found fully qualified to be chiefs of medical services at 250 or 500 bed station hospitals. Appraisal of the intrinsic qualifications of the medical officers could be made only on the basis of personal observation during actual ward rounds. Colonel Blumgart spent at least one or more hours with each officer on the wards reviewing in detail physical findings, clinical records, and treatment and administrative disposition of patients. Informal discussions of related general subjects such as infectious hepatitis, dengue, chemotherapy, and the significance of various laboratory procedures formed part of such visits. This personal evaluation by Colonel Blumgart and a review of each medical officer's personal records served as the basis for the proper assignment to each officer of a classification number and rating and made possible a full utilization of each officer's capabilities. In some instances, personality clashes rendered an officer's services ineffective at a particular installation and could be obviated by his assignment elsewhere. The Surgeon, USAFIBT, emphasized the importance of a personal evaluation of each medical officer by Colonel Blumgart and directed that the personnel officer consider Colonel Blumgart's opinion before effecting transfers and assignments. This appraisal of officers by the consultant proved helpful to the personnel officer, who was confronted constantly with shifting needs consequent to the departure or arrival of medical officers.
Editorial duties. - Colonel Blumgart was responsible for the preparation of the section on medicine in the ETMD report, submitted monthly to the Surgeon General's Office. It was found that the reports submitted by the hospitals had become routine and lacked material of medical interest. The Surgeon, USAFIBT, addressed a communication to all the installations in the theater as well as to the headquarters of subordinate commands stating the type of information desired. During a visit of Colonel Blumgart to the various installations, further effort was made to stimulate studies of groups of unusual cases, such as kala-azar, atypical pneumonia, and cerebral malaria. Much valuable material was thereby accumulated. Colonel Blumgart reviewed all medical articles submitted to the Surgeon, USAFIBT, for publication.
Colonel Blumgart was alsoresponsible forarticles or comments on current medical problems inthe Field Medical Bulletin. Medical officers were encour-
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aged to submit reports on their studies, andmany of these were published. The Field MedicalBulletin also provided a valuable means of conveying informationregarding recent advances inmedicine. Various irregularities or deficiencies, such as failuretocomply with certain directivesor misunderstandings regarding the intent or meaning of others, werecorrected by appropriatebrief notes. In some instances, where no suitable official guidesordirectives were available,appropriate circulars or memorandums were submitted to the Surgeon,USAFIBT, for approvaland then distributed. A more detailed account of such directivesisincluded later in this chapterin discussions of the various diseases of particular interest in thistheater.
Review of clinical records and post mortem findings - Soon after Colonel Blumgart's arrival in the theater, the Surgeon, USAFIBT, approved the request that complete clinical records and results of post mortem examinations for nonbattle casualties be submitted to headquarters for review. This proved to be an exceptionally valuable procedure. By this means, theater headquarters was kept informed of some of the most interesting cases, medical care of the most seriously ill was reviewed, and occasional suggestions or deficiencies were noted. These facts were made the subject of correspondence, or, more often, a conference with the hospital staff was held on Colonel Blumgart's next visit to the installation. It is believed that this procedure also had anticipatory value as it was generally understood by medical officers that the clinical record of any seriously ill patient would eventually be scrutinized in the theater Surgeon's Office.
Otheractivities. - In addition to the main duties just outlined, manymiscellaneous activitiesoccupied Colonel Blumgart's time while he was at headquarters. Manycommunications werereceived regarding medical practice and procedure that requiredreply. In addition, the availablecurrent periodicals, ETMD reports from other theaters, and otherreports were constantly scannedin order to maintain professional medical standards abreast of currentadvances.
Activities in the Field
Colonel Blumgart's activities in the field have been indicated as ramifying from his activities and relationships at headquarters and will be described in more detail here.???
During the 9 months he spent in the India-Burma and China theaters, the author spent somewhat more than half his time in traveling more than 40,000 miles in field visits to the various installations, although, as much as possible, the visits were grouped to conserve time. Many dispensaries were visited, but only a few of those of the Army Air Forces could be seen during his period of duty.
The isolation arising fromthe widedispersion of units and the poor lines of communicationmade it the more important for Colonel Blumgart to be regarded as atwo-way ambassadorbetween the theater surgeon and the installations, interpreting theaterpolicy locally andacquainting theater
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headquarters with the problems confrontingthe officers in the field. For the most part, medicalofficers had had no opportunity to discuss professional matters withanyone other than theirimmediate associates and had but little information regardingexperience with comparableproblems at other installations. The opportunity to display theirownaccomplishments was animportant morale factor. Colonel Blumgart himself had had littlespecialized training orexperience in the field of tropical medicine, but the clinicalexperience gained during initial visitsto some of the large installations together with collateral readingremedied this deficiency. Atmany installations, the experience and ingenuity of the medicalofficers provided constructivesuggestions that could be transmitted to the officers at otherinstallations. This function ofColonel Blumgart as a medium for exchange of ideas was probably one ofhis chiefcontributions. The confidence of hospital personnel in hishelpfulintent having been established,Colonel Blumgart's suggestions were accepted without resentment. Insome installations, therewas a surplus of medical talent; 2 or 3 highly able internists wereserving in a 200-bed hospital. In others, no internist with extensive knowledge and sound,conservative, clinical judgment hadbeen assigned. These instances were, however, few and werereadilyrectified by personnelreassignments.???
Training and education. - The scarcity of medical officers sufficiently skilled and personally qualified for positions of responsibility and leadership made it imperative that hospitals be considered as training centers. Thus, pivotal personnel lost through illness or rotation could be replaced. It was found that many young medical officers who were products of the emergency accelerated program of civilian medical education had considerable innate ability but meager clinical knowledge or experience. Whenever possible, such officers were assigned to duties under the immediate supervision of mature, seasoned clinicians and, after varying periods of time, were qualified to be chiefs of small station hospitals or heads of sections at general hospitals.
The criteria for diagnosisof disease and thetherapeutic regimes that were employed variedgreatly from hospital to hospital and indeed from ward to ward. Thiswas due to the fact that themedical officers--men with widely different types of training,experience, and personalviews--had not received the fundamental directives and guides issued bythe Surgeon General'sOffice. Few, if any, TB MED's (War Department technicalbulletins,medical), had beenreceived, and but few overall professional policies had beenestablished in the theater. To raisethe quality of medical care to the highest possible level, eachinstallation was directed to preparea list of the TB MED's it lacked, and adequate distribution waseffected. It was further directedthat a complete file of such bulletins as well as theater surgeon'scirculars, be maintained by thecommanding officer and by the chiefs of medical and surgicalservices. In the instance of somediseases such as amebiasis, which constituted one of the major problemsin the area, a theaterdirective was issued, since none had been made available by the SurgeonGeneral's Office. Every effort was made to encourage faithful adherenceto all directives.
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The consultant attemptedto stimulateprofessional interest by recommending the establishmentof a suitable reading and conference room in each installation, evenwhen a tent had to be erectedfor that purpose. Steps were undertaken to supply eachinstallationwith its authorized allowance of books and periodicals. Throughthe generosity of theJosiah Macy, Jr. Foundation,New York, N.Y., reprints of outstanding articles appearing in currentmedical periodicals weredistributed to the medical officers in this theater. By informalcommunication between theSurgeon, USAFIBT, and the medical director of the foundation, Dr. FrankFremont-Smith,material particularly relevant to the medical problems in India andBurma was made available. By this means, medical officers were encouraged to keep abreast ofadvancing medicalknowledge.?
In addition, medical officers were urged to review series of cases at their own installations and to prepare reports summarizing their experiences. In some instances, these reports were used solely as the basis for a talk at one of the medical conferences; at other times, they were found suitable for publication in the Field Medical Bulletin or even in current leading periodicals in the United States. A schedule of at least one medical conference a week and one grand ward round for the discussion of the most interesting and perplexing cases was established at the various hospitals. The value of such an educational program in improving medical care, in heightening the professional interest of the medical officers, and consequently in raising morale was gratifyingly evident. The numerous reports received from these installations were of invaluable assistance in obtaining a comprehensive knowledge of diseases peculiar to this theater.
Visits to hospitals. - The major portion of the time spent at each hospital by Colonel Blumgart was utilized in a careful review of medical practice on each of the wards. In the smaller installations, each patient was examined, the clinical records reviewed, and the clinical management discussed. In the larger installations, with a census of approximately a thousand patients, this was manifestly impossible. On each of the wards, however, at least five cases were spot checked; all patients with a fever of 101o F. or more were reviewed; and the seriously ill were examined, as well as any additional ones requested by the medical officers.???
In addition to the visits on the medical wards, an hour or more was usually spent in the laboratories. In some installations, the monthly report of the laboratory substantiated the impression on ward rounds that an excessive amount of laboratory data had been requested. This practice tended toward poor quality of laboratory work with occasionally misleading inaccuracies. In other instances, laboratory tests necessary for diagnostic purposes were omitted. General criticisms of such deficiencies were never expressed, however, until the indications and contraindications for such tests in the individual patient were pointed out at the bedside. Visits to the laboratories of the hospitals by Lt. Col. (later Col.) Howard A. Van Auken, MC, Commanding ???
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Officer, 9th Medical Laboratory, were ofgreat value in heightening the quality of laboratorywork performed.
The inspection of the X-ray department properly fell within the province of the surgical consultant, but Colonel Blumgart always made a visit in order to coordinate the activities of this department with those of the medical service. (During World War II, the radiology service in an Army hospital was frequently under time overall jurisdiction of the chief of surgery.)
At a few installations, itwas observed thatthere were too many consultation requests from oneservice to another, particularly at some of the general hospitalswhere, at times, such complaintsas headache led to a request for neurological consultation, backachefor orthopedic consultation,and precordial ache for a cardiac consultation. It was emphasizedthatsuch practice results in butlittle benefit to the patient when required of a specialist deluged byimpossible demands on histime. Time and effort were conserved by the proper use ofconsultationforms. The necessity forexplaining on such forms the purpose of a consultation prevented theexpenditure of muchfruitless effort by Colonel Blumgart. The presence of the wardofficerin charge of the patient atthe time of consultation was urged so that the medical consultant couldconfine himself to thepertinent issues and resolve any differences of opinion with themedical officer in immediatechange?
Clinical research. - The promotion of clinical investigation was considered an important function of Colonel Blumgart. A study of disease may appear at first somewhat remote from the primary mission of improving the quality of medical care, but the novel medical problems peculiar to wartime, particularly in a theater such as India-Burma, raised many issues concerning which there were no guideposts from prior experience. Clinical investigation had to be undertaken to answer such questions in order to provide the best medical care. The type of investigation that could be fostered was limited by certain definite factors but was favored by the rich clinical opportunities that were available. Any study had to be relatively simple and conform to the exigencies of time available to the medical officer from his immediate compelling clinical responsibilities. Observations had to be made by means of techniques readily at hand. The possibility of transfer of officers to another assignment made it imperative that any investigation should be undertaken by a group whenever possible. Some of the time, Colonel Blumgart acted as instigator in these research projects, while at other times he merely facilitated the progress of the study. Some investigations were initiated at the bedside when, during discussions on ward rounds, a question arose that required research to provide the answer.
It was important thatfruitless energy shouldriot be dispelled in clinical investigations. To thisend, it was emphasized that no research project should be undertakenwithout approval of theproper authority, that a definite protocol of the proposed study shouldbe submitted to the chief ofservice, and that the advice and assistance of the office of thetheater surgeon should be utilized.
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Assisting to establish contacts between officers at the different installations, making available technical assistance from the theater laboratories and other sources, and guiding the progress of investigations were functions that the medical consultant found interesting and gratifying.
Reports to headquarters. - At the conclusion of each field trip, Colonel Blumgart submitted a report to the theater surgeon summarizing the conditions at each installation and making recommendations for improvement. The procurement of basic statistical and personnel data was facilitated by the use of a form which was given to the commanding officer of each hospital on Colonel Blumgart's arrival and was returned completed to Colonel Blumgart within from 24 to 48 hours. The form provided space for information on the number of medical personnel, by corps, on each service in the hospital; the number of patients in the hospital's reconditioning program, the number sent to the Zone of Interior in a specified period of time, the number on the medical service and the length of hospitalization, the number acted on by the disposition board, transferred to other hospitals, and being retained in the hospital for other dispositions; the name, duties, and patient responsibility of each officer on the medical service; the number of admissions to the hospital and the medical service for a specified period, including breakdowns for admissions for diarrhea diseases, fevers of undetermined origin, and venereal diseases; and finally, the number of deaths on the medical service for a specified period, with a breakdown by date, diagnosis, and race (United States or Chinese).
CONSIDERATIONS IN DIAGNOSIS OF DISEASE
Medical practice in a tropical and subtropical theater such as India-Burma requires not only new knowledge but also a reorientation in processes of reasoning in arriving at a diagnosis and presents novel considerations in respect to treatment.?
1.. Effects of climate. - The consistently high temperatures prevailing in many parts of this theater, together with the meager recreational facilities and the isolation of many of the posts, had a profound effect on medical personnel (fig. 240). Even in the relatively brief experience of Colonel Blumgart-- somewhat less than 1 year--it was striking to witness alert, energetic, enthusiastic medical officers gradually 'flatten out' during the second monsoon of their stay. The same influences were apparent in many of the patients hospitalized for psychosomatic complaints, such as headache, backache, and dyspepsia.
Heat exhaustion and heatstroke were notprevalent and constituted a relatively minor problem. During the hot humid months of the monsoon season, oral afternoontemperatures as high as 100oF. in apparently healthy malesand as high as 100.4o F. in femaleswere observed innonhospitalized personnel engaged in routine activities. Thesubjectshad been in the area 4months and therefore had had ample opportunity for acclimatization.Similar
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FIGURE 240.-Recreation hall, 20th GeneralHospital.
elevations, in the absence of anyexplanation other than the climate, were observed in the wardsof hospitals.???
The widespread use of sulfonamides, 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 to saline purgatives or to intercurrent vomiting and diarrhea at times assumed considerable importance.
2. Diagnostic reasoning. - Prevalenceof diseases infrequently or never seen in the United Statesnecessitated acquisition of new knowledge by all medical officersentering this theater from theZone of Interior. Within the theater, certain diseases wereespeciallyevident in particular areasand, consequently, epidemiologic considerations were important inarriving at a diagnosis. It wasessential to know the geographic and the seasonal distribution ofdisease; one was required toknow how, when, and where to expect to encounter variousconditions. Sandfly fever wasparticularly likely to occur in Karachi, India, and Gaya, India, denguein Calcutta, India, cases ofhookworm along the Stilwell Road, and mite typhus in certain areas inthe Ledo district. Ahistory of having made the railroad journey from Bombay to Calcutta inthe early
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stages of the war was presumptive evidence of amebiasis in patients with gastrointestinal symptoms.?
The prevalence of acute febrile diseases posed particularly perplexing problems in patients entering hospitals with fever. At the onset, one commonly was unable to make a diagnosis unless the blood smear was positive for malaria. A patient with malaise, fever, and symptoms similar to influenza in the United States might turn out to have anything from malaria to infectious hepatitis, scrub typhus, or kala-azar. The problem was not made easier by the great variety of clinical manifestations of dengue and sandfly fever.
In the Zone of Interior,one is usually moreaccurate in ascribing all of the patient's signs andsymptoms to a single disease entity. In the India-Burma theater,however, a multiplicity ofdiagnoses was frequently indicated. A patient with any febrileillnesscould suddenly developchills and fever representing the activation of subclinical malarialinfection. Vague gastrointestinal complaints, not a prominentpart ofthe clinical picture, might represent chronic amebiasis. Laboratory diagnostic procedures were an indispensable aid and placed apremium on a well-staffed laboratory department.???
The challenging aspect of internal medicine in the India-Burma theater was well described in the following extract from a personal communication from Lt. Col. James E. Cottrell, MC, Chief, Medical Service, 142d General Hospital, Calcutta, India:
We are always taught, inthe United States,to hunt for a single diagnosis which will explain all the features ofthecase. On the other hand, in this country, we must always considerthepossibility that the patient has two or morediseases, and be on watch to find the others that we have not yetdiagnosed. I have myself seen a man brought infrom the Burma jungle with the following combination: malaria, scrubtyphus, amoebiasis, bacillary dysentery, anduncinariasis. Equally impressive combinations of diseases are notuncommon in Chinese soldiers.
MILITARYIMPORTANCE OF DISEASES ENCOUNTERED
The extremely high incidence2of the diarrheal and dysenteric diseases and malaria contributed heavily to the theater's noneffective rate. Scrub typhus and cutaneous diphtheria, though less important statistically, hampered military operations because of their occurrence in combat areas and the serious disability they occasioned. Some diseases, such as infectious hepatitis, dengue, and sandfly fever, were under constant scrutiny because of their possible epidemicity, while others, such as poliomyelitis, filariasis, and kala-azar, had a deleterious effect on morale. Certain diseases with considerable incidence in the native population were never encountered in the personnel of the U.S.
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2 Statistical data presented in this chapter are preliminary and are subject to revision on the basis of final tabulations of individual medical records. Statistics have been derived from several sources but mainly from the statistical health reports. From the beginning of the war, through October 1944, data on U.S. Army troops in Burma-India were included in the consolidated reports for the China-Burma-media Theater of Operations. The inclusion in the data of the experience of the troops in China during the early period does not significantly affect the validity of the analysis made in terms of Burma and India because before November 1944 the Army strength in Burma and India represented nine-tenths of the total strength in the China-Burma-India theater.
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Army forces in the theater but constituted a serious potential threat. Thus, not a single authentic case of cholera, yellow fever, plague, or the more unusual parasitic infections was reported; medical personnel were, however, constantly alerted to their possible appearance. In regions where morbidity and mortality from smallpox and typhoid fever were extremely high, the incidence in U.S. Army troops was extremely low.
Diarrhealand Dysenteric Diseases
Epidemiologicfactors
The prevalence of thediarrheal anddysenteric diseases among the indigenous Indian populationmade serious infection inevitable among military personnel unless theywere properly insulatedby appropriate public health measures (fig. 241). The incidence ofdiarrheal and dysentericdiseases in India is largely due to some of the followingfactors: Thewater supply is frequentlypolluted; the habits of the native population are grossly insanitary;night soil is frequently used asfertilizer; contamination of food by flies and other insects is likelyto occur; the hightemperatures prevailing during most of the year favor food spoilagebecause refrigerationfacilities are meager; and, even in installations where ice ismanufactured, the ice itself isfrequently polluted by fecal discharges. The long supply line tothetroops in this theater
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CHART 5.-Monthlyadmission rates, all causes,U.S. Army troops in India-Burma theater, January 1943-August 1945 1
and the necessary reliance on canned articlesled to a monotonous diet and increased tendency ofsoldiers to frequent civilian establishments. Although thelow-casteIndians employed in Armymesses often lived in fairly favorable sanitary surroundings adjacentto the military area, most oftheir insanitary habits were unaffected by contact with U.S. Armypersonnel. The Indians hadspent their lives in an environment in which defecation waspromiscuous, usually taking placenear bodies of water and wells. The use of toiler paper isobjectionable to them, for they considerit an insanitary method of cleansing. They perform anal ablutionafterdefecation, washingthemselves with the left hand and then rinsing the hand with anyavailable water. Soap is rarelyused, not only because it is frequently out of their economic reach butalso because it is oftenmade from animal fat, with which they avoid all contact for religiousreasons. Even those thatcan afford knives, spoons, and forks do not use them, preferring to eatwith their fingers. Theentire family eats from one or two central dishes, all using theirhands in place of tableware. Thelow-caste Indian regards the presence of flies as inevitable as themonsoon rains; swarmsfrequently can be seen resting on prepared food, which may be only ashort fly hop fromexcrement on ground near their dwellings.
The urgent military necessity of sending military personnel into this part of the world did not permit the inauguration of adequate preventive measures from the outset, and it was almost inevitable that diarrheal diseases would constitute one of the most serious medical problems (charts 5, 6, 7, 8, and 9). The noneffective rate caused by the diarrheal diseases in 1944 was very similar
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CHART 6.-Monthlyadmission rates,alldisease, U.S. Army troops in India-Burma theater January 1943-August1945 1
to that caused by malaria (chart 9). Many patients with gastrointestinal disorders undoubtedly continued to serve on active duty, and consequently the actual incidence was probably even greater than the statistics would indicate.
Types encountered
AMEBIASIS
Of the diarrheal anddysenteric diseases,amebiasis presented the most serious problem (chart 8). It was so regarded not only because of its high incidence but alsobecause of its insidiouscharacter, the necessity for early diagnosis and thorough treatment toprevent infection fromspreading, the difficulties of laboratory diagnosis, and theseriousness of the late complications.???
The solution to this problem was along two distinct lines: Prophylaxis and early vigorous action in identifying and treating already infected individuals. The protection of military personnel from infection with Endamoeba histolytica was the responsibility of the preventive medicine section of the theater surgeon's office. The measures undertaken are described elsewhere. In brief, these consisted of providing a clean supply of water (fig. 242), fly control, elimination of native food handlers from Army messes as far as practicable, periodic examination of all food handlers at suitable intervals, inspection of civilian eating establishments and placing unsatisfactory ones out of bounds, surveys of various units to detect carriers, and the supervision of laboratory
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FIGURE 242.-Water purification plant at18thGeneral Hospital constructed by hospital personnel
teams engaged in special studies of thepathogens responsible for the diarrheal diseases.
The importance of some ofthese factors wasillustrated by the experience of various medicalunits in which the incidence of amebic infection soon after arrival inthis theater was alarminglyhigh. For instance, in observations on 833 cases of amebiasis byMaj.(later Lt. Col.) MaxEllenberg, MC, and his associates at the 24th Station Hospital atJorhat, India, it was found thatapproximately 45 percent of the military personnel of the hospitalsuffered from amebiasis soonafter the installation began operations. To curbthishigh rate, all drinking water was boiled, freshvegetables were scrupulously prepared under constant supervision, andnatives were not allowedto enter the kitchens nor permitted to handle any utensils aftersterilization. The entire personnelof the installation was surveyed, and all infected persons weretreated. Instructions in regard topreventive measures were issued and enforced. The incidence ofamebiasis showed a strikingdecrease, and finally not a single case occurred in the personnel ofthis installation in a period ofmore than 6 months.???
Treatment was the province of the medical consultant. At the time Colonel Blumgart was assigned to USAFIBT, the available evidence indicated that more than 25 percent of diarrhea in the region was due to amebic infection. Visits to the hospitals revealed that its manifold clinical manifestations were not appreciated. Brief episodes of watery stools were being diagnosed as
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simple diarrhea, cases of chronic hepatitiswere being diagnosed as psychoneurosis, and thestools of such patients usually were not being examined. It wasnotrecognized that 'DelhiBelly' and food poisoning were frequently amebic dysentery. Theimportance of securing properstool specimens, the technique to be employed in detecting E.histolytica in the stools, and thedistinguishing characteristic of E. histolytica from E. coliand other nonpathogenic endamoebawere not always clearly understood. The therapeutic regimeemployed intreating the patientsvaried not only from hospital to hospital but from ward to ward,according to the medical officerin charge. Appropriate tests of cure were frequently neglected attheconclusion of treatment, andthe followup of patients was woefully inadequate. The medicalconditionof many patients wasnot evaluated after a single course of treatment had beencompleted. Some patients entered otherinstallations because of recurrence or reinfection, and records ofprevious hospitalization werenot available.
The professional medical attack on these problems was along the following three main approaches: (1) Increased accuracy in the detection of cases of
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clinical amebiasis and the identification ofall carriers who entered the hospital because of otherdiseases, (2) improved treatment in order to eliminate the disease inthe individual patient andprevent his becoming a carrier, and (3) followup observation of allpatients in order to be certainthat repeated tests of cure would be made and therapy instituted in theevent of recurrence. Byencouraging reports of the results of the various measures undertaken,improved methods ofpractice were hoped for.
The initial step in this program was the preparation of Circular No. 9, which was issued on 2 April 1945 by the Office of the Surgeon, Headquarters,
CHART 9.-Noneffectiveness for diarrhea and dysentery and for malaria among U.S. Army troops in the India-Burma theater, by month, 19441
USAFIBT. This directive outlined thesalientclinical diagnostic criteria for the various forms ofamebic infection. The pathology of amebiasis and the technique ofstoolexaminations werebriefly reviewed. A section on preventive measures was included.Thevarious complicationsand sequelae of amebic dysentery were delineated. To achievegreatereffectiveness anduniformity in treatment, a conservative basic scheme of therapy wasrecommended for amebiasisin each of its various manifestations including complications andsequelae. This circular was thefoundation of the entire program. The following paragraphselaborate oneach of the three phasesof the clinical problem.
Diagnosis of the disease group. - The first main approach to the problem was by increased accuracy in the detection of cases of clinical amehiasis and of all carriers who entered the hospital because of other diseases. The onset of amebic dysentery is frequently insidious and may be characterized by only vague symptomatology with but slight constitutional reaction. Consequently, the disease was often not diagnosed. It was essential, therefore,
715
FIGURE 243.-20th General Hospital.
to increase the index of suspicion of allmedical officers. The prevalence of diarrhea in militarypersonnel, even in the absence of amebic infection, only added to thedifficulty of diagnosis. Forexample, Capt. Albert Ehrhich, SnC, in a study at the 20th GeneralHospital, Assam, India (fig.243), of the carrier rate in 506 apparently healthy United Statessoldiers who had spent 23months in India, found that of 47 E. histolytica carriers only11 (23 percent) gave a past historyof diarrhea. In the 459 found free from infection, 12. 6 percentgave apast history of diarrhea. This experience was similar to that observed elsewhere in the theater.???
Major Ellenberg and his associates in their study likewise observed that of 486 patients who entered the hospital for complaints directly or indirectly related to amebic infection, diarrhea was by no means a uniformly characteristic diagnostic symptom. Abdominal pains were by far the most frequent complaint (70 percent); actual diarrhea was only half as common. Moreover, the patients with diarrhea rarely had marked frequency of bowel movements. The high incidence of nausea and vomiting (29 percent) and anorexia (26 percent) often led to an erroneous diagnosis of gastritis or of peptic ulcer, as shown in a study on pneumoperitoneum in the diagnosis of deformities of the liver by Clark, Bercovitz, and Jones at the 69th General Hospital, 5 miles northeast of Ledo, Assam, India. In their opinion, examination of the abdomen elicited characteristic physical signs, leading to a high percentage of correct clinical diagnoses prior to the receipt of the laboratory report. In
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this study, abdominal examination typicallyrevealed a tender, squashy cecum; a less tender,palpable, ropy sigmoid; right upper quadrant tenderness; and shocktenderness over the hepaticarea.???
Prominence of some of these symptoms and signs was not uncommonly due to amebic colitis simulating acute appendicitis. The combination of abdominal pain, vomiting, and tenderness of the right lower quadrant frequently resulted in the admission of such patients to the surgical service. The surgeon alert to amebiasis was not readily deceived, for a history of diarrhea, abdominal tenderness over other portions of the large bowel as well, and indurated, tender segments of the large intestine indicated the advisability of stool examinations, proctoscopy, and other diagnostic tests. The presence of amebic colitis was, however, no guaranty that the patient did not also have acute appendicitis and require surgical intervention: The general clinical impression was, indeed, that amebic colitis predisposed the patient to acute appendicitis. It was therefore advised that, when any patients showed convincing signs of acute appendicitis, delay in surgical intervention was not to be countenanced. When, however, the evidence was equivocal, symptoms and signs vague, and continued observation considered safe, a short course of antiamebic therapy often resolved the dilemma.
In the general experience of most observers, physical examination was entirely negative in from one-third to one-half of the patients hospitalized for amebiasis. When physical signs were present, they were frequently not striking and were confined to the abdomen. Increased reliance on stool examinations was, therefore, necessary.?
To insure accurate laboratory diagnosis, it was essential to have well-trained personnel and to maintain close liaison between the medical ward officers and the laboratory. Few well-trained laboratory technicians were available, and as a consequence there were missed diagnoses or, equally deplorable, falsely positive diagnoses. This situation was corrected in time by visits of Colonel Van Auken of the 9th Medical Laboratory to the laboratories of the hospitals in this theater. Laboratory technicians were sent to the 9th Medical Laboratory for a refresher course of several weeks. Steps were taken to supply dispensaries with microscopes and necessary equipment to perform suitable stool examinations. ?
In the larger station and general hospitals dysentery wards were organized, if this had not already been done. A part of the ward was partitioned off and equipped for laboratory studies of stool specimens and sigmoidoscopy. This arrangement favored prompt delivery of specimens; increased the interest and proficiency of the medical officers in the management of the various dysenteric diseases; familiarized the fixed ward personnel with routine techniques, which were consequently carried out with greater dispatch and efficiency; and facilitated employment of the necessary precautions against infection (fig. 244). Such an arrangement had been in operation at the 20th General hospital and was fully described by 1st Lt. (later Capt.) Arthur
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M. Rogers, MC, and Capt. (later Lt. Col.)Kendall A. Elsom, MC, in a report on amebiasis asseen in a general hospital in Assam (fig. 245).
Certain details essential for accuratediagnosis, although generally known, required specialemphasis. Particularly stressed were the importance of repeatedexaminations of fresh stoolsafter saline purgatives if the patient was passing formed stools, thevalue of zinc flotation-concentration method, the importance ofselecting proper portions of the stool containing flecksof bloody mucus for examination, and the invaluable information gainedby proctoscopy. Proctoscopy was not recommended unless adequately skilled medicalofficers were available.Whenever practicable, however, examination of material taken directlyfrom the lesions with a 1-cc. pipette with a small aspirator attachedoften led to more rapid diagnosis and at times revealedamebas despite repeatedly negative stool examinations.
Laboratory examinations ofthe bloodgenerally revealed normal findings, except in cases ofhepatitis and liver abscess when the white count usually was elevated.
The diagnosis of amebic hepatitis or liver abscess was frequently missed by newcomers to this theater. Patients with these conditions at times were hospitalized with vague symptoms and a diagnosis of psychoneurosis. In other instances, amebic hepatitis with or without abscess presented an acute,
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FIGURE 245.-Medical ward, 20th GeneralHospital
severe, clinical syndrome characterized byintense pain in the right lower chest or right upperquadrant, frequently intensified by breathing and occasionally referredto the right shoulder.Chills and fever were common. Physical examination usuallyrevealed atender enlarged liverwith rectus muscle spasm, compression or percussion tenderness,leukocytosis of from 14,000 to24,000, and limitation of motion of the diaphragm revealed by X-ray.Physical signs ofpneumonitis were not uncommon. A prior history of dysentery wasfrequently unobtainable, andstool examinations were often negative for E. histolytica. Some patients complained solely ofepigastric pain and other symptoms not usually associated with hepaticpathology. Simulation ofpeptic ulcer, gall bladder disease, bronchopneumonia, or pleurisy wasnot rare.
During his visits to the various installations, Colonel Blumgart emphasized that a presumptive diagnosis of acute amebic hepatitis may be made on the basis of any three of the four following features: (1) History of diarrhea, (2) pain and tenderness over the liver, (3) fever, or (4) leukocytosis. He also emphasized that, of these four features, the second is the most constant and occasionally may be represented only by referred pain to the shoulder. The diagnostic importance of pain and tenderness over the liver made it essential that percussion or compression tenderness be sought generally in every patient as part of the physical examination.
Many of these considerations were discussed by Maj. (later Lt. Col.) G. Klatskin, MC, in a review of his experience with classification, diagnosis,
719
and treatment of amebiasis. In analyzing 62of his cases, he found they fell into four distinctgroups, which were readily differentiated clinically, as follows: Acute amebic liver abscess, acute amebichepatitis, subacute amebic hepatitis, and chronicamebic hepatitis. Major Klatskin stated:
The acute abscess cases were characterized by liver pain, high fever arid frequently by cough. A definite mass was demonstrable in the liver either by palpation or by X-ray examination in every instance. The right lobe of the liver was generally enlarged and exhibited compression tenderness. Abnormal pulmonary findings were frequent. Marked leukocytosis with only slight increase in the percentage of polymorphonuclears was the rule.
The acutehepatitis cases resembled theabscess cases except that no mass could be demonstrated in the liver,liverpain and cough were less common, diarrhea and cramps were more commonand leukocytosis was less marked.
The subacute hepatitis cases differed markedly from the others. Only half of them complained of liver pain. Many were admitted because of diarrhea and cramps and were found to have enlarged tender livers. Fever was inconstant and when present was low grade in character and intermittent. Cough and abnormal pulmonary findings were unusual. Leukocytosis occurred infrequently and when present was usually mild.
In contrast tothe first three groups ofcases, in which symptoms were usually present for less than ten days,thechronic hepatitis cases were admitted with liver pain of long duration,ranging from two to twelve months. As in thecase of subacute hepatitis, fever and leukocytosis wereinconsistent. Diarrhea was fairly common and cough andabnormal pulmonary findings occurred occasionally. * * * It mustberemembered that cases in one group mayadvance or regress to another, either as a result of treatment orspontaneously under the influence of factors alreadydiscussed.
In this series of cases, the most characteristic symptom common to all groups was liver pain. This pain had a number of distinct features. It was usually localized in the right upper quadrant of the abdomen beneath the costal margin and less commonly in the left upper quadrant, in the epigastrium, and in the right lower chest. It was usually described as a constant ache or an intermittent sharp pain and, as a rule, was only moderate in severity. Major Klatskin noted:
Aggravation of the pain by movements and change in position was a prominent feature and was of great diagnostic significance. The principal aggravating factors were deep breathing and cough, bending and twisting, lying on either or both sides in bed and jarring. Frequently the patient spontaneously offered the information that these produced or aggravated his pain, but in many instances it was necessary to inquire specifically about their effect. The effect of jarring, especially on riding over rough terrain, probably occurred more frequently than indicated, as many of our patients were not asked about it.
Radiation of the pain was very common, especially on movement or change in position. In several instances, the first complaint was pain at the site of radiation, and only later was pain noted in the liver. This led to a number of diagnostic errors, especially when radiation was to the chest. The common sites of radiation were the shoulder, chest and lumbar region. On one occasion, it radiated to the neck. Radiation was always to the right, except in the three patients with involvement of the left lobe of the liver in whom radiation occurred to the left.
The compressiontest proved to be of greathelp in differential diagnosis. It clearly demonstrated the hepaticoriginof the pain and differentiated it from that arising in other structuresabove and below the diaphragm. The test wastried in a great variety of conditions including pneumonia, pleurisy,renal colic, pyelitis, acute dysentery, peptic ulcerand malaria with enlargment of the liver and was invariablynegative. It was also of some value
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in differentiating amoebic from infectioushepatitis. In a large series of infectious hepatitis cases, inwhichthe testwas tried, it was negative in all but a few. The only otherconditionin which the test was invariably positive wasacute cholecystitis. No doubt there are other conditions, such assubphrenic abscess, in which the test may bepositive.
Compression tenderness is by no means to be considered pathognomonic of hepatic amoebiasis, but it has proved its worth as a confirmatory finding, and in a few instances it has made an early diagnosis possible in the absence of other findings.
Therapy. - The second main approach in clinical attack was by improved treatment in order to eliminate the disease in the individual patients and prevent their becoming carriers. The importance of early adequate treatment of amebic dysentery, well recognized by those familiar with the disease, was not fully appreciated by most U.S. Army medical officers. In the absence of prior directives, the therapy of the various clinical manifestations was variable and characterized at times by practically sole reliance on carbarsone or one of the iodine compounds. The treatment outlined in the theater directive on amebiasis (Circular No. 9, April 1945) was similar to that advocated in paragraph 7 of Circular Letter No. 33, 2 February 1943, Office of the Surgeon General, United States Army, entitled "Treatment and Control of Certain Tropical Diseases.' This therapeutic regime will be evaluated when the results of treatment as recorded in the amebiasis registers are finally available and analyzed.???
It is of interest that a similar regime was employed independently by Major Ellenberg and his associates and by Captain Rogers and Colonel Elsom with apparent success. In their study of 833 cases, Major Ellenberg employed three types of treatment, all of which were similar in that emetine and carbarsone were administered during the first 10 days, one of the oxyquinoline derivatives such as chiniofon, Vioform (iodochlorohydroxyquinoline), or Diodoquin (diiodohydroxyquinohine) from the 11th to the 19th day, with either carbarsone or chiniofon enemas on alternate days during this latter period. The average time of disappearance of signs and symptoms was 8 days. The investigators described a not infrequent reaction to treatment on or about the 4th day, which closely simulated the original symptoms and usually consisted of cramps, diarrhea, a moderate rise in temperature, and general malaise. They stated: '* * * one must consider the possibility of this representing a 'Herxheimer' type of therapeutic response and not necessarily a toxic reaction* * * . 'At the conclusion of treatment, a proctosigmoidoscopic examination was performed in every case and was followed by stool examinations after a saline purge. Of the 833 cases, the stools were found to be negative in all but 10; these responded to a second course of treatment. The results did not indicate the relative superiority of any of the three oxyquinoline drugs used. There were 9 recurrences in the series of 833 cases. Of the 9, 3 recurred within 3 months following completion of therapy. The other six recurred from 3 to 6 months after completion of treatment and may have been reinfections. Thus, there was an overall cure rate of 99 percent. These successful results may be attributed in part to early diagnosis and treatment of the cases; approximately 75 percent had had symptoms for less than 1 month and only 7 percent longer than 3 months. ???
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Toxic effects fromthe drugs in the dosagesrecommended were infrequent and never serious. Subcutaneous instead of intramuscular administration of emetine wasless painful and had no illeffects. In a few patients, two injections of 34 grain daily,insteadof the customary singleinjection of 1 grain, obviated the attendant nausea.?
Major Klatskin analyzed the effectiveness of treatment in 69 cases of amebic abscess and hepatitis. He employed the following criteria for cure: (1) Complete absence of pain and fever, (2) absence of liver enlargement, (3) absence of subcostal and compression tenderness, (4) normal white blood cell count and sedimentation rate, and (5) absence of E. histolytica from the stools. The treatment consisted of repeated courses of emetine until the criteria of cure were observed. Thereafter, emetine was supplemented with one or more courses of Diodoquin or chiniofon, followed by carbarsone, to eradicate the associated colonic amebiasis presumed to exist in all cases. The schedule of treatment consisted of a first course of 12 grains of emetine given over a 15-day period; then a course of 1 grain daily, given with a 3-day rest period after the 6th or 9th dose, depending on the patient's reaction to the drug. Most patients tolerated 9 grains, but occasionally patients complained of weakness and exhibited a fall in blood pressure after 6 grains. After a 3-day rest period, Major Klatskin found they were able to complete the 12-grain course with no ill effects. He wrote:
The first course is followed by a two-week rest period, at the end of which emetine therapy is resumed. Courses of six grains each are then alternated with two-week rest periods until the criteria of cure are met. A rest period of two weeks was chosen because it proved to be sufficiently long to prevent the cumulative toxic effects of the drug. Also it was noted that considerable improvement often occurred up to two weeks after the drug was stopped, so that the total dosage of emetine could be kept down to a minimum. Where the rest periods were prolonged beyond two weeks in the face of liver tenderness, leukocytosis or an increased sedimentation rate, a clinical recrudescence frequently occurred. In a few of the more acute cases the second and third courses of emetine were given at eight to ten day intervals with no untoward effects. It may be necessary to shorten the rest periods in this manner if a recrudescence with fever occurs.
Except for the occasional weakness and fall in blood pressure during the first course of emetine, no toxic effects were seen.
The totalemetine dose required to effectcure varied with the type of hepatic amoebiasis. The abscesscasesrequiredthe largest doses (average 21.9 grains in 47.6 days), the acutehepatitis somewhat less (average 14.4 grains in 33.4days), and the subacute and chronic cases the least (average 11.2 and12.4 grains respectively in 16.1 days).
The largest dose of emetine administered toany patient was 27 grains, the smallest 6 grains.The response to emetineusually was sodramatic that it was considered diagnostic of the disease. Of the 69 patients treated, 68 were cured. One patient, thoughafebrileand greatly improvedclinically, had a persistently enlarged and tender liver.?
Relatively few cases of hepatic abscess requiring aspiration or drainage were seen in the theater. Captain Rogers and Colonel Elsom, in their study of 444 cases of amebiasis, at the 20th General Hospital, observed only 4 patients
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with liver abscess. In timelocalization ofsuch lesions, the possible usefulness ofpneumoperitoneum was studied by Colonel Bercovitz and his associates atthe 69th GeneralHospital. Their observations were not conclusive but indicated thepossible value of thistechnique as a diagnostic adjunct. In the theater ETMD for August1945,Col. Harry C. Hull,MC, and his associates at the 142d General Hospital reported acontribution, of considerablemerit, to therapy of hepatic abscesses. These officers treatedtwopatients with amebic abscess ofthe liver by closed drainage after visualization with diodrast. Bothpatients were gravely illdespite employment of all accepted measures, including repeatedaspiration. Under localanesthesia, a catheter was inserted into the abscess cavity, closeddrainage with suction wasinstituted, and penicillin injected daily into the abscess cavity andalso intravenously. Bothpatients made full recovery.?
To appraise the plan of treatment in use and to elaborate improved methods of therapy, a program of clinical investigation of the diarrheal diseases was planned and put into operation at the 142d General Hospital. The relative value of the oxyquinoline drugs, the evaluation of emetine and the possibility of either omitting it from the treatment of acute dysentery or substituting an oral preparation, the efficacy of the oxyquinoline derivatives in treatment of asymptomatic carriers, and the possible value of chemotherapy, such as use of the sulfonamides and/or penicillin, in affecting the secondary bacterial invaders in the bowel were some of the problems that were proposed for investigation. The end of hostilities interfered with the complete fulfillment of this program.
Followup observations. - The third medical approach was through followup observations of all patients in order to be certain that repeated tests of cure be made and therapy instituted in event of recurrences. Posttreatment examinations must be viewed as part of the management of the patient as well as part of the control of the spread of these diseases. The necessary transfer of personnel within the theater led to unsatisfactory followup of patients with amebiasis. Tests of patients' stools on return to duty after hospitalization usually were not performed. When patients reported to dispensaries or were readmitted to hospitals because of gastrointestinal complaints, records of previous hospitalization were not available. Results of previous clinical findings, the prior diagnoses and response to treatment were unknown. It was believed in the Office of the Surgeon, moreover, that the inadequately treated military personnel might, on their return to the Zone of Interior, present a public health problem as carriers. To remedy this situation, it was decided that an amebiasis register analogous to the syphilis register, should be initiated for each patient. This register contained a summary of all pertinent clinical data, results of examinations, and a summary of the treatment previously employed. The register was begun by the medical officer making the original diagnosis, was maintained by the medical officers currently in charge of treatment of the case, and was forwarded to the surgeon of the patient's new station or command. When a satisfactory result had been attained or when the patient was transferred out
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of the theater, the register was forwarded tothe Office of the Surgeon, Headquarters, USAFIBT. Besides the purposes of this register just mentioned, evaluation of thetherapeutic regimesemployed was made possible. When the registers were forwarded totheSurgeon General'sOffice at the conclusion of the war, they were studied and were madeavailable on subsequenthospitalization of the patient in the Zone of Interior.?
Only meager information was generally available regarding followup of patients hospitalized for amebiasis. Major Ellenberg and his associates, however, performed a 1-month followup stool examination in each of their 833 cases, a 3-month followup examination in 60 percent, and some were followed for varying periods up to 11 months.
Of particular interest were the results of their followup in 101 cases in the personnel of their own unit whom they were able to study with especial care. Twenty-six had been hospitalized because of clinical manifestations; the remaining 75 were asymptomatic carriers. All had a minimum followup period of 6 months, and 81 were followed monthly for 11 months. There were only 2 recurrences in this group of 101 cases; one a symptomatic and the other an asymptomatic case. As previously stated, the remarkable cure rate of 99 percent in the entire series is to be attributed in part to early diagnosis and effective treatment. ?
Of the 444 patients with amebic dysentery studied by Rogers and Elsom at the 20th General Hospital, 162 followups were requested and 84 (35 acute, 20 subacute, and 29 chronic) were obtained. The total followup period was from 3 to 6 months for 25 patients, 6 to 12 months for 24, and 12 to 23 months for 35. A summary of the findings in the 84 patients follows.
| Findings | Number of Cases | |
| History: | ||
| Abnormal bowelhabits | 9 | |
| Periods of diarrhea | 36 | |
| Abdominal pain | 19 | |
| Sick Call attendance | 7 | |
| Weight loss | 6 | |
| Weight gain | 45 | |
| Physical examination: | ||
| Liver palpable | 3 | |
| Liver tender | 1 | |
| Colon tender | 10 | |
| Stool examinations: | ||
| Trophozoites | 0 | |
| Cysts | 2 | |
| Sigmoidoscopicexaminations: | ||
| Active lesions | 0 | |
| Healed scars,definite | 3 | |
| Healed scars,possible | 3 | |
| Total history of findingssuggesting a recurrence of amebic disentary or chronic dysentery duringfollow up period | 0 |
At the various hospitals, readmission foramebiasis was not uncommon. In a theater whererepeated exposure to infection was inevitable, one could not
724
confidently distinguish betweenrecurrence and reinfection. Disposition to the Zone of Interiorofpatients with persistentdisability despite therapy and of patients with persistent organicintestinal damage limited clinicalexperience with this important group of cases.
BACILLARY AND OTHER FORMS OF DYSENTERY
The numerous cases ofdysentery prevailing inthe India-Burma theater and the limited laboratoryfacilities generally prohibited detailed laboratory diagnostic studyexcept in special instances. However, the Sub-Commission on Dysentery of the Army EpidemiologicalBoard reported inNovember 1944 that, of 369 cases admitted to the 20th General Hospitalbecause of diarrhea andof 175 cases seen in dispensaries, stools were positive for bacillarydysentery in 24 percent and16 percent, respectively. As Colonel Blumgart advocatedexamination ofstools for E. histolyticain every case and recommended equipment of the smallerinstallations and dispensaries withmicroscopes and the necessary laboratory supplies, this was done to anincreasing extent. Exceptin field, station, evacuation, and general hospitals, mild cases ofdiarrhea usually were treatedsymptomatically and the more severe or protracted cases withchemotherapy. Patients treated onan ambulatory basis usually were given sulfaguanidine, which, althoughtherapeutically inferiorto sulfadiazine, was not attended by the dangers inherent insulfadiazine. The hot climate in thistheater during much of the year predisposed patients to dehydration andrenal complications,particularly those patients with diarrhea whose fluid intake could notbe supervised. Under themore favorable conditions of hospitalization, sulfadiazine wasadministered with excellent resultsin accord with TB MED 119, November 1944, entitled 'BacillaryDysentery." Most cases of'Delhi Belly' cleared rapidly regardless of the regime employed. Evenin proved acute bacillarydysentery, the efficiency of chemotherapy was not always evident. Thus,in 300 Chinese patientsstudied by Major Elson, Maj. (later Lt. Col.) Dickinson S. Pepper, MC,and Lt. Col. (later Col.)James S. Forrester, MC, neither sulfaguanidine nor sulfadiazineshortened the course of diseaseor ameliorated the symptoms in comparison with the group of controls.However, the value ofchemotherapy in the treatment of bacillary dysentery and in theprevention of the carrier state wasgenerally impressive.
Differentialdiagnosis
The differential diagnosisof the diarrhealand dysenteric diseases in the India-Burma theaterpresented no unique or peculiar problems. As in other tropicalandsubtropical regions, thefollowing possible diagnoses required consideration: Amebic dysentery;bacillary dysentery;simple diarrhea, including food poisoning; and parasitic infestations,such as hookworm andstrongyloidiasis. The acute form of amebic dysentery could not bedistinguished from bacillarydysentery with absolute confidence on clinical grounds alone. Concurrent bacillary and amebicinfection was frequent: indeed,
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according to various estimates, from 10 to 25percent of patients with bacillary dysentery hadamebiasis as well. In general, however, certain diagnosticconsiderations served as guides fordifferentiation. In amebic dysentery, the onset was usually lessviolent, the symptoms were apt tohave existed for weeks rather than for hours, and the maximum number ofbowel movements perday was characteristically from 5 to 10 rather than from 15 to 20 as inbacillary dysentery. Highfever, prostration, and intense abdominal pain were less frequent inamebic dysentery; theleukocyte count was more likely to be normal or only slightly elevated;and the stools consistedprimarily of feces containing blood, whereas in bacillary dysenterythey often consisted only of avery small amount of odorless bloody mucus. Bacillary dysenterytendedto subside even whennot treated with sulfonamides, whereas amebic dysentery continuedunabated or improved onlyslightly until specific treatment was instituted.?
Simple diarrhea could be distinguished in the majority of cases by its more explosive onset, by its tendency to affect simultaneously a number of men in the same organization, by the absence of blood in the stools, and by its rapid subsidence within from 24 to 48 hours. Malaria was occasionally associated with bloody dysentery, but the abrupt onset of chills, a remittent type of fever of 104o F. or above, headache, and generalized bone, joint, and muscle pains were so highly characteristic of it and so atypical of amebic or bacillary dysentery that the differentiation was usually not difficult. Hookworm disease and strongyloidiasis frequently gave rise to low-grade, generalized abdominal pains and diarrhea. The two diseases did not cause bloody stools, and the abdominal symptoms produced by them were usually less clearly colonic in origin, consisting rather of generalized or upper abdominal discomfort with indigestion. Finally, an important diagnostic consideration was the fact that certain localities in India and Burma were known to be highly endemic centers of amebic infection, and personnel from these areas were always to be suspected.
Conclusions
The effective treatment ofpatients bypreventing their becoming carriers and by detecting andeliminating the carrier state in others undoubtedly was partlyresponsible for the reducednoneffective rate for the diarrheal and dysenteric diseases in 1945(chart 8). Of equal if notgreater importance was the improved sanitation throughout the theater.
Malaria
In a lecture on theimportance of malaria inIndia, Lt. Col. (later Maj. Gen. Sir) Gordon Covell,Director, Malaria Institute of India, stated: 'Although * * * thecasemortality from malaria isprobably less than one per cent, it has been estimated that in Indiaalone the disease is directlyresponsible for more than one million deaths per annum ina normalyear, whilst in years of greatepidemics this figure may be greatly exceeded.' 3
3 Covell, G.: Lectures on Malaria. HealthBull. No. 5, New Delhi: Government of India Press, 1941.
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This indicated theoccurrence of malaria inapproximately 100 million people in India each year,or in 1 of every 4 of the population. Into this situation U.S.Armytroops were sent in 1942,many of them going to the Province of Assam, which was described in the1943 annual report ofthe 20th General Hospital, as follows:
* * * a malaria infestedarea, one that iscontinually epidemic, as bad as any in the world * * *. From thebeststatistics available, the malaria infection rates of the nativepopulation were as high as 3,000 per 1,000 per annum, or300 percent during the rnalarious season. The rate dropped to about 70percent during the winter months or the so-called 'non-malarious'season.
Lest it be thought thatmalaria was confinedto the jungle regions such as Assam, one of the veryfirst letters in the medical files may be cited, reporting an outbreakof malaria in a detachment of20 men who traveled by rail from Karachi to Dinjan.4Ofthe 20 men, 7 (35 percent) contractedmalaria on the trip. This report was only the first of many tocome tothe theater surgeon'soffice. Any train trip that involved night travel, and all butthevery shortest did, almostinvariably resulted in new cases of malaria. In spite of controlefforts, this situation stillprevailed as late as August 1944. The 843d AAA Automatic WeaponsBattalion, mobile, leftBombay for Teok on 7 August, arriving on 18 August. Of the 726 men inthe battalion, 98developed malaria within a month of arrival; as far as could beascertained, 85 of the 98contracted the malaria on that trip. 5
Malaria control was grossly inadequate in most areas. Occasionally, as in New Delhi, moderately effective measures had been initiated; in August of 1942, only 12 cases occurred in U.S. military personnel stationed there.
However, during 1943 and1944, most of thetroops were in the parts of India where the malarialrate was highest and where there had been no control prior to theirarrival. A highly effectivemalaria control program was immediately instituted by the PreventiveMedicine Section, Officeof the Surgeon, Headquarters, USAFCBT, in areas where United Statestroops were stationed(fig. 246). A description of the control program is availableelsewhere. The following pages areconcerned with the disease as encountered by the medical officers ofthe India-Burma theater.
Statistical observations
In all, 39,906 cases of malaria among U.S.troops were treated in time several years of the theater'sexistence. Knowledge of the disease was furthered, andvaluable contributions totherapy were made. The great majority of the cases were seen inthe20th General and in the48th and 73d Evacuation Hospitals in the Assam-Burma region along thebeginning of the LedoRoad. Later, the 69th General Hospital and the 14th Evacuation Hospitalalso came into theLedo area. Many reports and scientific papers were submitted fromthese
4 Letter, Col. John M. Tamraz, MC, Surgeon, U.S. Army Forces in India, Burma, and China, to Chief of Staff, Services of Supply, 30 July 1942, subject: Malaria Contracted by Troops Traveling on Railways.
5 Letter, Maj. Mason Trupp, MC, Assistant Surgeon, Headquarters, 10th Air Force, to Commanding General, 10th Air Force, 21 Oct. 1944, subject: Report of Excessive Number of Malaria Cases Within the 843d AAA AW Battalion.
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installations, all stemming from the thousands of cases seen during the monsoon seasons of 1943 and 1944.
The material available forthis review didnot lend itself to a chronologic study in the sense that aday-by-day development of the malaria problem and its solution in thetheater could easily bepresented. Ideas conceived in 1943 frequently could not hecompletelydeveloped until 1944,and in many instances the final report did not reach the theatersurgeon until late in 1944 onearly 1945. Consequently, it seemed best to present the materialbysubject, including under eachheading all the ideas that were developed in sequence as nearlychronologically as the materialpermitted.
INCIDENCE
U.S. soldiers. - From1 September 1942 to 30 June 1945, a total of 39,906 cases of malariawerereported in this theater. This figure included recurrences as well asoriginal cases. Table 5shows the total number of cases and the rates for each year. Chart 10shows the attack rate bymonth for January 1943 through August 1945.
Table 6 shows the malariastatistics of thetwo most active hospitals in the Assam-Burma area forthe part of 1943 that these hospitals were functioning. The 20thGeneral Hospital receivedpatients beginning 3 April 1943 and the 73d Evacuation Hospitalbeginning 26 April 1943. Thefigures for the 73d Evacuation Hospital are incomplete in that thebreakdown for the month ofNovember was not available. However, these figures suffice to show thatin a period less thanthe full year these two hospitals alone treated approximately 45percent of all the cases of malariain U.S. soldiers seen in 1943. The figures for the Chinesesoldiers areof interest; cases were notincluded in the U.S. Army statistics, but are shown in table 6, as theyformed a part of theexperience of these hospitals.
728
729
FIGURE 246.-Continued. C. Malaria control and sanitation staff, 20th General Hospital.
Deaths from malaria amongU.S. personnel wereuncommon, and in each death that did occurcerebral malaria was the cause.
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Chinesesoldiers. - The prevalence of malaria in the Chinese was due tomany factors, the chiefof which was the almost complete lack of interest in antimalariaprecautions on the part of theChinese. This was only another manifestation of the general lackofconcern about healthprinciples of any sort, and, indeed, lack of concern for lifeitself. It was also thought by somemedical officers that the Chinese were inherently more susceptible tomalaria, but whether thiswas a matter of racial susceptibility or a secondary result of the poorphysical condition of all theChinese troops flown to India from China was questionable. In anyevent, in the Chinese theincidence of infection from Plasmodium falciparum was muchhigher than in the Americans, thecondition of patients on admission usually much worse, and deaths morefrequent.
TYPES OFINFECTION
In U.S. personnel at the2Oth GeneralHospital, during the period April 1943 through March1944, there were approximately as many infections from P. vivax asfrom P. falciparum, whereasinfections from P. malariae were uncom-
731
mon. Figures differed somewhat in thefollowing year, when there was no appreciable change inthe number of infections from P. vivax but a pronounceddecrease in the number of infectionsfrom P. falciparum (table 7). The decrease in the latterreflected the decreased malaria rate; thehigh figure for malaria caused by P. vivax represented itstendency to recur. Infections with P.malariae remained relatively rare.?
Mixed infections were considered much more common than the figures indicated. Under the pressure of a caseload so great that surgeons as well as internists were caring for malaria patients, a laboratory could do very little more than a single malaria smear, and, once a parasite was seen and the diagnosis established, the luxury of a continued search for other forms was not always possible. Mixed infections always showed P. falciparum; P. vivax was usually the other parasite. As far as can be determined from the available material, a mixed infection did not necessarily present added difficulties in treatment.
The unclassified groupincluded all cases inwhich parasites were seen but the specific type notidentified. It will be seen from table 6 that in 1943approximately 25percent of all the malariacases seen at the 20th General Hospital and 21 percent of the casesseen at the 73d EvacuationHospital fell into the unclassified group. Table 7 shows apronounceddrop in this figure at the20th General Hospital in the following year: This differencerepresented a change in laboratoryconditions. In 1943, with limited time and laboratory facilities,prolonged efforts to make anabsolute identification were not justified. In 1944, with betterlaboratory facilities and moretime, it was possible to make a reduction in the unclassifiedgroup. Capt. (later Maj.) Calvin F.Kay, MC, of the 20th General Hospital, reported on primary infections,reinfections, and relapsesin the highly malarious district of Assam. In the unclassifiedinfections in this study, CaptainKay reported that, when further smears were obtained and identificationwas possible, almostwithout exception the previously unidentified parasite proved to be P.vivax. From this findingand from the similarity of the relapse rates in this group to those inpatients with malaria causedby P. vivax, Captain Kay was of the opinion that infectionscaused by P. vivax constituted thebulk of unclassified infections. in discussing this question, CaptainKay made the followingstatement:
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'We had at first expected the reverse to bethe case inasmuch as the later forms of P. vivax aremore easily identified than those of P. falciparum. However,with the thick blood smearsemployed, in many instances large numbers of P. vivax trophozoites werepresent with none ofthe readily distinguishable later forms in evidence.'?
On the other hand, this opinion apparently was not universally held at that hospital, because Lt. Col. (later Col.) Thomas Fitz-Hugh, Jr., MC, Maj. (later Lt. Col.) Henry U. Hopkins, MC, and Major Pepper, in their report on cerebral malaria, stated: 'We have also good grounds for believing that the majority of the 'Type Undetermined' and 'Clinical Only' groups are actually caused by P. falciparum infection.' The medical officers at the 73d Evacuation Hospital were of the opinion that a large proportion of the unclassified cases were caused by P. falciparum, since this was the more commonly seen parasite in that region. They also felt that, inasmuch as an unclassified case signified insufficient parasites in the peripheral blood for a definite diagnosis and since the finding of few parasites in the peripheral blood was usually an indication of an infection from P. falciparum this was further evidence that the unclassified group largely represented infections from P. falciparum.
The last subgroup in table6 includedpatients in whom the diagnosis was made solely on clinicalevidence without laboratory confirmation. In many instances,treatmenthad been started beforethe patient reached the hospital. Although some of these casesundoubtedly were not malaria, thesubsequent course and response to treatment of most of them and theknown fact that severalfactors contributed to the difficulty of obtaining positive smears madeit evident that in the largemajority the diagnosis was correct. Captain Kay, basing hisopinion onrecurrence rates and laterrechecks on smears, concluded that 66 percent of his group ofunclassified cases were due toinfections from P. vivax and33 percent to infections from P. falciparum.
RELAPSE RATES
Malaria relapses gave riseto the sameproblems in the India-Burma theater as elsewhere. MajorKay studied three Organizations and calculated relapse rates in 499individuals, of whom 407were followed for at least 4 months. In individuals with onepreviousclinical attack of malaria,the relapse rate was 25 percent for the entire group, includingpatients with unclassifiedinfections and those with infections caused by P. vivax and P. falciparum. Thosepatientswhohad malaria caused by infection from P. falciparum showed lessthan 5-percent relapse rate, andthose with infections caused by P.vivax showed 34-percent relapse rate. In individualswhohadalready had one relapse, the rate rose to 75 percent. The figureof 34percent, appreciably lowerthan the usually accepted figures for malaria relapse in other parts ofthe world, might have beengreater had the cases been studied longer. The studies of the 73dEvacuation Hospital in a 6-month period showed a relapse rate of 9.7percent following the initial attack.
733
The well-known fact thattrauma, operations,and acute illnesses can produce a recurrence of alatent malaria infection was adequately demonstrated in the experienceof this theater and led tothe use of suppressive Atabrine therapy in patients hospitalized forany medical or surgicalreason who gave a history of having had a previous attack of malaria.
Clinicalaspects
The word 'protean' has often been used indescribing malaria manifestations; however, itsfrequent use does not make it any the less applicable. Medicalofficerswho came to this theaterfrom the United States had had very little experience with malariabefore their arrival. Thoughtextbooks and courses on tropical medicine have always emphasized thatthis disease, likesyphilis, can be a great imitator, a doctor whose training andexperience have always associateddiarrhea with bacillary or amebic infection is not likely to considermalaria as a cause of waterystools. The difficulties in diagnosis are well described in thefollowing extract from a personalcommunication from Col. Francis C. Wood, MC, Chief, Medical Service,20th General Hospital:
We sawthe abdominal malarias, oftenindistinguishable from acute appendicitis, the dysentericmalarias, that looked somewhat like bacillary dysentery except that thepatients were more apt tohave chills and a higher fever. We saw the post operative and posttraumatic malarias; any feverwas malaria till proved otherwise. We saw some very queer malariapictures; our Chaplain had atypical attack of acute cholecystitis that turned out to be malaria.
Cerebralmalaria. - Cerebral malaria was the major clinical problem. Inthe early days,when malaria cases were pouring in, filling both medical and surgicalwards, the variousmanifestations of cerebral malaria were not fully appreciated.
The figures for incidencewere somewhatvariable, largely because of the varied opinion as towhat constituted cerebral malaria. Whereas at first only thosecaseswith convulsions, coma, orother severe cerebral symptoms were included in the classification, itlater became apparent thatdrowsiness or mild behavior changes were early manifestations and suchpatients had to betreated accordingly. Colonel Wood, whose letter was just referredto,described the situation inthese words: 'At first we didn't know what to look for. We didn'tknowhow drowsy a patienthad to be to be suspected of early cerebral malaria. Eventually wefound out that if, whenawakened, a patient was not fully awake and able to tell you his namepromptly, that patientneeded careful watching.'
At the three hospitals that saw practically all the cases of cerebral malaria, the average incidence of this manifestation in relation to the total number of malaria cases was 2.3 percent at the 20th General Hospital, 2.3 percent at the 48th Evacuation Hospital, and 1.1 percent at the 73d Evacuation Hospital (fig. 247), with an overall average of 1.9 percent. These figures included Chinese as well as U.S. troops. For U.S. personnel alone, the incidence at
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FIGURE 247.-73d Evacuation Hospital. A.Receiving office. B. American medical wards.
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FIGURE 247.-Continued. C. Chinesemedicalwards.
the 20th General Hospital was 2.2percent. Although the figure was not strikingly high, it issignificant that most of the malaria deaths came from this group. Included in the annual reportfor 1943 of the 73d Evacuation Hospital was a special report on malariaby Lt. Col. (later Col.)Edward R. Ware, MC, and his associates. In this study, whichcovered a6-month period, therewere 57 cases of cerebral malaria with 27 deaths, a mortality of 46percent. Only one of the 27deaths occurred in an American. From the 20th General Hospital,ColonelFitz-Hugh and hiscoworkers reported a mortality of 33 percent in Chinese patients and 5percent in Americans. The 48th Evacuation Hospital, which treatedchiefly Chinese troops, reported a 43 percentmortality in them and no deaths in U.S. personnel for the period from 1April 1944 to 16 March1945.6 The 14th EvacuationHospital, reporting on all its cerebralmalaria cases from itsopening in September 1943 to May 1945, had a total of 121 cases with 33deaths, a rate of 27.3percent; all deaths occurred in Chinese soldiers.7 Althoughthese figures do not all cover thesame period and better methods for diagnosis and treatment wereavailable as time went on, itwas apparent that the mortality for cerebral malaria made this adisease that required alertness indiagnosis and prompt action in starting treatment.
6 Essential Technical Medical Data, USA FIBT,dated 1 July 1945.
7 Essential TechnicalMedical Data, USAFIBT,dated 1 Sept. 1945.
736
The etiologic agent incerebral malaria hasgenerally been accepted as P. falciparumand in rareinstances as P. vivax. Practically all thedata that were collected supported this conception. Although Colonel Fitz-Hugh and associates made the statement that'cerebral malaria is chieflyif not exclusively a result of P. falciparum infestation * * *, " a table in their paper reveals5casesof cerebral malaria attributed to P. vivax-1case in an American and 4 in Chinese. The 14thEvacuation Hospital staff emphasized the fact that P. vivax can be acause of cerebral malaria. Although the possibility of a double infection in which P.falciparum was overlooked must beconsidered, the clinical impressions of these men together withlaboratory findings cannot bedisregarded.?
The clinical picture of cerebral malaria has been described by many authors and has been particularly well presented by Colonel Fitz-Hugh and his associates. All variations of cerebral manifestations were seen, from mild dizziness or slight drowsiness to severe headache, coma, and convulsions. Temperature charts showed no constant pattern, and a normal or slightly elevated temperature did not necessarily indicate improvement. Some cases that were admitted as ordinary malaria and seemed to be responding properly to treatment showed severe cerebral symptoms several days after admission. No adequate explanation for this was found, but it was observed that hypo-glycemia was occasionally a factor on prolonging cerebral symptomatology.
An interesting clinical observation, made at the 20th General Hospital in June 1945, was brought to the attention of this author by Colonel Wood. When a group of Chinese patients with malaria received no treatment for a period of several days preparatory to the use of a new drug, fraxine, all the patients with infection due to P. vivax became symptom free in 4 days without therapy, but the infections from P. falciparum did not subside spontaneously. Colonel Wood believed that this experience suggested why more infections from P. vivax were seen in American and more infections from P. falciparum in Chinese patients; the Chinese with infections from P. vivax recovered spontaneously and did not come to the hospital, leaving a relatively high proportion of patients with malaria due to P. falciparum to be hospitalized.
Treatment
The CBI theater was established in March1942. As far as can be determined, the first publicationon the subject of treatment of malaria appeared in first theater FieldMedical Bulletin, publishedin August 1942, and was a summary of a pamphlet issued by the BritishWar Office. Thetreatment recommended was different from that recommended by CircularLetter No. 56, Officeof the Surgeon General, U.S. Army, 9 June 1941, entitled 'Notes on theTreatment and Controlof Certain Tropical Diseases,' which was still in effect. In theNovember 1942 issue of the CBIField Medical Bulletin, another article on therapy appeared byMaj. (later Lt. Col.) Sydney P.Wand, MC, and Maj. (later Lt. Col.) Robert S. Crew, MC, of the 159thStation Hospital. Theseauthors mentioned that the article in the August issue recommended a
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treatment not in line with Circular LetterNo. 56, and they went on to present several changes inthe treatment of malaria gleaned from the School of Tropical Medicinein Calcutta, India. Thesealso were different from the recommendations of The Surgeon General.?
Finally, in the January 1943 issue of the theater Field Medical Bulletin, The Surgeon General's authority was recognized by reprinting Circular Letter No. 135, Office of the Surgeon General, U.S. Army, 21 October 1942, subject: The Treatment and Clinical Prophylaxis of Malaria. By January 1943, Circular Letter No. 135 had received complete distribution in the theater, and in the February 1943 issue of the Field Medical Bulletin, Lt. Col. Gordon S. Seagrave, MC, expressed doubts regarding the efficacy of Atabrine. He also presented his own views on the therapy of malaria, which included the use of liquor arsenicalis and neoarsphenamine.
The theater as a wholecontinued to use theplan of treatment outlined in Circular Letter No. 135(October 1942) and in Circular Letter No. 33 (Office of the SurgeonGeneral, February 1943),changing to Circular Letter No. 153, Office of the Surgeon General,U.S. Army, 19 August 1943,subject: The Drug Treatment of Malaria, Suppressive and Clinical,whenthis was received. Bythe end of 1943, installations in the heavily infested areas hadsufficient experience to reach theirown conclusions about the efficacy of the different methods oftreatment. In the special report onmalaria by Colonel Ware and his associates at the 73d EvacuationHospital, it was concluded thatall methods currently in use at that hospital were equally effectiveinsofar as end results wereconcerned but that the treatment recommended by Circular Letter No. 153did not reduce thetemperature as rapidly as methods employing quinine and Atabrine incombination. This wasvery nicely demonstrated by a graph which accompanied the specialreport. The same conclusionwas reached by the 20th General Hospital in the monthly sanitaryreport, dated December 1943,which states:
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.
The 48th Evacuation Hospital evidently was also somewhat concerned about the effectiveness of the therapy recommended by The Surgeon General, because, in addition to the recommended plan of treatment, Lt. Col. (later Col.) Herman A. Lawson, MC, and Capt. (later Maj.) John A. Dillon, MC, treated a group of Chinese patients with a somewhat larger total dose. They reported the results in the April 1944 issue of the Field Medical Bulletin. The conclusion was that the treatment recommended by Circular Letter No. 153 was satisfactory and no clear-cut advantage was demonstrated in the use of larger doses of Atabrine. The experience of the theater with Circular Letter No. 153 was summarized in the theater ETMD dated 30 July 1944. The general opinion was that the results were satisfactory and that only in the
738
very sick patients was it necessary tosupplement Atabrine treatment with quinine, usuallyintravenously. This will be taken up later under the treatment ofcerebral malaria.
STUDIES WITHVARIOUS DRUGS AND COMBINATIONS
During this period whenCircular 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 malariaseason of 1944, occasionalinvestigations were carried on, particularly at the 20th GeneralHospital, to determine theeffectiveness of other drugs or combinations other than thoserecommended in Circular LetterNo. 153. Observations were also made on the usefulness and sideeffectsof the commonly useddrugs. The following paragraphs summarize these observations.?
Plasmoquin (pamaquine naphthoate). - The hospitals in the Assam-Burma region, in which Negro troops were stationed, soon discovered that Plasmoquin, always recognized as a moderately toxic drug, was particularly dangerous in Negroes, producing a severe hemolytic reaction. Because of the frequency and severity of the reaction, this drug was eliminated from the therapy program in all the hospitals in that area and eventually in the theater.
Fraxine.-Thisdrug, of unknown composition, was tried atthe 20th General Hospital onChinese troops and reported on in that hospital's sanitary report,dated December 1943. It hadbeen sent by the Chinese for testing as an antimalaria agent. Itwascompletely ineffective inmalignant tertian malaria, and its value in benign tertian malaria wasopen to question, since itwas during this study that it was found that Chinese with malariacaused by P. vivax recoveredspontaneously if untreated.?
Arsenicals. - Arsenicals had long been recommended in the treatment of malaria. Although it 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 beneficial 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.
Atabrine. - Problemsoccasionally arose in the hospitals of the Assam-Burma region that werepeculiar to that locality and required special solutions. Thiswasowing to the large number ofChinese troops in the area for whom the U.S. Army hospitals providedmedical care. Althoughthe problems were precipitated by the Chinese, the solutions frequentlyhad a more general valueand contributed interesting and useful information. One suchproblemwas the difficulty inkeeping Chinese patients in the hospital long enough to be given fullantimalarial courses oftreatment. As soon as the patients felt well, they left thehospital orwere taken out by theircommanding officers. In an effort to circumvent this, Maj. ThomasE.Machella, MC, Capt.Roger A. Lewis, MC,
739
and T/3 L. J. Kimmelman, of the 20th General Hospital, worked. out a plan to give almost the complete week?s dose of Atabrine in the first 24 hours of treatment. It was felt that, if this method proved to be safe and effective, it would insure adequate dosage and at the same time shorten the hospital stay legitimately. The dosage used was 0.3 grains of Atabrine every 3 hours for 8 doses. Patients so treated were compared with other groups treated on different schedules. The final result compared favorably with other plans of treatment. In fact, the duration of fever and of parasitemia was less than usually observed in patients treated according to Circular Letter No. 153. Because 2 of 80 patients developed signs of stimulation of the central nervous system, the authors reduced the dosage to 0.2 grams every 3 hours for 8 doses. This seemed to be as effective as the original dose.
At various times, new drugs were sent into the theater for trial. One such drug was called SN 6911 Bisulfate. This drug was tested at the 20th General Hospital by Major Machella and Sergeant Kimmelman. It was given as a single intravenous infusion and compared with a corresponding dose of Atabrine, also given as a single intravenous dose. The drug was found to be effective but to have no advantages over Atabrine.
Major Machella, with 2d Lt. David F. Burgoon, SnC, and T/3 R. Fine, also studied the effects of the two drugs on the liver. Concerned primarily with the effect of a single intravenous dose of Atabrine or SN 6911, Major Machella limited the study to determination of Bromsulphalein (sulfobromophthalein sodium) excretion before, during, and after an attack of malaria. He found a definite impairment of the ability of the liver to excrete the dye during the period of fever; this impairment disappeared in the majority of cases within 96 hours after the institution of therapy and usually within from 48 to 72 hours after subsidence of fever. In general, the more prolonged the fever, the greater the dye retention; but in all but four cases the retention was only temporary. Those four cases all showed slight jaundice on admission. That the dye retention was related to the fever rather than to the disease per se was demonstrated by normal controls with artificially induced fever (typhoid vaccine) showing a similar degree of dye retention. It was impossible to demonstrate any effect of Atabrine or SN 6911 on the ability of the liver to excrete Bromsulphalein.
Failure to respond to oral administration of Atabrine was not common but did occur on a few occasions. Lt. Col. Frank B. Cutts, MC, and Capt. (later Maj.) Irving A. Beck, MC, of the 48th Evacuation Hospital reported in the April 1945 India-Burma theater Field Medical Bulletin on 8 cases, out of approximately 4,500, that did not show a typical response to oral administration of Atabrine. In 3 of the 8, the therapeutic response was delayed but eventually appeared. In the remaining five cases, there was no response. Atabrine was not found in the urine of any of these patients, and, since it was believed that they were taking the tablets, it was concluded that there was no absorption of the drug. Intramuscular Atabrine produced a prompt response and the appearance of the drug in the urine.
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DRUG REACTIONS
Plasmoquin. - All three drugs used in the treatmentof malaria produced reactions. Plasmoquinhad always been known as a toxic drug and proved to be particularlytoxic in Negro soldiers. Both the 73d Evacuation Hospital and the 20th General Hospital hadoccasion to treat Negrotroops since many Negro units were working along the Ledo Road. Asevere type of hemolyticreaction was the most serious difficulty associated with Plasmoquintherapy. The 20th GeneralHospital, in its annual report for 1943, reported on approximately 20instances of this reaction,all in Negro troops. The 73d Evacuation Hospital witnessed 10such reactions--9 in Negroesand 1 in a Chinese soldier. All patients developed a moderatelysevere anemia; in 6 of the 10patients at the 73d Evacuation Hospital the red blood cell count fellbelow two million. Becauseof the severity of these reactions, Plasmoquin was omitted from routineantimalaria therapy. There were also lesser reactions to Plasmoquin, such asgastrointestinal 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.
Atabrine. - Reactionsto Atabrine constitute a history in themselves. This theater sawall of thereactions commonly attributed to Atabrine, including atypical lichenplanus and various otherskin reactions (p.776), toxic psychoses, and the usual gastrointestinaldisturbances. WhenAtabrine suppressive treatment was instituted in February 1945, therewas apprehension in manygroups regarding its toxic potentialities. Many symptoms wereattributed to Atabrine withoutdefinite proof of a causal relationship. There were, however,occasional instances of unusualmanifestations that were reasonably attributed to Atabrine. Col. EdwardA. Abbey, MC, andMaj. Edgar A. Lawrence, MC, Surgeon, and Chief, Preventive MedicineSection, of the India-China Division, Air Transport Command,respectively, reported a study of the effects ofcontinued doses of Atabrine (0.1 gram daily) on visual acuity ofpilots. They concluded thatAtabrine in the dose used had no effect on visual acuity except inrare, highly sensitiveindividuals. Their report included a single case of ocularsensitivity to Atabrine characterized byblurring of vision and change in visual acuity in both eyes from 20/30to 20/50. Discontinuanceof Atabrine resulted in relief of symptoms; readministration of thedrug resulted in a recurrence,relieved by cessation of suppressive therapy.
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CEREBRAL MALARIA
Whereas Atabrine given orally practically always produced good resultsin the usual case, it wasfrequently ineffective in cerebral malaria, and other measures had tobe instituted. This waslargely owing to the fact that patients with cerebral malaria wereunable to take oral medicationand required more intensive treatment. Patients with cerebralmalaria who were respondingfavorably to oral treatment frequently suffered relapse after 3 or 4days. In the early days of thetheater when parenteral Atabrine was not available, practically allinstallations used intravenousquinine. Later, intramuscular and intravenous injections ofAtabrine were used with excellentresults.
In the ETMD for June 1945, Major Machella summarized the results in five cases of cerebral malaria treated with a single intravenous infusion of Atabrine. The dose varied from 0.6 gram to 1.0 gram, administered in 1,000 cc. of physiologic saline. One patient, in coma on admission, expired in 31 hours; he had received 0.8 gram of Atabrine intravenously. Two patients who received the infusion too rapidly had brief psychotic episodes which lasted less than 24 hours. When the infusion was given slowly, no toxic manifestations were noted. No conclusions regarding the relative merits of parenteral quinine and Atabrine were drawn from this very small series of cases; however, Major Machella felt that Atabrine was at least as effective as quinine and that 0.8 gram of Atabrine administered in a slow intravenous drip provided an effective method of clearing the blood of parasites. Aside from the specific drug therapy of cerebral malaria, certain general measures were tried. Some appeared to be of benefit; others were discarded. They were as follows:
1. Spinal tap. - There were no consistent results from this procedure. The group at the 20th General Hospital found it extremely useful and felt that an initial spinal tap was always advisable, whereas at the 73d Evacuation Hospital only in occasional cases did lumbar puncture, with reduction of the spinal-fluid pressure, have any appreciable effects. In most cases, it was of no avail.
2. Transfusion of whole blood. - The medical officersat the20th General Hospital felt that wholeblood transfusion was, at times, a life-saving procedure, particularlyin cases with pulmonaryedema.
3.Intravenous Adrenalin (epinephrine). - This drug was used bythe 20th General Hospital andthe 73d Evacuation Hospital. It was considered to be of value in somecases; however, becauseof untoward reactions, its routine use was not advised.
4. Sedation. - This measure was used universally inexcited or convulsive cases. IntravenousSodium Amytal (amobarbital sodium) and intravenous paraldehyde wereused most often.
5. Other measures. - Various othermeasures were tried,particularly at the 20th General Hospital.These included oxygen therapy, Benzedrine (amphetamine), ephedrine,aminophyllineintravenously and by intracarotid
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injection, andalso nitroglycerin into the carotid. No striking results wereobtained from thesemeasures. A suggestion that resulted in much correspondence wassubmitted by Capt. (later Maj.)Mason Trupp, MC, an Army Air Force surgeon. He recommended thecombined use of nicotinicacid and oxygen, the nicotinic acid to increase the cerebral blood flowand the oxygen to relievethe anoxemia produced by the plugging of the cerebral capillaries byparasites and pigment. Forsome reason, the suggestion received only a limited trial. A fewcases were treated at the 234thGeneral Hospital in Chabua, India, and occasional cases elsewhere, butno adequate clinical trialwas ever given.
Evacuation policy
In general, the results of malaria treatment recommended in thedirectives from The SurgeonGeneral were excellent, and very few patients, mostly cases ofblackwater fever and severalcerebral cases, required evacuation to the Zone of Interior.
Scrub Typhus
At least since 1932, typhus fever--louseborne,tickborne, fleaborne, and miteborne--has beenknown to exist in Burma. Interestingly enough, however, the firstreported case of scrub typhusin the India-Burma theater came not from Burma but from India where acivilian technicalrepresentative had been admitted to the 100th Station Hospital atDelhi, India, on 2 October1943, with fever and mild meningeal signs. Agglutination of OXKstrain of Proteus to 1/2500was found on the 10th day of hospitalization, and complement-fixationtests done later inWashington likewise indicated that the disease was scrub typhus. The history in this caserevealed that the patient had just returned from Kunming, China, whereseveral other cases oftyphus had been reported. The other cases were proved later to beof the epidemic variety; onlythe one case was proved to be scrub typhus.?
The chief focus of scrub typhus in the India-Burma theater was Burma. In November 1943, Chinese troops, stationed in Chinglow and Shingbwiyang, in Burma, began to develop a disease that at first was thought to be measles but later was diagnosed as a form of typhus fever.8 In one company of the 114th Infantry, 28 cases occurred with 4 deaths. At the end of November1943, two U.S. soldiers suspected of having this disease were hospitalized at the 20th General Hospital, and shortly afterwards Maj. Walter S. Jones, MC, who had been assigned to the Chinese as liaison officer and had also made a trip to Shingbwiyang, developed an acute illness which, following the appearance of a rash on the fifth day, was diagnosed as mite typhus. His own subjective reactions to this disease are described in detail in his 1 August 1945 report to the theater surgeon on his activities with the Chinese.
__________
8 Letter, Col. Elias E. Cooley, MC, Medical Inspector,to Theater Surgeon, CBI, 13 Dec. 1943, subject: Report ofOutbreak of Rickettsial-like Disease in Chinese Troops.
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FIGURE248.-Tick-infested jungle at 23-mile mark along the Ledo Road.
In December 1943, Major Pepper studied all the cases then at the 20thGeneral Hospital and inaddition traveled down the Ledo Road to investigate the focus ofinfection 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 mostlikely vector because, iffleas, ticks, or lice were the vectors, not only would there be ahistory and signs of bites but theinsects themselves would be found. Mites, on the other hand,would be practically impossible tofind and would not leave visible bites.?
Consequently, in his report on his investigations which he submitted on 9 December 1943 to the Surgeon, Base Section No. 3, Major Pepper concluded:
'The disease seen both in the Ledo Road section of Assam and in theregion of Shingbwiyang isa form of miteborne rickettsial disease which closely resembles themite typhus, tropical typhus,rural typhus of Malaya or Sumatra, scrub typhus etc. of theliterature.'
Captured Japanese medical reports indicated that the enemy was encountering the same disease among their troops. The reports show that there was some doubt in the minds of Japanese medical officers regarding its proper classification. They called it eruptive fever, found that it was caused by rickettsial bodies, and felt that it was closely related to Japanese
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riverfever. (Tsutsugamushi disease). Their reluctance to identify itspecifically asTsutsugamushi disease was apparentlydue to their failure to find the typical ulcer in most of thecases. In one group of 29 patients,only 2 showed the characteristic eschar. The descriptionspresented in the captured reports leaveno doubt that this was the same disease that was then appearing inChinese and U.S. troops.?
The British were having their own difficulties with this infection. Report No. 433 of the Joint Intelligence Collecting Agency, China-Burma-India theater, dated 24 February 1944, described an outbreak in the 1st Devon Regiment, which occurred between 21 October and 17 November 1943. Of particular interest in this report is a graph showing the number of cases that developed day by day and their relationship to the time the group entered and left the infected focus.
The initial outbreak of mite typhus among U.S. troops was of relatively brief duration. The first cases appeared in November 1943 and a considerable number in December 1943, but by January 1944 the incidence had fallen sharply. Col. Elias E. Cooley, MC, Medical Inspector, USAFCBI, submitted a preliminary report on scrub typhus among U.S. and Chinese troops in India-Burma, in which he included a report on the clinical aspects of the disease by Major Pepper and a report on possible vectors by Capt. (later Maj.) Virgil. Miles, SnC, entomologist of the 18th Malaria Survey Unit. Maj. (later Lt. Col.) John T. Smiley, MC, Surgeon, Base Section No. 3, then prepared a final report, dated 20 April 1944, summarizing the situation. His findings confirmed those already arrived at by Major Pepper. In addition, Major Smiley came to the following conclusions: 'It is highly likely that sporadic cases occurred throughout the year; however, these have been recorded as fever of unknown origin inasmuch as no serologic studies were done, but there seems to be a definite seasonal increase in the disease during November and December.' The concept of seasonal incidence developed support as time passed. However, there was good reason to believe that this factor was more apparent than real (p. 746).
A second outbreak of the disease began in April 1944 and lasted through July 1944. These cases were limited almost entirely to troops taking part in the battle around Myitkyina, Burma, chiefly to the group known as Merrill?s Marauders (5307th Composite Unit (Prov.)) (fig. 249). There were 148 cases with 17 deaths. Writing about this outbreak to the Surgeon, USAFCBI, on 23 August 1944, Maj. (later Lt. Col.) Kirk T. Mosley, the theater epidemiologist, said:
The outbreak of scrub typhus fever occurred while this force was engaged on a combat mission to clear the enemy out of North Burma, especially in the general region of the route of the Ledo Road. The area covered by the 5307th Composite Unit (Prov) during this period was in the lower ranges and foothills of the North Burma mountains where the head-waters and tributaries of the Mogaung, Tinai, and Irrawaddy rivers are located. These streams or their tributaries were crossed a number of times and sites along their banks
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FIGURE249.-Brig. Gen. Frank Merrill, USA, Commanding General, 5307thComposite 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 animportant feature in the epidemiology of the outbreak and offers areasonable explanation of the occurrence anddistribution of cases among the three (3) battalions and also thedistribution within the component elements of eachbattalion (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.
Excellent descriptions of scrub typhus have been prepared by the medical officers with considerable personal experience with this disease. Major Machella and Colonel Forrester, of the 20th General Hospital, reported on 64 cases seen in the first outbreak. Capt. Clarence M. Agress, MC, and Capt. Edward R. Evans, MC, of the 73d Evacuation Hospital, reported on a survey of 86 cases seen in the first and second outbreaks. At the 29 January 1945 British Army Medical Congress, Colonel Wood, 1st Lt. (later Capt.) John J. Sayen, MC, and Capt. Harold S. Pond, MC, submitted a paper that briefly summarized the findings in some 600 cases seen at the 20th General Hospital. Finally, these latter three officers, along with Colonel Forrester, prepared a comprehensive clinical review of the 616 cases seen at the 20th General Hospital.
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FIGURE 250.-Bivouac area at 12-milemarkalong Ledo Road.
Statistics
Incidence. -Chart11 shows the number of cases per month of scrub typhus in U.S. troopsfromDecember 1943 to July 1945. Deaths are also indicated. Although at first glance one mightsuspect a seasonal incidence, with peaks in late fall and spring, thisdistribution in all probabilitywas related to the movement of the troops into infected areas duringthose months rather than theseason of the year per se. There was a total of 726 cases and 52deaths in U.S. Army personnel.?
Mortality. - The overall case fatality ratio in U.S. troops was approximately 7 percent, although in the first two outbreaks it was almost 12 percent. The chief factor in producing the higher mortality may well have been the poor physical condition of the troops on arrival at the hospital. Many of the men in the Myitkyina campaign, already acutely ill, were forced to march for several days to reach an evacuation point. On 28 May 1944, in a preliminary report to the Commanding Officer, 20th General hospital, Lieutenant Sayen, officer in charge of the typhus investigation at that hospital, made the following comment on the epidemiology of the second outbreak:
The mortality of thepresent Scrub Typhus Epidemic is considerably higher; and theindividual patients are moreseverely and prolongedly ill than was the case in the outbreak whichoccurred late in 1943. This seems directlycaused by the physical condition of the
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troops when theyacquired the infection. The 1943 American victims were supply orliaisontroops in relative sound health. The present group is composed ofexhausted, malnourished men;often not evacuated from the battle front until several days after theonset of typhus. Notinfrequently the patients suffer from simultaneous diseases,particularly amoebiasis and malaria. The importance of early evacuation, institution of bed-rest, nursingcare and proper nutrition, aswell as the treatment of concomitant diseases for which specifictherapy is available cannot beoverestimated.
Clinical aspects
There is nothing characteristic of the early symptoms thatdistinguishes this disease from anyother acute infectious process.
Incubation period. - The incubation period is alwaysdifficult to determine in diseases withgradual onset and indefinite time of exposure. In two medicalofficers, who were in a knowntyphus focus for only 4 days, it was from 9 to 13 days in one and from10 to 14 days in the other. One had a typical skin lesion 2 days, the other 4 days, before theonset of fever. The incubationperiod for the fever in these two cases corresponded closely with theone determined by theBritish, which was from 9 to 17 days for 121 cases.
Signs. - Three physical findings were found sufficiently characteristic to make them of considerable diagnostic importance. These were the typical eschar, generalized lymphadenitis, and the rash.
The following tabulation shows the incidence of these signs in the series of 600 cases reported on by Colonel Wood and Captains Sayen and Pond from
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the 20th GeneralHospital and in the 86 cases reported on by Captains Agress and Evansfrom the73d Evacuation Hospital:
Incidence of Clinical Signs (in percent)
Hospital | Eschar | Generalized | Rash |
20th General | 60 | 90 | 71 |
73d Evacuation | 78 | 94 | 48 |
The eschar, shown in figure 251, was the most pathognomonic physical finding, although it was seen less frequently than lymphadenitis. Although the lesion was found on all parts of the body, in most cases it occurred on the trunk or in the axillae. Unusual sites were the eyelids, the penis, and the perianal region. More than one eschar was very rare; Colonel Wood and Captains Sayen and Pond mention one case. The importance of the eschar as a diagnostic sign lay in the fact that usually this primary lesion was present for several days before the actual onset of symptoms. If the lesions had been discovered and the significance recognized, the affected individuals might have started their arduous trip back to a hospital 2 or 3 days before the onset of the disease instead of moving deeper into the jungle, as they unquestionably did in groups such as Merrill's Marauders. The best descriptions of the eschar
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were found in Lieutenant Sayen's preliminary report of 28 May 1944 and in the article on 616 cases of Captains Sayen and Pond and Colonels Forrester and Wood, the latter containing the following comment:
A typical primary ulcer, or eschar, of Scrub Typhus begins as an inflamed, painless papule which soon ulcerates, forming a central crater over which a dark, reddish-black scab forms. In moist areas, or when the scab is pulled off a deep ulcer with raised edges and thin yellowish-white exudate is seen. An essential characteristic is that it does not heal, possibly not until many days after the patient has recovered from his systemic symptoms. Although resembling other types of bites in its early phase, the mite ulcer shortly becomes so distinctive that it can scarcely fail to be recognized if seen. It is a raised lesion about the size of a dime with a black scab at the center (2 to 8 mm. in diameter) and a red, angry flare surrounding it for a distance of a centimeter or more. One or more regional lymph nodes soon become enlarged and tender and it is these rather than the symptomless ulcer which may attract the attention of the soldier. Since the eschar may occur anywhere on the body, commonly in moist, protected areas such as the axillae and the genital or perianal regions, a thorough search must be made of every suspected case. Medical corpsmen and line officers could probably be taught to recognize such lesions in addition to members of the Medical Corps.
Lesionson moist intertriginous surfaces (axillae, scrotum, perianal region)appeared as shallow, yellow-based ulcerswithout much surrounding hyperemia and without the black crust;consequently they were easy to overlook. Lesionson the hands and those below the popliteal space were oftenindistinguishable from the many cutaneous erosions andleech bites sustained by troops traversing the jungle * * *. The vastmajority of patients did not report feeling any'bite.' Secondary infection was rare * * *. The presence orcharacter of the ulcer appeared to have no relation toany other manifestation of the disease, including the OXK titer and theseverity.
The lymphadenopathy was the most frequent single physical finding. Generalized lymphadenitis was the rule, but it was common to find enlarged tender lymph nodes draining the site of the primary ulcer a day or two previous to the appearance of the generalized adenopathy. Because of the wide variability in the site of the eschar, careful search was necessary in order not to overlook the regional lymph nodes. The nodes were usually large and rubbery but at times small and firm.
Fever. - An irregular spiking type of temperature curve with double daily rises was regarded as characteristic of scrub typhus by Captain Sayen and his associates. It was exhibited by 70 percent of the patients at some time during the course of the disease. This characteristic type of curve was usually not persistent but was supplanted by long or short periods of remittent or sustained fever.
Laboratory findings
Agglutinations of the Proteus OXK antigen were found to be ofthe greatest diagnostic value. Adetectable titer was not usually found until the 10th day of thedisease or later. Opinions variedas to what constituted a diagnostic titer. Observers at the 20thGeneral Hospital, using 1/100 asthe diagnostic dilution, found only 55 percent of their 600 cases withthis titer or a higher one. At the 73d Evacuation Hospital,observers considered a titer of 1/50 as strong evidence of scrubtyphus; 70 percent of their 86 cases showed this or higher.
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FIGURE252.-Scrub typhus (Tsutsugamushi disease). Macular eruptioncharacteristic of thedisease.
The rash in most instances was a nonpruritic maculopapular eruption(fig. 252), which usuallyappeared between the 3d and 7th day of the disease and lasted from 5 to7 days. It involved thetrunk always and the extremities in about a third of thepatients. The face was involved in 15percent. It never involved the palms or the soles. Therewas no correlation between theappearance, character, or persistence of the rash and the severity ofthe disease. When florid ortypical, the rash was diagnostic, but this occurred in only half thepatients.
Late manifestations
In time first week of the disease, there were no unusual features thatdistinguished scrub typhusfrom any other severe generalized infection associated with markedtoxemia. However, theaverage patient continued to have fever for approximately 3 weeks, andit was during the 2d and3d week that such manifestations as typhus pneumonia, major involvementof the central nervoussystem with coma or convulsions, cardiovascular involvement, andhemorrhagic phenomenaappeared. These complications were described in detail by theobservers at the 20th GeneralHospital. They were the most
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seriousdiagnostic and therapeutic problems; there were other less significantfeatures, such astender toes, conjunctivitis, deafness, visual disturbances, and edemaof the face, hands, and feet.?
Respiratory manifestations. - Involvement 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:
a. The most important sign to look for is tachypnea, 35 or more per minute. When this persists for 2 or 3 days, a fairly extensive typhus pneumonia is probably present whether or not physical or roentgenologic signs confirm this suspicion.
b. Less extensive typhus pneumonia is often indicated by persistent rales, impairment, and restricted breath sounds, in the absence of marked tachypnea.
c. Theordinary roentgenologic signs of pulmonary consolidation are rarelyseen. The chest film often shows nothingbut prominent hilum and trunk shadows in a patient with extensivetyphus pneumonia. Occasionally there is diffusemottling. Typhus pneumonia is a lesion which is not adequatelydemonstrated by x-ray of the chest. When abnormalities are foundthey usually fail to indicate the true extent of the lesion. Theoccasional case will die withextensive typhus pneumonia without having had the degree of tachypneaindicated in (a), but this is rare. Inconclusion, then, the most important clinical indicator of thecondition of the lungs in scrub typhus is the respiratorrate chart. It rarely fails to show a rate above 35 per minutefor at least 2 days when the lesion is extensive enough tobe of major clinical significance.?
Cardiovascular findings. - In the cases observed at the 20th General Hospital, cardiovascular findings were summarized by Colonel Wood in the theater ETMD for March 1945. In 500 cases, no true congestive heart failure was seen. Cardiac enlargement determined by percussion and the position of time apical impulse was found in 28 percent of 200 cases; however, Colonel Wood questioned whether X-ray findings would corroborate such a high percentage. In the same 200 cases, 24 percent had a gallop rhythm and 33 percent a soft first heart sound. Electrocardiographic tracings were taken on 42 patients in the 2d and 3d week of the disease. In 30 of this group, the tracing was taken because a cardiac complication was suspected; 8 showed P-R interval prolongation of 0.22 seconds or more, 18 showed minor and 3 showed definite abnormalities of the Q.R.S. and/or T segments. In the remaining 12 cases, the tracings were taken merely to determine the incidence in unselected cases of scrub typhus. Although the series was too small for conclusions, 3 cases showed P-R intervals prolonged to 0.22 seconds or longer, and 2 showed marked RST segment deflections and/or T wave inversion.
Colonel Wood concluded his report on the cardiovascular findings, as follows:
These cardiac phenomena rarely occur in the first week. They appear from the 7th to the 16th day. We do not as yet have the figures for the duration of enlargement, gallop, etc. Moreover the correlation between pathologic and clinical findings is not yet available. The patients with the largest hearts did not all die, by any means. In fact most of them recovered. As they got well, their hearts returned to normal size. None of them showed congestive failure. A few patients who died showed mild to moderate degrees of right sided cardiac dilatation at autopsy. Pericardial effusion was not seen.
* * * * * * * * * * * *
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e. Conclusion. - Although our data are as yetincomplete,it is our impression that these cardiacsigns all disappear during convalescence, and that the 'effortsyndrome' picture seen in someconvalescent typhus patients is not due to heart disease per se.
Ocular changes. -Maj.Harold G. Scheie, MC, studiedthe eyes of the patients at the 20thGeneral Hospital at weekly intervals during the course of thedisease, consolidating the results ofhis studies in a brief but comprehensive report. He stated as follows:???
* * * The first and most uniform change found in the fundi of the patients with scrub typhus was progressive venous engorgement with onset late in the first or during the second week, continuing until the veins are two to two and one half times the diameter of the arteries. Accompanying this change the veins become more tortuous, irregular and sausage like in caliber, most marked near the disc. The outlines of the venous walls become indistinct while the arteries remain well defined. Apparent compression of the veins occurs at the arteriovenous crossings where the veins frequently appear interrupted by the arteries, which at these points have a diffuse veil along their walls. As these latter changes progress, the disc and retina become edematous and the posterior pole of the eye appears somewhat veiled particularly in the region of the disc. The disc and surrounding retina appear pale and more opaque than normal. In a few cases retinal hemorrhages and cotton wool exudates occur when the retinal changes are at their height.
Conjunctival injection occurred in 38 percent;subconjunctivalhemorrhages in 6.5 percent. Retinopathy, when present, was of diagnostic significance inasmuch aslesions of this type werenot seen in other febrile diseases. Edema of the disc and retinawas noted in 36 percent, wasalways bilateral, and was preceded by engorgement of the veins. Retinal hemorrhages occurredin 6.6 percent. They were usually superficial and flame shapedbut occasionally deep andpunctate. Retinal exudates, usually of the cotton-wool type,occurred in 4.9 percent. MajorScheie failed to find evidence in the retinal vessels of theperivasculitis mentioned in TB MED31; he felt that the changes were rather those of a truevasculitis.?
Neurological manifestations. - Involvement of the central nervous system was evident in practically all cases. A nerve type of deafness was seen in the majority of patients during the 2d or 3d week. Tinnitus was usually an accompaniment. Peripheral nerve symptomatology, such as paresthesias, numbness, and weakness, was seen in a few. These phenomena generally disappeared with defervescence. Meningoencephalitis was evident at post mortem examination in all fatal cases. Clinically, involvement of the central nervous system was reflected by apathy and drowsiness in the early stages of the illness and, in the 2d and 3d week, by confusion, delirium, restlessness, convulsions, and coma. Captains Sayen and Pond and Colonels Forrester and Wood described the restlessness in their 616 cases as follows:
Twenty-six patientsdeveloped a peculiar, persistent restlessness. Such individualswould not lie quietly, butconstantly thrashed about, sat up, or tried to get out of bed. They would not tolerate an oxygen mask, or anintravenous infusion. They required constant nursing supervisionand sedation. They were all gravely ill and worethemselves out at a time when their physical reserves were precariouslylow.?
Malignant restlessness or convulsions were among the most ominous developments, and coma was usually followed by exitus. In 200 cases at the 20th
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GeneralHospital, only 12 patients had convulsions; coma occurred in 14 cases.
Hemorrhagic phenomena. - To a variableextent, hemorrhagic phenomena were seen at thedifferent hospitals. In the theater ETMD for June 1945, the 73dEvacuationHospital reported that at that hospital relatively few patients showeda bleeding tendency exceptas a terminal event; whereas, in the theater ETMD for April 1945, Capt.(later Maj.) Horace H.Hodges, MC, at the 20th General Hospital, found the reverse to be true,as follows:
It was concluded that, in a considerable proportion of patients with scrub typhus, there is an abnormality of the clotting mechanism. A lowered prothrombin content seems to be frequently associated with prolonged clotting. An actual purpura, with platelet deficiency, was encountered twice with long clotting and low prothrombin. The significance or cause of this is unknown. In itself, prothrombin in the range of 50 percent normal is not enough to prolong clotting. Other unknown factors must be operating.?
Also in the June ETMD, the 14th Evacuation Hospital in reporting on a gross pathologic study revealed the following incidence of vascular or hemorrhagic manifestations:
1. Of 16 autopsies performed on U.S. soldiers, therewas 1 caseof acute infarction of liver, 2cases of acute infarction of spleen, 1 case of acute militarymyocardial infarction with perirenalhemorrhage, 2 cases of adrenal medullary hemorrhage, 1 case of massivehemorrhage into psoasmuscles and retroperitoneal tissue, 1 case of massive hemorrhage intosmall and large intestines,and 1 case of acute infarction of kidney.
2. Of 7 autopsies performed on Chinese soldiers,there were 3 cases ofmassive hemorrhage intopsoas muscles and retroperitoneal tissues; 1 case of massive hemorrhagefrom nasopharynyx; 1case of acute infarction of kidney; and 1 case of massive aspiration ofblood into lungs, sourceundetermined.?
These were all post mortem findings. No mention was made in the report of the incidence of hemorrhagic phenomena in nonfatal cases.
Treatment???
Therapy was primarily supportive and symptomatic. Strict bed rest was essential, and it was generally agreed that nursing care was of the utmost importance. At the 20th General Hospital, it was the consensus that the care a patient received in the first week of the disease might be decisive in determining ultimate survival.
Sufficient fluids to insure an adequate intake were essential, particularly during the monsoon season; at times it was necessary to administer fluids parenterally. In the theater ETMD for May 1945, medical staffs of the 20th General and the 48th and the 73d Evacuation Hospitals agreed that slow and cautious administration of intravenous fluids did not constitute a serious hazard; however, the medical staff of the 14th Evacuation Hospital expressed the following opinion:
b. Fluids: We are strongly of the opinion that the interference with fluid balance by means of intravenous fluids in this disease is hazardous and, at best, not as beneficial as he frequent administration of fluid, even in small amounts, by mouth. An intravenous infusion,
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FIGURE 253.-Continued. C. Interior viewof an air-conditioned ward.
which in other illnesses would be expected tobeneficially affect dehydration, will most frequently be found to failinthis 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 andhypoproteinemia. Sedation, inadequate doses, was essential for restless patients; narcotics, rectalparaldehyde, and intravenousbarbiturates were used. Oxygen was administered for cyanosis.Sulfonamides and penicillinwere employed by all installations. It was agreed by all thatthese drugs had no effect on thetyphus itself and that they were of questionable value in complicationssuch as pneumonia.
The installation of air conditioning (fig. 253) in the typhus wards ofthe 20th General Hospital inJune 1944 was followed by a prompt drop in mortality from 17 percent to3 percent. However,although it was reasonable to believe that air conditioning made thepatient feel morecomfortable and generally improved his subjective feelings, there wasno proof that the drop indeath rate was a consequence of the air conditioning, in view of theadditional fact that thepatients admitted to the hospital at that time were in better physicalcondition than those whocame in during the early weeks of the Myitkyina campaign.
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In the treatment of the complications, vitamins E and K were used tocontrol bleeding tendencies.Digitalis was not used in the cardiovascular complications at the 20thGeneral Hospital becauseof the impression of the staff that the drug was not helpful in acutefebrile diseases. On the otherhand, the 14th Evacuation Hospital staff made the following statement:'Digitalis has proven amost valuable drug when used in cases with any manifestations ofcardiovascular impairment ordysfunction, as well as in cases with obvious cardiac failure.' The 48th Evacuation Hospital wasalso of the opinion that digitalis was beneficial.?
Prolonged convalescent care was the rule. The majority of patients with scrub typhus were returned to duty within a period of from 3 to 4 months. A complete program for reconditioning of such patients, based on the program in use at the 20th General Hospital, was published in Circular No. 11, Office of the Surgeon, Headquarters, USAFIBT, 23 December 1944, subject: Scrub Typhus Reconditioning. The convalescent period required from 3 to 4 months for patients who were to return to combat duty. Because of the severity of the illness and the prolonged convalescence, there was a tendency for patients to develop an effort syndrome if the physical reconditioning was pushed too hard. Patients who had been severely ill, usually with a complication such as pneumonia, myocarditis, meningoencephalitis, or severe hemorrhage, were evacuated to the Zone of Interior.
Cutaneous Diphtheria
Chronic ulcerative skin lesions originating in unhealed, infectedabrasions or bites are commonduring the monsoon season in the Assam-Burma jungle. They are generallycalled tropical ulcersor, 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 theirextremities, the lesions were considered to be a form of tropicalulcer. Under the pressure ofcombat conditions, many men continued to remain on duty and receivedlittle or no treatment. Soldiers given local treatment usually showed some degree of healing ofthe ulcers; their returnto duty, however, resulted in almost immediate relapse.?
The more severe and persistent cases were evacuated back to general hospitals. When some of the patients on the dermatology service at the 20th General Hospital developed neuritis and cardiac symptoms in August and early September 1944, Colonel Wood, chief of the medical service, and Maj. (later Lt. Col.) Clarence S. Livingood, MC, of the dermatology service, both submitted reports on 15 September 1944 to the commanding officer of the hospital, suggesting that these skin ulcers were cutaneous diphtheria.
As a result of these reports, Maj. (later Lt. Col.) John L. Arbogast, MC, of the 9th Medical Laboratory, made an epidemiologic and bacteriologic survey of the Myitkyina area, sending in a preliminary report to the commanding officer of the laboratory on 16 October 1944 and a more complete report on
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FIGURE254.-Typical tropical ulcer or Naga sores.
16 November1944. Thie survey showed that the units involved in the outbreak wereexposed toliving conditions that were severe even for combat. In additionto the hardships of foxholefighting, these men suffered from numerous minor abrasions from thethick jungle undergrowth,from leech and insect bites, and from the intense heat and humidity ofthe Burma monsoonseason. Poor personal hygiene was unavoidable; bathing facilitieswere rarely available. Clothing and equipment were always damp, and, since much of thefighting took place throughrice fields, it was impossible for the men to keep their feet dry.?
The source of the infecting micro-organism was a matter of great interest and was intensively studied. The 9th Medical Laboratory studies included cultures from the rice paddies; these were uniformly negative. Rare cases of faucial diphtheria were reported among the troops from time to time, but 129 nose and throat cultures from a group of the 475th Infantry showed only one positive for Corynebacterium diphtheriae; it proved to be avirulent. No definite relationship could be traced between faucial diphtheria and cutaneous diphtheria. It is of interest that the Joint Intelligence Collecting Agency, in its report No. 2078, dated 14 November 1944, observed that during the same months the British hospitals in India were also seeing a number of cases of cutaneous diphtheria.
Cutaneous diphtheria was not reported untilSeptember when thediagnosis was first establishedat the 20th General Hospital in a group of patients with myocardial andneuritic complications. Earlier cases undoubtedly had occurred. One soldier, admitted toanother hospital because ofulcers of the leg, developed myocarditis and died in congestive heartfailure 12 days afteradmission. No electrocardiograms or cultures were made. At post
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mortemexamination, inflammatory changes consistent with diphtheriticrnyocarditis wereevident.
Once cutaneous diphtheria became established as a disease entity,patients were diagnosed earlyand hospitalized. A more complete report on 9 October 1944 from Major Livingood of the20thGeneral Hospital to his commanding officer followed the original briefreports, and in Octoberthe 69th General Hospital reported on 30 cases. Additionalreports were submitted in 1945. Inthe theater ETMD for April 1945, Capt. (later Maj.) Harvey Blank, MC,of the 69th GeneralHospital, reported on another 40 cases from that hospital, and Maj.Herbert S. Gaskill, MC, oftime 20th General Hospital, reported on neurologicalcomplications. In the May 11945 ETMD,Captain Blank reported on 3 cases from time 69th Genera] Hospitalenlisted detachment. MajorKay of the 20th General Hospital submitted a report on the cardiaccomplications.
Clinical manifestations
The clinical findings have been described in manytextbooks and in TBMED's on the subject. It was apparent from the histories of thesecases that, like tropical ulcers, time diphtheritic ulcersarose from minor cuts, abrasions, and mosquito bites which failed toheal. Multiple ulcers werethe rule, in most cases located on the lower extremities, usually belowthe knees. The hands andthe forearms were the next most frequent sites; other parts of thebody, such as the scalp, trunk,axillae, and perianal regions, were less commonly involved.?
Major Livingood, in his preliminary report of 15 September 1944, stressed the following three diagnostic features:
1. An ulcer with a black adherent crust; thiswas the mostimportant clinical finding.
2. A greyish, yellowish, or brownish-greymembrane in asuperficial or deep ulcer.
3. An ulcer surrounded by an inflammatoryreaction out ofproportion to that usually seen ineczematous ulcers of a similar size.?
Captain Blank, in his analysis of 40 cases at time 69th General Hospital, described the lesion as punched-out ulcers with a black or brownish-black eschar or, in the absence of an eschar, a greyish membrane. The scars were 'deep, very destructive, and atrophic, with a volaceous tan color.' Darkening of the skin around the ulcers was described by all observers, and anesthesia of the skin immediately surrounding the ulcer was common. Pain was not a prominent feature except when an attempt was made to remove the eschar or membrane.
Under local treatment, the ulcers healed slowly fromthe peripherytowards the center. The scardid not contract when healing was complete, and the final scar was anatrophic circular spot thesize of the original ulcer.?
The healed ulcers frequently broke down. The process was usually preceded by the formation of a bulla or vesicle in time center of the healed scar.
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When this ruptured, the rest of the ulcer soon broke down completely. Healing generally took place fairly rapidly after such a breakdown, but because of the frequency of such occurrences hospitalization was usually prolonged. In a final report on the cases seen at the 20th General Hospital, Capt. Daniel J. Perry, MC, of the dermatology and syphilology section, wrote to the consultant in dermatology in the Surgeon General?s Office, as follows:?
This tendency of diphtheritic ulcers to break down is perhaps explained by the microscopic picture which shows massive fibrous tissue formation enclosing small vessels and capillaries surrounded by a round cell exudate. The process extends peripherally into the normal skin beyond the ulcer and also downward into the subcutaneous fat. The histologic picture suggests that a local toxic agent has produced severe cutaneous and subcutaneous changes. The destruction of nerve endings probably accounts for anesthesia present in the scars of cutaneous diphtheritic lesions.?
Cultures from the recurrent ulcers did not show virulent C. diphtheriae.
Complications
The 7 cases with cardiac complications (in the 141 cases reported on byMajor Kay of the 20thGeneral Hospital) constituted only 5 percent of time total group. Only 4 of the 7 cases haddefinite myocarditis; the others were listed as probable. One ofthe four died. There was no -'typical picture' of cardiovascularcomplications. The one fairly consistent finding was an inversionof the T wave in lead CR3 this was present in all cases ofmyocarditis except the one withfatal termination. Interestingly, no instances ofintraventricular conduction defects were noted inthe cutaneous diphtheria group, although two patients with faucialdiphtheria who developedmyocarditis showed this type of lesion. Cardiac manifestations usuallydeveloped between the3d and the 7th weeks. At the 69th General Hospital, only twocases with cardiac involvementwere seen.?
Neurological complications were much more common. At the 20th General Hospital, 43.5 percent of the cases showed neuritic involvement. At the 69th General Hospital, in a group of 40 cases, 48 percent developed neuritis. The important neurological complications seen at the 20th General Hospital were summarized in the theater ETMD, dated 10 May 1945. These complications were discussed, in general, as follows:
Neuritis appeared in the average case 70 days after the onset of cutaneous diphtheria (the extremes were from 23 to 158 days). The clinical course of the neuritis proceeded in regular sequence through certain definite steps, which were in some cases partially superimposed and in others quite separate. The steps in order of their appearance were (1) cranial-nerve involvement, (2) peripheral-nerve involvement (sensory), and (3) peripheral-nerve involvement (motor). In the majority of cases, cranial-nerve involvement failed to appear, but the stated sequence in peripheral-nerve involvement was maintained. In many cases, the peripheral motor symptoms did not occur, the patient showing only sensory phenomena.?
The manifestations of these three types were as follows: ?
1. Cranial nerve involvement (duration from 10 to 30 days) . - The most common symptom was blurred vision due to loss of accommodation. Other less frequent signs were weakness of the pharynx and palate, loss of taste, and numbness of the lips and tongue.
2.Peripheral nerve involvement,sensory (duration from 28to 56 days) . - This always
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beganwith paresthesia (numbness and tingling of hands or feet or both).Later, there was adiminution in perception of light touch and pain.
3.Peripheralnerve involvement, motor (duration from 60 to 90 days) . - Thisalways began withthe subjective symptom of weakness of arms or legs, accompanied bydiminished or lost tendonreflexes. In severe cases, atrophy occurred. A very few individualsshowed posterior columnsigns, loss of position and vibration plus mild ataxia.
Cranialnerve involvement was usually followed by moderate or very severeneuritis.Consequently, it seemed to be a prognostic indication. The duration ofneuritis was directlyrelated to its severity. The average case lasted 100 days (extremesfrom 21 to 184 days). Thesite of the cutaneous lesion bore no relation to the location of theneurological involvement.Severity of cutaneous lesions could not be correlated with severity ofneuritis, but it did correlatewith frequency of neuritis. The spinal fluid proteins were found to beelevated in nearly everycase of neuritis. In general, the elevation was proportional to theseverity of the neuritis andpersisted until the neurological phenomena disappeared. Completerecovery from neuritisoccurred eventually, even in the most severe cases.
Treatment
Antitoxin, in doses of from 20,000 to 40,000 units intranmuscularly asearly in the course of thedisease as possible, was the most important measure. Injection ofthe antitoxin in theneighborhood of the lesion had no apparent advantage over intramuscularinjection into thebuttocks.?
Nonspecific therapy consisted of pressure dressings after cleansing with various antiseptics, such as penicillin solutions, potassium permanganate, mercury bichloride, and sulfonamides. Cod liver oil ointment under a firm dressing was used effectively in several instances, and zinc peroxide also was used with beneficial results. Parenteral penicillin was ineffective.
The ulcers of twelve cases at the 20th GeneralHospital were treatedsurgically, and reported onby Maj. (later Lt. Col.) Henry P. Royster, MC. It was the opinion ofMajor Royster that morefrequent use of surgery would have resulted in a larger proportion ofmen returned to duty andwould have reduced the length of hospitalization. He concluded thatsurgery should. beconsidered in every case when the lesion fails to heal after from 60 to70 days; excision of theulcer during the acute stage is contraindicated. Excision of the ulcerand a small cuff of skinfollowed by application of a split skin graft apparently yielded thebest results. The nutritionalstate of the patient seemed to exert a profound influence on thehealing process. In a patient withanemia and hypoproteinemia associated with hookworm infestation, thewound failed to healuntil these factors were taken into account and corrected. Adequatefeeding of protein andtransfusion of blood and plasma were necessary in some cases. Nomanifestations of vitamin Cdeficiency were apparent.
Bacteriology
The first intensive bacteriologic studies were begunby the 9th Medical Laboratory in October1944 and reported on to the commanding officer of the laboratory by 1stLt. (later Capt.) CharlesCox, SnC, on 14 November 1944. In addition to cultures from the ulcers,the study alsoincluded cultures from the soldiers of one of the organizations locatednear Myitkyina. Nose andthroat cultures from the 475th Infantry, one of the units mostaffected, showed
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128 negativecultures and 1 morphologically positive, but avirulent, culture.Cultures from therice paddies, considered a possible source of infection, were uniformlynegative.?
Of 53 cultures taken from leg ulcers, 10 showed morphologic characteristics typical of C. Diphtheriae - 9 were avirulent, and 1 was positive to virulence test. Later cases showed a higher percentage of virulent cultures. Of the 10 positives, the single virulent culture came from a patient whose ulcers were only of 6 days? duration and who had a Schick positive reaction, whereas in the other 9 patients the lesions were from 23 to 110 days old and the Schick reactions were negative.
Schick negativity, however, did not mean protection against thedisease. In Major Livingood'sreport of 9 October 1944, one patient, a medical officer treated at the20th General Hospital, haddefinite knowledge of having a negative Schick reaction for 6years. This individual not onlydeveloped clinical cutaneous diphtheria but also neurologicalcomplications. A soldier in the69th General Hospital enlisted detachment, reported on by CaptainBlank, developed typicalclinical cutaneous diphtheria 3 weeks after a negative Schick test hadbeen found in the course ofa routine survey of his unit. 9 Although no cultures weretaken in this case, it resembled in everyrespect the other cases of cutaneous diphtheria. A second case atthe 69th General Hospitaldeveloped typical skin diphtheria with a positive virulent culture for C.diphtheriae in March1945; this patient also had had a Schick negative reaction in October1944 when the unit wassurveyed.
Comment
Cutaneous diphtheria proved serious in manyrespects. Two deaths were directly attributable toit. A tremendous number of man-days were lost to the Army because ofthe slow healing of theulcers and the high incidence of neurologic complications requiringprolonged hospitalizationand convalescence. The total number of hospital days of 140patients at the 20th GeneralHospital was 18,783. Many of the patients lost a total of 5months from duty, and several lost asmuch as 7 months. The average healing time of the ulcers for the wholegroup at the 20thGeneral Hospital was approximately 42 days, with extremes of from 12 to128 days. Sixtypercent of the patients at the 20th General Hospital returned to fullduty after an average periodof hospitalization of 85 days, and 18 percent returned to limited typeof duty.?
The most important lesson learned from this epidemic was that these patients had to be recognized in the early stages by the forward medical units and evacuated immediately. The earlier specific treatment was instituted, the shorter was the stay in the hospital and the lower the incidence of complications.
9 The question of the potency of the testing materialsmay be raised in these last two cases, orfor that matter in almost any case tested with Schick material andfound negative, unless it isknown whether others tested from the same vial were Schick positive.The diphtheria toxin isheat labile, and, with the high temperatures reached in India, it isconceivable that the testingmaterial may have been rendered useless.
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Fever ofUndetermined Origin
Diagnostic problem
The medical officer arriving in India or Burma from the temperate zoneof the United States isstartled by the omnipresent diagnostic problem of the patient whopresents himself at dispensaryor hospital solely because of fever with attendant malaise, headache,and generalized pains andaches. A careful physical examination soon after the onset failsto reveal army diagnosticfindings. The medical officer soon learns that repeated carefulphysical examinations andlaboratory studies during the succeeding days may reveal findings thatwill declare the diagnosisof malaria, dengue, sandfly fever, infectious hepatitis, kala-azar,smallpox, typhoid fever,poliomyelitis, typhus fever (louseborne, tickborne, fleaborne, ormiteborne), amebic hepatitis, orone of the dysenteries. Then, too, many patients will reveal thepresence of diseases more usualin the previous professional experience of the medical officer, such asnasopharyngitis, primaryatypical pneumonia, or infectious mononucleosis. The fact thatthe patients were mainly a youngvigorous group from which the sickly had been screened, accounted forthe few instances ofmetabolic or degenerative diseases, such as diabetes, nephritis,tuberculosis, or chronic rheumaticheart disease.
Statistical fallacy
The incidence rate per 1,000 per annum of patientswith undiagnosed fevers, or FUO (fever ofundetermined origin), in the India-Burma theater was not equaled in anyother theater ofoperations. It is unfortunate that the term 'fever of unknownorigin' as used in the statisticalreports carries the connotation that such patients manifested feverthat could not be diagnosed bythe medical officers. In point of fact, this applied as a ruleonly when the patie nt first presentedhimself at the dispensary or other local installation soon after theonset when there were nocharacteristic diagnostic findings. These installations were not alwaysequipped with thelaboratory facilities to make the requisite diagnostic studies. Themajority of such patients, whenobserved during their clinical course, revealed some definite diseaseor syndrome entity and wereappropriately reported. Such an individual appeared twice in thestatistical reports, initiallyunder FUO and, later, under dengue, sandfly fever, malaria, or whateverdiagnosis was finallymade. The extent to which the official FUO rate of this theaterreflected the initial perplexity ofthe medical officer rather than the final diagnosis is notascertainable. Chart 12 shows the theaterrnonthly incidence rate from January 1943 through 1 July 1945.?
Dengue and sandfly fever group. - Many patients exhibited a febrile course of from 1 to 10 days with clinical characteristics consistent with either sandfly fever or dengue. Certain patients, to be sure, showed a rash, blood findings, or temperature curve wholly characteristic of the one or the other. For the most part, however, clinical observation permitted no such differentiation. The fact that sandflies are prevalent in Karachi, India, and the Aedes
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aegypti in Calcutta, India, led to diagnoses of sandfly fever in the former and dengue in the latter on epidemniologic grounds, although the clinical findings might be identical. Elsewhere in Burma and India, knowledge of insect vectors is rather incomplete.
Throughout the India-Burma theater generally, the problem of diagnosis of these two diseases was confused by several factors. There is no conclusive evidence that Phlebotomus papatasii is the only competent vector of sandfly or that A. aegypti is the only insect that can transmit dengue in India or Burma. Moreover, no accurate entomologic surveys of India or Burma had come to the attention of the U.S. Army Medical Department. The medical officer was caught in a further dilemma. Only the following three official diagnoses were permissible under the reporting procedures in effect: Dengue, sandfly fever, or fever of undetermined origin. Unable to make a definite diagnosis of either of the first two, he retreated to the comparative safety of the third classification. This problem of diagnoses was not peculiar to the Medical Department of the U.S. Army stationed in this theater. Outbreaks of febrile
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illness of shortduration with practically no mortality are rather extensively referredto in theIndian and British medical literature by such vague terms as 'Madrasfever,' 'Bombay fever,' or'Assam fever.'?
It was not unusual at the time of visit of the medical consultant to encounter groups of patients from a particular unit with surprisingly uniform characteristics such as fever lasting from 5 to 6 days, severe moderate prostration, pains and aches in the muscles, photophobia, headache, moderate lymphadenopathy but no rash, leukopenia, or secondary rise of temperature. Such groups of cases were frequently given such diagnoses as '1880th Engineer fever,' '610 Ordnance Ammunition Co. fever, and 'Signal Corps Construction Battalion fever.' This phenomenon of a disease exhibiting striking uniformity during temporary outbreaks is similar to that witnessed in many other conditions. Even the common cold at certain times may affect almost all victims with sinusitis, or gastrointestinal symptoms may assume striking prominence.
On occasion, this predominance of a single feature of the illness wasperplexing. At severalinstallations in this theater during the spring months of 1945,interesting groups of cases wereobserved with symptoms and signs consistent with either dengue orsandfly fever but, in addition,striking evidence of meningeal inflammation. From the 18thGeneral Hospital, Myitkyina,Burma, Capt. Frank W. Kibbe, MC, reported 22 cases. He summarized hisobservations asfollows:
These 22 patients wereadmitted to the 18th General Hospital during the month of June 1945. Itis noteworthy thatthe patients are not all from a single group or outfit, but that fourof the patients are from one group, and that threeothers not only came from the same outfit, but lived in the sametent. Their fourth tentmate was not admitted to thehospital, but had mild symptoms for one day at the company. Questioningof patients in an effort to discover a modeof infection common to all has thus far proved unsuccessful.
The patients were admitted to the hospital with a variety of symptoms, the most constant of which was severe frontal headache. This was nearly always accompanied by pains in the eyes. Six of the twenty-two patients had definite prodromal symptoms of a mild head cold or slightly sore throat. Four others had mild diarrhea, one severe enough to simulate an acute dysentery. There was no history of bite in anyone and no local papules or wheals as described in pappataci fever. At the height of the disease, the single striking symptom was the intense frontal headache over and in the eyes. On physical examination they showed no sinus tenderness, but marked eyeball tenderness both on pressure and with motion. Every patient had small cervical nodes along the posterior chain. Only three of the group showed even moderate nuchal rigidity and in nearly half the cases it was absent altogether. All the patients had mild fever ranging from 100o to 103o. The elevation lasted from two to five days and did not recur in any instance.
Everypatient had a routine examination of the hemoglobin, white blood-cellcount, differential, and urine. Thewhite counts varied from about 5,000 to 12,000 with normaldifferentials while other laboratory studies werenegative. The spinal fluids showed varied reactions, the whitecell counts ranging from 0 cells up to 490, almost allof which were lymphocytes in all cases. The protein concentrationranged from normal to 70 mgms. per 100 c.c. Inthree of the reported cases, only the elevated protein was present withno increase over normal of the white cellcount. Up to the present time various other studies have been negativeincluding occasional proteus and heterophileagglutinations, Kahns and spinal fluid chlorides. No late studies havebeen completed as the disease is not suffi-
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ciently long lasting. Throat cultures, whereindicated, showed no diphtheria (K-L) organisms.
Because ofthe suspicion of lymphocytic choriomeningitis, ten mice were givenintracerebral inoculations. Ourlimited supply of animals did not allow us to do this procedure on allpatients so characteristic ones were picked,some from the high cell count group, others from the increased proteingroup, etc. Three of the mice were injectedwith the patient?s blood, 3/100ths c.c.'s I.C.) taken at theheight ofthe illness. The other seven were all injected withspinal fluid. None of the mice showed the typical leg symptoms andconvulsions of lymphocytic choriomeningitis. Two of the mice diedviolently (crushed by the case) on the eighth day, while all the restsurvived showing nosymptoms at all at any time. The two crushed mice were autopsied andshowed no evidence of disease.
The majority of the patients were over their acute symptoms by the end of six days, and were discharged from the hospital by their fourth week. At the time of discharge none of the patients showed any gross abnormalities. No residua were noted at this time.
Similar cases were observed at the 234th General Hospital in Chabua, 100th Station Hospital in Delhi, and the 99th Station Hospital in Gaya. Appropriate tests of the sera in two of the cases at the 234th General Hospital were negative for lymphocytic choriomeningitis. Occurring at the time when instances of poliomyehtis and of lymphocytic choriomeningitis were encountered, these cases raised an important clinical problem. Were medical officers dealing with lymphocytic choriomeningitis, abortive poliomyelitis, or were the findings merely expressions of the inflammatory reaction of the meninges to a virus similar to or identical with that which causes dengue or sandfly fever? None of these patients gave evidence of other diseases in which meningeal irritation is recognized; namely, acute infectious mononucleosis, mumps, acute infectious hepatitis, primary atypical pneumonia; bacterial pneumonia, or influenza. It was believed that, although further virus studies would be helpful and additional complement-fixation studies for lymphocytic choriomeningitis would be desirable, the clinical evidence permitted a diagnosis of the dengue-sandfly group of fevers, probably pappataci fever, it was of considerable interest to note that in the extensive experience of the Mediterranean (formerly North African) theater, sandfly fever with a similar benign, lymphocytic meningitis was observed.10 Napier, likewise, states that sandfly fever may simulate benign lymphocytic meningitis.11
HookwormInfestation
Although hookworminfestation was prevalent in the native population of India and Burma,itwas not a problem of great moment in U.S. troops except in certainareas under particularcircumstances. In a survey on the incidence of intestinalparasitism in Assam, by Capt. (laterMaj.) Franklin Carter, MC, of the 9th Medical Laboratory, single stoolexaminations were donein 6,422 U.S. soldiers; only 13 were positive forancylostomiasis. Similarly, only 9 hookworminfestations were found in a survey by Captain Ehrhich
10 Circular Letter No. 40, Office of the Surgeon, Headquarters, North African Theater of Operations, 29 July 1944, subject Sandfly Fever (Pappataci Fever).
11 Napier, L.E.: The Principles and Practice of Tropical Medicine. London: W. Thacker & Co., 1943, p. 318.
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of 506 personnel of the medical detachment of the 20th General Hospital. This is in contrast with the finding of 280 positive stools from 1,000 Indian civilians. These studies, although not highly accurate because of the inevitable handicaps incident to wartime conditions, nevertheless, provided a general estimate of the incidence of infestation.
The extent to which hookworm disease wasresponsible for hospitalization is not known since report of the disease was not required on Form 82 ab, Statistical Health Report. The experience of the medical consultant on his visits to the various installationswas in general accord with the low incidence of infestation found in the surveys just mentioned,except, however, that thedisease was far more common than had been suspected in the patients hospitalized in Ledo andalong the Stilwell Road. These patients had worked in maintenance and construction units, hadbathed in streams, occasionally had walked barefooted along river banks or in fields, and had hadample opportunity for infection. Similarly, early in the war,combat units were not infrequentlyaffected. It is probable that almost all of these patients contracted hookworm infestation in thistheater. Only about 20 percent had lived in the hookworm belt in the United States, and Ancylostoma duodenale, a species encountered in the UnitedStates, was recovered in a high percentage.
The experience with hookworm infestation in combat troops was excellently described by Captain Rogers and Lt. Col. Gustave J. Dammin, MC, in their report based on 50 consecutive cases admitted or transferred to the gastrointestinal and dysentery wards of the 20th General Hospital. Several hundred additional cases both with and without symptoms were seen on the general medical wards during the same period of time. The authors, stressing particularly the syndrome of acute onset of moderately severe gastrointestinal symptoms associated with eosinophilic leukocytosis, and stated:
It differs from the traditional clinical picture of hookworm disease chiefly in the abruptness of onset, the prominence of acute and sometimes disabling digestive symptoms and the lack of anemia * * *. In many, a sudden onset of nausea, vomiting, abdominal pain and diarrhea occurred. In others, a more gradual onset of cramping and burning abdominal pains after meals was the initial manifestation. The nausea, vomiting and diarrhea tended to subside and to become intermittent.
These authors described pain as the most prominent and persistent of the gastrointestinal symptoms. It was usually epigastric but sometimes periumbilical, and it tended to be diffuse. In many patients, the pain appeared immediately after meals. The frequency of time various symptoms of the hookworm infestation found in the patients in this study is shown in table 8.
Physical findings were notstriking exceptfor the almost universal loss of from 10 to 40 lbs. inweight. The definite diagnosis of hookworm infestation depended on the.demonstration of theova in time stools. In accord with extensive experience elsewhere,Captain Rogers and ColonelDammin found that direct examination of the stools, even when repeatedseveral times, was not asatisfactory procedure. Repeated examinations by the directmethodestablished the diagnosis inonly approximately 60 percent of the patients;
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only 20 percenthad positive stools on the initial examination. On the other hand, whenthe zincsulfate flotation method was utilized, hookworm ova were consistentlyfound after not more than3 stool examinations, and in 85 percent of the patients they weredemonstrated on the initialexamination. In accord with general experience, one of the moststriking features was theprevalence of eosinophilia.
TABLE 8.- Symptoms observed among consecutive cases of hookworm infestation at the 20th General Hospital, U.S. Army troops, 1945
Gastrointestinal X-ray studies in these patients was the subject of a report in which the so-called cogwheel pattern was described. This abnormality in the pattern of the small intestine was considered a characteristic finding in many cases and was due to deep broad indentations in the column of barium made by the thickened rugal folds of the jejunum and distal duodenum.
Colonel Blumgart visited the various installations only late in the course of the war, at which time the clinical manifestations of hookworm infestation did not present the acute fulminating syndrome described in the report by Captain Carter of the 9th Medical Laboratory but were rather those commonly recognized as indicative of chronic infection. Malaise, anorexia, upper abdominal discomfort or pain with insidious onset and accompanied by psychoneurotic disturbances were frequent. The clinical diagnosis of hookworm disease was rendered difficult, since practically each of the symptoms of this disease was prevalent throughout the theater regardless of the presence or absence of hookworm infestation. Thus, 'Ground Itch' was simulated by foot infections or dermatitis and respiratory symptoms by nasopharyngitis, while abdominal pains, vomiting, and diarrhea occurred in practically all military personnel at one time or another during their stay in India and Burma. Detection of cases, therefore, rested largely on suspecting the condition in all patients with any of these symptoms, insisting on a differential count of the leukocytes in all suspected patients, and examining the stools by con-
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centrationtechniques. Not a few diagnostic mysteries, temporarily residingunder thedesignation of dyspepsia or psychoneurosis, were classified by carryingout these simplemeasures.
Filariasis
Occasional cases of filariasis contracted elsewhere were seen in theIndia-Burma theater fromtime to time, but no outbreaks occurred in U.S. Army personnel. Nevertheless, the presence ofendemic foci of infection among the congested native population inclose proximity to some ofthe Army encampments and the prevalence of one of the chief vectors ofthe disease, Culexfatigans, raised important problems.
During May 1945, three cases of filariasis were reported from the Hastings Air Base near Calcutta. They were referred for study to the 142d General Hospital in Calcutta. Eighteen additional cases were under observation at this time at the Hastings air station.
An epidemiologic survey of the problem was made by preventive medicinepersonnel of thetheater surgeon's office and reported in the theater ETMD for August1945. The Hastings AirBase was adjacent to the community of Rishra, a slum district, in whichthere were many cases ofelephantiasis. No factual data regarding the epidemiology of filariasisin this community wereavailable. It was clear, however, that transmission of the diseaseoccurred in this population andthat living conditions and sanitation at the air base during the firstfew months after opening ofthe stations were such that it would have been possible fortransmission of filariasis to occur. Awell-organized and vigorous mosquito-control program plus a successfulsanitary cleanupprogram resulted in the control of the chief vector. It was believedthat these measures greatlyreduced or eliminated the possibility of contracting the disease atHastings Air Base.
When seen at the 142d General Hospital, the three cases referred from the air base showed no positive evidence of filariasis. Orchitis had completely subsided, and, in the opinion of the chief of the genitourinary section, little or no residual changes were present. The chief of the surgical service, who had extensive experience in the Southwest Pacific Area in an endemic area of filariasis, was of the same opinion. The chief of the medical service, who had seen many cases of filariasis returned to the Zone of Interior, was in agreement. It was acknowledged that many infections remain asymptomatic for years, or even for their duration, and that the cases examined might have been filariasis. It was believed, therefore, that the three patients should be classified as suspects, their clinical status checked monthly, and, if further evidence of filariasis appeared, they should be returned to the Zone of Interior.
A conference was held in Calcutta attended by the Surgeon, Base 2; by representatives of the Air Forces and of the 142d General Hospital; by a member of the Preventive Medicine Section, Office of the Surgeon, Headquarters, USAFIBT, and by the consultant in medicine. This conference concerned itself mainly with the development of a common policy in respect to the dispo-
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sition ofpatients suspected of harboring the infection. It was generally agreedthat patients witha definite diagnosis of filariasis should be evacuated to the Zone ofInterior. The chiefdifferences of opinion revolved about the disposition of the filariasissuspect, in whom there wasinsufficient evidence to warrant a definite diagnosis but in whom, onthe other hand, thepossibility of harboring infection could not be confidentlyexcluded. The various views werereduced to writing and communicated to the theater surgeon. Aftercareful study, the theaterpolicy was laid down in Circular No. 21, 29 July 1945, Office of theSurgeon, Headquarters,USAFIBT, on the diagnosis and disposition of cases of filariasis. It was recommended that anypatient in whom the diagnosis was seriously entertained should betransferred early while stillshowing acute manifestations. It was further stated that:
It is imperative that a definite diagnosis of filariasis be made only when reasonal clinical evidence exists. This is particularly important because of the serious emotional impact on the individual concerned, and the adverse effect on the morale of troops in the area, as demonstrated by experience with the disease in the Pacific theater. The impossibility of making an absolute diagnosis early in the course of the disease by detection of microfilaria in the blood or by biopsy of affected regional lymph nodes makes reliance on sound, conservative clinical judgment essential. If a reasonable basis for the diagnosis is established in a general hospital by a thorough and careful review of the case, the patient is to be evacuated to the Zone of the Interior in accord with War Department policy.
The criteria which must be exercised in establishing the clinical diagnosis in the early stages of the disease are outlined in paragraphs 3 and 4, TB Med 142. In some patients the available evidence will not justify a clinical diagnosis of filariasis; on the other hand, its possible presence cannot be confidently excluded. Such suspects should be returned to their organization and the unit medical officer be informed of the status of the case so he can make periodic examinations at monthly intervals or oftener if considered necessary, for at least four months.
Particular caution must be exercised in basing the diagnosis on a single finding, particularly when such a finding frequently occurs unrelated to filariasis. A single recurrence of epididymitis or orchitis, without other evidenc of filariasis and with only equivocal residual changes, is not considered to be sufficient basis for the diagnosis of filariasis. The diagnosis should, however, be suspected. In the physical examination of the scrotal contents, it should be remembered that there is a considerable range of normal variation. In order to evaluate correctly the earliest changes in the scrotal contents extensive experience in the palpation of the normal and abnormal is necessary.
If an individual is a noneffective repeatedly because of unexplained recurring inflammation of the scrotal contents which cannot be arrested or cured by appropriate medical or surgical management, he should be evacuated to the Zone of Interior because of inability to render consistent and effective service in the theater. Such cases, without any other evidence of filariasis however, should not be evacuated as filariasis, although the clinical records should indicate that such a diagnosis has been considered.
Lead Poisoning
The diversity of clinical problems encountered in the India-Burmtheater is illustrated by theoccurrence of lead poisoning in petrolatum pipeline companies. One ofthe major missions ofthis theater was the construction and maintenance of the pipelines toChina. Jungle andmountainous terrain presented
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constructiondifficulties such as have been rarely encountered in a project of thisnature andnecessitated a great number of pumping stations (fig. 255). Theoperation of the pipeline wasbegun in December 1943. The first case of suspected leadpoisoning appeared in December1944 in a patient admitted to the 20th General Hospital because ofmoderate anemia. A surveywas then made by 1st Lt. (later Capt.) Benjamin S. Golub, MC, of allexposed personnel in thecompany to which this patient belonged; 16 men, or approximately 11percent of all exposedpersonnel, were found to show a significant degree of basophilicstippling. These men wereadmitted to the hospital for further study. The majority hadsuffered from headaches, and allshowed an abnormal degree of basophilic stippling with an increasedurinary excretion of lead.Except for one patient with a red count of 4.15 million, the red bloodcell count in all patientswas 4.5 million or more. A field survey revealed that thepumping-station operators andmaintenance crew were, exposed to leaded gasoline from the following:
1. Normal leakage of gasoline from pumps intodrip pans. Menconstantly watched gauges onpumps and were continually exposed to fumes.
2. Water laden with fumes drawn off from storagetanks into adjacentditches for evaporation.
3. Frequent failure to wash hands before eating.
4. Pumping-unit exhaust fumes.
5. Frequent washing of hands with gasoline.
6. Pumping units washed with gasoline every 12 hours.
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7. Pumping units refuelled every 6 hours with gasoline carried overfrom storage tanks in 5gallon cans.
8. Heavy concentration of fumes around leaks beingrepaired.
9. Common practice of standing in pool of gasoline either barelegged or with legs covered with grease.
The following measures were put into effect tominimize exposure:
1. Construction of an observation and control tower50 ft. from thepumps to afford adequatesupervision and minimize exposure.
2. Use of nonleaded gasoline for washing hands andfor cleaning pumpingunits.
3. Frequent showers.
4. Change of clothing after work.
5. Periodic rotation of personnel.
6. Careful washing of hands before eating.
7. Use of high rubber boots and rubber gloves.
8. Prompt washing with soap and water after exposureof skin to liquidgasoline.
All personnel with signs of lead absorption wererotated and removedfrom exposure for aminimum of 6 months. Pipeline-company personnel who were exposed togasoline were requiredto have blood-smear examinations every 3 months. During the entiresurvey, 475 exposedindividuals were examined; 14 (2.9 percent) showed basophilic stipplingof erythrocytes.
Skin Diseases
The incidence of diseases of the skin in the India-Burma theater, as inall tropical climates, washigh. The 20th General Hospital reported that skin diseases constituted10 percent of alldispositions from the hospital in the first year of operation and 8.6percent in the second,approximately the same as the figures for diarrheal diseases. Inaddition to the patients thatrequired hospitalization, many were seen as outpatients.
Disorders of the skin, more than any other group of diseases, reflected the effects of the climate of India and Burma on U.S. military personnel. Capt. Neal Phillips, MC, of the 18th General Hospital, writing on skin diseases in Burma, made the following observation on the climate and its relation to the various dermatologic manifestations; the remarks apply equally to India:
In Burma, as in some parts of India, there are roughly three seasons of the year, the months of May, June and October, the hot dry period; November through April, when it is fairly comfortable; and the monsoons of July, August and September, when it rains daily, usually in the morning until noon. During the latter period the sky is overcast and it is fairly cool but humid. At the time of the hottest months preceding and following the monsoons, the temperature reaches 110-120 degrees daily with correspondingly hot nights * * *.
Dermatologically, then, it is obvious that the monsoon period with its dampness encourages the growth of molds,yeasts and fungi while the hot dry season promotes disturbances in thecoil glands and pilosebaceous system. * * * with the body continuously bathed in sweat, such diseases as contactdermatitis, eczematous dermatitis, miliaria,
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folliculitis, infectious eczematoiddermatitis and possibly dermatophytids are the problem confronting thedermatologist during the hotter period, while during the monsoons,fungus diseases flourish.
Not only were fungus infections and eczematous and infectious eczematoid skin conditions more frequent and more severe than in the United States but there were also skin disorders peculiar to the tropics though not due to the climate per se. These included tropical ulcer, dhobie-mark dermatitis, and sensitivity to exotic plants. Atypical lichen planus also was of importance in this theater and was studied extensively, particularly at the 20th General Hospital.
Prickly heat. - InIndia, prickly heat, also known as miliaria, miliaria rubra, andsudamina, wasundoubtedly the most prevalent skin disorder, and it affected the vastmajority of U.S. Armypersonnel. Discomfort and interference with sleep frequentlylowered efficiency in militarypersonnel. Although rarely disabling, extensive casesoccasionally became secondarily infectedand required hospitalization. The characteristic features ofsmall red papules or vesicles, whichappeared principally on the trunk and upper extremities and wereassociated with intense itching,presented rio diagnostic difficulties. A powder containing sulfur,boric acid, starch, and zincoxide was the most commonly used therapeutic agent, but there werealmost as many othermethods of treatment as there were doctors treating patients withprickly heat. Some advised adeep tan; others advised staying out of the sun. Both tanned anduntanned individuals hadprickly heat. Very little effect was noticed with any of the methodsrecommended; when theweather cooled, the prickly heat disappeared.
Dhobie-mark dermatitis.12 - This was one of the surprising medical experiences of U.S. troops in this theater. The dhobie, the Indian laundryman, marked clothes with the intensely irritating juice of the bichi nut.13 When these marks came in contact with a sensitive skin, a localized contact dermatitis resulted. When the source of irritation was removed, the dermatitis disappeared in a few days. Colonel Fitz-Hugh, Major Livingood, and Lieutenant Rogers, as well as Major Waud and Capt. Henry Fein, MC, published reports on this type of dermatitis in the Field Medical Bulletin for June 1943.
Tropical ulcer. - Necrotic,sluggish skin ulcers are found in most tropical countries and areknown by different names in each country where they occur. InIndia, particularly in theProvince of Assam, and in Burma, they were referred to as tropicalulcer, Naga sore, or Assamulcer. They were commonly seen during the monsoon season andfrequently found in individualssuffering from some systemic disease or chronic malnutrition. Theulcers originated in infectedcuts, abrasions, or insect bites and usually developed into rapidlyprogressive, painful lesionswith a necrotic base, undermined necrotic edges, and a blue-greyborder. In time, the lesionsbecame chronic,
12 Not to be confused withdhobie 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.
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paindisappeared, and progress was slower; the base of the ulcer thengenerally showed somegranulations, and the border was raised, indurated, and red. Bacteriologic examinations showedfusiform bacilli and spirochetes.
Except among Merrill's Marauders, there were very few instances of tropical ulcer among U.S. personnel. Merrill's unit, fighting during the monsoon season under highly insanitary and exhausting conditions in the country where Naga sore was endemic, inevitably developed cases of tropical ulcer. The major part of the experience of U.S. hospitals with this disease came through care of the Chinese troops who, malnourished and insanitary, were fertile soil for this type of lesion. Several reports on treatment were published; these were largely based on the experience with Chinese troops.
Lt. Col. Clarence J. Berne, MC, of the 73dEvacuation Hospital appendeda preliminary report ontherapy of tropical ulcers to the annual report of the hospital for1942. He was of the followingopinion: 'Treatment of tropical ulcer should consist of twophases; an initial phase during whichthe septic factor is eliminated, utilizing chemotherapy, if helpful,and a secondary phase initiatedwhen the ulcer becomes free of significant infection.' Skingrafting was not done in his series,which was in its initial stages at the time of the report. No definiteconclusions were drawn.
In the Field Medical Bulletin for October 1943, Maj. (later Lt. Col.) James M. Beardsley, MC, of the 48th Evacuation Hospital reported on the treatment of 21 cases of tropical ulcer by a more radical surgical approach. This group showed large ulcers with a sloughing necrotic base. He concluded that the best treatment for such large tropical ulcers was immediate excision followed by skin grafting and that prolonged conservative therapy resulted in a loss of valuable time. Small ulcers were treated conservatively with sulfanilamide powder and pressure bandage.
Maj. (Later Lt. Col.) John H. Grindlay, MC, who had been in Colonel Seagrave's unit 14 and who had had occasion to treat many tropical ulcers in the men forced out of Burma in 1942, published his experiences with this condition in the January 1944 issue of the Field Medical Bulletin (fig. 256). He recommended, in the early stages of the ulcer, excision of necrotic tissue and use of magnesium sulfate and glycerine dressings daily. In cases where the ulcer had progressed to deep tissue involvement, complete excision of the ulcer and all necrotic material was recommended. After the application of sulfanilamide crystals to the tissues, the cavity was packed with petrolatum-impregnated gauze and the entire limb placed in a cast. In 3 weeks, the cast was removed, revealing fresh granulation tissue. A fresh cast was applied and again removed in 3 weeks. The procedure was repeated until the crater was filled with granulating tissue, at which time pinch grafts were applied.
Contact dermatitis. - Major Livingood of the 20th General Hospital made an extensive study of a type of contact dermatitis seen in the Assam-
14 A hospital of the American Baptist Mission at Namkham, Burman, at the start of World War II; later served with the British Army in Burma and the United States, British, and Chinese Armies in India, Burma, and China. Its commander was Lt. Col. Gordon S. Seagrave, MC, who had been in Burma since 1922.
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FIGURE256.-Burmese nurse bandaging infected leg of Chinese soldier.
Burma region(fig. 257). The etiologic factor was ultimately shown to be thesap of certainspecies of trees.15 This skin condition was seenchiefly in engineer and other organizationsworking along the Ledo Road between Ledo and Shingbwiyang. It wasacquired by contact withthe sap of these trees and, in unusually sensitive individuals, bycontact with the leaves. It wasalso suspected that smoke of burning wood from these trees couldproduce the dermatitis.
The skin manifestations were not severe. The eruption was characterized by 'finely vesicular erythematous, rather ill-defined patches with varying degrees of edema. Excoriations, crusting and oozing follows scratching and in some instances secondary pyogenic infection takes place, in which case a relatively chronic impetiginous eczema may ensue.' The symptoms of itching and burning were severe and out of proportion to the extent of the other manifestations.
Major Livingood believed that the trees belonged to the Anacardiaceae family and that at least two genera were capable of producing the irritating sap. These were Drimycarpus and Semecarpus. The most characteristic feature of the sap was its change in color from milky white, yellow, or light red to black on exposure to the air.
15 Letter, Maj. Clarence S. Livingood, MC, Chief, Section of Dermatology and Syphilology, 20th General Hospital to Base Surgeon, Base Section 3, 27 May 1944, subject: Contact Dermatitis in Base Section No. 3 (Tree Sap Dermatitis).
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Hypohidrosis syndrome.- Eighteen cases of an unusual syndrome peculiar to hot climates andnot described in most textbooks were seen at the 20th General Hospitaland reported by MajorLivingood in the Field Medical Bulletin for May 1945. These cases were very similar to thosereported by Wolkin, Goodman, and Kelley.16 In his report, Major Livingood quoted the clinicaldescription of the syndrome described by these three authors. Becausefeatures described bythem are so characteristic, the quotation used by Major Livingood ispresented here, as follows:
In general they all presented a typical history, viz. a rather sudden onset of generalized weakness, subjective warmth and discomfort, dizziness 'all-in' feeling, headache and shakiness. These symptoms occurred during exposure to sunlight, either with or without physical exertion. The onset of the symptoms was associated with or preceded by a cessation of sweating in each case. This was in turn often preceded by a distinct period of profuse outpouring of sweat from a few days up to several weeks' duration. The loss of sweating was limited uniformly to the body region below the neck in pronounced contrast to the outpouring of sweat from the face and neck. The objective findings were characterized most of all by a warm, dry skin from the neck down, whereas the fact and neck showed
16 Wolkin, J., Goodman, J. I., and Kelley, W.E.: Failure
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profusedroplets of sweat. The skin of the entire body below the level of theneck had theappearance of goose flesh. However, this fine papular eruption did notappear and disappear in amatter of minutes like goose flesh. The papular eruption was diffuseand uniform, each papulebeing about the size of a large pinhead. In cases of longer standingthere was a fine, brannydesquamation. As this condition improved, the fine papular eruptiondisappeared and the skinresumed its normal appearance.
Major Livingood's group included both white and Negro soldiers; 6 of the patients had atypical lichen planus and 3 were recovering from typhus fever when the symptoms appeared. All cases gave a history of excessive sweating and generalized pruritus prior to onset of the syndrome; most of the patients 'tended towards a seborrhoeic habitus.' As in the cases previously described, failure of the sweating mechanism was noted most frequently on the trunk and limbs, with a dry skin and a 'fine branny desquamation' in the involved areas. The parts of the body usually not affected by the disturbance were the face, palms, soles, and axillae; those regions generally showed hyperhidrosis. Asthenia and weakness were a constant feature; hyperpyrexia did not occur.
Seven of the group improved spontaneously, andtheir sweating functionreturned to normal infrom 2 weeks to 4 months. The remainder continued to show hypohidrosis,and at the time of thereport 4 months had elapsed without evidence of improvement. Inthis respect, MajorLivingood?s cases differed from similar cases described by otherauthors who found thatsweating returned to normal in practically all cases within a few weeks.17 Another point ofdifference was the gradual onset in Major Livingood's patients ascompared with the rapid onsetwith evidence of heat exhaustion reported by the other authors.
Although the number of cases showing hypohidrosis was small, the syndrome was of considerable interest and of some military significance; in several instances, evacuation to the Zone of Interior was contemplated because a deficiency in normal sweating constituted a serious hazard in this theater.
Atypical lichen planis. - Ina letter dated 30 October 1944 to the Surgeon, USAFCBI, TheSurgeon General requested a r?sum? of the experience in the theaterwith the clinical syndromeknown as atypical lichen planus (fig. 258). The letter included abrief description of thesyndrome and stated that it was seen with striking frequency in theSouthwest Pacific Area. Acopy of the letter was forwarded to all medical installations.
As far as can be determined, the diagnosis of atypical lichen planus was not made in this theater prior to November 1944. On 15 November 1944 in a letter to the Commanding Officer, 20th General Hospital, Major Livingood, in reply to The Surgeon General's request, reported three cases and made the following statement:
About five weeks ago, I received a personal letter from a dermatologist of my acquaintance informing me that he had seen a group of cases from the Southwest Pacific Area
17 (1) See footnote 15, p. 774. (2) Allen, S. D., and O?Brien, J. P.: Tropical Anidrotic Asthenia: A Preliminary Report. Med. J.. Australia 2: 335-336, 23 Sept. 1944.
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presenting signs and symptoms suggesting an atypicalform of Hypertrophic Lichen Planus-hedid not include a detailed description of the syndrome. At thattime I reviewed all of my cases ofHypertrophic Lichen Planus as well as other chronic recurrentdermatoses and came to theconclusion that I had not seen the syndrome in this hospital. Therefore, it seemed an amazingcoincidence to see three cases which probably fall into this group inthe past four weeks, one ofthem a General Officer. We forwarded biopsy specimens to the ArmyMedical Museum on onecase about 10/26/44 and on the other two cases a few days ago. Inthe clinical protocol, I referredto the fact that I thought that these patients had an atypical form ofHypertrophic Lichen Planuswhich had been seen in the Southwest Pacific Area and asked forinformation on the pathology ofthe lesions as it had been noted in those cases.
In his comments on the disease, Major Livingood said: 'I havefound no clues as to etiologyexcept in two patients particularly there seemed to be a questionablelight sensitivity factor. Allthree of these patients had been living under field conditions at thetime of onset.'
The 234th General Hospital reported a single case that was thought to fit the description in The Surgeon General's letter.18 Although the description
18 Letter, Col. Bennett G. Owens, MC, Commanding Officer, 234th General Hospital, to Surgeon, Headquarters, Services of Supply, USAFIBT, 2 Dec. 1944, subject: Information on Occurrence of an Unusual Skin Disease.
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stronglysuggested atypical lichen planus, the history revealed that the diseasehad its onset 18months earlier, while the patient was still in the United States. In January 1945, acommunication from the 18th General Hospital reported two cases of askin disorder consideredto be atypical lichen planus.19 Both patients had been taking suppressive Atabrine; patch testswith this drug were negative. One of the two patients was foundsensitive to SKAT, developinga positive patch test with this mosquito repellent but with no other.
On 23 February 1945, Major Livingood submitted a followup report on the 3 original cases and in addition reported 6 more full-blown cases of the disease; 3 others were mentioned in which the diagnosis was not definitely established. This report was very comprehensive, and the findings may be summarized as follows:
These cases were characterized by: Combination ofeczematoiddermatitis, eczematous plaques,and violaceous lesions of various morphes identical with those seen inatypical lichen planus;generalized distribution with predilection for certain sites; severepruritus; long course; markedresidual changes in the skin including loss of hair and markeddisturbance of sweating function.
All patients who were seen with the disease had had intimate contact with the jungle. All patients except one had been on suppressive Atabrine prior to onset. Most patients had antecedent eczematous lesions.
The probable multiple etiologic background waspossibly a combinationof exposure to jungleand a drug allergen - Atabrine in the majority of cases. Onepatient had never taken Atabrine atany time but had had arsenicals for early syphilis. Light sensitivitywas a possible predisposingfactor. Exacerbation was seen after the following: Atabrinetherapy for malaria, sulfathiazol,typhoid vaccine, ultraviolet light, sunlight, and possibly foodallergens.
It was suggested that men who work and/or live in the jungle might acquire a contact sensitization dermatitis from the sap and leaves of trees and shrubs which occur only in tropical and semitropical zones of the world and that these sensitized individuals might develop the atypical-lichen-planus syndrome when an endogenous allergen (Atabrine in most instances) is administered.
There was evidence that the patients in this series had disturbances of glucose metabolism, and of gastrointestinal and liver function, manifested by flat glucose-tolerance curves, X-ray changes in the gastrointestinal tract, and decreased liver function with Bromsulphalein excretion test.
A third report, dated 19 March 1945, by Major Livingood, brought the total number of cases seen at the 20th General Hospital to 15. In this report, he emphasized the possibility that exposure to the irritant black sap of certain tropical trees might be an etiologic factor. Major Livingood wrote:
We have notaccumulated any new information. All of these new patients had been inthe jungle in forward areas,and had been in contact with tree-sap and plants either directly or asthe result of exposure to wood fires. Again Iwish to emphasize that thus far all of our
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.
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patientswiththis disease had been in contact with the jungle with exposure topotentiallyallergenic contact agents-tree-sap, various plants, etc. Iconsider this a possible importantpredisposing factor; also dietary deficiencies, and multiple insectbites are possible predisposing factors.
To facilitate study, it was decided to concentrate all cases of this disease in a few hospitals. The 20th General Hospital was designated as the center in the Advance Section, the 234th General Hospital in the Intermediate Section, and the 142d General Hospital in the Base Section. The 20th General Hospital prepared a form for the study of the cases, and, in July, Maj. (later Lt. Col.) James M. Flood, MC, who succeeded Major Livingood at the 20th General Hospital, submitted a report on 19 cases seen between 14 March and 1 July 1945. The report opened: The experience in this theater leaves little doubt that atabrine is the main causative factor of atypical lichen planus as seen in this area. Whether there is an associated factor still remains a question, but it must now be assumed that atabrine is the principal etiologic agent.'
This report was accompanied by a paper by MajorMachella and coworkerson liver-functionstudies. Although the studies suggested the possibility of hepaticdamage, no patients withatypical lichen planus showed any clinical evidence of liverdisturbance.
The 234th General Hospital reported that 11 patients with the disease were being observed but no data were submitted in this preliminary report. 20
Other cutaneouseruptions. - In addition to atypical lichen planus, there wereother skineruptions that were attributed to Atabrine. Major Livingoodreported a number of skin reactionsseen at the 20th General Hospital. These included an extensivemaculopapular eruption with aviolent systemic reaction in a dental officer and a pruriticmaculopapular toxic erythema in twonurses, 14 days and 4 days after the suppressive Atabrine program hadbeen initiated. Theeruption reappeared in both nurses when the drug was again administeredat a later date. Twoindividuals developed a flareup of an old eczematoid dermatitis shortlyafter the Atabrine regimewas instituted.
In the theater ETMD for August 1945, Captain Blank of the 69th General Hospital reported on 12 cases of an urticaria-like syndrome that he attributed to Atabrine sensitivity, and in a communication dated 23 July 1945 to the theater surgeon's office, he later reported 2 additional cases. In 12 patients, who gave no previous history of Atabrine ingestion, the eruption did not appear until 2 or 3 weeks after the institution of the suppressive Atabrine program. In 2 patients, both of whom had previously taken Atabrine, the eruption appeared within 3 days; in both, the symptoms disappeared spontaneously without discontinuance of the drug. In the other patients, the urticaria disappeared when the drug was stopped and reappeared briefly in 4 patients when Atabrine was again administered. All 14 patients eventually were able to take suppressive Atabrine treatment without difficulty. Skin tests with pure
20 Letter, Capt. Joseph A. J. Farrington, Chief of Dermatology Section, 234th General hospital, to Office of the Surgeon, headquarters USAFIBT, 6 July 1945, subject: Atypical Lichen Planus.
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powdered Atabrine were done in six cases,with results negative to both patch and intradermaltests.
One case of urticaria thought to be due toAtabrine was reported from the 234th GeneralHospital.21 A patch test in thiscase was strongly positive.
RespiratoryDiseases
Upperrespiratory infections
The newcomer to India,particularly if he had recently endured the snow and sleet of northernUnited States and had arrived in India during the sunny months of Marchthrough June, withdaily temperatures of 80o-100oF., was startled by the prevalence of upper respiratoryinfections. This fact is reflected in the high incidence rate forthis condition in the India-Burmatheater (chart 13 and table 9). The actual incidence was muchhigher 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.
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disabled were admitted to hospitals or keptin quarters. The extent to which these infectionscontributed to the total noneffective rate was, however, small (charts13 and 14 and table 9).
The clinicalcharacteristics of nasopharyngitis in India were astonishingly similarto those seen inthe United States; the complications of chronic sinusitis, middle earinfections, and the notinfrequent association of tonsillitis and bronchopneumonia wereapparently as frequent. Bacterial pneumonia was relativelyuncommon, and but few deaths occurred.
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CHART 14.-Noneffective rates for common respiratory disease in U.S. Army troops in India-Burma theater, January 1943-July 1945 1
Primaryatypical pneumonia
With the onset of warmweather in this theater, the increased prevalence of respiratoryinfectionswas striking. This increased incidence was particularlynoticeable in Delhi and occurred duringuninterrupted sunshine and equable temperature. Actual observation ofmany of these cases bythe consultant in medicine revealed that the clinical characteristicsand X-ray and laboratoryfindings were in the main identical with those observed duringepidemics in the United States. The increased incidence could not be ascribed to any discerniblefactors. Among otherpossibilities, ornithosis was considered since, at the time ofincreased prevalence of primaryatypical pneumonia, swarms of migratory birds made their appearance - asingle tree, forinstance, often being occupied by at least several hundredparakeets. Inquiry by the consultant inmedicine, however; failed to uncover any supporting evidence for thispossibility. Attention wasdirected to this condition by the publication of notes in the FieldMedical Bulletin, discussionswith the staffs of the various hospitals, and requests for reports fromthe representative group ofhospitals. The subject was summarized in the theater ETMD report,dated 1 June 1945.
Incidence. - In general, there was an increased incidence of atypical pneumonia for the first 3 months of 1945 as compared with the corresponding period in 1944 (table 9 and chart 15). At the 100th Station Hospital, there were 96 cases in the first quarter of 1945, whereas only 14 cases were reported for the same period in 1944. The 234th General Hospital and the 73d Evacuation Hospital treated approximately twice as many cases of atypical pneumonia in 1945 as in 1944. In all instances, the hospital census was roughly the same
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CHART 15.-Monthlyincidence rates for primary atypical pneumonia in U.S. Army troops inIndia-Burma theater, January1944-July1945 1
for both periods. Two reports indicated that the increase in respiratory infection was coincidental with movement of new troops into the area. The rotation of personnel, with the arrival of replacements from the United States, also began at the same time the increase in disease was noted.
Epidemiology. - Although atypical pneumonia is apparentlytransmitted by contact and isusually associated with an increase in upper respiratory infections,the disease was not highlycommunicable. Certain other factors were involved in addition tosimple exposure. In thisconnection, the following paragraphs are quoted from an excellentcomprehensive analysis of 96cases prepared by Capt. Abraham Gootnick, MC, Chief, Medical Service,100th Station Hospital:
In considering the epidemiology of this outbreak, it should be mentioned that the usual criterion for admitting a patient to the hospital was the finding of a temperature above100o at the dispensary. A great many of the milder cases of upper respiratory infection were thus screened out - at least as many as were hospitalized. But this screening did not apply to the more severe upper respiratory infections, and even less to the pneumonias. One check on the incidence of unrecognized pneumonia was provided by one organization, consisting of 34 personnel, 13 members of which were in the hospital with respiratory infections at one time. All remaining members were called in for mass x-ray check-up. All chests were clear.
The experience with thisorganization is also illustrative of the mode of transmission of theinfection, which appearedto 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, theincubation period ranged from 9 to 16 days. An incidental findingof interest was the apparent immunity of medical officers, nurses, andward
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attendants - personnel whose contact withrespiratory infections was close; and the considerable susceptibilityofhospital personnel whose contact with patients was tangential. Enlisted men working in the laboratory, in the x-raydepartment, and in the admitting office came down with respiratoryinfections of varying severity.
Clinicalcharacteristics. - The clinical characteristics of primaryatypical pneumonia in theIndia-Burma theater coincided closely with those reported in outbreaksof the disease in theUnited States. The majority of the cases were troubled initially withan apparent upperrespiratory infection, which ranged from a mild nasopharyngitis to asevere bronchitis. A dry,hacking cough was a conspicuously disturbing symptom in many of thepatients. Two symptomsfrequently mentioned as rare in primary atypical pneumonia were foundrather commonly in thepatients in this theater. In Captain Gootnick's report justmentioned, he stated as follows: '(1)Repeated shaking chills lasting 15 to 45 minutes were recorded in 25 ofthe 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 inthe chest on inspiration was thechief complaint leading to hospitalization.'
Examination of the chest on admission often revealed inconstant physical signs of patch consolidation. X-ray of the chest, at this stage of the disease, frequently yielded diagnostic evidence of the characteristic changes of primary atypical pneumonia. The white blood counts and differential smears showed the usual findings, as did examination of the sputum. Blood cultures performed in representative patients were uniformly sterile. The 100th Station Hospital reported that: 'A spot check for the presence of cold agglutinins was done in a total of nine cases. In 3, cold agglutinins were not present in the one sample of serum examined; in 6, the serumn was positive for cold agglutinins and showed an increasing titer after the second week of illness, reaching a titer of 256 in 2 at the end of the third week.'
Reports from otherhospitals were essentially in agreement with Captain Gootnick'sobservations. An interesting finding was the occurrence ofpleural reactions, a feature consideredby some observers to be rare in this disease. Captain Gootnickreported 4 cases with pleural rub. The 73d Evacuation Hospital reported 6 pleural reactions - 2 inAmericansand 4 in Chinese. Ofthese, 1 American and 1 Chinese patient had small effusions. The99th Station Hospital reportedon 24 cases, of which 2 showed pleural rubs. Another featurenoted in all reports and alsoobserved in previous reports on atypical pneumonia was the highproportion of cases that wereafebrile or showed only a low-grade temperature.
Sequelae. - Very few significant complications or sequelae were reported from this theater. The 99th Station Hospital observed one case of extension from one lung field to the other. The 234th General Hospital reported one mild case of purulent bronchitis following the pneumonia, and the 73d Evacuation Hospital found one case with suggestive findings of bronchiectasis. There was no followup report on these cases.
785
Bronchial asthma
Little statisticalinformation is available regarding the incidence of bronchial asthma inthe India-Burma theater. The condition was more frequent than might beanticipated and was prone torecur even after hospitalization induced temporary improvement. Ifreturned to duty, the patientscontributed little of military value and were almost always finallysent to the Zone of Interior. Twenty-three such patients were sent tothe United States during 1944 from the 142d GeneralHospital, 68 from the 181st General Hospital, Karachi, India, and 76from the 20th GeneralHospital. In this connection, a personal communication from ColonelContrell of the 142dGeneral Hospital is of interest:
India is a bad county for allergic conditions. Many persons who had had allergic symptoms find that they are much worse than in the U.S., or that new manifestations appear-e.g. a person who had hay-fever in childhood develops asthma in India. Sometimes, one can return a mild asthmatic to duty for time, but I have never seen one that lasted long. In general, if a soldier has been seen to have an unequivocal, moderately severe, asthmatic attack, it is useless to return him to duty in this country. I suspect that mods are important as allergens here, but I do not know.
Not infrequently,individuals who had never had allergic manifestations prior to servicein thetheater were affected with disabling allergic conditions. Ingeneral, skin testing was notperformed and when performed was of little assistance in diagnosis ortherapy. Climate,allergens, and psychologic stress and strain were presumably etiologicfactors, but the extent towhich each or all were contributory cannot be stated.
Pulmonary tuberculosis
The incidence of pulmonary tuberculosis among the military personnel in the theater was low (table 9). Among the Chinese, however, tuberculosis was prevalent. An ETMD report, dated 3 May 1945, from the 48th Evacuation Hospital stressed this high incidence of tuberculosis in Chinese patients who constituted the bulk of the hospital census. The average Chinese soldier neither understood the American interest in sanitation nor was he particularly interested in practicing its precepts. The Chinese used no precautions in the disposition of their sputum, the floor being most convenient for expectoration. The personnel of the 48th Evacuation Hospital were, therefore, extensively exposed to the disease. Frequent routine checks were made on the personnel and, up to the time of the report, no cases of tuberculosis were discovered that could be attributed to contact with the Chinese. The commanding officer of the hospital suggested that members of the hospital staff be observed carefully for some time after return to the United States.
Homologous Serum Jaundice and Infections Hepatitis
Infectious hepatitis was under continuoussurveillance by the theater surgeon from the verybeginning of the establishment of the USAFCBI
786
theater in March 1942. On 30 May 1942,acable was received from the Surgeon General'sOffice alerting the theater to Jaundice of unknown etiology followingadministration of yellowfever vaccine. Among the first cases to be reported from theIndia-Burma theater were seveninstances of jaundice following yellow fever vaccination in UnitedStates troops. GeneralStillwell himself developed jaundice on 3 June 1942, having receivedvaccine from lot No. 334on 2 February 1942.
From the available scattered and incomplete reports, it is apparent that many cases of jaundice of unknown etiology were observed in 1942 and that a significant number of these patients had had vaccine from lot Nos. 334, 335, 338, and 367. In a report by the Surgeon, USAFCBI, 17 October 1942, to The Surgeon General, complete questionnaires on 80 cases of jaundice without known cause were transmitted. Thirty-six of this series had received yellow fever vaccine from lot Nos. 331, 335, and 371. Of the other cases, 19 had had contact with jaundiced patients. On 28 November 1942, another report of 35 patients was submitted, most of whom had received yellow fever vaccine from lots of the 300 series. Complete information regarding the number and distribution of the cases following yellow fever inoculation was not available, but it was apparent that the number constituted a serious problem.
The only available comprehensive report was submitted from the 73d Evacuation Hospital by Colonel Ware, Capt. (Later Maj.) Coleman B. Hendricks, MC, and Capt. Thomas H. Brem, MC. The 405 patients who constituted the basis of the study had all received yellow fever vaccine at approximately the same time. Information concerning the lot numbers and the exact date of inoculation was recorded in 305 cases. The report read, in part, as follows:
For all lots of yellow fever vaccine, the majority of patients became ill between 70 and 110 days after inoculation, the peak being reached between 90 and 100 days. Extreme variations were 46 and 170 days. Although 18 different lots of vaccine are included, two particular lots account for 222 of the 305 cases. In each of these two major lots of suggestive-lot No. 367 at 70 days and lot No. 338 at 100 days, while the peak of the aggregate of all cases falls at approximately 90 days.
The clinical course, including the symptomatology and physical signs, was that observed in the extensive series of cases observed elsewhere in the U.S. Army. No deaths occurred.
The energetic action initiated by The Surgeon General was effective in subduing the outbreaks of postvaccinal jaundice in the U.S.Army. In a letter dated 21 December 1942 from Col. (Later Brig. Gen.) Stanhope Bayne-Jones, MC, Office of the Surgeon General, to the Surgeon, the opinion was expressed that the cases reported from the China-Burma-India theater in the last months of 1942 were probably unrelated to the administration of yellow fever vaccine. The cases of infectious hepatitis occurring in 1943 and thereafter were consequently to be considered in a similar light.
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The incidence ofinfectious hepatitis during1943, 1944, and 1945 is graphically presented inchart 16 and table 10. In accordance with experience in the NorthAfrican theater and in theNorthern Hemisphere, a seasonal increase during the late summer months,particularly inSeptember and October, was apparent. This increased incidencereflectedan increased numberof cases occurring sporadically throughout the theater and alsooccasional outbreaks. Theclinical characteristics observed in these case of infectious hepatitiscoincided with thosewitnessed elsewhere in the U.S. Army.
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TABLE 10.- Incidence of infectious hepatitis in U.S. Army troops in India-Burma theater, by month and year, January 1943-July 1945 1
Occasional sporadic groupsof cases wereobserved from time to time. During August 1944, 122patients with infectious hepatitis were admitted to the 98th StationHospital, Chakulia, India,from 14 units in the theater. As in other outbreaks, the sourceofinfection was undetermined. These cases were considered to be unrelated to the administration ofyellow fever vaccine. Asimilar increased incidence had been noted 1 year previously. Thefactthat a considerableproportion of these cases originated in two of the 14 units is ofepidemiologic interest. It wasevident that the increased incidence of infectious hepatitis in the twounits was not related totroop strength.
Poliomyelitis
No statistics concerning the incidence ofpoliomyelitis among the native population could beuncovered. Clinical observation on casual visits in the congesteddistricts of Karachi, Delhi, andCalcutta impressed the visitor with the rather frequently observedresidual flaccid paralyses. It isof interest, however, that experience in the British Army in Indiareveals a low incidence inIndian troops as compared with British troops.
Poliomyelitis was seen only sporadically in the military personnel of the India-Burma theater. The case fatality ratio, between 20 and 25 percent, the ever-present possibility of an epidemic, and the effect on morale when sporadic cases appeared made the disease one that commanded continuous consideration (table 11 and chart 17).
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There were no majoroutbreaks ofpoliomyelitis; a focus of three cases, however, occurred in Agra,India, duringSeptember 1945, and this area was accordingly placed out of bounds toall personnel except those on official militarybusiness. In the British Army, a seasonal increased incidence wasevident from March to October for the years1942-44. The data of table 11 are too small to be statisticalsignificance in this connection. The incidence ofrespiratory and/or bulbar involvement in U.S. military personnel wasapparently high although no compilation ofexperience was available. In a group of 10 cases at the 263d GeneralHospital, Calcutta, India, in August andSeptember 1944, there were 7 cases of respiratory paralysis orbulbarparalysis or both; 4 of the 10 patients diedbecause of respiratory paralysis.
The clinicalcharacteristics of poliomyelitisin the India-Burma theater were identical with those seen in the UnitedStates. The principal problem was the supply and maintenance of therespirators. With sporadic cases occurring atinstallations thousands of miles apart and often in relatively secludedplaces, it was imperative to maintain respiratorsat certain key points in usable condition ready for immediate airtransport. One Drinker-Collins respirator was keptin readiness at Ledo and one at Karachi, and two were stationed inCalcutta. Arrangements were made with theBritish for the loan of mechanical respirators. Several of these wereused but were unsatisfactory. They were subjectto mechanical breakdown, and the bellows almost invariably developedleaks. By maintaining competent techniciansconstantly on duty, however, these respirators were invaluable inemergencies. 'Savalife' respirators, employed atseveral installations, were useful in emergencies and during airtransport of patients. They were foundimpracticable
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for prolonged use, as indicated in a letterto the Surgeon General's Office from the Surgeon,USAFIBT:
Evenwith the best nursing care the machinewas extremely uncomfortable with pressure from the metal and intenseitching and maceration of the body tissues from constant contact withthe rubber. As a result there were manymacerated and blistered areas around the neck, trunk and arms.
The apparatus is sufficiently difficult to remove and replace as to make it impossible (because of the time element involved) 1st, to give the skin proper care and 2d, to allow the patient to have periods out of the machine so that he can begin using his own respiratory muscles as tolerated.
There were numerousmechanical difficulties. One death was attributed to mechanical failure ofone of the British respirators, and on another occasion a hand bellowwas used for 9 hours whilethe respirator was being repaired. In general, however, the use of theBritish respirators, with thesplendid co-operation of the Air Transport Command in rushing arespirator to any installationimmediately on call, proved adequate in the treatment of emergencies.
TABLE 11.-Incidence ofpoliomyelitis inU.S. Army troops, India-Burma theater, by month andyear, 1942-45 1
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TyphoidandParatyphoid Fevers
Although the statisticsfor typhoid andparatyphoid fever in the native population were grosslyinaccurate, it was evident from the available information that entericfever was widespread. Statistics in India always err on the low side because of theimpossibility of obtaining accuratehealth reports. In one town, an epidemic was recognized by themedicalstaff of the local hospital only because of the unusual number of casesof fever that were being treated as outpatientsat a time when malaria was not prevalent. In the 1940 annualreport ofthe Health Commissionerof India, there were 1,738 deaths recorded in Delhi Province as due toenteric fever. Delhi Citycontributed 683 to this figure, and New Delhi, the capital of BritishIndia and certainly one of thebest controlled cities in India from a public health standpoint, wasresponsible for 72. The restcame from the rural areas.
No epidemics occurred in U.S. Army personnel, but sporadic cases were reported throughout the 3 ? years of the theater's existence. Table 12 shows the number of cases of typhoid fever; table 13 shows the cases of para typhoid fever (A and B are not differentiated).
TABLE 12.-Incidence of typhoid fever inU.S. Army troops in India-Burma theater, by monthand year, 1942-45 1
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TABLE 13.-Incidenceof paratyphoid fever in U.S. Army troops in India-urma theater, bymonth and year,1942-45 1
The first case of typhoidfever, reported inSeptember 1942, was in a soldier stationed in Delhi. He wastreated atthe British Military Hospital, Delhi Cantonment, where the diagnosiswasestablished by positive blood culture. One week later a case ofparatyphoid A developed, whichwas also treated by the British. In October 1942, a soldier fromtheDelhi area was admitted tothe 100th Station Hospital and proved to have typhoid fever; in thefollowing month, a fourthpatient was admitted and the case was diagnosed as typhoid fever. Threeof these patients werefrom the headquarters squadron of the Tenth Air Force, but no commonsource of infection wasfound.
As a consequence of these cases, it was suspected that the antityphoid vaccine prepared in the United State was not highly effective against Indian strains, and it was directed that U.S. military personnel in China, Burma, and India be required to take a stimulating dose of Indian-type typhoid vaccine. This policy was also adopted by the British Army, whose experience was similar to that of the U.S. Army. Although this program was carried out for a brief period, it was later discontinued, apparently on advice from the Surgeon General's Office. It is impossible to say whether the incidence of typhoid and paratyphoid fever was affected.
No unusual clinical problems were encountered; in general, diagnoses were arrived at more slowly because of the lack of laboratory facilities. There
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were only three deaths from typhoidfever. This low mortality rate in a country where thetyphoid micro-organisms have lost none of their virulence, at least forthe native population,demonstrates the efficacy of antityphoid immunization.
Smallpox
The 1939 annual report ofthe Public HealthCommissioner of India on smallpox begins asfollows: 'The epidemiological statistics published by the LeagueofNations shows that BritishIndia ranks higher than all other countries in its rate of incidence ofsmallpox.' The disease isendemic in India, with localized minor epidemics occurring at all timesduring the year with aseasonal peak around March, April, and May. A cyclic increase inincidence occurs every 5 or 6years. This is attributed to the increased proportion ofsusceptiblechildren, a result of theinefficient enforcement of vaccination. An epidemic year wasexpectedin 1942 or 1943; actuallyit occurred in 1944 and 1945.
?No cases of smallpox were reported in U.S. military personnel in 1942 and 1943. Table 14 shows the cases and deaths by months for 1944 and 1945. The first case was admitted to the 111th Station Hospital at Chabua and, as far as could be determined, was acquired from Chinese soldiers in the nearby staging area. Subsequent cases resulted from contacts with both the native Indian population and the Chinese troops.
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Although the incidence ofsmallpox in U.S.Army troops was not high, the fact that it occurred atall was of great concern to the Preventive Medicine Section of thetheater surgeon's office, andmany investigations were carried out, as reported by thatsection. Theessential finding thatemerged from most of these studies was that either vaccination had notbeen accomplishedrecently or, if it had been, an immune reaction was recorded on theimmunization registerwithout sufficiently careful observation to distinguish between animmune reaction and anunsuccessful vaccination.
The disease was frequently severe and the case fatality ratio high. Sulfonamides and penicillin were used to combat secondary infection. The only unusual clinical problem that arose was the differentiation between generalized vaccinia and smallpox in 4 cases seen at the 18th Field Hospital and reported on by Major Mosley. These 4 cases, 1 or which was fatal, were originally reported as generalized vaccinia, because the patients had been vaccinated 5, 7, 3 and 4 days before the onset of their illness. However, investigations by the theater epidemiologist, Major Mosley, revealed exposure in each case to the native population at either Bombay or Calcutta at a time when smallpox was at its peak incidence. Major Mosley concluded that these cases of generalized vaccinia were actually instances of smallpox.
In view of the prevalence of smallpox, the theater policy was vaccination every 12 months; in addition, whenever a diagnosis of smallpox was made, all units in the vicinity of the suspected source were revaccinated. When the actual number of cases of smallpox among U.S. Army troops is considered in relation to the possibilities of exposure to this extremely virulent disease, the immunization program may be regarded as highly successful.
Cholera
Cholera is endemic inIndia and constituted aconstant potential threat to U.S. military personnel. Itsprevalence inlower Bengal and other localities in close proximity to Armyinstallationsprovoked energetic preventive measures, as described elsewhere.
?Despite particulary heavy outbreaks in 1945, such as that in Calcutta, an area where many troops were stationed and were on leave, not a single case occurred in military personnel in the India-Burma theater from 1942 to October 1945. On 20 July 1945, the theater surgeon addressed a letter to the surgeons of the base, intermediate and advance sections, alerting all medical officers to the possible occurrence of cholera and advising certain modifications in the treatment outlined in TB Med 138, February 1945, subject: Cholera. One mild case was observed in a Red Cross worker who had been repeatedly vaccinated in accordance with theater policy. At the 181st General Hospital where she was hospitalized, Vibrio cholerae was isolated from the stools, and the finding was confirmed at the 9th Medical Laboratory. The patient made an uneventful recovery.
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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 arerecorded, mostlyfrom Burma, predominantly in males. Although onlyabout 100 cases have been recorded in the past 30 years since thedisease was first described,there is reason to believe it is more widespread than the diagnosiswould indicate. In Rangoon,the estimated incidence is 4.5 per million. It is of interestthat acase of this disease wasdiagnosed in a U.S. soldier and verified by recovery of themicro-organism from skin pustulesand blood culture while the patient was alive and from post mortemabscesses from the lung,blood, liver, and spleen, by the 9th Medical Laboratory. Identificationof the micro-organism ofmelioidosis was confirmed by the Army Medical School, Washington, D.C.
The disease is extremely varied in its manifestations and readily escapes diagnosis. The condition may simulate cholera, pneumonia pyemia, plague, or typhoid fever. The case reported in the April 1945 Field Medical Bulletin, by Lieutenant Cox and Major Arbogast, exhibited the pyemia syndrome. The patient had been ill 24 hours before admission with headache; fever and chills, accompanied by nausea and vomiting; and pain in the chest, the lower back, and the joints of the lower extremities. He had been a mule skinner, and some of his mules had died of the illness. During the 7 days in hospital before death, he developed scattered pustules over the entire body with a septic temperature ranging as high as 103o and 105o F. and the appearance of pneumonic consolidation of the base of the left lung. Laboratory studies revealed a white count of 7,000-9,000 and a red count of from 2.5 to 3.5 million; the causative micro-organism was recovered from cultures of the blood and contents of the skin pustules. During the last 2 days of the patient?s life, 40,000 units of penicillin were administered intramuscularly every 4 hours but without discernible effect. Post mortem examination revealed the characteristic findings of this disease.
The disease has been recorded as uniformlyfatal, but with earlier diagnosis and newer modes ofchemotherapy the course of the disease may be favorably affected.
SchistosomiasisNo cases of schistosomiasis originated in theIndia-Burma theater. Twelve cases caused bySchistosoma haematobium were reported in a letter, dated 11January 1945, from the Surgeon,329th Air Service Group, to the Surgeon, U.S. Army Air Forces,IBT. Inall of these cases, thedisease was acquired when the group bathed in a pond while travelingacross Africa. All the
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patients had symptoms of pyelitis or cystitisand 60 percent had hematuria. Two patients wereevacuated to the United States; the remainder eventually became free ofsymptoms followingseveral courses of treatment with Fuadin (stibophen).
Leishmaniasis
Cutaneous leishmaniasis orkala-azar was seenbut rarely in this theater. Reliable statistics werenot available, but it appears that only 1 case was reported in U.S.military personnel in the theaterin 1944 and 13 cases in the first 5 months of 1945. Kala-azar isespecially prevalent among thenative population of Bengal and Assam, but relatively uncommon amongthe white people inthose areas. The low incidence among those enjoying better livingconditions and amongmilitary personnel is probably to be attributed in part to protectivemeasures against insects,which are particularly effective against the Phlebotomus vectorof the disease with its flight rangeof not more than a few hundred yards.
A few cases of kala-azar were seen at the 48th Evacuation Hospital and other installations caring for Chinese military personnel. Of the 14 cases reported among U.S. military personnel, 8 were studied at the 142d General Hospital. All had evidently contracted the disease in India, and Leishmania were demonstrated in 7 of the 8 cases; in the remaining 1 case, the diagnosis was established by the clinical course and response to treatment, in spite of 3 negative sternal punctures. The experience of the 142d General Hospital with these cases was summarized in the theater ETMD report dated 1 July 1945, which reads, in part, as follows:
The average time elapsingfrom apparent onsetof illness until the diagnosis was established was about two months;the longest time was one hundred and twenty-one days and shortest (in acase diagnosed before transfer here) wastwelve days. This wide variation suggests that Medical Officer's 'indexof suspicion' of kala-azar has been too low,and it is noteworthy that this index', in the staff of this Service,has risen sharply. The remittent and recurring natureof the fever has, in many cases, led to diagnoses such as typhoidfever, paratyphoid fever, brucellosis, amebicabscess of liver or spleen, malaria, and dengue at one time oranother. The matter is further complicated by the notinfrequent coincidental occurrence of malaria or amebiasis. Onepatienthad had several hospitalizations forundiagnosed febrile illnesses which, in retrospect, were exacerbationsand remissions of kala-azar.
The clinical findings and the course of the disease in these patients were in accord with common experience as described in TB MED 183, July 1945, subject: Visceral Leishrnaniasis-Kala-azar. The diagnosis was suspected by reason of unexplained fever for several weeks, comparative well-being of the patient, and gradual enlargement of the spleen and liver together with the characteristic blood changes. The definitive diagnosis was established by sternal puncture. Splenic puncture was not practiced. Since the cases were relatively recent in origin, the formol-gel reaction and the distilled-water tests were of little help.
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Response to treatment wasgenerallysatisfactory. Fuadin (trivalent antimony) given to 2 patientsappeared to be entirely ineffective and in 1 case was followed by analarming febrile episode ofseveral day's duration.
The ETMD report states:
The pentavalent antimonypreparation Neostamwas given to three of these patients, and Neostibosan to five. Bothhave proved effective, but Neostibosan appears to be distinctly thebetter of the two. The total dosage of Neostamhas been from 4.0 to 4.7 gm., and of Neostibosan from 3.0 to 3.6gm. One of the eight patients is now undertreatment. The other seven have made apparently complete clinicalrecovery.
Every effort was made to emphasize the necessity of considering kala-azar in the differential diagnosis of fevers of undetermined origin. The increased number of cases reported in 1945 was possibly in part attributable to raising the level of suspicion in the medical officers of this theater. It is not improbable, however, that in some instances of this infection the diagnosis was missed.
EVALUATION OF CONSULTANT SYSTEM
Detailed descriptions ofthe educational andeditorial activities of Colonel Blumgart, his role infurthering clinical research, and his relationships with otherconsultants have been delineated. Further comments have been made on these activities in relation to theproblems posed byspecific diseases. The following comments concern an evaluationof theconsultant system as itoperated in the theater.
On the basis of 3 years of experience as consultant in medicine (2 years in the Zone of Interior and 1 year in the India-Burma and the China theaters) the author considers the consultant system to be invaluable in enhancing the quality of medical care.
In the India-Burma theater, the role of the consultant as a two-way ambassador between the theater surgeon in Delhi and the installations in the field facilitated the interpretation of higher policy and directives of headquarters to those engaged in caring for the soldiers and conversely permitted bringing to the attention of higher authority some of the problems in the field. Important knowledge and experience gained in some of the installations could be transmitted to other installations having only fragmentary experience with certain diseases and conditions of medical practice.
The isolation in this theater arising from wide dispersion of units and poor lines of communication frequently resulted in medical officers having noopportunity to discuss professional matters with anyone other than their immediate associates.Colonel Blumgart's visits established a line of professional communication with theater headquarters. The improvement in morale was one of the most gratifying consequences of the consultant system.
