CHAPTER XXI
Cholera
Kirk T. Mosley, M. D.
HISTORICAL NOTE
The early history of Asiatic cholera in the United States Army is based upon the experience of the military forces with the disease when cholera pandemics originating in the endemic centers of the Far East invaded the North American Continent and gave rise to widespread epidemics within the United States on at least four different occasions in the 19th century.1 The disease entered the United States through seaports, particularly New York and New Orleans, being brought in by infected immigrants from cholerastricken areas of western Europe. In the first three epidemics, which swept this country in the fourth, sixth, and seventh decades of the 19th century, troops of the Army often suffered as severely as did the civilian population from outbreaks of the disease. In some instances, troops were responsible for the spread of the disease as infected units were moved from a station to a new post where the disease had not yet appeared. In many instances, the disease was introduced among the troops from civilian communities. One of the first experiences of American soldiers with cholera fully demonstrated its devastating character and showed how disastrous an outbreak can be to a military operation. During the Black Hawk Indian War in 1832, seven companies of infantry troops destined for this campaign embarked on the steamer Henry Clay at Buffalo, N. Y., on 1 July. Cholera broke out among the troops on 4 July. By 9 July, only 68 men of the 7 companies that departed from Buffalo were left. Many died of the disease on board ship; many others deserted in panic and died of cholera in the surrounding countryside.
Fortunately, cholera has not been a serious problem to military operations of the Army in any of the major conflicts involving the United States. The disease had not reached the North American Continent at the time of the Revolutionary War and the War of 1812.The Mexican War had just ended when the second American invasion by cholera began in 1849.Cholera was absent from the United States during the Civil War but entered shortly thereafter, in 1866, for the third major outbreak in this country. Cholera apparently played no role in the Spanish-American War, but in 1902 and 1903 the disease, broke out among American troops on duty in the Philippine Islands.
1 Wendt,Edmund C.: A Treatise on Asiatic Cholera. New York: W. Wood & Co.,1885.
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The islands at that time were suffering from a severe epidemic ofcholera which had spread fromthe Asiatic mainland.2 For the next 15years, sporadic cases of Asiatic cholera appeared inAmerican troops stationed in the Philippine Islands.During World War I,11 admissions forcholera with 2 deaths occurred among American troops overseas; bothdeaths and 10 of theadmissions were among American troops on duty in the Philippines andChina.3 An additional 6admissions for cholera, with 5 deaths, occurred among Philippine nativetroops.In World War II there were only 13 cases and 2 deaths fromcholera among American troops, though large forceswere involved in extensive military operations in the highly endemiccenters of the disease onthe Asiatic mainland. The remarkable achievement of the Army in choleraprevention in WorldWar II is attributable to well-developed and well-executeddisease-control measures by ourmilitary forces. Principles of sanitation effective in the preventionof infectious diseasestransmitted by way of the gastrointestinal tract were particularlyemphasized in the preventivemeasures against cholera.
ADMINISTRATIVE PREVENTIVE MEASURES
With the entry of the United States into the war,necessary revisions were made in Armyregulations in order to take full advantage of the latest developmentsin the field of sanitationand preventive medicine for the protection of troops against infectiousdiseases, includingcholera. Army Regulations No. 40-205, Military Hygiene and Sanitation,was revised andpublished on 31 December 1942. Army Regulations No. 40-210, Preventionand Control ofCommunicable Diseases of Man, was published on 15 September 1942 afterextensive revision.This revision greatly simplified and condensed a large number ofprevious regulations and WarDepartment circulars and represented a most valuable accomplishment inthe administrativeservice of the Surgeon General's Office in communicable disease control.
Circular Letter No. 56, published by the Surgeon General's Office on 9 June 1941, provided technical guidance, on the prevention of cholera. This letter was revised and published as Circular Letter No. 33 on 2 February 1943. Ill each of these letters, a section was devoted to cholera. The cholera section in the latter publication was superseded by TB MED 138, published in February 1945. These publications provided medical officers with the latest knowledge concerning the epidemiology and clinical aspects of cholera. The facts that cholera was in the category of an exotic disease and was little more than a name to most medical officers enhanced to a great degree the value of the technical directives on cholera prepared by the Surgeon General's Office.
2 AnnualReports of The Surgeon General of the Army, 1902. 1903,1904.Washington: Government Printing Office.
3 TheMedical Department of the United States Army in the World War.Statistics. Washington: GovernmentPrinting Office, 1925, vol. Xv, pt. 2, pp. 86-89, 134-137.
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Research
Although principles of sanitation for theprevention of cholera were well established and ofproved value, there was a constant effort to increase the effectivenessof the known preventivemeasures against this disease and to develop new ones through researchand investigation. Thisactivity of the Surgeon General's Office may be divided into twogeneral fields: Improvementand evaluation of the effectiveness of the cholera vaccine andinvestigation of drugs andchemicals which might be effective in the prophylactic treatment ofindividuals exposed tochlorea. Also, knowledge of the pandemic tendencies of cholera and itsability to reach majorepidemic proportions under conditions of warfare made it necessary toforestall the menace ofcholera even before our country became militarily involved in World WarII.
The preliminary precautionary measures were chiefly directed at improving the effectiveness of cholera vaccine. In the spring of 1941, information regarding the use of vaccines for the prevention of cholera and the method of obtaining the best vaccine possible was sought from medical authorities. In the fall of 1941, direct approach was made to the National Research Council for aid and advice in solving the problems connected with the use of immunization procedures against certain infectious diseases, including cholera.4 Acting quickly on this request, the National Research Council assembled a conference of experts which met on 22 October 1941 and prepared resolutions proposing policies to be followed in the immunization of American troops against certain infectious diseases. These resolutions were submitted to The Surgeon General and were the basis of policies adopted by the Army in its immunization program against cholera.5 The chapter on immunization in another of the preventive medicine volumes gives details of the cholera immunization policies and practices adopted by the War Department.6
The establishment of policies governing choleravaccine and its use didnot lessen the interest ofThe Surgeon General in investigations to improve the effectiveness ofvaccine as a protectivemeasure. Arrangements were, made to obtain from East Indian andEgyptian sources new strainsof Vibrio cholerae for the study of their immunizing propertiesand for possible use inpreparation of vaccines.7 The SurgeonGeneral made valuable use of the resources of theNational Research Council to keep informed about progress in thestudies on cholera vaccine,including the chemical aspects, various strains of cholera vibrios, andtechniques used incontrolling the production and testing the potency of vaccines againstcholera. In the, summer of1942, Col. (later Brig. Gen.) James S. Simmons, MC, recognizing theneed for organized effortto
4 Memorandum,Surgeon General's Office (Col. J. S. Simmons), for Dr. L.H. Weed,National Research Council, 8Sept. 1941, subject: Immunization Against Certain Infectious Diseases,Notably Plague, Cholera, and Typhus.
5 WarDepartment Circular No. 4, 6 Jan. 1942, sec. 3, Vaccination AgainstTyphus Fever, Cholera, and Plague.
6 Long,Arthur P.: The Army Immunization Program. In Medical Department, UnitedStates Army, PreventiveMedicine in World War II. Personal Health Measures and Immunization.Washington: U. S. Government PrintingOffice, 1955, vol. III, pp. 314-317, 347-348.
7Memorandum,Surgeon General's Office (Lt. Col. Rogers), for the Adjutant General'sOffice, 22 Dec. 1941.
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further the Army's knowledge concerning protection against cholera,especially in respect to thevalue of vaccines, urged that the National Research Council establish asmall committee tocoordinate cholera research activities. A committee was appointed on 26August 1942. Thecommittee, in a report made a few weeks later, summarized the existingstatus of knowledgeabout cholera vaccines, with particular reference to research beingdone at the time.8 It wasagreed, on the basis of this report, that the cholera vaccine incurrent use by the Armed Forcesshould be continued in its present form, though research was to beencouraged on the antigenic,chemical, and other aspects of the cholera organism, with the hope ofimproving the vaccineagainst the disease.
In the latter part of 1942, an informal suggestion was made concerning the advisability of establishing a cholera commission similar to the Typhus Commission. This suggestion, however, did not receive favorable consideration.
In a conference on cholera vaccine held by the National Research Council on 1.6 June 1943, it was decided that a field experiment in a cholera area was needed to determine the efficacy of the vaccine then being used by the Armed Forces and such other vaccines as might be selected in protecting a population against the disease. By a strange but fortunate coincidence, a very extensive field study on this same problem was actually in progress in India. A preliminary report of this study, conducted in Madras Province, India, under the direction of Dr. R. Adiseshan, Director of Public Health, Madras, with the assistance of Dr. C. G. Pandit and Dr. K. V. Venkatraman of the King Institute of Preventive Medicine, Guindy, Madras, and other scientists, was made available to the National Research Council by the end of the year and indicated that a considerable degree of protection was afforded by immunization.9According to the evidence presented in a final report, ail immunized population is at least 10 times less susceptible to the disease than an unimmunized population.
Research in the use of drugs in the treatment of cholera, though chiefly the concern of the Medical Consultants Division of the Surgeon General's Office, was of great interest to the Preventive Medicine Division. This interest was an outgrowth of the remarkable success in the use of drugs in small doses for prophylactic or suppressive effects in such diseases as malaria and meningococcal meningitis. Also, pressure for information about drugs effective against cholera developed when it became obvious that an increasingly larger number of troops would be exposed to cholera and that complete protection to exposed individuals is not assured by cholera inoculations. The logical place for studies on the therapeutic effectiveness of drugs is in an endemic area of the disease. Since India is such an area, the National Research Council was requested in February 1945 to consult with the Director General of the Indian Medical Service concerning plans of scientific groups of that country for investigating newer drugs in the therapy of cholera. The council was also re-
8 Minutes,Committee on Medical Research,National Research Council, 26 Sept. 1942, subject: Conference onCholera Vaccine.
9 Minutes,Subcommittee on Tropical Diseases,Committee on Medical Research, National Research Council, 28Jan. 1944.
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quested to ascertain whether a representative of the United Stateswould be welcomed to observeand participate in the investigations. Reports of investigations byIndian scientists conductedunder the auspices of the Indian Research Fund Association had been thesource of most of theinformation on the use of newer chemotherapeutic agents in thetreatment of cholera. The closeliaison of the International Health Division of the RockefellerFoundation with scientificorganizations and agencies of India was of great benefit in makingavailable to The SurgeonGeneral information on the results and progress of research beingconducted in that country.While there were indications that Indian authorities and scientistswould give favorableconsideration to the proposals of the National Research Council, thetermination of the waroccurred before final arrangements were completed, and the projectnever materialized.However, the results of an investigation of the treatment of cholera,conducted in Calcutta by aNavy epidemiologic team, led to The Surgeon General's issuance of aletter suggesting certainmodifications in the therapy of cholera as described in TB Med 138.These modifications wereconcerned chiefly with the use of penicillin and plasma in thetreatment of acute cases. At theclose of the war, no reliable information had been obtained on the useof drugs in thechemoprophylaxis of cholera.
ARMY EXPERIENCE IN THEATERS AND AREAS
India-Burma Theater
The greatest exposure of United States troops tocholera occurred in the China-Burma-India(later India-Burma) theater. Cholera was a constant menace to a largenumber of troops in thisarea, especially to those stationed in or near Calcutta or passingthrough or visiting thismetropolis and its environs. In this section of India along the lowerGanges River, the disease isnearly always present with the danger of large epidemics occurringduring the cholera seasoneach year.
In spite of an ever-present possibility of cholera outbreaks and the occurrence of extensive epidemics among civilians in proximity to military installations, no cases of the disease were reported among United States Army troops stationed in this theater. This excellent record is even more unusual when compared with that of Indian and British troops (table 77) who were stationed in the same area and potentially subjected to the same. exposure as the United States troops. While cholera outbreaks were known to have occurred among Chinese troops stationed in India and Burma, reliable information could not be obtained on the number of cases and deaths from this disease among Chinese soldiers assigned to this theater.
Except for immunization directives requiring troops to be immunized against cholera and to receive stimulating doses of vaccine every 6 months, very few administrative actions at theater level were specifically directed against cholera, although a survey on the cholera situation in Assam and
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Bengal Provinces was made by the theater surgeon's office in thelatter part of 1943.10 Theabsence of theater action specifically dealing with cholera is madeapparent in the officialcompilation of directives affecting the Medical Department which werein force as of 31December 1944.11 In that section of thecompilation arranged according to subject matter, thesubject of cholera did not appear once, since no directives in force atthat time pertainedspecifically to this disease. The explanation for this seeming failureto appreciate the hazard ofcholera lies in the fact that, from the very beginning, othergastrointestinal infections, especiallythe diarrheas and dysenteries, presented the theater with a serioushealth problem andovershadowed cholera as a cause of concern to the Medical Department. 12The increasingly highrates for the diarrheas and dysenteries approached a critical level in1944 and were the basis oftwo extensive surveys, one by a subcommission of the ArmyEpidemiological Board 13 and asecond by a special commission from the Office of the Surgeon Generalheaded by Brig. Gen.Raymond A. Kelser.14 Each survey listed agreat number of defects in sanitation which mightreadily account for a high incidence of gastrointestinal diseases,particularly in an environmentwhich is heavily seeded with the infectious agents of these diseases.As a consequence, most ofthe administrative actions taken in regard to gastrointestinal diseaseslead as their primarypurpose the control and prevention of the diarrheas and dysenteries. Inmost instances, thesemeasures were by their very nature equally effective against cholera.
10(1)Circular No. 50, Rear Echelon, Headquarters, U. S. Army Forces,China-Burma-India Theater, 17 Aug. 1943,subject: Immunization. (2) Circular No. 5, Headquarters, U. S. ArmyForces, India-Burma Theater, 20 Jan. 1945, sec.V, Immunization. (3) Essential Technical Medical Data, Headquarters,China-Burma-India Theater, 13 Dec. 1943.
11 CircularLetter No. 1, office of the Surgeon, Headquarters, U. S. Army Forces,India-Burma Theater, 1 Jan. 1945,subject: Compilation of Directives Affecting the Medical Department,India-Burma Theater.
12 VanAuken, H. A.: A History of Preventive Medicine in the U. S. Army Forcesof the India-Burma Theater, 1942-45. [Official record.]
13 (1)Monthly Report for July, Sub-Commission on Dysentery, ArmyEpidemiological Board, 8 Aug. 1944. (2)Progress and Final Report, Sub-Commission on Dysentery, ArmyEpidemiological Board, 20 Nov. 1944.
14 Letter,Headquarters, Services of Supply, U. S. Army Forces, India-BurmaTheater; to Commanding General, U.S. Army Forces, India-Burma Theater, 9 Nov. 1944, subject: Report of:Medical Department Mission.
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There were occasions, however, when the threat ofcholera was particularly dangerous andreceived special attention from the Medical Department in specificcommands and areas in thetheater. The most serious threat of cholera to American troops in theIndia-Burma theateroccurred in the Calcutta area in the spring of 1945 when a severeepidemic broke out among thecivilian population in Calcutta and the surrounding territory, with asmany as 100 cases and 35deaths being reported daily. At the height of the outbreak, theepidemic spread to British troopsbilleted in the Grand Hotel, with 14 cases reported in this group. The135 American officers alsobilleted in the hotel were immediately removed, and the dining quartersof the establishment wasput out of bounds for American forces. To Lt. Col. K. R. Flamm, MC, thesurgeon of this basesection, can be attributed much of the success of the vigorous attackagainst this threat ofcholera. The precautionary measures launched against the diseaseincluded: (1) An intensiveeducational campaign explaining to troops how cholera is spread andflow to avoid it; (2) specialmeasures to insure that all troops stationed in the area or passingthrough were properlyimmunized against cholera; (3) rigorous inspection of civilian eatingestablishments in bounds toUnited States troops, with special attention given to water protectionand sanitation,foodhandlers' hygiene, exclusion of serving of fresh raw fruits orvegetables to troops who werepatrons, and other sanitation requirements essential for the preventionof cholera; and (4)enforcement of strict sanitary discipline in all the Army messes andother food-dispensingestablishments on Army posts, with particular attention to nativefoodhandlers and their personalhygiene. The use of Indian labor for foodhandling lead been discouragedas far as possible, bututilization of cheap labor for this type of service was nevercompletely abandoned by manyunits. These special measures taken by the commanding general of BaseSection 2, whichincluded Calcutta and the surrounding area, represented the onlylarge-scale effort directedprimarily at prevention and control of cholera in the India-Burmatheater. Because of thestrategic importance of Calcutta and the relatively large number oftroops (24,500) stationed inthe city and its immediate environs, as well as a great flow of Armypersonnel through thismilitary center, an extensive epidemic of cholera among troops in thearea would have gravelyimpaired the functions of this vital supply base and resulted inserious interference to the theateroperations.
Other incidents involving cholera reported in the theater were of much less military significance but were of considerable medical interest. In the spring of 1943, a severe cholera outbreak occurred among the civilian population in several villages, including Pandaveswar, which were in the immediate vicinity of airbases of the 7th Bombardment Group. Special measures were taken by the local commanders to prevent the spread of the disease to personnel in these installations.15 In the spring of 1945, three suspected cases of cholera in American troops were reported by the 4th Combat Cargo Group stationed
15 Letter, Surgeon, 7thBombardment Group, to the Commanding Officer, 7th BombardmentGroup, 16 June 1943, subject: Cholera Epidemic Among Natives in Panda.
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at Chittagong. These suspected cases and the circumstancessurrounding their occurrence werethoroughly investigated by the theater epidemiologist, who was unableto find sufficientevidence to support the tentative diagnosis of cholera. Anotherincident later in the same yearwas the occurrence of a case of cholera in a Red Cross worker who waspresumably infected inCalcutta but developed her illness in Karachi while she was waiting forpassage to the UnitedStates. This case, though mild, was confirmed by positive stoolcultures.16
It is very difficult to draw any satisfactory conclusions concerning the unique record of the India-Burma theater in regard to cholera. While there were no cases among Army personnel, reports of the two separate extensive surveys, which included observations on sanitary conditions in military units, indicate that there were certainly opportunities for exposures to the disease, particularly in those areas where the disease is known to be endemically present at all times. Thus, much of the protection against cholera might be attributed to the effectiveness of the cholera vaccine. While such an assumption seems reasonable, an excellent summary of the American forces' experience with cholera in India contained in a report from the theater, points out certain difficulties in determining the protective value of cholera inoculations as well as in evaluating the relative merits of immunization and sanitation as cholera preventive measures.
China Theater
American troops assigned to the China section ofthe China-Burma-India theater (later, October1944, the China theater) faced essentially the same threat from cholerawhich troops faced inIndia. The disease was endemic throughout the area of Free China inwhich American troopswere stationed, and epidemic outbreaks occurred periodically. Duringthe war years, 1942-45,widespread outbreaks struck the civilian populations in many of theseareas of Free China, insome instances in the immediate vicinity of Army installations. Becauseof the constantpossibility of an explosive outbreak, routine immunization againstcholera with stimulatingdoses at 6-month intervals was administered to all United States Armypersonnel.17 Sanitationwas emphasized as an important measure for the prevention of choleraand similar entericdiseases. The Fourteenth Air Force published a memorandum which wasordered to be read to allmembers of that command at monthly intervals.18
American troops remained relatively safe from cholera until the summer of 1945, when outbreaks seriously threatened units in various parts of Free China. As a result of these outbreaks, a special cholera commission made up of civilian experts was sent to assist the Chinese National Relief and Rehabilitation Administration in controlling the disease among the civilian population. The first of these threats developed in Chungking, the provisional capital of Free
16 EssentialTechnical Medical Data, India-BurmaTheater, 1 June 1945.
17 AnnualReport, Office of the Surgeon, Headquarters, China Theater, 26 Oct.-31Dec. 1944.
18 FourteenthAir Force Memorandum 25-8, 10 May 1944, subject: Rules for Health inChina.
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China and also the headquarters of United States Army forces inChina, with the occurrence of asevere epidemic among the civilian population. This outbreak wascarefully investigated by thetheater medical inspector, and his report is one of the remarkabledocuments on cholera duringWorld War II. His investigation revealed that sanitary conditions inthe American installationswere in many instances very unsatisfactory, and of particular concernto him were the seriousdefects observed in sanitation and in protection of water supplies.Necessary corrective actionswere taken in accordance with his recommendations and included thepublication of directiveson cholera control for troops in the Chungking area. The efforts toprevent cholera fromspreading to American forces in the Chungking area were apparentlysuccessful, since no casesof the disease appeared in our troops in this area.19
However, only a few weeks later, two separate sharp outbreaks of cholera, the only outbreaks to involve American troops in World War II, appeared in units stationed in other sections of China.20 The first outbreak, which resulted in six cases with one death, occurred during the later part of July 1945 among the enlisted personnel of the 1836th Ordnance Company stationed at the Liangshan Air Base. This outbreak was attributed to the consumption of cakes and cookies which, against instructions, had been purchased from a bakery in the city of Liangshan, where a serious epidemic of cholera was raging. The cakes were served at a snackbar operating on the base. At the same time that these cases of cholera occurred, there was a sharp increase in the number of cases of diarrhea among troops of the 1836th Ordnance, Company which operated the snackbar where the questionable food was being served. The six cases of cholera were diagnosed on clinical grounds and treated in the station dispensary. The five who recovered responded well to therapy which included in some instances penicillin and sulfaguanidine in addition to parenteral fluids. According to the immunization records of these six cases, the initial immunizations against cholera were completed in August 1943 with American vaccine. All except one received a stimulating dose of Chinese vaccine in April and May 1944. Five cases received stimulating doses of Chinese vaccine in October 1944; the sixth received American vaccine in September 1944. In April 1945, five cases received American vaccine, and in May 1945 the remaining case received Chinese vaccine. Only two of the cases received another stimulating dose in July 1945.
The other outbreak occurred at Chihchiang duringthe first week of August 1945 and involvedpersonnel of the 547th Quartermaster Depot Supply Company. In thisoutbreak, there were sevencases with one death. The vehicle of transmission in this outbreakapparently was contaminatedwater, since all of the patients were known to have, on one or moreoccasions, drunk
19 Essential TechnicalMedical Data, Headquarters, China Theater, 12 Aug. 1945, inclosure 2.
20 (1)Essential Technical Medical Data, U. S. Army Forces, Headquarters,China Theater, 2Oct. 1945, pp. 4-5 and inclosures 2 and 3. (2) Annual Report, Office ofthe Surgeon,Headquarters, Fourteenth Air Force, 1945 , (2d and 3d quarters). (3)Annual Report,Headquarters, Army Air Forces, China Theater, 1945 (3d and 4thquarters), annex III, inclosure4.
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water, unboiled and unchlorinated, from a well at the Catholic Missionin the city of Chihchiang.Samples of water taken from this well on two separate occasions weresubmitted to the 1724General Hospital for analysis and were found to be positive forcolon-group organisms. One nunat the mission developed cholera from which she recovered.
In this outbreak, the patients were hospitalized and treated in the 21st Field Hospital. Stool specimens which were examined in the 172d General Hospital were positive for all seven cases. All patients received adequate amounts of parenteral fluids to combat dehydration and acidosis. Four patients also received penicillin, and, according to one source of information, there was no appreciable difference in response between the patients who received penicillin and those who did not. The patient who died received penicillin therapy. There is lack of information on the immunization histories of these cases, though it is known that one patient lead received a stimulating dose of American vaccine on 29 July 1945 and that the other six patients had received stimulating doses of Indian vaccine on 26 April 1945.
The seriousness ofthe cholera situation in the China theater was called to the attentionof alltroops in a theater circular dated 2 August 1945 in which the followingmeasures wereemphasized: Water sanitation, including purification and handling aftertreatment; precautions inthe preparation and handling of food; avoidance of prepared food anddrink from civiliansources; insect control measures; provision of adequate waste-disposalfacilities for Americanpersonnel and for Chinese personnel working in American installations;and the maintenance ofhigh immunity to cholera by administration of stimulating doses ofvaccine at intervals of notmore than 4 months. No further outbreaks occurred among United Statesforces in China. The,absence of additional cases is attributed to the combined effectivenessof sanitation andimmunization.
Southwest Pacific Area
The medical history of the United States Army in the Southwest Pacific Area in respect to cholera is an excellent account of wise precautions and careful preparation for eventualities. Although during the initial stages the campaign in this area was far removed from endemic cholera areas, the disease spread far beyond the usual endemic centers, having been seeded by the movement of Japanese troops throughout Southeast Asia including Indo-China, Siam, Singapore, and islands to the south and east of the mainland including the Philippines, Java, Sumatra, Celebes (Makassar), Truk, and possibly New Britain (Rabaul). There were reports that the, disease had occurred in units of the Japanese Army in many of these areas, and it was believed that the spread of the disease was partly due to the movement of infected Japanese troops from endemic foci to previously uninfected areas.
The spread of cholera from the mainland of Asia toward areas which
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were in the line of the offensivefrom Southwest Pacific bases, together with the possibility thattroops at any time might encounter the disease in infected units ofenemy troops, stimulated thedevelopment of a careful cholera-control program. Evidence of thecareful planning designed tominimize any potential threat of cholera to the success of militaryoperations in this area iscontained in a letter from the Chief Surgeon to the Surgeon, Sixth U.S. Army, dated 3 April1944, recommending (1) vaccination of all troops against cholera; (2)the establishment, in thesupplying base of each operation, of a special stock of supplies (suchas cresol, gowns, mosquitoand fly netting, and salt solution infusion sets), earmarked forepidemic use; (3) equipment offorward laboratory sections for prompt bacteriologic diagnoses ofcholera; (4) publication of atechnical memorandum for all medical officers on the diagnosis andtreatment of cholera and onspecial precautions to be taken in addition to usual sanitary measures;and (5) a report to the taskforce surgeon of any evidence discovered of epidemic disease amongenemy troops. Thesemeasures were all implemented by the necessary official directives andletters.21In the planningof the specific preventive measures for cholera, full use was made ofthe counsel and advice ofthe Combined Advisory Committee on Tropical Medicine, Hygiene, andSanitation. TheCommittee addressed a letter dated 22 June 1944 to the Commander inChief, Southwest PacificArea, giving full support to the cholera-control measures outlined inthe letter of 3 April 1944referred to.
Although no cholera cases or incidents occurred among United States troops in the Southwest Pacific, the planning in this area was well designed to meet any cholera situation which might be encountered under conditions of combat.
Cholera in Other Theaters and Areas
Cholera did notpresent a problem in other theaters and areas. However, each theaterhadregulations concerning the requirements for cholera immunizations, and,because of pandemicpotentialities of cholera, especially under conditions of warfare, acareful watch was maintainedin all theaters for any evidence indicating the spread of the diseasefrom its endemic centers.From time to time, false alarms of spread in the Western Hemispherewere received; however,during World War II, the extension of the disease beyond the usualendemic centers occurredonly in areas which came under the influence of Japanese militarycontrol.
21 (1)Technical Memorandum No. 1, Office ofthe Chief Surgeon, Headquarters, U. S. Army Forces in the Far East,17 Apr. 1944, subject: Cholera. (2) Letter, General Headquarters,Southwest Pacific Area, to Commander, AlliedLand Forces; Commander, Allied Air Forces; Commander, Allied Naval Forces; Commanding General, U.S. ArmyForces in the Far East; Commanding General, U. S. Army Services ofSupply, 24 Sept. 1944, subject: Cholera. (3)Letter, Headquarters, Advance U. S. Army Forces in the Far East, toCommanding General, Sixth Army;Commanding General, Eighth Army;Commanding General. Far East Air Forces; Commanding General, XIV Corps;Commanding General, U. S. Army Services of Supply; Commanding General,14th Antiaircraft Command;Commanding General, Replacement Command, 12 Oct. 1944, subject: Cholera.
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SUMMARY
The history ofcholera in the United States Army is paradoxical in that this diseaseexacted aheavier toll among troops in times of peace than during periods ofmajor military campaigns,when epidemic diseases such as cholera are usually most prevalent anddestructive. Such arecord owes much to the fortunate circumstance that peace prevailed onthe North AmericanContinent when cholera made its invasions of the Western Hemisphere inthe 19th century. Also,there is the factor that military operations by United States troops inhighly endemic areas inWorld War II did not include ground-combat activities to anysignificant degree. Most of thetroops in the India-Burma and China theaters were primarily engaged inopening andmaintaining communication and supply lines to Free China by way ofIndia and northern Burma.Air Force personnel engaged in aerial warfare in these theaters werestationed in bases whichwere in most instances comparatively safe from enemy action, so that itwas possible to maintaina high degree of sanitation in these military establishments.
Both sanitation and immunization were emphasized as preventive measures against cholera by the Medical Department of the Army. From the experience in World War II, it is impossible to evaluate the relative merits of each of these measures separately. Used together, they proved very effective under the conditions and circumstances faced by United States troops in the highly endemic areas of the disease.
While a creditable record was made in the prevention of cholera, very little was added to basic knowledge about the epidemiology of the disease. The opportunity for increasing understanding of basic factors influencing its peculiar restricted geographic distribution, epidemic and pandemic properties, and other unsolved problems was not pressed with the same intensity as were the investigations of other diseases of less catastrophic potentialities. Most of the investigative work centered around attempts to improve the cholera vaccine and a somewhat belated effort to discover a chemical prophylactic.
