Experience of the 4oth Evacuation Kos ital 
in the treatment and management of Chinese Patients. 
A considerable number oh personnel of this organiza- 
tion have cared for Chinese soldiers almost exclusively for 
the past 14 months. During tne past 4 months the entire per- 
s nnel of the organization has taken care of Chinese patients 
only. During the past 14 months, therefore, the personnel 
have exar. ined and tr eated approximately 17,000 to 10,000 
Chinese individuals. This has provided a rich and tremendously 
interesting professional experience, especially for the inter- 
nists and the la Donatory i en. These patients have presented 
a wide variety of interesting diseases and pathological condi- 
tions. The following observati ns and impressions are presented 
as of interest and pertaining es] ecially to medical work in 
this part of the Southeast Asiatic theater. 
The average Chinese soldier that we have seen is 
small cor pared to Americans. Some are v-ry youthful; the 
majority are in their 20's'. He is not more than feet tall 
and weighs on an average 125 to 130 lbs. As a rule he is 
slender with small bones, but well built and capable ol ,reat 
endurance, and hard work when he is not sick with the 'iany 
diseases that nay afflict hit when he first comes- from China. 
V/e have observed great variations in weight because among 
soldiers newly arrived from China, ralnutrition is common, pro- 
ducing in some cases extreme degrees of emaciation. This is 
corrected by the better diet afforded the Chi ese training and 
operating in India and Burma. Some of them appear plump and 
well nourished, but we have never encountered a case of true 
obesity, and not a single case of endocrine conditions such as 
Frohlich’s Syndrome. 
One of the rest striking differences between our 
experiences with Chinese and experiences in medical practice 
in the United States is the fact that the Chinese soldiers 
suffer commonly not a single disease condition, but from 
a multiplicity of diseases. The symptoms and physical findings 
which they present, therefore, are very frequently to be explain 
ed not on the basis of one disorder such as we have been accus- 
tomed to in t' e past, but by nore than one disease. For example 
in a soldier who entered the hospital recently with a diagnosis 
01 relapsing fever, examination of blood smears showed not only 
the spirochetes of relapsing fever, but numerous Falcip, Plas- 
modia. Cerebral symptoms and neurological findings suggested 
the possibility of cerebral malaria, but a spinal tap showed 
purulent spinal fluid probably due to meningococcus meningitis. 
At autopsy, both kidneys showed wnat appeared to be multiple 
small abscesses throughout the substance of each kidney, the 
exact nature of which is not yet known. Very numerous similar 
1 examples of 2, 3? 4, or even 5 diseases existing in the 
same individual could be given. 
As mentioned above, man}' patients suffer from varying 
degrees of malnutrition and deficiency states due to lack 
of specific vitamins. Beriberi is the most common specific 
deficiency disease which we have encountered. In the summer 
and early fall of 194-3 at a Chinese training center, a large 
number of cases of this disease were encountered. Our ex- 
perience with this outbreak was reported in C3I Field Medical 
Bulletin for December 194-3 . During the past 4 months at this 
post we have seen occasional cases of beriberi, but the inci- 
dence has not been high. Doctors who have practiced in China 
for a number of years have told us that there is a seasonal 
increase in beriberi beginning in the summer, and we are 
watching with considerable interest to see whether or not we 
shall have a repition of our experience beginning in August 
of this year comparable to the experience of 194-3 . Evidence 
of deficiencies of *he other components of the Vitamin B 
complex have been encountered, especially those due to lack 
of Riboflavin, We have also seen an occasional patient with ' 
glossitis in various stages, presumably due to lack of nico- 
tinic acid, but never any instances of skin changes typical 
of pellagra. Frequent complaints of night blindness have 
been made by the Chinese soldier . It seems probable that 
this represents a deficiency of Vitamin A since even in the 
hospital the diet provided is definitely lacking in this 
essential substance. Many of the cases examined, however, 
have shown other eye diseases which of themselves were an 
adequate cause of defective vision. No cases of xerophthal- 
mia or keratomalacia have been seen. No cases of scurvy have 
been encountered. It has not been possible to determine the 
plasna proteins, but we believe that a deficiency of this con- 
stituent of the blood may be accountable for an occasional 
case of edera. Nutritional anemia is also common usually 
occurring in association with hookworm and ascaris infestation 
which is very common in the Chinese soldiers. 
Skin disorders due to pyogenic and fungus infections 
have been common. 
The teeth of the Chinese soldiers are very good. In 
the majority they are white, strong, and regular. Caries 
does occur, but it is not common. Not a single edentulous 
soldier has been seen. Pyorrhea is very rare; a few cases 
have been seen in older soldiers. The dental surgeons have 
surveyed thousands of Chinese soldiers and agree with the 
above statements. The most common condition bringing them 
to the dentist is impacted or retained 3rd molars. Gross 
accumulation of tartar is likewise common. In general the 
undersigned believes that' the teeth of these Chinese young 
men and youths are infinitely better than those of the 
general run of men examined for selective service by him in 
1940, 41 and 42. The undersigned has never encountered in the Chinese anything comparable to the extreme decay and 
loss of teeth which was so coraronly seen in men examined 
for the draft. 
Diseases of the eyes have been common, almost entirely 
disease of the anterior segment. There is a high incidence 
of trachoma, and of conjunctivitis, acute and chronic. Ptery- 
gium and keratitis of various types have likewise been common. 
Dermatitis venenata" of the lids has been observed due to 
jungle vines and toxic trees. Other conditions peculiar to 
this area include corneal abrasions and perforations due to 
bamboo branches, and retinal hemerrhages,and optic neuritis 
due to scrub typhus. During a seven mouth period at a Chinese 
training center in India, eye diseases ranked 6th as a cause 
of admission to the hospital, being exceeded only b> dysentery 
and diarrheal diseases, respiratory infections, miscellaneous 
surgical conditions.and injuries, malaria and venereal disease. 
■Except for malaria ano various forms oT dysentery, 
contagions diseases have not been an important problem. Over 
a period of 14 months not 'a single case of keasies, Rubella, 
bcarlet fever, or Chicken Fox were encountered in the 17,000 
soldiers treated. Pumps, how* ver, has'been almost endemic, 
but no or extensive outbreaks have been encountered. 
During a ceriod of ten months at another post with a nean 
strength of Chinese troops rang’ng from 12,000 to 22,000, there 
were in che hospital almost constantly from six to twelve 
cases of Lumps, Presumably there are not many susceptible 
individuals, because all of the soldiers were t loroughly ex- 
posed by ren in their unit with Pumps who usually did not report 
to the hospital until they had been ill for several days, and 
occasionally reported only when they developed complications 
such as orchitis. To case showing symptoms of menigo-encepha- 
litis has been encountered, but the spinal fluid in these 
soldiers was not examined so that there may have been cases 
of symptomless pleocytosis. It is most fortunate that there 
has been such a low incidence of the common contagious diseases 
since it is practical!./ impossiole to isolate these patients 
without resorting to an an. ed guard and barbed wire fence. In 
spite of all explanation and orders to the contrary, they will 
not remain in bed, and mingle freeiy with patients on the same 
ward and other wards unless prevented. During the winter 
1943-44 several hundred cases of relapsing fever were admitted; 
at the same Time, 60-70 cases of typhus, a variant of louse 
borne t,rpe, were seen. Occa*sionally the two diseases occurred 
in the sane patient. 
There has been a relative high incidence of venereal 
disease In all forms both acute and chronic. Jince no infor- 
mation as to the mean strength of organizations ia available 
the exact incidence cannot be given. During, a period of seven 
months at the training center mentioned above, venereal diseas ran]ed >th as a cause of hospitalization at that post. The 
incidence of venereal disease at this hospital in 3ase Sec #3 
has been distinctly less. Various manifestations of tertiary 
syphilis have been common, and we have been particularly 
impressed with the frequency of bone involvement. The medical 
ofiic rs of this organization have had more experience with 
various late forms of syphilis during the past 14 months than 
in their entire previous professional experience. Syphilitic 
involvement of the nervous system has not been encountered 
and cardio-vascular syphilis has been rare. 
Pulmonary tuberculosis is common, often in an 
advanced form. Disserinated or miliary tuberculosis with 
meningitis has been seen not infrequently, and there has been 
undoubtedly a much higher incidence of this disease than is 
ever seen in the American army or in civilian practice in the 
United States. We have encountered only a rare case of acute 
rheumatic fever, but a.considerable number of cases of rheu- 
matic heart disease have been treated. Generalized vaccinia 
in soldiers recently vaccinated has occurred with surprising 
frequency according to our own standards. We have seen 10 or 
12 such cases. Rare cases of Leishmaniasis in the form of 
Kala azar have been seen. Two cases of leprosy have been en- 
countered. 
A number of cases of severe,generalized polyneuritis 
running a long course, not associated with beri beri, and of 
unknown cause have been seen, Lental disturbances, sometimes 
in a violent form, have not been rare, and their custody and 
disposition create a difficult problem. Diagnosis of milder 
or more obscure types of mental disturbance has been diffi- 
cult or impossible because of language difficulties. Several 
instances of hysterical paralysis and hemianaesthesia have 
been seen. 
Diseases of the digestive system in general have been 
uncomron, except for the very high incidence of hookworm and 
ascaris infestation, and various forms of dysentery. A rare 
case of acute gall bladder disease has been seen, in one or 
two instances apparently precipitated by the presence of 
ascaris worms in the cystic duct. Gall*stones and appendici- 
tis have been rare, particularly in comparison with Americans. 
Peptic ulcer has never been diagnosed, but language difficul- 
ties and the lack of any means for making x-ray examinations 
of the g.i. tract have prevented any adequate studies of 
digestive complaints. Fistula in ano has been comparatively 
common. 
Nephritis has been seen infrequently. It is our 
impression that kidney stones occur much less commonly than 
in the American soldier, and American young men of the same age group. Bladder stones though rare have occurred more 
often than is found in Americans in the sane age group. 
Rheumotoid arthritis is rare as are other forms of 
arthritis and bone diseases. Tumors have been uncommon. 
The only form encountered has been malignant lymphoma of 
w ich we have seen 5 or 6 cases in the 17,000 soldiers 
examined. Ho case of leukemia or other primary blood dis- 
order have been seen. Not a single case of diabetes mellitus 
or hyperthyroidism has been seen. 1 ontoxic goiters have not 
been rare. 
In summation, the comron corplaints which the 
Chinese soldiers have presented have been dysentery of all 
forms,. intestinal parasites, malaria, respiratory infections, 
and tuberculosis, various forms of nutritibnal disorders and 
anemia associated with malnutrition and intestinal parasites, 
venereal disease, and during the cooler months, relapsing 
fever which has been a common disease in our experience. 
Other than, battle casualties the surgeons have been concerned 
mostly with the treatment of serious Injuries resulting from 
auto accidents and other minor surgical ailments such as 
hemorrhoids, fistula in ano, circumcision, treatment of boils 
and abscesses, sprains and strains. 
Our personnel coming directly from the United States 
and havin0 had no prior contact with Chinese, faced an interest- 
ing problem in assuming the medical care of large number of 
Chinese soldiers. In general they have handled this difficult 
situation in a commendable fashion. The Chinese soldiers have 
received medical and surgical care of a very high quality such 
as they have never received before in their experience or in 
the history of the Chinese Army. It has been the best that 
well trained, superior, and well equipped doctors and nurses 
could give. In our effort to care successful! and efficiently 
for these patients, it was realized early that it involved 
more than the possession of technical knowledge and skill. 
It was necessary to try to understand these patients who have 
had such an utterly different background, both individually 
as a nation. The langur difficulties, although interpre- 
ters were provided, presented no small problem. Instruction 
in spoken Chinese was given all personnel for a period of three 
months, fany s owed a gratifying ability to learn, and their 
ability to speak and understand Chinese has increased with 
constant practice. Americans perhaps can never completely 
understand the feelings and mental processes of Chinese without 
a lifetime experience, and a nore thorough knowledge of their 
ancient culture and civilization than any of us possess. We 
have had a concentrated experience with them., however, over a 
period of almost 15 months, and have gained certain impressions, 
especially as regards the manner of of approach w ich must be 
followed in dealing with them. As in any nation or race there 
have been many physical and psychological typ'es. The common soldiers, however, have for the most part had a similar 
background .• The great majority of them are illiterate 
and have come from isolated farms and small villages wher 
life has often been hard and for many a persistent struggle 
for existence. This poverty and ignorance of necessity has 
caused them to develop habits and reactions which one cannot 
expect them to abandon as soon as the,, enter an American 
hospital. One of the most trying difficulties with which 
we have had to struggle, has been their great ignorance of 
and complete indifference to what we consider important sani- 
tary practices. It has been a constant struggle, therefore, 
to maintain tie wards and their surroundings in anything 
like a clean and sanitary condition. It is their custom to 
throw uneaten food and other garbage out of the window or 
even under the bed, and they are not disturbed in the sligh- 
test by the tremendous swarms of flies that accumulate. 
They spit anywhere that is convenient even though cax.s or 
other receptacles are provided for them. Because of the 
frequency of pulmonary tuberculosis this has constituted a 
serious menace to tne health of American personnel caring 
for them. Although an abundance of food is provided, the 
diet, au tires at least, has a monotonous sameness which 
they seek to correct by preparing and cooking food for them- 
selves. ward officers are no longer surprised to find 
chickens tied under the bed, with all of the unsanitary con- 
ditions whicn result from feeding this chicken in the hospi- 
tal ward . In order to obtain firewood for their cooking, 
which goes on allover tie hos it.: 1 grounds, they will break 
off , ieces of the bamboo basha flooring, and by now have 
almost completely used up the bamboo rails which were put 
around the slit trenches as a protection to people walking 
about in the dark. V/e have not had - the common problem which 
is encountered in the Indians of defecating in the grass and 
bushes, for obey do use latrines on which they squat no matter 
whether seats are provided or not. They show a remarkable 
nonchlance, however, about urinating Just outside the door 
of the .ards. It has been a constant and difficult struggle 
to induce thor to use malaria preventive measures. During 
the hot weather it is almost imp ossible to revent large 
numbers froi rolling up the mosquito bars which are provided 
for t her , and they atwend the movies in various stages of 
undress at .i.gut 1: s.h.t • o ’ all reasonable measures to per- 
suade or compel them to do otherwise. 
Another difficulty whi.eh has been encountered has 
seen the tendency to interfere with treatment. They not un- 
commonly out a way portions of plaster casts and rarely remove 
them, entirely. The orthopesic surgeons nave iound it best 
in cases of comround fracteres of the femur to use traction 
with stelmman in through'the heel, since this is.the only 
apparatus ioa they will net remove. This does not prevent 
them., however, from inducing their friends to remove the brie, s and other weights which are used to provide traction. 
They not infre 4uently rer.ove their dressings sometirr.es out 
of pure curiosity to ermine their wound. Others go to the 
extreme and derand daily dressing o“ wounds which do 
not rec lire dressing rore than once weekly. As mentioned 
above it is impossible to isolate patients with contagious 
diseases. It is likewise not uncor.iron for patients to 
refuse to take redicine if it does net taste good, and our 
I. edical Officers, nurses, and ward personnel have long since 
learned to look under pillows and in the pockets of pajamas 
to see whether atabrir.e tablets provided for patients have 
been taken. 
It is irpossible to keep these matients in bed 
unless their injuries prevent them completely from getting 
out of bed or unless they feel too weak or too ill to get 
up. Doctors have been startled and sur; rised to find their 
pneumonia patients with high fever up and walking around. 
The same is true of post-operative cases. One striking 
example -was provided by a patient who entered the hospital 
with malaria, and was found on physical exanination to have 
a lar,-e spleen. During the period of treatment he left the 
ward, presumably to go to the bazaar, and fell into a ditch 
striking his left side. He suffered a rupture of the spleen 
so that it was necessary to remove the s^leen. 11 hours later 
he was found visiting another ward where he had gone to re- 
trieve some personnel ;s. TIe made an uneventful 're- 
covery. We have had to reconsider our ideas as to the impor- 
tance and necessity of confining patients to bed with severe 
illness and post operatively, because for the most part these 
patients have seemed to do just as well as our patients at 
home who regain in bed for a week or two weeks under similar 
circur stances. 
One of the most serious or annoying tendencies of 
the patients is the pilfering or appro riati.n of the be- 
longings of others for their own use. We have been rather 
appalled at the frequent lack of sympathy or compassion for 
the afflictions or disabilities of their fellows, which often 
excite their mirth or amusement. They are very quick, however, 
to resent vigorously any real or fancied injury to their 
fellows by Americans, The.' have always been and are still 
content with little, buc again they opject strenuously if they 
suspect teat anything which suould be forthcoming is withheld 
from ther . The same mental reaction causes them often to be 
very demanding. Contrary to our preconcieved ideas, these 
patients are not stolid, but are e:citable, and as quick to 
angtr as to laughter. This enumeration should not stop with mention of 
difficulties and undesirable traits, because these patients 
have rr any admirable qualities. One that has impressed us 
greatly is their universal natural cheerfulness and good 
nature. They 1to laugh and it is easy to cause them to 
laugh or smile even hough they do not understand what is 
said to them. are mischievous and full of pranks, and 
this along with their cheeifulness makes them resemble 
children. Occasionally their mischief is annoying, especially 
when they plague the meek and submissive Indians who work about 
the hospital. They are eager to learn, and many of them are 
quick to grasp new ideas and knowledge. They are distinctly 
and in striking contrast to Indian coolies and 
laborers. They are not easily downed by sickness, injuries, 
or misfortune. One must acknowledge that the majority of 
then show patience and courageous resignation to suffering, 
and such t ings as the loss of an eye or a limb. In their 
own way they frequently express their appreciation of what 
has seen done for them. Others no doubt have some psycholo- 
gical handicap sue as is often found-in other races which 
prevents thei. fror openly expressing a sincere appreciation 
v. rich they nevertheless feel within them. In general, in 
spite of the difficulties enumerated above, they are good 
patients and easy to handle with the proper approach. The 
proper approach is of the greatest importance, for without 
it there may be serious trouble. One cannot con.pel or coerce 
these patients tc do anything. They must be persuaded and it 
has beer, very striking to witness the marked improvement in 
the general sanitary conditions and cleanliness of the wards 
which can be accomplished with good matured persuasion and — 
jollying. Our nurses in particular have been successful 
in getting the cooperation and good will of tire 'patients. 
It should be added at this point also, that during the 14 
months we have been caring for these soldiers there has never 
been a single instance of any improper attitude toward or 
treatment of our nurses, whom the Chinese soldiers in general 
have always treated with respect if not with courtesy. For- 
tunately there has never been any serious difficulty or 
clashes with these patients. One cannot avoid speculating 
on the effect of a 13 this upon future relations between our 
country and China, relations which will be of vital impor- 
tance in tVer post war period and eventual maintenance of 
peace, ierhaps this practical form of friendly rclat uns 
and demonstration of .goodwill will, like actions, speak 
louder than the words of diplomacy. 
L, 
c