The following account is an actual medical report written by Tanbaya Hospital's O.C., Major Bruce Hunt depicting the atrocious conditions in which the Imperial Japanese Army (I.J.A) treated the sick and injured P.O.W'S and which he had to run a fully operational Hospital under.
TANBAYA HOSPITAL BURMA
MEDICAL REPORT AUG. 1ST. - NOV. 24TH 1943
FACTORS CONCERNED IN THE HIGH DEATH RATE.
1. STATE OF DISEASES. Very many patients were in such an advanced state of disease that on arrival to Burma that even with the best hospital facilities in the world recovery would have been impossible. This applied particularly to patients from Sonkurai (No. 2) Camp, where, as we understand, evacuation of all very sick patients was practically compulsory.
2. STATE OF NUTRITION. Apart from the state of their disease, the nutritional state of many of the patients also gravely prejudiced their chance of recovery. In part this was due to poor rations at the working camps, but in part it arose from the failure of medical officers in certain of the working camps to insist on consumption by their sick patients of their full daily ration; in many cases of dysentery liquid diet had been prescribed for an unconscionably long time, resulting in practical starvation of the unfortunate patient. Apart from the emaciation a long-standing deficiency in vitamins A, B1 & 2, and C also greatly lowered the patients power to combat their disease.
3. EFFECTS OF JOURNEY. The journey was made under very arduous conditions. An inadequate supply of fit men was available to help sick patients - food was poor and long exposure to rain storms and severe jolting for hours were the lot of all. Under these circumstances many patients whose fate hung in the balance had their last chance of survival taken away from them by the strain of the journey.
FACTORS OPERATIVE AT TANBAYA.
1. DIET. So far from the diet being better than at the working camps it was for a long periods considerably worse, as will be seen from a study of the ration issues as set out in the War Diary. Rice was in general adequate, but every other essential for a complete diet was grossly deficient. In particular, until the bean ration was raised from 1/3 of a bag to 1 bag on the 22nd September, the diet contained practically no vitamin B or C. Innumerable protests and requests for rice polishings and for more beans were made to the I. J. A. but always met the answer that rice polishings were quite unobtainable and that there was a great shortage of beans which were being reserved for the camps further from the railhead. In this connection it is interesting to note that when on October 10th we learnt that the "A" Camp Hospital Camp. 5 kilos away, had been receiving an adequacy of beans since its formation in July, and pointed this fact out to the I. J. A. Camp Commandant he raised the bean issue from 1 bag to 2 1/2 bags forthwith. It is also interesting to note that from October 26th onwards regular issues of rice polishings were made available to the camp. Had these two steps been taken earlier in the camp's history it is my considered opinion that upwards of 100 lives would have been saved. The deficiency in vitamins A and C undoubtedly produced a marked lowering in the resistance of tissues to infection, thereby increasing the frequency and severity of ulcers, furuncles, impetigo, pemphigus and other cutaneous infections. The deficiency in protein produced a lowering of general vitality as also did the deficiency in calcium.
2. DRUG SHORTAGES. Until 5th November no drugs were received from the I. J.A and even then the supply was pitifully small and inadequate. In particular no specific therapy was available for the treatment of Amoebic of Bacillary Dysentery, the major killing diseases in the camp. There was no Iodoform or other drug suitable for local treatment of the numerous tropical ulcers. No sulphur (a common, cheap and easily procurable product) was available to treat scabies until 5th November by which time the whole camp was infected with much secondary suppuration and ulcer formations. Dressings were also woefully deficient and many mosquito nets had to be sacrificed to dress the enormous ulcers. No Iron was available to build up the anaemic patients, and no concentrated B1 was available for the numerous severe Beri Beri cases.
3. MALARIA. Tanbaya was an area where Malaria of a particularly severe type was hyperendemic. 87 deaths are shown as being due either wholly or partially to Malaria, but beyond this the disease had a debilitating effect throughout the camp where its incidence reached approximately 100%. In particular Malaria caused marked deterioration in the condition of patients suffering from ulcers or dysentery.
SYSTEM OF ADMINISTRATION:
The system of administration adopted at Tanbaya differed in several respects from that customary in military hospitals. In part these differences were dictated by local necessity, in part they were devised as possible improvements. Lt. Col. Hutchinson as Administrative Commandant of the camp was responsible for such services as cooking, securing of wood and water, hygiene and pay; Major Hunt, as O C Hospital, was responsible for all medical treatment and for the administrative control of all medical personnel whether professional or amateur and of all patients. This sub-division of authority worked very smoothly, and I should like here to pay my tribute to Lt. Col. Hutchinson's loyalty, to this unfailing tact, and to his untiring efforts in the interests of patients and of the camp as a whole. Details of medical administration were as follows:-
Patients were segregated so far, as was possible according to their complaints; this facilitated treatment and prevented much cross infection. Thus, one ward was devoted solely to dysentery, one ward to pure dysentery and ulcers combined with dysentery. Two wards to ulcers and three wards to general medical diseases, chiefly Malaria and Beri Beri. Each ward contained in the early stages approximately 190 patients and was under control of a Wardmaster. The Wardmaster was a combatant officer, usually of Company Commander status or above, he had as assistants; an assistant Wardmaster, usually a subaltern, 2 N. C. O's who acted as C.S.M. and C.Q.M.S. respectively and a clerk. The Wardmaster was responsible for nominal rolls, for discipline, for hut cleanliness, for messing, for canteen supplies and in general for everything which took place in the ward except such matters as involved technical medical knowledge or skill. He had in addition, through the medical officer or senior nursing N.C.O. supervisory control over the activities of the nursing orderlies in regard to their non-technical functions.
This system of Wardmaster control, first devised in Shimo Sonkurai Camp and further extended in Burma, proved of the greatest possible assistance in running the hospital. Discipline and general ward efficiency were better than they usually are under N. C. O. control. In particular messing functioned much more efficiently and with less complaint than is usually the case. I was particularly fortunate in having a very able body of Wardmasters; they worked, ate and slept in their wards and were completely devoted to their duties and to the interests of their patients. I should like here to express my appreciation of their valuable services. Wardmasters were (in numerical order of their wards) Lt. I. Perry (2/1 Heavy Bty A.I.F.), Capt. H. Walker (2/26 Bn A.I.F.). Major R. Hodgkinson (R.A.S.C.), Major W. Auld ( M.A.O.C.), Capt. B. Berry (2/10 Fd. Rgt. A.I.F.), Capt. G. W. Gwynne (4 M.G. Btn A.I.F.), and Lt. Col. Ferguson (18 Div H.Q.)
A Wardmasters conference, attended also by O. C. hospital, Registrar and Messing Officer, was held at 1530 daily, and this proved a most satisfactory means of keeping the wards in close touch with camp policy.
In view of the shortage of drugs, all drug requisitions were checked and countersigned by O. C. Hospital before completion. This took place daily at 1500 hours and permitted a just distribution of drugs between various wards and also of the conservation of necessary supplies.
As patients in the wards improved and became fit for camp duties, they were sent to the "labour exchange" where they were vetted by the O. C. Hospital and then assigned to various sections of the hospital according to the requirements of the different departments.
Although the number of R.A.M.C. and A. A. M. C. personnel at Tanbaya was at its highest 142, very many of these men arrived as patients and either died at Tanbaya or remained as patients throughout their stay in Burma. Nine members of the R.A.M.C. and 8 members of the A.A.M.C. died at Tanbaya, and five R.A.M.C. and 9 A.A.M.C. were left behind as seriously ill patients when the bulk of the camp moved in November. The maximum number of Medical Corps personnel available for duty at any one time was 62, but the number generally varied between 40 and 50. Under these circumstances it was necessary for the greater part of the nursing work to be done by volunteers from non-medical units, and the steadfast devotion to duty of these men under circumstances of much difficulty and discomfort is worthy of the highest praise. Many of the volunteers showed a marked aptitude for the more technical branches of nursing and in some cases were as good as, if not better than, the majority of the professionals.
Four diseases dominated the clinical picture. These were in the order of mortality which they produced, Dysentery, Tropical Ulcers, Beri Beri and Malaria.
1. DYSENTERY. In the absence of facilities for bacteriological or sigmoidescopic examination it was impossible in most cases to differentiate between Amoebic and Bacillary Dysentery. Clinically however, I formed the opinion that the former disease predominated, and autopsy and the result of treatment of five cases by Emetine in November (this was all the Emetine we ever received0 tended to confirm this impression. The dysentery wards were amongst the most tragic places in the camp. Many of the patients put up a gallant struggle forcing their rice down day after day and week after week in a heroic effort to stay alive until adequate facilities for treatment arrived. Dysentery alone caused 114 deaths, and in association with other diseases played a part in killing 334 men. In many cases an attack or recurrence of Dysentery was the terminal factor in carrying off patients suffering from Beri Beri or Ulcers.
2. TROPICAL ULCERS. These were of very great frequency and, in many cases, of horrifying severity. Huge areas of skin, flesh and in some cases bone were eaten away and the skin appeared to posses little or no resistance to the infecting organisms. Ulcers followed small scratches or cuts with distressing frequency and not a few patients died of Ulcers which actually developed in the camp. Capt. F. J. Cahill was in charge of the Ulcer Wards throughout, and has prepared a detailed memorandum on the subject of these ulcers. The lower extremity, and in particular the region of the Tibia was the site of election for the formation of ulcers. they could, and did however occur in almost any area of the body, as for example over the great trochanter, over the lower spine, in the groin, over the scapulars, on the elbows, wrists and fingers. A few cases responded strikingly to the application of Sulphanilamide or Iodoform, and had these drugs been available in anything like adequate amounts much life would have been saved. In the absence of these drugs simple cleansing with Eusol or Saline two or three times daily provided the best results, which however in many cases were disappointing. Amputations were performed in 60 cases (for details see Capt. Cahill's memorandum), but here also the results were in general disappointing, owing to the poor general condition of the patients and the frequent occurrence of severe secondary sepsis in the stump. It was noticeable that an attack of Dysentery or Malaria caused considerable deterioration in the condition of the ulcer which hitherto had progressed quite favourably. Ninety two patients died of ulcers alone and 105 of ulcers complicated by other diseases.
3. BERI BERI. Beri Beri was widespread through the camp, and at one time there was upwards of 600 patients showing clinical manifestations of the disease. It was also more severe than any which I had previously sen, the oedematous and cardiac types predominated. A further complication which caused much loss of life in Beri Beri cases was the frequency with which grossly oedematous Beri Beri patients developed a rapidly spreading gangrene in their water logged extremities. This complication was almost invariably fatal. Many patients remained oedematous for several weeks and in such cases cardiac deterioration generally occurred or followed on the oedema. Cardiac Beri Beri was both common and severe. Practically every clinical cardiac abnormality ever recorded in Cardiac Beri Beri was observed at Tanbaya. Hearts were enlarged both to the right and to the left, chiefly the latter. The rate varied both upwards and downwards, bradycardia was very common. Abnormalities of rhythm were relatively frequent. These generally took the form of extra-systoles, although auricular fibrillation was observed on a number of occasions, frequently just before death. Variations in pulse volume were not infrequent and generally of poor prognostic significance. Abnormalities in heart sounds were frequent. A splitting of the first sound was the most characteristic change. Systolic murmers occurred frequently. Gallop rhythm was noted sometimes. Thee pulmonary secondary sound was frequently loud and banding. Cyanosia and other sounds of congestive heart failure were relatively infrequent. Sudden death occurring in the middle of the night was not uncommon. Administration of Vitamin B1 intravenously saved a certain number of lives when cardiac emergencies occurred, but of this, as of all other valuable drugs, supplies were grossly inadequate. 68 patients died of Beri beri alone and in a further 260 cases Beri Beri was one of the causes of death.
4. MALARIA. Malaria was practically universal throughout the camp, and in August and September relapses were very frequent, as owing to the shortage of supplies it was not possible to give quinine treatment for longer than 7 days. After the end of September supplies increased considerably, and it was possible to increase the course from 24 grs. daily for 7 days to 32 grs. daily for 12 days, accompanying the latter with .02 grs. Plasmoquin daily. After this step was taken there was a marked fall in the incidence of malarial relapses. Microscopic examination conducted by the I. J. A. showed a relatively frequency of B. T. and M. T. infection of approximately 2 to 1.
5. TYPHUS. A 14 day fever clinically resembling typhus in many respects was observed in about 40 cases. No rash and no eschar were seen, but previous experience of this disease left me in little doubt as to the nature of the fever. Serological confirmation of the diagnosis was of course impossible. The typhus in general was relatively mild and only two or three cases succumbed.
6. CATARRHAL JAUNDICE. About 50 cases of this disease were seen, all mild and none fatal.
7. RESPIRATORY DISEASES. Coryzas were frequent, but only about half a dozen pneumonias were seen, two of which were followed by empyaema.
8. SCABIES. Scabies spread steadily from the formation of the camp onwards, and by November when the supplies of sulphur arrived it was almost universal. Scabies had of course a high nuisance value, but in addition to this it gave rise to much secondary infection, and in some cases to severe ulcers which resulted fatally. Treatment was instituted immediately on the arrival of the sulphur in early November (coking oil being used as a base). Much improvement naturally occurred in the scabies but the sulphur came too late.
The register of deaths is contained in the War Diary. The camp roll contains an entry of the diseases from which the various patients suffered during their stay at Tanbaya. With view to giving such patients some individual record of his illnesses, entries signed by medical officers were made in both British and Australian pay books. Where pay books had been lost, cards or bamboo slips were issued on which the appropriate particulars were inscribed. Every man who left Tanbaya should have with him a full record of the illnesses from which he suffered in that camp.
As early as September strong representations were made to the I.J.A. that many hundreds of patients would not successfully survive a long railway journey (see the letters from Major Hunt quoted in extense in the War Diary). As a result of these representations considerable leniency was allowed in the selection of patients to travel. Much care was taken with this selection and as a result, of the 900 patients who left Tanbaya for Kan Chan Buri only two failed to survive the arduous 5 to 6 days journey.
The Burma Hospital Camp for reasons stated above, could not be regarded as a success. its partial failure however was much mitigated by the work of the administrative staff, by the devotion to duty of the wardmasters and by the professional skill and knowledge displayed by some of the medical staff. In this connection I would particularly mention Major W. J. E. Phillips (R.A.M.C.), Capt. Emery (R. A. m. C.), Capt. F. J. Cahill (A. A. M. C.), and Assistant Surgeon Wolfe (I. M. D.). Outstanding nursing work was performed by Sgt. G. Nichol (A. A. M. C.). and by Cpl. Skippen and Cpl. Sutton (R. A. M. C.)
KANCHANABRI (Sgd) Bruce Hunt. Major A.A.M.C.