MEDICAL DEPARTMENT 
UNITED STATES ARMY 
IN WORLD WAR II MEDICAL DEPARTMENT, UNITED STATES ARMY 
PREVENTIVE MEDICINE IN WORLD WAR II 
Volume III 
PERSONAL HEALTH 
MEASURES 
AND IMMUNIZATION 
Editor in Chief 
Colonel John Boyd Coates, Jr., MC 
Editor for Preventive Medicine 
Ebbe Curtis Hoff, Ph. D., M. D. 
Assistant Editor 
Phebe M. Hoff, M. A. 
OFFICE OF THE SURGEON GENERAL 
DEPARTMENT OF THE ARMY 
WASHINGTON, D. C., 1955 PREVENTIVE MEDICINE IN WORLD WAR II 
Prepared under the direction of 
Major General George E. Armstrong 
The Surgeon General, United States Army 
Historical Unit 
Colonel John Boyd Coates, Jr., MC, Director 
Major I. H. Ahlfeld, MSG, Executive Officer 
Captain J. K. Arima, MSC, Special Projects Officer 
Donald O. Wagner, Ph. D., Chief, Historians Branch 
Willa B. Dial, Chief, Editorial Branch 
Josephine P. Kyle, Chief, Archives and Research Branch 
Hazel G. Hine, Chief, Administrative Branch 
Gertrude G. Johnson, Publications Editor 
Advisory Editorial Board 
on the 
History of Preventive Medicine 
Brig. Gen. James Stevens Simmons, USA (Deceased), 
Chairman, 19 Jj8-5 4 
Brig. Gen. Stanhope Bayne-Jones, USA (Ret.), Chairman 
John E. Gordon, M. D. Paul F. Russell, M. D. 
William A. Hardenbergh Thomas B. Turner, M. D. 
Anthony J. Lanza, M. D. Douglass W. Walker, M. D. 
Elliott S. A. Robinson, M. D. Col. Tom F. Whayne, MC 
Ebbe Curtis Hoff, Ph. D., M. D., Editorial Director (Ex Officio) 
Colonel John Boyd Coates, Jr., MO (Ex Officio) Volume III 
PERSONAL HEALTH MEASURES AND 
IMMUNIZATION Foreword 
Health of military personnel is one of the first important matters to be 
considered in the buildup, development, and active operations of military forces. 
Any history of the Medical Department of the United States Army in 
World War II must present the more important personal health considerations 
which influenced the sum-total and day-to-day life and experience of officers 
and men in the Army. Each contributed in its own way to the overall 
effectiveness of our troops. 
While such matters as personal hygiene, immunization, food and nutrition, 
prevention of injury, and preventive psychiatry—to mention a few—were of 
broad interest and concern to many within the Army, their detailed program of 
development and management on a scale of size, scope, and ramifications never 
before attempted—or fully envisioned—was primarily the responsibility of 
the Medical Department. In carrying out these responsibilities it should 
always be remembered that while dealing the cold realities of war, the 
Medical Department by expectation and necessity also dealt with the complexi- 
ties revolving about the physical, mental, and moral constitution of man. 
The objectives of military preventive medicine, namely the prevention or 
control of disease and injury among the members of the military forces, the 
maintenance and conservation of health, and the physical and mental fitness 
of the troops, provided the guiding keynote to the personal health program 
throughout the war. 
Principles of personal health maintenance were established and practiced 
in the Army long before the onset of hostilities of World War II. These were 
continued on an expanded scale and others were developed as the situation 
required and as time and circumstances permitted. Valuable assistance and 
cooperation was extended to the Medical Department by many allied health 
agencies. In some instances, as might be expected, divergencies of opinion 
prevailed as to the proper courses of action. As in any comparable situation, 
there were some errors of omission or commission, despite every effort to avoid 
them. Many problems were unfolded and revealed for the first time, and, in 
not all cases were completely satisfactory solutions forthcoming. Many and 
varied forces and exigencies of war, both at home and overseas, aided as well 
as militated against the perfect answer to and implementation of the Army’s 
personal health program. Further study and research, coordinated application 
of practical methods, and full indoctrination of all concerned within the Army 
are essential for the continued success of this program in the future. VIII 
FOREWORD 
This volume admirably discusses in proper perspective the major problems 
encountered and the measures taken by the Medical Department to safeguard 
the personal health of all Army personnel during the period of World War II. 
The results form a splendid record of which the nation can be proud, and a 
pattern which should be carefully studied by those who plan the health program 
of future military forces. 
GEORGE E. ARMSTRONG 
Major General, United States Army 
The Surgeon General Preface 
The complexities of the theory and practice of military preventive medi- 
cine were well demonstrated during World War II. It was learned and re- 
learned during that period that effective prevention and control of disease and 
injury depends upon the judicious, timely, and vigorous application of the basic 
truths and principles developed in the various disciplines involved. That so 
much re-learning of this apparently elementary concept was required was 
unfortunate, if for no other reason than that it was wasteful of time and energy. 
It is principally this that demands the study, evaluation, and recording of the 
experiences of that time. These experiences arranged themselves generally 
and quite naturally into the triad of epidemiology, environmental sanitation, 
and personal health measures. 
It is with the last of the triad that this volume is concerned. Grouped 
within it are the accounts of the policies and practices concerned with the vari- 
ous direct personal aspects of preventive medicine as it was applied for the 
United States Army during the war period. It is hoped that this concentration 
of these highly personalized procedures—ranging from personnel selection 
through nutrition and clothing to the stimulation of specific individual immu- 
nity through immunization—emphasizes that preventive medicine is more than 
the sanitation of the environment and that the prevention of the disease is more 
to be desired than the nice description of the epidemic and its control. This 
volume will serve a useful purpose if those who need to learn will read it and 
if those who read are willing to benefit from the experiences, mistakes, and 
repetitive efforts of the past. 
The authors of the various chapters were chosen because of their peculiar 
qualifications to deal with their allotted subjects. They need no introduction 
here. They alone, however, did not nor could they have accomplished this work 
unaided. Much credit and appreciation are due to the many others who 
through their advice, guidance, and reviews helped materially in the prepara- 
tion of this work. If any of these are not named here, apologies as well as 
thanks are due. Specifically, the most sincere thanks and appreciation of the 
authors and editors are due to the following reviewers: Lt. Col. William H. 
Anderson, MC, USA; Dr. William Ashe; Dr. Stanhope Bayne-Jones; Prof. 
Georges F. Doriot; Dr. John E. Gordon; Dr. Wendell Griffith; Dr. Anthony 
J. Lanza; Dr, Karl R. Lundeberg; Col. Clark B. Meador, MC, USA; Dr. Her- 
bert Pollack; Dr. Elliott S. A. Robinson; Dr. Harvey J. Tompkins; Dr. 
Douglass W. Walker; and Col. Tom F. Whayne, MC, USA. 
IX X 
PREFACE 
The editorial office at the Medical College of Virginia was provided with 
the facilities and staff necessary for carrying out this project through the 
wholehearted cooperation of Dr. William T. Sanger, President, and Maj. Gen. 
William F. Tompkins, Comptroller. Their great interest and encouragement 
have been warmly appreciated. Thanks also are due to Mrs. Jacqueline Pate, 
Mrs. Geraldine Glick, Mrs. Jeannette Martin, and Mrs. Virginia Wilson for 
their secretarial wrork in the editorial office. 
All of the statistical data in this volume, except as otherwise indicated, 
were provided or reviewed by Mr. E. L. Hamilton, Chief, Mr. A. J. McDowell, 
Assistant Chief, Mr. M. C. Rossoff, and members of the staff of Medical Statis- 
tics Division, Office of The Surgeon General. All photographs were obtained 
from Department of Defense files and were prepared for publication by the 
Armed Forces Institute of Pathology under the direction of Mr. Herman Van 
Cott, Chief, Medical Illustration Service. 
The advice of members of the Preventive Medicine Division, Office of The 
Surgeon General, who willingly gave their professional help throughout the 
many stages of processing these manuscripts has been most valuable. The 
staff of the Archives and Research Branch, Historical Unit. Army Medical 
Service, who screened the voluminous wartime records, supplied much of the 
source material and references to authors. General administrative support 
and final typing was performed in the Administrative Branch of the Historical 
Unit under supervision of Mrs. Catherine F. Marshall. Mrs. Hazel G. Hine 
served as editorial clerk for this volume. 
Arthur P. Long 
Colonel, MC, USA 
26 April 1955 Contents 
Page 
FOREWORD vii 
PREFACE ix 
INTRODUCTION xm 
Chapter 
I. MANPOWER SELECTION AND THE PREVENTIVE MEDICINE PRO- 
GRAM 1 
II. PERSONAL HYGIENE 13 
III. CLOTHING 31 
IV. NUTRITION 85 
V. MALNUTRITION AND DEFICIENCY DISEASES 159 
VI. PREVENTIVE PSYCHIATRY 171 
VII. ACCIDENTAL TRAUMA _ 233 
VIII. THE ARMY IMMUNIZATION PROGRAM 271 
Appendixes 
A. ADMINISTRATIVE REQUIREMENTS FOR YELLOW FEVER VACCI- 
NATION 343 
B. ADMINISTRATIVE REQUIREMENTS FOR CHOLERA VACCINATION.. 347 
C. ADMINISTRATIVE REQUIREMENTS FOR TYPHUS VACCINATION.. 349 
D. ADMINISTRATIVE REQUIREMENTS FOR IMMUNIZATION OF OVER- 
SEAS AREAS BY DISEASES 351 
INDEX 363 
XI Introduction 
Colonel Tom F. Whayne, NIC, USA 
The development of preventive medicine has been an evolution which 
progressed rapidly during the first half of the twentieth century. In World 
War I, major efforts were devoted to sanitary science and to the control of 
infectious diseases. In World War II, preventive medicine emerged as a 
special field of the practice of medicine having to do with all of the factors 
that influence the maintenance of health in the individual and in the military 
community. These factors may arise from physical or social environment, 
may be inherent in people as individuals or groups, or may be those activities 
or procedures which directly affect the health and well-being of military per- 
sonnel as people. It is the latter type of factors with which the authors are 
concerned in this volume. 
The personal health of those coming into the military services is first 
influenced by the manpower selection process. Viewed as a mass procedure, 
selection during mobilization has unquestionably established that the study of 
the physical and mental defects of examinees, whether accepted for the military 
service or not, greatly aids in determining the most effective health maintenance 
programs and the most efficient utilization of manpower. 
Personal hygiene in the military sense is broad of scope. It includes all 
of the measures an individual may utilize to maintain or improve his health. 
Thus it includes personal measures to prevent or control disease and injury, 
the maintenance of a good nutritional state, mental hygiene, and the proper 
wearing of clothing to avoid trauma from heat or cold. Because of the per- 
sonal nature of such practices, they are of necessity difficult to supervise. 
Health education and training for personal health practices overlap and it is 
hard to evaluate the effectiveness of each. The results of good or poor indi- 
vidual or group practices cannot be easily measured in disease or injury 
incidence in a causal relationship, yet may be indirectly responsible for much 
saving of time or for much noneffectiveness. Moreover, the level of practice 
of personal health measures is directly related to unit leadership. 
Since American forces operated on a global basis in World War II, in 
vastly different environments, under varying degrees of stress, and often with 
a minimum of personal supplies and equipment, it is apparent that a sensitive 
evaluation of personal health practices of the Army as a whole is not feasible. 
Much was learned and recorded which should serve as a guide for the future. XIV 
INTRODUCTION 
Hygiene, sanitation, control of the environment, disease and injury prevention 
and control, immunization, mental hygiene, maintenance of nutritional status, 
and other practices bearing on health were planned, organized, and supported 
on a scale never before necessary in United States military efforts. Despite 
the many variables involved and the difficulty of amassing irrefutable evidence 
as to the effectiveness of personal health measures, the authors of the chapters 
of this volume have made a careful effort to sift the experiences of World War 
II, and to evaluate personal health measures in the light of World War II 
conditions. The evidence lends added weight in the need for further develop- 
ment of health maintenance practices and the requirement for more effective 
methods of health education in the armies of the future. CHAPTER I 
Manpower Selection and the 
Preventative Medicine Program 
Gertrude G. Johnson* 
The Surgeon General is responsible for establishing physical standards to 
prevent induction, enlistment, or commission of the physically and mentally 
unfit. The Physical Standards Division determines the standards and super- 
vises their administration. The maintenance of these standards was not a 
function of the Preventive Medicine Service during World War II, but the 
effectiveness of physical and psychiatric screening had a highly important 
bearing upon preventive medicine and materially influenced the measures and 
procedures necessary to plan and carry out the prevention and control of the 
acute and chronic infections which condition the health of the Army and the 
loss of manpower and man-days in military operations. 
The experience of the Army in World War I made The Surgeon General 
particularly aware of the necessity for strict screening against tuberculosis. 
The incidence of tuberculosis during World War I averaged 11 per thousand 
per year and before World War I was over, about 3,000 soldiers had died of 
tuberculosis. Throughout that war, tuberculosis had been a leading cause of 
disability discharges, accounting for 12.7 percent of these.1 At its end, the 
newly organized Veterans Administration had inherited a huge and costly 
program to provide medical care for these casualties. 
World War I also pointed up the desirability for adequate psychiatric 
screening. About 122,000 men were hospitalized as neuropsychiatric patients 
during that war. It has been estimated that around 84 percent of these men 
had to be discharged.2 By 1941 the Federal Government had paid out well 
over 1 billion dollars for disability, compensation, and hospital treatment of 
neuropsychiatric patients who were World War I veterans.3 
The objective of physical screening, therefore, was to eliminate the phys- 
ically and mentally unfit who would not be capable of performing a useful 
♦Historical Unit, Army Medical Service. 
1 The Medical Department of the United States Army in the World War. Washington, Government 
Printing Office, 1928, vol. XV, pt. 2, Tables 46, 48, 50, and 82. 
2 Information furnished by Medical Statistics Division, Office of The Surgeon General, 9 Feb 54. 
s Menninger, William C.: Psychiatry in a Troubled World. New York, The Macmillan Company, 
1948, p. 267. 2 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
military function, and also those who might reasonably be expected to break 
down while on active duty. This would provide an Army most likely to with- 
stand the physical strain and other exigencies of service and would also avoid 
inducting men who might shortly be discharged and thereafter be eligible for 
disability payments and hospital expenses by the Government. 
The Available Manpower Pool 
Both the needs of the service and the available manpower pool fluctuated 
from time to time. The Selective Service System made the initial classification 
of registrants, complying with current requirements set by Congress as to age, 
occupation, dependents, and education. The Army determined the number of 
men needed each month, specified the minimum physical and mental standards 
required for military service, and conducted the physical examinations.4 
When mobilization was ordered in the fall of 1940, the basic aim was to 
get a group of 900,000 highly qualified men who would be trained for 1 year 
and who would then form part of a reserve pool. This w’as a relatively small 
number to take out of the manpower pool of registrants available at that time, 
which totaled about 17,000,000. It was, therefore, possible to select only those 
who would be able to enter immediately upon a period of intensive training and 
who could reasonably be expected to remain fit for a period of years thereafter. 
Consequently no reparative or therapeutic work was considered; standards were 
set high; and psychiatric screening was designed so as to exclude anyone who 
might not respond well to Army life. 
After the United States entered the war, the picture changed radically. 
A large Army was needed immediately. About 3,800,000 men entered the 
Army during 1942, through inductions and enlistments. Physical standards 
had to be lowered to get the number of men needed, and limited service personnel 
were accepted at a fixed percentage of the quota. 
Industry and agriculture also expanded to keep pace with the enlarged 
Army. A great effort was made to increase the available manpower pool. 
Women formed the greatest labor reserve in the United States and hundreds of 
thousands became industrial workers. Women’s branches were formed, on a 
volunteer basis, for the Army, including Air Force, and for the Navy, including 
Marines and Coast Guard. Labor was also drawn from the previously unem- 
ployed group and from the older age brackets. There was a decrease in civilian 
activities and in self-employment. To make the best possible use of the labor 
available, the work week was lengthened to 48 hours. 
The Army and the Navy (including Marine Corps and Coast Guard) com- 
peted for manpower through voluntary enlistments. The Army offered a choice 
4 Up to January 1942, the main medical examination was made by the local boards of Selective 
Service and the Army’s function was limited to the final physical examination. After that date, how- 
ever, the whole medical processing was taken over by the Army, and the function of the local boards 
was limited to elimination of the obviously disqualifying defects. MANPOWER SELECTION 
3 
of assignment to the Ground, Air, or Service Forces as an inducement; most 
Army volunteers chose the Air Forces. Since the physical and mental standards 
for enlistment in the Navy and Army Air Forces were higher than the general 
requirements for induction, the result was that they were able to obtain men of 
better physical and mental caliber than were the Ground and Service Forces.5 
Lack of control over the number of available men and the resultant inability to 
plan accurately laid an undue burden upon Selective Service machinery. 
President Roosevelt6 therefore, in December 1942, stopped all voluntary en- 
listments of men between 18 and 38. Registrants were thereafter processed 
through Selective Service and allotted to Army and Navy according to estab- 
lished quotas. 
The manpower shortage seemed so acute by the end of 1943 that Congress 
directed the appointment of a commission to study requirements for the Armed 
Forces.7 It was hoped that some of the large group rejected for physical 
reasons (estimated at that time at 3,000,000) could be inducted, especially for 
limited service. The commission reported that existing physical requirements 
could not be reduced further without impairment of efficiency. The chief 
need, the report concluded, was for men for general duty.8 As a result, it be- 
came routine procedure to induct men with dependents; deferments for essen- 
tial industries were more strictly scrutinized. 
By the middle of 1944, the Army had attained the bulk of its procurement 
objective. With offensives on all fighting fronts, it urgently needed young 
men as replacements. Exemptions for those under 26 were rigidly screened; 
deferments in older age groups were liberalized. Men becoming of age for 
registration were the chief source of replacements for the Armed Forces. Con- 
currently many were being discharged, primarily for physical reasons, and be- 
came available as civilian labor. When once again the Army’s mission changed 
after the defeat of Germany, it was possible to use more limited service person- 
nel, and induction of such men was resumed. 
Throughout the period of mobilization and war Selective Service main- 
tained a continuous program of registering, classifying, and reclassifying. 
Registrants were not considered frozen in one category, but were constantly 
screened and reevaluated. 
Physical Standards for Induction 
Basic physical standards for induction were published in August 1940 as 
Mobilization Regulations (MR) 1-9 in anticipation of the passage of the Selec- 
5 Karpinos, B. D.: Evaluation of the physical fitness of present-day inductees. U. S. Armed Forces 
Med. J. 4 : 415-430, Mar 1953. 
6 Executive Order 9279, 5 Dec 42. 
7 Amendment to Selective Training and Service Act of 1940, Public Law 197, 78th Congress, ap- 
proved 5 Dec 43. 
8 Selective Service as the Tide of War Turns, The 3rd Report of the Director of Selective Service 
1943—1944. Washington, Government Printing Office, 1945, p 55. 
346336 0—55—-2 4 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
tive Training and Service Act. The President declared them part of Selective 
Service regulations9 and they wTere used both by examining physicians of the 
local boards and by Army induction examiners. 
Mobilization Regulations 1-9 went through several major revisions during 
the war and were also amended from time to time by War Department directive 
with respect to specific items. Although for some conditions very sharp lines 
of demarcation were drawn, the introduction to each of the published regula- 
tions stated that they were to constitute a guide to the medical examiner. It 
was expected that he would exercise his professional judgment. In many 
instances it was the degree of incapacity which led to classification for general 
or limited service, or for rejection. An analysis for rejection for cardiovas- 
cular disorders showed a particularly wide range of professional difference of 
opinion upon what would be disqualifying.10 If the examining physician 
believed that the general condition of the man would not allow him to perform 
satisfactorily, he could recommend rejection, even though no specific item was 
the cause. 
The examiner’s rigid or liberal interpretation of existing standards, shift- 
ing with the need to fill a quota, in effect caused these to fluctuate. The most 
drastic changes in the regulations themselves were those relating to visual 
acuity and dental requirements. The first MR 1-9 in August 1940 set the 
minimum dental requirements at a total of 6 masticating teeth and 6 incisor 
teeth properly opposed. As soon as the first statistics were available, it was 
discovered that failure to meet these requirements had resulted in rejection of 
approximately 9 percent of those examined. If that standard had been main- 
tained, it has been estimated that by the end of 1943 nearly 1,000,000 men 
who were inducted under the liberalized dental standards would have been 
lost to the service.11 Dental requirements were revised downward, and an 
extensive reparative program by the Dental Corps initiated, until in October 
1942 a man completely edentulous could be inducted if his condition was 
corrected or correctable by dentures.12 
In 1940 minimum visual acuity for general service was set at 20/100 in 
each eye without glasses, if correctable to 20/40 bilaterally. This was the 
second most important cause for rejection, and these requirements were 
progressively lowered. The lowest visual acuity requirements were reached in 
April 1944,13 when 20/200 in each eye, or 20/100 in one eye and 20/400 in the 
second eye (if correctable to 20/40 in each eye, 20/30 in the right and 20/70 in 
the left, or 20/20 in the right and 20/400 in the left), was sufficient for general 
8 Executive Order 8570, 18 Oct 40. 
10 Levy, R. L., Stroud, W. D., and White, P. D.: Report of reexamination of 4,994 men disquali- 
fied for general military service because of the diagnosis of cardiovascular defects. J. A. M. A. 123 : 
937-944, 11 Dec 43 ; and 1029-1035, 18 Dec 43. 
11 ASP Monthly Progress Rpt, Sec 7, Health, 31 Jan 44. 
« MR 1-9, 15 Oct 42. 
18 MR 1-9, 19 Apr 44. MANPOWER SELECTION 
5 
service. The registrant did not have to supply the corrective glasses himself; 
the Army furnished more than 2 million pairs of glasses. 
In general, no registrant with an acute infectious disease, with the excep- 
tion of venereal diseases which are considered separately, was to be inducted 
until he had recovered without disqualifying sequelae. Although intestinal 
parasites were not considered cause for rejection, such findings were to be noted 
on the record so that medication could be undertaken. Other parasitic in- 
fections such as filariasis, trypanosomiasis, amebiasis, and schistosomiasis were 
cause for rejection. 
Tuberculosis. The Subcommittee on Tuberculosis of the National Re- 
search Council, at the request of The Surgeon General, made recommendations 
regarding screening standards for tuberculosis. The aim was to exclude all 
men with active tuberculosis or tuberculosis of doubtful stability that might 
break down and lead to active disease during military service. At the same 
time it was recognized that tuberculous infiltrations of minor extent not in- 
frequently heal completely, and it would be a waste of manpower to reject all 
persons showing any traces of healed tuberculous lesions. 
The 1940 standards included detailed instructions on the physical exami- 
nation of lungs by palpation, percussion, and auscultation although it was 
recognized that these methods were of less value than X-ray. The Subcom- 
mittee on Tuberculosis pointed out that at least 75 percent of early active 
tuberculosis can be discovered only by X-ray examination, and that about 1 
percent of the male population of military age has active tuberculosis.14 
Examination by X-ray was carried out wherever facilities permitted and 
in all doubtful cases. Approximately 1 million men were inducted without 
X-ray.15 Many of these however, were X-rayed after acceptance at reception or 
basic training centers and those found to have active tuberculosis were dis- 
charged. In March 1942 chest X-ray on all inductees became mandatory.16 
The criteria for rejection were made arbitrary because induction was rapid 
and many of the roentgenologists used were inexperienced in the field. The 
average rejection rate for tuberculosis for the years 1942-45 was approximately 
1 percent. The incidence rate of tuberculosis in the Army during those years 
was 1.24 per thousand, approximately one-ninth that of World War I. 
A roentgenogram of the chest was made a routine part of the separation 
physical examination as well. Cases of active tuberculosis discovered averaged 
1 per thousand. All those discovered at induction centers or on discharge 
were required to be reported to the soldier’s State Board of Health, thus 
advancing the cause of tuberculosis control in the nation as a whole. 
uMinutes of Meeting, NRC Subcommittee on Tuberculosis, 23 Jul 40. HD: 040(TB). 
“ Long, E. R., and Lew, E. A.: Tuberculosis in the Armed Forces. Am. J. Pub. Health 35 : 469- 
479, May 1945. 
w MR 1-9, 15 Mar 42. 6 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
It cannot be claimed that the examination for tuberculosis as conducted 
was perfect. A considerable number of men with small active tuberculous 
lesions escaped detection.17 But the general view of responsible authorities 
was that the screening process was a highly creditable one, that it eliminated the 
overwhelming majority of active cases sent to induction stations, and provided 
a body of troops so nearly free from tuberculosis that further infection from 
exposure in the Army was negligible.18 
Venereal Disease. According to the physical standards in effect in 1940,19 
registrants with any form of venereal disease were not acceptable for general 
service. Registrants with acute or chronic syphilis, including latent syphilis, 
were classified as limited service. No limited service registrants were called 
for induction, however, until July 1942. Gonorrhea was considered a remedial 
defect, and registrants with this disease were temporarily deferred until a cure 
had been effected. 
Several things happened to change this attitude. One was pressure of 
public opinion which produced a flood of letters of protest against a policy 
which seemed to penalize good conduct. It was soon obvious, also, that a num- 
ber of men, otherwise qualified, were being lost to the services.20 After war 
was declared, and the limitations of American manpower became evident, 
regulations were reviewed. Some draft boards, particularly in the South, were 
hard pressed to meet their quotas because a high percentage of the Negroes in 
their districts were infected. 
The treatment of uncomplicated venereal diseases was very much simplified 
by new therapeutic discoveries. In the summer of 194221 the Medical Depart- 
ment conducted an experimental program of inducting men with venereal 
diseases and curing them before they reported for active duty. Since successful 
results were achieved, induction boards were directed to accept infected men 
within the limits of facilities for their treatment. By March 1943, about 7,000 
venereally infected men were inducted into the Army. About 4,500 of these 
inductees were infected with syphilis. The induction of men with venereal 
disease reached its peak in the last quarter of that year, when about 12,000 men 
with venereal disease were inducted each month. By the end of the first half of 
1944, the backlog of all registrants previously rejected for venereal disease was 
completely rescreened and inducted. It has been estimated that with the 
liberalization of the standards regarding venereal disease the Army absorbed 
17 Myers, J. A.: Failure to detect all tuberculosis on induction to military service. J. Lancet 64 : 
111-113, Apr 1944. 
18 Long, B. R., and Hamilton, E. L. : A review of induction and discharge examination for tubercu- 
losis in the Army. Ami. J. Pub. Health 37 : 412-420, Apr 1947. 
19 WD Cir 117, 18 Oct 40. 
20 Selective Service Med. Statistics Bull.. 1, 10 Nov 41. HD : 327. 
See footnote 11, p. 4. MANPOWER SELECTION 
7 
during World War II somewhat over 200,000 registrants who had venereal 
disease.22 
Psychiatric Screening. During the first 2 years of the war great effort was 
made to screen out all men with actual mental disorders, also those with psycho- 
neurotic traits which might make it difficult for them to adjust to Army life. 
But the speed of induction, lack of adequate social histories of the registrants, 
and shortage of trained psychiatrists made it very difficult to make a definitive 
appraisal. 
The Army emphasized that men with psychoneurotic traits were a detri- 
ment to the morale of a unit, were likely to take up needed hospital beds, and 
wmuld be a great expense to the Government if they had to be discharged as 
psychiatric patients.23 Complaints were received from combat officers who had 
in their commands some of the men who had been misclassified. One War 
Department directive stated: “There is no classification for duty of military 
personnel with such mental diagnoses as psychoneurosis. . . .”24 
As a result of this Army attitude, it became the rule in many induction 
centers that if there were any doubt at all as to whether a registrant would per- 
form satisfactorily, he should be rejected. If the candidate gave any suggestive 
evidence of emotional instability, such as nervousness at the time of examina- 
tion, sweaty hands, or expressed fears, he was usually rejected.25 
In April 1944, a War Department directive emphasized that accumulating 
evidence indicated that many individuals with minor personality disorders and 
mild neurotic trends could be of service to the Armed Forces. It was noted 
that, on the basis of previous directives, many such men were being rejected at 
induction stations. The acute need for manpower made it necessary to admit 
all individuals who had a reasonable chance of adjusting to military service.26 
In order to aid the examiners, who frequently had 3 minutes rather than the 
planned 15 minutes for the psychiatric interview, a test, known as the Neuro- 
psychiatric Screening Adjunct, was composed which was aimed at selecting 
those who needed further psychiatric study. This 23-question test was adopted 
in October 1944 and used in all induction stations.27 
There was little difficulty in identifying men with serious mental disorders. 
The borderline cases posed the real problem. The psychiatrist at the induction 
center had no possible way of evaluating the four most important factors of 
influence on the adjustment of a soldier: the type of leadership he would receive; 
22 Karpinos, B. D.: Venereal disease among inductees. Bull. U. S. Army M. Dept. 13: 806-820, 
Oct 1948. 
23 SG Clr Ltr 19, 12 Mar 41. 
« WD AG Memo W600-39-43, 26 Apr 43. 
25 Menninger, op. cit., pp. 266-292. 
26 WD TB MED 33, 21 Apr 44. 
27 WD AG Memo 40-44, 19 Sep 44. 8 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
the degree of motivation he would have to do his job; the type of job and unit 
to which he would be assigned; and the degree of external stress which might 
confront him.28 
Functionally effective screening processes may reduce the number of psy- 
chiatric casualties during military service. But since a man’s personality at 
time of induction is only one of the factors involved in breakdown, screening 
cannot be expected to eliminate all such breakdowns. It was also shown that 
many men at first rejected by psychiatric examiners were able to perform for 
long periods in a satisfactory manner.29 
The Physical Profile Serial System 
Throughout the major portion of the war there were only two physical 
classifications used: general and limited service. Classification for job place- 
ment was carried out by an extensive program of testing and interviewing. A 
real attempt was made to match the individual’s training, experience, and 
aptitudes with his military assignment. However there was no simple system 
of assessing the man’s physical stamina and including that as a part of the 
classification for job assignment. 
The Canadian Army had evolved the PULHEMS system which indicated 
the physical and mental capabilities of the individual. The personnel division 
graded each job in terms of the minimum PULHEMS requirements necessary 
to carry it out. The United States observed the Canadian system and, after 
experimentation in this country, adopted in May 1944 a modified form known 
as the physical profile serial system.30 
The initials PULHES represented six factors in an individual which were 
to be evaluated: P—general physical stamina and strength; U—upper extrem- 
ities ; L—lower extremities; H—hearing; E—eyes; S—psychiatric evaluation. 
Each of these letters had four potential grades, so that a man’s profile might 
read 121121 for a general service man.31 The “M” in the Canadian PULHEMS 
which stood for mentality and intelligence was omitted from the American 
factors because it was considered adequately covered by the Army General 
Classification Test. A lettered code to represent certain combinations of 
grades in the various factors was adopted for statistical, assignment, and re- 
porting purposes.32 
The profile system proved to be a timesaver in choosing men for particular 
types of assignment, although the United States Army did not use it as ex- 
28 Menninger, op. cit., pp. 266-292. 
29 Banes, R. H. : Standards used by Selective Service and a follow-up on neuropsychiatric rejectees 
in World War II. In Selection of Military Manpower : A Symposium. Washington, National Research 
Council, 1951, pp. 149-156. 
30 WD Memo W40-22, 18 May 44. 
81 Developments in military medicine during the administration of Surgeon General Norman T. 
Kirk ; preventive medicine and professional care. Bull. U. S. Army M. Dept. 7 : 594-646, Jul 1947. 
32 Supplement, 12 Jun 45, to MR 1-9, 22 May 44. MANPOWER SELECTION 
9 
tensively as did the Canadian Army. It was particularly helpful when trans- 
fers of large numbers of troops were to be made from one type of unit to 
another since it was possible to check PULHES serial numbers quickly in order 
to determine who was physically capable of serving in the new assignment. 
Physical Standards for Special Categories 
The physical standards as given in MR 1-9 applied only to the induction 
or enlistment of enlisted men. Standards for commission as an officer or as a 
cadet in the United States Military Academy were embodied in AR 40-105, 
and were higher than those for enlisted men, particularly with respect to eye- 
sight and physical stamina. The physical standards for all female personnel 
serving in the Army were adapted from the Army Nurse standards. To admit 
women of Oriental descent, adjustments were made in measurement 
requirements. 
During World War II the Army did little to devise special testing for 
specific jobs or climates. More emphasis was placed upon adapting the en- 
vironment to the man, that is, on developing uniforms and equipment. The 
Army Air Forces, however, carried out considerable experimentation to arrive 
at valid tests for determining physical aptitude for aircrew training. To pre- 
dict success in only three aircrew jobs—pilot, bombardier, and navigator—it 
was found that a battery of 20 tests was required. Each of these tests con- 
tributed significantly to the prediction of success in at least one of these special- 
ties.33 Followup studies of bomber and fighter pilots in the European theater 
showed high correlation between aptitude scores and performance in the field.34 
Special physical standards were devised for officers and enlisted men en- 
gaged in training and service in marine and simulated marine diving and in 
the use of rescue apparatus.35 In October 1943, physical qualifications for para- 
chute duty for both officers and enlisted men were adopted.36 Requirements 
for cardiovascular condition and blood pressure level were higher than under 
induction standards; many orthopedic conditions were disqualifying for this 
type of service. 
Conclusion 
Selection of military manpower during World War II was essentially a 
negative process; the unfit were to be excluded. It was assumed that all men 
in the Army should be able to fight, regardless of assignment, should the ex- 
igency arise. Screening was set up to eliminate rather than to classify in- 
33 Selection of Military Manpower: A Symposium. Discussion by Dr. John C. Flanagan, pp. 215- 
224. Washington, National Research Council, 1951. 
M Grant, D. N. W.: The medical mission in the Army Air Forces. Jn Flshbeln, Morris; Doctors 
at War. New York, B. P. Dutton & Company, Inc., 1945, pp. 275-302. 
» AR 40-100, C 4, 22 Jul 43. 
» AR 40-100, C 6, 12 Oct 43. 10 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
dividuals and did not take into full consideration the related demands upon the 
country’s total manpower pool. 
Physical standards were written so that commanders would have the best 
manpower available to carry out their missions. The Army wanted to induct 
only men who would not increase pension or retirement costs to the taxpayer 
except where disease or injury was incurred in line of duty. It was also con- 
sidered necessary to select men who would not burden the Medical Department, 
during critical periods, because of foreseeable physical or mental health break- 
downs.37 
Physical standards were originally set high and were progressively lowered 
as manpower resources became depleted. Manpower needs of the Army Service 
Forces, once that element had been organized, were rather stable; the Ground 
Forces suffered relatively higher casualty rates and required more replacements 
for combat troops. Thus, when physical standards were lowered, less fit men 
were assigned to the combat forces. It may be argued that this desire to retain 
men in jobs for which they have been trained is a reason that, from the outset 
of mobilization, the less fit should be inducted as well as the best.38 
The physical selection of personnel was of great importance not only to the 
Army, but to the health of the whole country. By exposing the physical defects 
of the large groups of rejected individuals, it provided a unique opportunity 
to correct many health deficiencies in the civilian population.39 
The physical standards for selection for Army service established and 
administered by the Physical Standards Division were effective in screening 
out those unfit for military service. Psychiatric screening was found to be less 
effective. Both influenced preventive medicine planning and practice, the 
former by reducing the reservoir of infectious disease and possibly eliminating 
a part of the most highly susceptible; the latter by screening out those less well 
able to understand and absorb health training and to withstand the rigors of 
military service under conditions of unaccustomed stress. Data on causes for 
rejection were important indices of the status of health of the United States 
manpower pool, and formed the basis for further preventive medicine planning 
for health protection when it became necessary to utilize personnel who could 
not meet the original high standards. Consideration of these data also greatly 
influenced the trend of research under the Office of Scientific Research and 
Development and the National Research Council as to the development of the 
best practices for full utilization of all segments of the manpower pool. 
37 Stone, W. S.: Measuring men for useful assignment. In Selection of Military Manpower: 
A. Symposium. Washington, National Research Council, 1951, pp. 79-84. 
38 Bill, R. A.: Medical screening (physical standards) and Its relation to service requirements and 
to retirement. In Selection of Military Manpower: A Symposium. Washington, National Research 
Council, 1951, pp. 84—103. 
39 Simmons, J. S.: Preventive Medicine In the Army. In Fishbein, Morris: Doctors At War. New 
York, E. P. Dutton & Company, Inc., 1945, p. 142. MANPOWER SELECTION 
11 
The administration of the medical aspects of selection was, without ques- 
tion, a proper function of clinical medicine. Evaluation of the World War II 
experience, however, also leaves no question of the importance of selection to 
preventive medicine and unequivocably established that clinical and preventive 
medicine must work in close coordination in establishing standards and studying 
the physical and mental defects of prospective candidates for military service 
in order that the most effective health and medical programs can be established 
and the most economical use be made of a not inexhaustible manpower pool. CHAPTER II 
Personal Hygiene 
Colonel Robert L. Callison, MC 
In the Army, personal hygiene is defined as the measures each individual 
must employ to keep in good physical condition and the precautions he must 
take to protect himself from disease. As such, it includes not only cleanliness 
of the body, but also proper use of insect repellents, avoidance of unauthorized 
water and food, and any other measure that the soldier is directed to take to 
preserve his health. Trenchfoot, which was a major cause of disability in the 
European theater during World War II and for which care of the feet is a 
necessary preventive measure, will be fully covered in a separate volume to be 
published as part of the history of the Medical Department of the United States 
Army in World War II. Sex hygiene, a part of the educational program for 
the prevention of venereal diseases, will not be considered in this chapter since 
it is discussed in detail in the section on venereal diseases in another of the 
Preventive Medicine volumes. 
The basic principle of cleanliness of person and neat appearance of troops 
is a traditional policy of the Army. Even in the American Revolution, when 
little was known about transmission of disease, some officers were aware of the 
hazards from louse infestation. An order of 23 January 1778 issued by Lt. 
Colonel Marion at Fort Moultrie (S. C.), recommended that each soldier have 
his hair cut so that it was no longer than the top of the shirt collar in back, and 
short at the forehead and sides. Otherwise, “. . . those who do not have 
their hairs in this mode must have them platted and tied up. . . .” Provision 
was also made to have a certain number of soldiers act as barbers for the 
regiment.1 
Personal cleanliness improved in the Army as it improved in the civilian 
population. As more became known about the transmission of disease, stress 
wTas placed upon particular phases of personal hygiene, such as washing hands 
after using the latrine, and proper use by the individual of sanitary measures 
for disposal of waste and purification of water. 
By World War I the basic rules for personal hygiene and command respon- 
sibility for their enforcement werfe well established. The Medical Department 
was taken by surprise, therefore, in April 1918 when it received word from the 
American Expeditionary Forces that 50 percent of the troops arriving in 
1 Medical Men in the American Revolution. The Army M. Bull. No. 25, Medical Field Service 
School, Carlisle Barracks, Pennsylvania, 1931. 14 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
France were louse-infested. Although a certain amount of lousiness among 
troops in combat had been foreseen, facilities for disinfestation at United 
States camps had not been considered necessary. A quick survey of training 
camps in the United States showed that some lousiness existed although the 
percentage of infested persons was very low. A high degree of louse infesta- 
tion was discovered at the Newport News, Virginia, embarkation point, how- 
ever. The overcrowding of transports and their inadequate bathing facilities 
insured the rapid spread of lice among troops. Disinfestation equipment was 
immediately set up at all large camps in the United States and troops were care- 
fully examined for lice before leaving the country. Conditions in Europe 
provided no new hazards for which rules of personal hygiene had to be revised. 
It was impossible, however, to maintain satisfactory levels of personal hygiene 
under all combat conditions. When facilities were available, rigid compliance 
with rules was enforced.2 
WAR DEPARTMENT POLICY 
War Department standards and directives for personal hygiene as con- 
tained in Army Regulations (AR) 40-205, 31 December 1942, were in effect 
throughout World War II. Fundamentally they were the same as in AR 
40-205, 15 December 1924, merely rewritten and somewhat expanded. As 
with all aspects of military sanitation, commanding officers were responsible 
for enforcement of the provisions concerning personal hygiene. The Medical 
Department was to conduct inspections and recommend appropriate action to 
correct deficiencies. It was required that each member of the Army be given 
a course of instruction in hygiene. 
The paragraph of AR 40-205 devoted specifically to personal cleanliness 
stated: 
Every member of a command will bathe once daily while in garrison, and in the field 
at least once weekly. The hands will be washed before each meal and immediately after 
visiting a latrine. Teeth will be cleaned with a brush at least once a day. Fingernails 
will be cut short and kept clean. The hair will be kept short and the beard neatly 
trimmed. Clothing and bedding will be kept clean. Soiled clothing will be kept in 
barrack bags. At prescribed physical inspections particular attention will be given to 
personal cleanliness. 
Unit commanders were instructed to determine that the men of their com- 
mands had been properly fitted with socks and shoes and that all foot defects 
were suitably cared for. An undue amount of foot injury and disability from 
shoes was to be regarded as evidence of inefficiency on the part of responsible 
officers. 
Precautions for care of feet during marches were specified. Before long 
or protracted marches, unit commanders were to inspect the bare feet of their 
a The Medical Department of the United States Army in the World War. Washington, Govern- 
ment Printing Office, 1926, vol. VI, pp. 380-382. PERSONAL HYGIENE 
15 
men for defects which might require treatment. While on marches, com- 
manders were to have their men wash their feet each day as soon as practicable 
after reaching camp, cover blisters or excoriations with a light dressing or zinc 
oxide plaster, dust the feet with foot powder, and put on clean socks. 
Measures that the individual soldier could take for his own protection, as 
well as measures the Army would take for him, were included in each of the 
appropriate sections. Under mosquito control wrere listed the proper wearing 
of clothing, use of repellents, and use of bed nets. Frequent and thorough 
bathing was specified as one of the precautions against body lice. 
The personal hygiene of men assigned to certain duties was specified in 
other sections of AR 40-205. Barbers, for instance, were cautioned to wash 
their hands thoroughly before attending each patron as well as to keep all 
equipment cleaned or sterilized. All men on duty in kitchens, messhalls, and 
bakeries were also instructed to bathe frequently, wear clean clothing, and be 
especially careful to keep their hands and fingernails clean. 
TRAINING AND EDUCATION 
The policies of AR 40-205 were implemented by a continuing program of 
training and education. Each soldier was issued Basic Field Manual (FM) 
21-100, “Soldier’s Handbook,” 3 which contained a section entitled “Military 
Sanitation,” consisting of instructions for individual compliance with AR 
40-205 and simple explanations of the reasons for each rule. The soldier was 
instructed to report for sick call at the first signs of illness. 
A 1-hour class in personal hygiene was part of basic training for all soldiers. 
Training Film 8-155, “Personal Hygiene,” was used to demonstrate proper 
application of rules of cleanliness. Because the material included in this 
instruction contained little that was new to the soldier, the main purpose of 
the lesson was to provide motivation for careful observance of the rules and 
to make clear the relationship of individual health to the health and efficiency 
of the unit. 
Field Manual (FM) 21-10, “Military Sanitation and First Aid,”4 a basic 
field manual, and FM 8-40, “Field Sanitation,” 5 a medical field manual, were 
used as references for the basic training class and were available at company 
level throughout the Army. Field Manual 21-10 outlined the general groups 
of diseases and the sanitary measures for their prevention and control. It 
included a chapter on personal hygiene and also one on the particular problems 
of march hygiene. Field Manual 8-40 dealt primarily with environmental 
sanitation, but contained a chapter on factors relative to personal hygiene: care 
* WD FM 21-100, 11 Dec 40, and subsequent revisions and reprintings. 
* WD FM 21-10, 1940, and subsequent changes. 
5 WD FM 8-40, 1940, and subsequent changes. 16 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
of the feet, especially for the prevention of dermatomycoses; other skin dis- 
eases ; scabies; and oral hygiene. 
A course in personal hygiene, somewhat broader in scope than that for 
trainees, was given to cadets of the United States Military Academy, candi- 
dates in officer candidate schools, reserve officers in training camps, and com- 
missioned officers in refresher courses. Medical Department personnel received 
further training in personal hygiene at field service schools or medical replace- 
ment training centers, with particular emphasis on the individual measures 
taken to prevent diseases.8 
The soldier’s education in personal hygiene did not end with the 1 hour 
of classroom instruction included in his basic training, although the effective- 
ness of further training varied considerably from unit to unit according to the 
degree of interest of the commanding officer and his appreciation of command 
responsibility for enforcement of proper standards of hygiene. Regular 
monthly physical inspections by medical officers, and barracks and dress inspec- 
tions by commanding officers, served as constant checks and reminders of the 
fundamental rules of cleanliness. Additional applicatory training was carried 
out at all times on marches, bivouacs, and training problems. 
Maneuvers were an important part of the training program for ground 
troops, and also served to demonstrate both the difficulties of and the necessity 
foi* maintenance of personal hygiene under field conditions. Commanders 
observed that troops often felt, once they were away from base camps, that 
sanitary regulations should be relaxed. A report of sanitation during First 
United States Army maneuvers in 1941 noted: “Rubbish, waste paper, fruit 
skins, discarded sandwiches and food scraps, and, in certain instances, freshly 
deposited human feces were noted in and around many of the bivouac areas.”7 
As late as 1944 a report on Second United States Army Tennessee maneuvers 
stated: “. . . defecation on the ground was not uncommon. . . . Enlisted men 
obtained food and water from unauthorized sources even though this was 
strictly prohibited.” The report concluded that training in basic medical sub- 
jects and military sanitation required continuous emphasis and recommended 
that instruction be realistic and concurrent with other training.8 
Training directives which included elements of personal hygiene were 
issued by all command headquarters. The Eastern Defense Command, for 
instance, provided for a minimum of 1 hour per week to be utilized in instruc- 
tion pertaining to the health of the individual.9 Occasionally, directives per- 
taining to a local hazard, such as ticks in Virginia, were issued to present 
appropriate preventive measures. 
6 See copies of training courses filed in HD : 353. 
7 History of preventive medicine in World War II, Eastern Defense Command. HD: 314.7-2. 
8 Annual Rpt, Med Sec Hq Second Army, 1944. HD. 
8 Training Memo 13, Hq Eastern Defense Command, 20 Dec 43. HD : 314.7-2. PERSONAL HYGIENE 
17 
When units were preparing for overseas, or when replacements were 
processed through staging areas, further instruction in personal hygiene per- 
taining to the area of assignment was given. Visual aids supplemented direc- 
tives and pamphlets which described the environmental conditions to be ex- 
pected and the diseases prevalent in the overseas theater. For troops destined 
for the European theater, particular emphasis was placed on louse control for 
prevention of typhus and care of the feet for prevention of trenchfoot. Troops 
going to the Southwest Pacific or China-Burma-India theaters were specifically 
trained in preventive measures against malaria, scrub typhus, and schisto- 
somiasis and warned of the dangers from using unauthorized food and water. 
Since the overseas destination was not always known accurately or was 
sometimes changed, not all personnel leaving for overseas were adequately 
prepared. In February 1944 a War Department circular10 established mini- 
mum standards of proficiency in sanitation and personal hygiene for enlisted 
men, noncommissioned officers, and officers. It stated that the probable incidence 
of disease warranted major consideration in the planning of any operation 
because reports from all theaters had indicated that malaria, diarrheal diseases, 
and neuropsychiatric disorders were causing more hospital admissions than all 
battle casualties. Each major command was ordered to provide such inspections 
and tests as were necessary to determine and assure the attainment and main- 
tenance of the appropriate minimum standards of proficiency by all individuals 
and units. At least one inspection and test was to be made within the 6 months 
preceding a unit’s departure for overseas. Refresher courses were to be given 
in all officer pools, overseas replacement depots, and staging areas. Excessive 
sick rates from preventable diseases would be investigated and appropriate 
command action was directed if it was found that reasonable preventive meas- 
ures had been neglected. 
The Training Division, Office of The Surgeon General, had from the begin- 
ning of mobilization carried on an extensive program of providing training 
aids such as posters, films, film strips, and three-dimensional aids. In January 
1945 a Health Education Unit was established in the Preventive Medicine 
Service to produce educational media for a comprehensive continuing program 
of instruction for the soldier in methods of maintaining his health.11 The 
organization of the unit was necessitated by the anticipation of the shift of 
emphasis in the war to the Pacific where troops would increasingly come into 
contact for the first time with many diseases against which there was no vaccine 
or other known specific immunization procedure, and the prevention of which 
was dependent to a very large degree upon the individual soldier’s knowledge 
and application of proper protective measures. 
10 WD Cir 48, 3 Feb 44. 
» Annual Rpt, Prey Med Serv SGO, FY 1945. HD, 18 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
The general educational program for the soldier in the overseas theaters 
depended principally on unit training. While preparations for the North 
African invasion were underway, training in the United Kingdom included 
indoctrination in methods of protection against louse infestation. Again, as 
the time of the Normandy invasion approached, troops were specifically briefed 
on the subject of typhus just prior to embarkation for the Continent. Soldiers 
were issued individual cans of louse powder in all areas where it was considered 
advisable. 
Special discussion hours were held in the United Kingdom for units moving 
to France. These talks were based on the assumption that troops were familiar 
with the principles of good field hygiene and were directed at the specific 
problems to be encountered, particularly continental customs with regard to 
disposal of human feces. Later, in 1944, the Preventive Medicine Division, 
Office of the Chief Surgeon, European Theater of Operations, was able to 
publish information in the Stars and Stripes on individual protection against 
food-borne infection under combat conditions. 
Training in the European theater also emphasized individual measures 
applicable in the control of respiratory infections. The features of personal 
hygiene especially stressed by unit commanders and medical officers included 
the importance of avoiding contact with patients who had common colds or 
other forms of acute upper respiratory infections; the proper methods for 
disposal of sputum and nasal secretions, with stress on the dangers of pro- 
miscuous spitting; the possibility of contracting infections from common drink- 
ing cups, canteens, towels, and other personal items. The importance of personal 
cleanliness, of thorough hand washing, and of frequent changes to clean fresh 
clothing were other matters that received attention. (See Fig. 1.) 
An intensive theater-wide program to train men in prevention of trenchfoot 
was begun in November 1944. Replacement depots were instructed to make 
an entry on the War Department Adjutant General’s Office Form 20 of each 
man who had received instruction in the prevention of trenchfoot, and were not 
to assign replacements until this instruction had been completed.12 
In the China-Burma-India theater greater reliance upon individual per- 
sonal hygiene measures was necessary than in other theaters. Units were 
scattered over a wide area and troop movements across country usually involved 
only small groups. An extensive program of environmental sanitation was 
therefore considered impractical except in fixed installations. Directives and 
orientation lectures warned soldiers to protect the skin from prolonged ex- 
posure to direct rays of the sun. They were told not to work or exercise 
strenuously in closed spaces. As in all tropical climates, it was important to 
la Gordon, J. B.: History of preventive medicine In the European Theater of Operations, United 
States Army, 1941-1945. HD : 314.7-2. PERSONAL HYGIENE 
19 
Figure 1. Disregarding the presence of the enemy just across the hill, a member of an anti- 
tank unit takes time out to brush his teeth behind a shell-torn house in Germany, IdJjJj. 
3463.36 0—55 3 20 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
bathe frequently and to drink plenty of cool water.13 It was a rule never to 
drink any but boiled or chlorinated water, which the individual usually had 
to supply for himself during travel.14 
It was a common experience in India to remain in good health while in a 
fixed station only to pick up diarrhea or malaria while traveling. Educational 
literature given to troops prior to train movements outlined specific directions 
to follow. Troops had to make judicious use of native foods, because quarter- 
master subsistence was not always available during train travel. Throughout 
India in the larger stations there were restaurants where clean and reasonably 
palatable food was served. In small stations a hot curry or vegetable “pilau” 
could be eaten safely. Soldiers were continuously warned against eating raw 
fruits and vegetables unless they had been adequately treated.15 
A constant educational program was carried on by the China-Burma-India 
theater antimalaria organization to remind individuals of the dangers of 
malaria and what they could do to protect themselves. Greatest emphasis 
was placed on the importance of repellents, protective clothing, bed nets, sprays, 
and atabrine. The troops were reminded repeatedly that they had all the 
instruments of protection, it was up to them, as individuals, to utilize them.16 
PERSONAL HYGIENE IN OVERSEAS THEATERS 
European Theater of Operations 
Standards of personal hygiene varied according both to the facilities 
available and the type of combat the individual was engaged in. Theater 
preventive medicine officers at all levels realized the necessity for convincing 
company officers of the importance of command responsibility for enforcing 
adequate standards of personal hygiene. Trenchfoot became such a serious 
problem that disciplinary action was initiated against the soldier when it was 
discovered that he had failed to observe any of the prescribed measures. (See 
Fig. 2.) 
Bathing and Laundry Facilities. In the early period of the United King- 
dom Base, troop accommodations were overcrowded and bathing facilities were 
correspondingly inadequate, or even absent entirely. Baths and showers were 
usually installed in separate buildings, often inconveniently far from bar- 
18 Memo 75-31, US Air Forces in India and China, 10th USAF, 28 Sep 42, sub : Health precautions. 
HD: 314.7-2 (Ref). 
■* Ltr, Dlv Malarlology Lab, 1333d AAF Base Unit, India-China Div ATV, to Uiv Surg, Hq ICD 
ATC, 1300th AAF Base Unit, 15 Nov 44, sub : Sanitary survey of a train trip from Calcutta to Chabua. 
HD: 314.7-2 (Ref). 
15 See footnote 13. 
19 Van Auken, H. A.: A history of preventive medicine in the United States Army Forces of the 
Indla-Burma theater 1942 to 1945. HD: 314.7-2. PERSONAL HYGIENE 
21 
Figure 2. A member of the 101st Airborne Division takes care of his feet. Belgium, 
January 1945. 22 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
racks.17 A survey late in 1942 brought out the fact that men were not bathing 
with the frequency that they should because the bathhouses were unheated.18 
Gradually adequate facilities were built and stoves were authorized for each 
bath and ablution house. 
After operations were started on the Continent, local bathing facilities in 
towns were surveyed and inspected by Medical Department officers. In some 
areas the Quartermaster Corps operated shower points; in others, existing pub- 
lic baths and showers were used.19 As an example of the assignment of quarter- 
master fumigation and bath companies in the combat zone, 16 complete com- 
panies were allocated to the 12th Army Group. Normally a system of clothing 
exchange was operated at bath points and sections of the company handled 
troop laundry for divisions in the vicinity. One platoon operating separately 
at a bath point could provide baths for 1 division in 4 days if the division 
was in a temporary noncombat status.20 
Bathing facilities were variable depending on the unit’s location, but that 
a shortage existed in combat units is indicated by numerous requests made by 
various headquarters and units for additional bath equipment. It was recom- 
mended that bath facilities be provided organically with all types of divisions.21 
The 9th Infantry Division reported, for example, that corps shower units with 
clothes turn-in privileges provided excellent service, but that the disposition 
of infantry troops prevented removal of more than 2 to 3 percent of any unit 
from the front at one time. This allowed only 1 bath per man in a 3- to 4-week 
period.22 
The 2d Armored Division reported that during combat a bathing unit was 
always available to troops. Troops were rotated to get showers frequently.23 
The 35th Infantry Division, on the other hand, reported that during the sum- 
mer months bathing facilities consisted chiefly of local streams. In October 
1944 quartermaster bath units began servicing the division, augmented by unit 
bath centers generally consisting of heated rooms furnished with GI cans and 
immersion heaters. Laundry service was erratic, ranging from almost non- 
existent to satisfactory.24 
An example of the experiences of another unit is contained in a report 
from the 44th Cavalry Reconnaissance Squadron which stated that bathing 
facilities were always adequate but not always convenient. During the static 
warfare on the Roer, men had to be transported at intervals to rear areas where 
17 Ltr, Chief Surg ETO to CG ETOUSA, 13 Oct 42, sub: Overcrowding of troop accommodations. 
HD : 024 ETO. 
18 History of medical service, SOS ETOUSA, from Inception to 31 December 43. HD: 314.7-2. 
ln See footnote 12, p. 18. 
"General Board Study 108, “Service Operations of the Quartermaster Corps, ETO.” AG : 321.8. 
» Ibid. 
» Annual Rpt, Surg 9th Inf Div ETO, 1944. HD. 
23 Annual Rpt, Surg 2d Armored Div ETO, 1944. HD. 
« Annual Rpt, Surg 35th Inf Div ETO, 1944. HD. PERSONAL HYGIENE 
23 
the shower facilities of coal mines were available. After crossing the Roer 
and Rhine Rivers, bathing facilities in towns and civilian communities were 
more adequate and available to the troops. Dirty clothing of units was col- 
lected and exchanged for an equal amount of clothing from the Quartermaster 
laundry service. This resulted in some dissatisfaction with regard to sizes but, 
in general, was very satisfactory.25 
Water Discipline. Water discipline in combat units improved as soldiers 
became accustomed to field conditions. (See Fig. 3.) Sporadic outbreaks of 
diarrhea due to individuals drinking water from local sources, without using 
halazone tablets or other field purification methods, were reported throughout 
1944. More untreated nonpotable water ordinarily consumed by combat 
troops in the rear Army and communications zone areas than in the forward 
zone, primarily due to the natural laxity and letdown associated with rest areas 
and fixed installations, but also through leave and furlough in municipalities 
not having approved water supplies. 
Figure 3. Drinking tvater is tested for its chlorine residual, 26th Infantry Division, 
Luxembourg, January 1945. 
25 Semiannual Rpt, Surg 44th Cay Recon Sq (Mecz), 1945-1. HD. 24 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Many of the units in the communications zone had spent considerable 
periods in Great Britain or were newly arrived from the United States. The 
common attitude toward any water coming from a tap was that it was potable 
and that it was the responsibility of others to see that it was so. Such wTater 
supplies were frequently used when not authorized in spite of definitely posted 
instructions to the contrary. 
When the Army occupied Germany, efforts were made to remedy sanitary 
defects in existing water supplies and bring them to the level of United States 
Army standards of potability. The general policy was to release troops from 
the obligation of using field methods of water purification as soon as possible.26 
Louse Control. A survey of 1,800 units in December 1944 and 1,500 others 
in January 1954 showed that about 0.5 percent of units gave some evidence of 
infestation with body lice, but the total number of individual infestations in 
all units was less than 100. The infestation usually occurred in combat troops 
who had slept in quarters recently vacated by German soldiers or civilians. 
The great value of the educational work on louse control was exemplified by 
the fact that the few infestations which did appear among combat troops were 
quickly eradicated and only rarely did the same unit have infestation in 
successive months.27 
Personal Supplies. Because tonnage was extremely curtailed during the 
summer and fall of 1942, post exchanges could supply only limited quantities 
of tobacco products, toilet articles, and candies. Transient troops in embarka- 
tion areas were issued ration accessory convenience kits. These kits contained 
a daily allowance of razor blades, shaving cream, tooth powder, toilet soap, 
cigarettes, tobacco, matches, hard candy, and gum. Just before embarkation 
each soldier received a week’s free supply. When post exchanges were not 
available on the Continent, United States troops received exchange supplies 
on a free and automatic basis.28 
The barber kit was requested more and more frequently as the campaign 
progressed. Initial supplies had been inadequate and replacement parts were 
not available. Many barbers used equipment sent them from home. It was 
not until the latter part of 1945 that the contents of the kit and Army require- 
ments became standardized and the supply adequate.29 
North African, Mediterranean, and 
Middle East Theaters of Operations 
Experience in both North Africa and Italy seemed to indicate that prior 
to arrival in the theater individuals had not been well indoctrinated in the 
See footnote 12, p. 18. 
27 See footnote 12, p. 18. 
28 Quartermaster Supply in the European Theater of Operations in World War II, vol. V. The 
Quartermaster School, Camp Lee, Virginia, 1949. 
» Ibid. PERSONAL HYGIENE 
25 
importance of food and water sanitation.30 Limited fly control supplies and 
lack of proper toilet facilities made strict enforcement of sanitary measures a 
necessity. The methods of transmission in the outbreaks of diarrhea in the 
spring and fall of 1943 in North Africa and in the fall of 1944 in Italy have 
not been proved, but inadequate protection against flies, improper cleansing 
of cooking and eating utensils, improper disposal of human wastes, drinking 
of unchlorinated water, and infected food handlers all seem to have been 
implicated.31 
At a meeting of medical representatives of Fifth United States Army, 
2d Medical Laboratory, II Corps, and IV Corps in the fall of 1944 to discuss 
intestinal disease rates it was concluded that the chief problem in sanitation 
lay in the difficulty of maintaining good personal hygiene by frontline troops 
under existing conditions. Soldiers were known to eat unauthorized food and 
to drink unauthorized water without the use of halazone tablets even though 
they were available. A previous investigation of 18 cases of typhoid fever had 
indicated poor water discipline of the individuals involved.32 
Once-a-week laundry service for troops was provided in Oran where cloth- 
ing salvage operations had been set up. Mobile laundries were in the theater, 
although they could not be provided in sufficient numbers to meet all the bath 
and laundry requirements of troops in the field. (See Fig. 4.) Typical of 
the mobile laundry groups was the 487th Quartermaster Laundry Company 
which followed the Allied armies through North Africa, the invasion of Sicily, 
and into Italy, “Always within a stone’s throw of the advancing combat 
soldiers, the 487th nevertheless has continued to break records in laundry pro- 
duction and service to front line troops.”33 Individual enterprises also played 
a role in providing bathing and laundry facilities. In North Africa an officer, 
a laundryman in private life, created an overseas “branch” of his civilian busi- 
ness by hiring village women and setting up shop with tubs and irons.34 Home- 
made baths wTere set up in Italy by a quartermaster service company and many 
units improvised showers. In 1945 the preventive medicine officer for the 
theater was able to write: “The units of this theater have achieved a high level 
of personal hygiene.”35 
No particular problems in personal hygiene were encountered in the 
Middle East theater although the potential hazards were very real. Serious 
discussion regarding the relationship between desert sores and the lack of bath- 
ing facilities led the Preventive Medicine Section, Office of the Surgeon, United 
States Army Forces Middle East, to recommend an increase in ocean bathing. 
30 Final Rpt, Prev Med Officer, Off of Surg MTOUSA, 1945. HD. 
31 Diarrheal diseases in Fifth Army, cause and prevention. The Medical Bulletin of the North 
African Theater of Operations, 1944-45. AFML. 
32 Annual Rpt, Surg II Corps, 1944. HD. 
33 Filler, Louis: Laundry and Related Activities of The Quartermaster General. QMC Historical 
Studies No. 13, OQMQ, 1946. 
MIbid. 
35 See footnote 30. 26 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Figure 4- An infantryman takes a shower in the new 85th Division shower and clothing 
exchange unit, close behind the frontlines. Fifth United States Army, October 1944- 
This recommendation was carried out by furnishing more transportation and 
more time for personnel to bathe in the sea. Personal hygiene was emphazied 
in health talks to members of the command by preventive medicine personnel.36 
In the early history of the theater it was not unusual for over 70 percent 
of personnel among newly arriving units to suffer a gastrointestinal upset 
within a few weeks of arrival, because they had not been adequately informed 
of the dangers of consuming uncooked fruits and vegetables from native sources. 
As preventive medicine procedures became better understood, and were more 
thoroughly enforced, the rates for dysentery and diarrhea approached a reason- 
able figure.37 
The provision of adequate bathing and delousing facilities, the use of 
anti-louse powder, and the placing of native villages out of bounds helped to 
88 Ward, T. G.: History of preventive medicine United States Army Forces in the Middle East 
from 19 October 42 to 23 June 44. HD : 314.7-2. 
37 Ibid. PERSONAL HYGIENE 
27 
prevent typhus and other diseases prevalent in native quarters from occurring 
among American Forces. 
Southwest Pacific Area 
In the Southwest Pacific area the principal efforts were directed toward 
unit sanitation. Elimination of the insect vectors of diseases such as malaria 
and scrub typhus with the aim of area control was stressed. Individual pro- 
tective measures, particularly suppression of symptoms by the use of atabrine, 
were also important preventive measures. 
Reports from Australia and New Guinea show that frequent physical in- 
spections of troops and informal inspections of all units were carried out to 
determine the status of training and adherence to standards of all phases of 
medical, sanitary, and personal hygiene matters. Personal hygiene suffered 
during early months in the theater because only cold water was provided for 
showers and in many places bathhouses were dark, cold, and offered little pro- 
tection from the wind.38 One division surgeon attributed the occurrence of 
fungus infections to the inadequate laundry facilities.39 Personal hygiene 
was raised to a satisfactory level as hot water systems were installed and con- 
struction of bathhouses improved.40 The inadequacy of supplies of some items 
of clothing, insect sprays and repellents, and screening also presented an early 
problem for many units.41 
Disease Control. Instructional periods for all personnel on mosquito con- 
trol covered organizational and individual protective measures. The latter 
included sleeping under mosquito nets, using repellents, and proper wearing 
of clothing. Atabrine discipline was rigidly enforced but was not considered 
to take the place of preventive measures. 
When the Army moved into the Philippines early in 1945 an intensive 
training program was carried on to give troops an understanding of the various 
diseases to be encountered. One of the dangers with which there had been 
little previous experience was schistosomiasis. Newspaper items, posters, 
roadside signs, and demonstration vans all warned of the dangers of bathing or 
swimming in fresh water streams and ponds. The educational program was 
the main weapon against this disease, and as troops recognized the severity 
of the illness and understood its mode of transmission, the incidence of 
schistosomiasis decreased. 
Consumption of food and water from civilian sources was forbidden as a 
protective measure against diarrhea, amebiasis, and intestinal parasites. Dis- 
38 Sanitary Rpt, 32d Inf Div SWPA, Jun 1943. HD. 
39 Sanitary Rpt, 32d Inf Div SWPA, Apr 1943. HD. 
40 Sanitary Rpts, 32d Inf Div SWPA, Aug 1943, and succeeding months. HD. 
« (1) Quarterly Rpt, Hq I Corps, 1943-1. HD. (2) Quarterly Rpt, Base E SWPA, 1944-1. 
HD. (3) Quarterly Rpt, Hq X Corps, 1945-1. HD. (4) Quarterly Rpt, 6th Army, 1944-2. HD. 
(5) Sanitary Rpt, Adv Base D SWPA, Jul 1942. HD. 28 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
regard of these directives by individual officers and soldiers was a factor in 
outbreaks of these infections.42 
Although personal hygiene was generally considered excellent throughout 
the command, combat conditions necessarily sometimes had an adverse effect. 
The Sixth United States Army reported that sanitation and individual hygiene 
suffered during the second quarter of 1945 because of the fatigued condition of 
the men after several months of fighting and the terrain conditions imposed 
by the combat situation. The health record became better when troops reached 
a stable position and began to improve their personal hygiene.43 
Another extremely common hazard of the Southwest Pacific area was 
fungus infection. Observance of directives concerning care of the feet was 
especially important in an area where fungus infections might become dis- 
abling. Frequent bathing, with thorough drying of the skin and powdering 
of the body helped to lower the incidence of fungus infections. (See Fig. 5.) 
Periodic inspection of troops was necessary to assure early treatment.44 
Bathing and Laundry Facilities. Bathing facilities were reported as 
adequate at most times and ranged from mountain streams, ocean, and lakes 
to improvised showers. Many units improvised hot water systems for showers. 
In the Philippines, after an immediate problem of water supply, shower rooms 
were provided for all troops.45 
Even hospitals reported laundry facilities as inadequate during 1943. In 
Australia, civilian establishments were utilized, but were working so far beyond 
capacity that the quality was frequently substandard. Small handwashing 
machines and many types of makeshift laundry facilities were utilizied in 
New Guinea. By 1944, quartermaster laundry facilities were being provided, 
primarily for hospitals. Units, in general, provided facilities for the individual 
to wash his own clothes.46 
China-Burma-India 
As has been indicated, an educational program in individual protective 
measures was necessary, particularly for small isolated units and individuals 
traveling between fixed installations or on leave. Reports as late as 1944 in- 
dicate that troops continued to arrive in the theater without proper instructions 
in malaria prevention and demonstrating poor malaria discipline.47 
42 Quarterly Rpt, Base K SWPA, 1945-3. HD. 
43 Quarterly Rpt, 6th Army SWPA, 1945-2. HD. 
44 (1) Quarterly Rpt, Base B SWPA, 1943-4. HD. (2) Quarterly Rpt, Base E SWPA, 1944-1. 
HD. (3) Quarterly Rpt, 6th Army, 1944-2. HD. 
45 Quarterly Rpt, Hq I Corps, 1943-3. HD. (2) Annual Rpt, Chief Surg USASOS SWPA, 1943. 
HD. 
46 Quarterly Rpt, Base G SWPA, 1944-4. HD. 
47 Memo, Hq US Forces China-Burma-India, 20 Jun 44, sub: Notes on malaria control for reference 
In conference at SGO. HD : 314.7-2 (Ref). PERSONAL HYGIENE 
29 
Figure 5. Men of the 27th Division take time out to dry their clothing, apply foot powder, 
and re-dig foxholes filled with mud by the night's rain. Okinawa, May 19^5. 
Bathing facilities were in the majority of cases improvised, but adequate. 
In 1943, it was reported that some of the smaller stations in the Assam area 
had only washracks with drains; however, by 1944 each company and detach- 
ment had provided itself with showers. At convoy camps along the Ledo Koad 
soldiers were permitted to sponge off at the rivers, but river bathing was for- 
bidden because of resulting skin infections. In China, each group of Americans 
constructed their own showers, based upon directions in the Army field manual 
on sanitation. For a time no heating units were available, but when closed 
buildings were constructed, hot water was provided for washing and shower 
facilities.48 
In 1943 the native “Dhobies” did most of the laundry for soldiers and officers 
in India. Their crude methods of beating out and stamping out the dirt were 
« (1) Annual Rpt, Hq 478th QM Gp (India), 1943. HD. (2) Annual Rpt, Hq SOS Area Comd, 
USF in China, 1944. HD. (3) Annual Rpt, Southern Comd, Hq 9th Army Gp, American Liaison 
Team (China), 1944. HD. 30 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
not particularly efficient. Soldiers associated the prevalent skin lesions with 
these laundry methods and called them all “dhobie itch.” Many unit facilities 
and quartermaster laundries were established during 1944. Individual experi- 
mentation also created some novel laundries as the following example of a 
combination of American ingenuity and Indian tradition indicates:49 
Beating blocks were built, on which the Indian help could beat instead of scrub 
clothes. However, the concession stopped there. Running water was piped to the site; 
GI cans were installed, in which laundry is soaped and boiled in lye. It is then rinsed, 
resoaped and beaten upon the blocks and rinsed again. After bleaching it is hung out to 
dry on clothes lines. 
CONCLUSIONS 
The relative role of personal hygiene in control of disease varied consider- 
ably according to the degree of unit sanitation and area control achieved and 
according to the degree of specific protection afforded by measures such as 
immunization. There are few outbreaks of disease in which only one factor 
can be implicated; it is therefore difficult in most cases to correlate specifically 
good or bad personal hygiene with disease incidence. 
A continuing educational program, combined with frequent inspection by 
both commanders and medical personnel, was found necessary to keep individual 
health observance at proper levels. A problem of the Medical Department was 
to convince line officers of their responsibility in enforcing health precautions, 
such as water discipline, eating only authorized foods, care of the feet, and 
proper wearing of the uniform for protection against arthropod vectors of 
disease. The soldier, too, had to be convinced of the relationship between his 
actions and his health and the health of his entire unit. Agencies were set up, 
within the Office of The Surgeon General and at all major command levels, to 
insure the dissemination of information necessary for the soldier to safeguard 
his health. 
The effectiveness with which personal hygiene measures were applied, 
both in training situations and in active theaters, varied widely. Experienced 
observers agree that there were numerous lapses from established minimum 
standards and that, in future military operations, thorough training in personal 
hygiene will be necessary. This training must include not only the principles 
and methods to be applied, but should also serve to motivate personnel of all 
ranks. In addition, there must be command and medical inspections coupled 
with provisions for effective corrective actions. 
« (1) Annual Rpt, Hq Med Det 472d AM Gp, 1943. HD. (2) Annual Rpt, Disp 478th QM Gp, 
1944. HD. (3) Also see footnote 33, p. 25. CHAPTER III 
Cloth ins 
Colonel Tom F. Whayne, MC, USA 
PHYSIOLOGIC MECHANISMS FOR ADAPTATION 
TO HEAT AND COLD 
The study of clothing to meet military needs and protect the health of the 
American soldier in World War II became a science. The application of this 
science materially influenced the comfort, efficiency, well-being, and health of 
the soldier. This was of basic interest to preventive medicine in its mission 
of the conservation and maintenance of mental and physical health. 
Man is a tropical animal. Without the aid of clothing he is physiologically 
best adapted for the warm climates. Since man must wear clothing, the best 
types of garments can be developed only by full consideration of his physiologic 
makeup and his mechanisms for adaptation to heat and cold. For optimum 
well-being, the human body must maintain a relatively constant internal body 
heat by a balance between the rate of heat dissipation and heat gain. Funda- 
mentally, the problem is conservation of heat in the cold and the efficient dissi- 
pation of heat in the hot climates. In heat regulation and heat exchange, the 
human body has a remarkable adaptation through a wide range of temperatures. 
Several mechanisms are involved. 
At least two centers, located in the hypothalamus, appear to act as “ther- 
mostats,'’ one basically concerned with heat dissipation, the other with the con- 
servation of heat. These centers are closely connected by nerve pathways and, 
by a mechanism that is not well understood, react reflexly to sensory stimuli 
from peripheral thermoreceptors and probably to internal body temperature, 
including that of the brain stem itself. Newburgh 1 and his associates favored 
the hypothesis that the thermoreceptor mechanism lies in a gradient across 
the skin between the surface and the blood and that the steepness of the gradient 
in one direction gives rise to the sensation of cold, while that in the other 
stimulates the feeling of warmth. It is well understood that heat regulation 
is intimately related to blood and the flow of the blood stream. Central nervous 
system control of vasodilatation and vasoconstriction and certain local reflex 
mechanisms comprise a large part of heat regulation. Thermal adaptation 
through the nervous system is rapid. 
1 Newburgh, L. H., ed. : Physiology of Heat Regulation and the Science of Clothing. Philadelphia, 
W. B. Saunders Company, 1949. 32 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Prolonged adjustment to temperature appears to be a function of the endo- 
crine system and is under the master control of the pituitary gland. The mech- 
anism of control through the endocrine system probably is chemical by means of 
hormones, the products of metabolism, or the metabolic reaction of special 
chemicoreceptor cells. Metabolism, as the principal process through which 
body heat is produced, comes under endocrine control through the internal 
secretions of the thyroid, the medulla of the suprarenal gland, and possibly 
other internal glands. Adrenalin produced in response to stress undoubtedly 
increases heat production. The role of the secretion from the cortex of the 
suprarenal gland and the reaction of the human body to stress has received 
considerable attention at the hands of Selye2 and others, but is not completely 
understood. Lange and co-workers 3 have demonstrated the protective influ- 
ence of thyroid gland administered to rabbits exposed to extremes of cold, and 
Leblond and his co-workers,4 through the use of radioactive iodine, have shown 
an increased thyroid response in rats exposed to cold after a latent period of 
approximately 3 days. Return to normal activity occurred after a period of 
exposure of 40 days and probably indicated that other mechanisms of adapta- 
tion had come into play. Schachner and co-workers,5 working in the Armored 
Medical Research Laboratory at Fort Knox, Kentucky, after the war, extended 
the range of observations to shorter and longer intervals, 2 hours to 60 days, 
and in general confirmed the work of Leblond, The endocrines also exert a 
definite influence in the control of water balance and the blood level of chlorides. 
Bazett6 and others have described blood volume changes characterized by an 
increase in heat and a reduction in cold. 
Bazett stressed the point that body temperature is not constant for all parts 
of the body, and that variations in surface temperature and even deep muscle 
temperatures in the extremities occur in the process of heat regulation and the 
maintenance of thermobalance according to external temperatures. The most 
constant body temperature is probably represented by that of the liver, the 
brain, and of the blood as it leaves the heart. Even deep rectal temperatures 
vary according to heat stress or heat loss. 
In response to cold, there is an initial general vasoconstriction involving 
all types of superficial blood vessels, possibly accompanied by deep splanchnic 
dilatation, Gooseflesh roughens the skin and the, hair rises in an effort to 
2 Selye, H.: The general adaptation syndrome and the diseases of adaptation. Practitioner 163 : 
393-405, Nov 1949. 
3 Lange, K. ; Gold, M. A. A.; Weiner, D., and Kramer, M.: Factors influencing resistance to cold 
environments. Bull. U. S. Army M. Dept. 8 : 849-859, Nov 1948. 
* Leblond, C. P.; Gross, J.; Peacock, W., and Evans, R. D.: Metabolism of radio-iodine in the 
thyroids of rats exposed to high or low temperatures. Am. J. Physiol. 140 : 671-676, Feb 1944. 
5 Schachner, H. E.; Gierlach, C. S., and Krebs, A. T.: The response of the thyroid gland to low 
environmental temperature as studied with radioiodine. Med Dept Fid Research Lab Project Rpt 
6-64-12-02, 1 Jun 49. AFML. 
6 Bazett, H. C.: The regulation of body temperature. In Newburgh, L. H., ed., op. cit., pp. 
109-192. CLOTHING 
33 
decrease airflow over the skin surface and to maintain a layer of air insulation 
over the body, Bazett points out that the level of deep body temperature, as 
exemplified in rectal recordings, is influenced by so many factors of adaptation 
that it is not readily depressed in cold nor increased by moderate warmth. Data 
collected carefully by Bazett and his group, however, do demonstrate that such 
an effect is discernible. He states that, “Thus the data . . . indicate differences 
in average rectal temperature of 0.7° C. (1.3° F.) for the whole range from 
just endurable cold to sweat-causing heat.” 
Reflex shivering increases the metabolic rate as part of the physiologic 
protective response to cold. If exposure to cold is prolonged, the continued 
vasoconstriction sets up a need for a reduction in blood volume to compensate 
for splanchnic dilatation. As a result, there is some concentration of plasma 
protein, which eventually disappears. An increase in cell concentration may 
occur, but over a long period this also is reduced and the cell composition of 
the blood is comparable to that seen in subjects in equable temperatures. In 
vasoconstriction, which affects arteries and veins alike, the blood returns through 
the venae comites in close apposition to the arteries. Under these circumstances, 
arterial blood on the way to the surface is cooled and venous blood, coursing 
centrally, is warmed by an exchange of heat. This results in a gradual cooling 
of the extremities and eventually allows surface temperatures to fall. This may 
cause a decrease in evaporation, radiation, and convection from the skin and act 
as a mechanism for the conservation of heat. 
Acclimatization to cold appears to be less specific than adaptation to heat. 
Increase in thyroid activity in man exposed to cold has not been substantiated. 
There is some evidence that plasma protein is reduced to accommodate sustained 
vasoconstriction of the superficial vessels. Roughening and drying of the skin 
may occur and probably afford better insulation. Individuals exposed to cold 
develop tolerance and greater comfort within about 1 week. Optimum acclima- 
tization to cold requires long periods of experience in cold climates and appears 
to involve more of “learning to live with cold” than physiologic adjustment, 
about which very little fundamental knowledge exists. 
Physiologic adjustment of the body to heat is largely a function of the cir- 
culatory system insofar as is now known. The basic reactions are the opposite 
of those described above for cold. A continuous vasodilatation is an early 
response to heat and apparently depends upon reflex responses to peripheral 
thermoreceptors acting through thermocenters in the hypothalamus. There is 
an increased flow of blood, especially at the periphery, and the route of flow 
of returning blood is in the superficial veins. This allows blood flowing toward 
the periphery to carry heat outwardly, to lose it near the skin surface through 
the cooling effects of evaporation and convection, and to return centrally at 
lowered temperatures to accomplish internal cooling. In the initial adaptation, 
vasodilatation is accompanied by splanchnic constriction. With further adjust- 34 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
ment, however, there is an increase in blood volume. Blood protein increase 
subsequently parallels the fluid increase, but elevation of hemoglobin levels has 
not been conclusively substantiated. 
The physical mechanisms through which body heat is lost are primarily 
evaporation of sweat and convection and, to some degree, by conduction of heat 
through the tissues. The sweating mechanism is largely controlled by the 
sympathetic nervous system and to a less extent by peripheral heat stimuli 
acting through a thermocontrol mechanism located in the hypothalamus. 
Robinson 7 has summarized evidence to the effect that local heat stimuli may 
also initiate sweating. He further states that the center in the hypothalamus 
is influenced by afferent impulses from temperature receptors in the skin, direct 
temperature changes in the center which are determined by the temperature of 
the arterial blood supply, and possibly by stimuli arising from neuromuscular 
activity. The initiation of sweating depends largely upon the skin temperature 
and increases rapidly above a threshold of 34.5° Centigrade.8 Water output 
through sweating is therefore in proportion to the heat stress to which the body 
is exposed. Under heavy stress, dehydration ensues if water is not replaced 
in adequate quantities. Total water balance in the heat is largely related to 
sweating, kidney function, and thirst. Robinson 9 has studied the rate of 
sweating and points out that in addition to the factors noted above, sweating 
may vary by individual, degree of acclimatization, fatigue, and excessive salt 
intake. Under stress up to 4 liters of sweat per hour may be lost through the 
sweating mechanism, although averages are considerably less. High rates of 
sweating cannot be maintained indefinitely because of fatigue of the sweating 
apparatus. The ability to sweat and resistance to fatigue of the sweating 
mechanism vary by individual. Indeed, a few individuals appear to be incapa- 
ble of sweating to any great degree and therefore are unfit for living in the 
hot climates. 
Acclimatization of men to heat stress is a complex process. Ability to 
sweat increases, the chloride content of the sweat decreases, and there appears 
to be some general lowering of the metabolic rate. Robinson points out that 
in the acclimatized individual, sweating begins earlier upon exposure to heat 
than in the unacclimatized individual. The heat regulation mechanisms of 
the body adapt themselves rapidly to increased heat loads and most individuals 
accomplish a large part of the acclimatization process within a week of having 
been placed in a hot environment. Robinson notes the great capacity of the 
circulation to make adjustments to heat stress, and gives as an example observa- 
tions on well-acclimatized men studied in his laboratory who could maintain 
thermal equilibrium and water balance while working for 6 hours with a 
7 Robinson, S.: Physiological adjustments to heat. In Newburgh, L. H., ed., op. cit., pp. 193-231. 
8 Winslow, C.-E. A. ; Herrington, L. P., and Gagge, A. P.; Physiology reactions of the human 
body to varying environmental temperatures. Am. J. Physiol. 120 :1-22, Sep 1937. 
9 See footnote 7. CLOTHING 
35 
metabolic rate of 190 calories per square meter per hour in an air temperature 
of 50° C. and a relative humidity of 18 percent, or in an air temperature of 
33° C. and a relative humidity of 95 percent. Under such circumstances, these 
men were meeting a threefold demand over and above metabolic requirements 
as far as the circulatory system was concerned. 
The period required for complete acclimatization in hot climates is not 
known. For practical purposes, however, the war experience demonstrated 
that the vast majority of men who were transferred from temperate to hot 
climates had become acclimatized within a period of 1 month to 6 weeks. 
This brief summary of the physiologic aspects of the body’s adaptation to 
the extremes of temperature was taken largely from Newburgh10 and his 
collaborators and from the reports of the Subcommittee on Clothing of the 
Aviation Medicine Committee, National Research Council. The purpose has 
been to emphasize the concept that the development and use of clothing must 
be predicated upon man’s physiologic responses to his environment and not 
alone to fit, wearability, and adaptation to combat efficiency. This point of 
view was slow in its evolution. As late as 1940 the development of clothing 
was largely the responsibility of the Quartermaster Corps School and Depot 
in Philadelphia, Pennsylvania, aided by field testing for field use and combat 
adaptation by the Boards of the appropriate Army branches. 
In 1940 and early 1941, the Quartermaster Corps Technical Committee was 
developing the clothing program with the aid of civilian experts in clothing 
production.11 Their major interests were fabrics, fit, durability, adaptation to 
combat and other military requirements, appearance, and supply. It was not 
until The Surgeon General expressed interest in the development of clothing 
in relation to the physiologic requirements of the soldier that intensive studies 
on this subject were begun. Thus, the concepts briefly summarized above were 
largely an outgrowth of the combined efforts of The Surgeon General and The 
Quartermaster General during the war, with the assistance of the National 
Research Council and a number of exocrimental laboratories. 
PROPERTIES OF PROTECTIVE CLOTHING 
Forbes12 has described the properties of clothing as porosity, permeability, 
flexibility, elasticity, design and fit, thickness, number of layers, color, texture, 
and weight. Utilization and proper weighting of these properties of clothing 
promote human comfort and efficiency, and are potent factors in the prevention 
of injury and disease. They govern the passage or retention of heat and water 
vapor, and decrease the effect of solar radiation, convection, and wind. Those 
10 See footnote 1, p. 31. 
u Risch, E., and Pitkin, T. M. : Clothing the Soldier of World War II. QMC Historical Studies 
No. 16, Washington, Government Printing Office, Sep 1946. 
1J Newburgh, L. H., ed., op. cit., pp. 320-329. 
346336 O—55 4 36 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
who develop clothing for military purposes cannot ignore the effects of design 
and appearance upon the morale of the soldier, for what makes up fashion in a 
uniform is oftentimes neither physiologically sound, nor operationally practi- 
cal. Fourt and Harris13 have remarked that “clothing is often chosen on the 
basis of fashion rather than physiology and physics.” 
The development of special types of clothing for the protection of the 
soldier against diverse environmental hazards was a necessity during World 
War II. The American soldier experienced combat in the dry heat of the 
desert, the wet moist heat of the tropics, the cold of winter in Italy and Western 
Europe, and the damp cold at Attu and the Aleutians. (See Fig. 6.) Thus, 
even with the knowledge of body regulation to heat and the development of 
fabrics and design of uniforms that existed at the end of the war, uniforms 
for special requirements could not be avoided. 
The characteristics of the uniform for hot climates were lightness, perme- 
ability to water vapor, lack of absorbability for water, insectproofness, and 
firmness of weave sufficient to protect the skin from injury and abrasion. 
White or other light colors were desirable because of their ability to reflect 
radiated heat, but were unsuitable for camouflage. Fabrics should be able to 
conduct heat, dry quickly, reflect radiated heat, interfere as little as possible 
with the cooling process of evaporation of sweat, and give maximum ventilation 
during periods of activity while at the same time affording some protection 
against the wind and lower night temperatures when the soldier is at rest. 
In hot humid climates, any type of clothing may impede evaporation of sweat 
to such an extent as to interfere with heat balance. In hot dry areas, a cover- 
ing of clothing over the body protects from radiation from the sun and prevents 
heat coming in contact with the body in much the same way that arctic clothing 
in the cold protects from excessive heat loss. 
The effectiveness of clothing for cold climates depends upon thermal insu- 
lation properties. Thermal insulation requirements of the human body, how- 
ever, vary so greatly between hard physical activity and rest in cold climates 
that great flexibility in design is required. In activity, layers must be shed 
and neck and cuff openings undone to facilitate ventilation and evaporation 
of sweat for the maintenance of thermal equilibrium. When sweating is in- 
tense, clothing picks up much moisture which later turns to frost or ice and 
greatly reduces thermal insulation during periods of rest. 
Still air is a good insulator. Consequently, the design and construction of 
clothing for cold climates came to embody those principles which trap air in 
the interstices of the fabric and between layers of clothing. Moving air on the 
other hand rapidly dissipates heat so that wind in contact with porous clothing 
covering the body rapidly causes loss of body heat. It was learned during the 
14 Fourt, L., and Harris, M.: Physical properties of clothing fabrics. In Newburgh, L. H., ed., 
op. clt., pp. 291-319. CLOTHING 
37 
Figure 6. A. Men of 160th Infantry stalking through Waikia Forest Reserve jungle site, 
Hawaii, June 19Jj3. B. Armored troops in a frontline position in Holland receive an 
issue of clothing. October C. Alcan Highway, D. Below the snowline, 
the patrol stops to change hack to OD’s. Fifth United States Army, Italy, December 
19U. 
war that a tightly woven, lightweight, windproof outer garment, worn over 
more porous fabrics as inner layers to give the effect of layers of still air for 
insulation, gave the best protection. Another characteristic was looseness of 
fit to encourage the trapping of air and to avoid fatigue by friction or restric- 
tion of movements. 38 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Other problems in the development of military clothing have largely to 
do with special problems, such as protection against fire and chemical warfare 
agents, and clothing in relation to industrial hazards. At least three hazards 
required the impregnation of clothing with separate chemical substances. 
These were fire, vesicant gases, and insects. In all three, toxic effects from the 
chemicals used provided a difficult problem during the war and necessitated 
many laboratory man-hours of testing. These chemical substances must be 
nontoxic, effective for the purpose for which they were designed, and change 
the characteristics of the fabrics used in the uniform as little as possible. The 
processes for impregnating them into the fibers of the fabric or in the fabric 
itself must be simple and preferably susceptible to use in the field or in im- 
provised field installations. These problems became more complex when the 
type of operation was such that protection against both fire and chemical war- 
fare agents might be anticipated and impregnation with insect repellents or 
insecticides was a requirement. 
Protection of the extremities in both heat and cold gave rise to special 
problems during the war. In tropical climates fungus infections were preva- 
lent and constant wetness from perspiration or water conditioned the skin to 
trauma. In the areas of dry cold, frostbite commonly affected hands and feet. 
Where cold was experienced in association with wetness, the problem of pro- 
tecting the feet was especially difficult. Footgear alone could not be expected 
to solve the problem. Conservation of total body heat by efficient protective 
clothing for other parts of the body had to complement the provision of 
properly designed, constructed, and fitted socks, and appropriate shoes such 
as the shoepac and the arctic overshoe in the prevention of trenchfoot. Loose- 
ness of fit to avoid constriction of the extremities, layering of socks, wet- 
proofness of the shoe, and ventilation through the uppers of the shoe came 
to be important considerations in the development of the best type of footgear 
for protection against cold injury. 
CLOTHING IN WORLD WAR 114 
The development of clothing for the American Expeditionary Forces in 
Europe in World War I was largely on the basis of expediency. The American 
Army had had no experience with operations on such a large scale and no 
basic research had been initiated to develop the best items of clothing and 
equipment for operations in a temperate climate where winters are relatively 
severe. Supplies were short, and it was necessary to purchase many items of 
clothing abroad to meet requirements for United States Forces. Inadequacies 
in transportation made unit supply difficult. 
u The Medical Department of the United States Army in the World War. Washington, Govern- 
ment Printing Office, 1926, vol. VI, pp. 608-661. CLOTHING 
39 
Until late in the war, the preventive medicine aspects of clothing appear 
to have received little attention, but great emphasis was placed upon the weight 
of equipment and clothing. It had been determined that the burden of the 
individual soldier should not exceed one-third of his own weight if he was 
to have maximum freedom of action on the march and in battle. The mean 
weight of American soldiers varied between 141 and 144 pounds. The average 
equipment for the rifleman weighed 61 to 7B pounds. When clothing was 
added, the weight was 80 to 91 pounds. There are no reports which point out 
the effect of these loads on the health in the American Expeditionary Forces. 
It was a common practice, however, for the World War I soldier to discard 
clothing and equipment. It is recorded that 50 percent of the men discarded 
extra shoes, 30 percent the extra blanket, and 25 percent the extra suit of 
underwear. 
Operations late in 1917 demonstrated that the 16-ounce Melton cloth for 
service coats was too light. The Chief Quartermaster, American Expedi- 
tionary Forces, recommended an increase to 20-ounce Melton, and a change 
in construction and lining materials. With the increase of wool consumption 
and the resulting shortages, the cloths produced were coarse and patchy in 
appearance. The American soldier appeared poorly dressed in comparison 
to those of other armies in Europe. Gen. John J, Pershing recommended a 
new design which, however, was not produced in time for use in Europe. 
Great difficulty was experienced in the proper fitting of clothing. Sizes 
recorded on paper labels were lost and resizing of salvaged clothing was fre- 
quently careless in practice. 
Special types of clothing were developed for the American Expeditionary 
Forces in Siberia and northern Russia in late 1918 and 1919. These consisted 
largely of overcoats with sheepskin lining under an outer shell of moleskin 
cloth or cotton duck. Parkas came into use, along with heavy fur headgear and 
fur-lined hoods. Some use of the layering principle was made in winter cloth- 
ing for Europe as demonstrated by the development of a leather jerkin which 
was designed to be worn over the uniform coat and under the overcoat. The 
jerkin was a popular garment and often was worn to the exclusion of the 
overcoat. 
Footgear 
The shoe developed by the United States Army before World War I did 
not stand up in combat use. Changes in design and construction were made 
in May 1917, but because of the Goodyear-welt construction these, shoes were 
not waterproof and were unsatisfactory. It was not until January 1918 that 
the Chief Quartermaster, American Expeditionary Forces, investigated the 
failures of this shoe and recommended improvements, a circumstance redupli- 
cated by the January 1945 conferences on clothing in the European Theater of 
Operations. 40 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
The “Pershing shoe” developed in World War I had such sound military 
characteristics that its principal features were recommended for inclusion in the 
military shoe for spring, summer, and fall operations toward the end of 
World War 11“ 
/Shoe Tariffs. Even in World War I, shoe tariffs for United States Forces 
included 90 sizes: 5 to 12 in half sizes and A through EE in widths. Companies 
recorded the sizes of the soldiers’ shoes. Supply based on these records re- 
sulted in a preponderance of the smaller sizes. The problem was further com- 
plicated by the recruitment of division personnel by region. Tariffs for the 
New York City units, made up largely of men of average or small stature, could 
not be the same as those for units comprised of the men of average to large 
stature from the Midwest. 
Fitting of Shoes. It is recorded that “In the American Expeditionary 
Forces the fitting of soldiers’ shoes was far from being satisfactory practically 
throughout the existence of these forces.” 16 There were no fitting machines, 
and the selection of shoe sizes was largely a responsibility of the commanding 
officer of the unit. This personal element and added command responsibility 
gave rise to much variance in the efficiency with which shoes were fitted. Even 
when fitted well, due regard was not given to the fact that the foot of the 
soldier increases in size under the exigencies of marching and combat, and that 
it was necessary to wear two pairs of socks for comfort during the wdnter 
months. Misfitting prior to the winter of 1917-18 was so much in evidence that 
some divisions reported as much as 90 percent of their men as suffering from foot 
trouble. Nearly all of the misfits were too small. In the fall of 1917, General 
Pershing cabled the War Department to stop the shipment of small sizes and 
established a new tariff in January 1918. In addition, The Quartermaster 
General caused a study of the problem to be made at Camp Upton, New York, 
in the spring of 1918. Some divisions called upon division orthopedic surgeons 
to supervise shoe fittings with improved results. 
Reasonably satisfactory dubbins for waterproofing shoes were developed 
during World War I. Success in their use, however, appears to have depended 
upon the method of use, which was time consuming and tedious. 
The design and construction of rubber boots and arctic-type overshoes were 
found to be defective. Cloth (cashmerette) uppers for overshoes were failures. 
They did not wear well and leaked after short periods of wear as was found 
to be the case with the cloth-type arctic used in World War II.17 
Socks. Wool socks were worn exclusively. A heavy wool sock worn over 
a lighter wool sock was the standard procedure. As in the case of shoes, sizing 
15 Memo, L. B. Sheppard, Off Chief QM, for Maj Gen R. M. Littlejohn, Chief QM BTOUSA, 18 
Mar 45, sub : Footwear and socks for use in the ETO. HD : 332.31 ETO. 
18 The Medical Department of the United States Army in the World War. Washington, Govern- 
ment Printing Office, 1926, vol. VI, p. 630. 
17 ETMD, ETO, Dec 1944. HD : 350.05. CLOTHING 
41 
seems to have been the greatest deterrent in the use of these otherwise satis- 
factory items. Because of the difficulties in the supply and exchange of socks, 
it was necessary for a general order to be published early in 1918 which directed 
that all soldiers in forward areas would be provided with three pairs of wool 
socks so that at least one change per day could be made.18 The order further 
established a sock exchange system roughly similar to that found to be so essen- 
tial in the prevention of trenchfoot in World War II, 
Clothing for Hospital Patients 
Clothing for hospital patients was not considered satisfactory in the Ameri- 
can Expeditionary Forces. A uniform convalescent suit patterned after a 
similar British item was recommended, but was not adopted. The nightshirt 
which was recommended as part of this suit was adopted, and the number of 
blankets issued to each patient was increased from 3 to 4 in the spring of 1918. 
Nurses’ Uniforms 
At the beginning of the war, there was no prescribed outdoor uniform for 
nurses in the American Expeditionary Forces. The American Red Cross fur- 
nished many items for American nurses. It was not until late in the war that 
the War Department finally approved initial issue of clothing for nurses at 
Government expense and provided facilities whereby they could keep them- 
selves comfortable and well clad. The nurse’s uniform was standardized 
towards the end of the war and a basis of issue was established. In the period 
between the two World Wars, little effort was made to develop a satisfactory 
field uniform for members of the Army Nurse Corps so that at the beginning of 
World War II the nurses were little better off than they had been when World 
War I started. 
Laundering 
Mobile field laundries were not originally part of the American Expedition- 
ary Forces. Late in June 1917, the Chief Quartermaster and the Chief Sur- 
geon, Headquarters American Expeditionary Forces, jointly recommended the 
establishment of laundries and the Chief Surgeon again on 19 August 1917 
reemphasized the need and recommended that laundries be established along- 
side or in conjunction with delousing stations and the facilities for the steriliza- 
tion of clothing. Until January 1918, however, the laundering of clothing was 
left to the individual soldier. Local village women were the laundresses or the 
soldier did his own, usually using cold water from muddy streams. This did 
not accomplish efficient cleansing and certainly did not disinfest the clothing. 
A general order late in January 1918 directed the establishment of free laun- 
dries and the first mobile laundry was shipped to Europe on 5 June 1918. 
» GHQ AEF GO 11, 17 Jan 18. 42 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Three more were in the theater by 18 August and it was only on Armistice Day 
that 24 additional mobile laundries were shipped from the United States. 
The impregnation of clothing for the control of lice was not practiced in 
World War I. It is interesting, however, that a member of the Medical 
Research Committee of the American Red Cross in Paris urged a practical trial 
for the impregnation of underclothing with an emulsion of cresol and soft soap 
as a louse control measure. While members of the Medical Research Committee 
wore underclothing thus impregnated for many days without reported cutaneous 
irritation or allergic manifestations, there is no record of field trial or use by 
American military personnel. 
Control of the ubiquitous “cootie” was largely confined to disinfestation 
of clothing and the provision of bathing facilities. Methods of disinfestation 
were by steam sterilization, hot air, and a variety of improvised methods, such 
as the Serbian barrel or steam boxes which were dependent upon heat or steam. 
Large delousing plants were established under the control of a bathing and 
delousing division. The technical director in the division was a medical officer 
who, in most instances, had had experience as a division medical gas officer. 
Subsupervisors operated by echelon downward to include regiments and bat- 
talions. Successful disinfestation was accomplished at great expense in time 
and large static facilities. Disinfestation for the individual and for small 
groups was unsatisfactory. Reinfestation occurred easily because simple heat 
sterilization of clothing provided no residual insecticidal effect. The bath and 
delousing units of World War I were the antecedents of the bath and steriliza- 
tion and the bath and fumigation units of World War II. In contrast to the 
methods used in World War I, MYL and DDT dusting, together with bathing 
and laundering and methyl bromide treatment of clothing, kept the American 
soldier essentially louse-free during World War II. The residual effect of 
DDT was the factor of greatest importance. 
Trenchfoot was not a significant cause of disability in American Forces 
in Europe in World War I. The role of clothing in the prevention of cold 
injuries, however, came to be well understood.19 
In World War I the development of clothing in relation to the function 
of the soldier and to meet his physiologic requirements received little study and 
no emphasis. Medically, major interests were directed toward the sanitary 
aspects of clothing, especially those having to do with laundering and disin- 
festation. The relation of footgear to trenchfoot was appreciated. 
CLOTHING IN WORLD WAR II 
Clothing as a preventive medicine interest received little attention in the 
period between the two World Wars. At the beginning of World War II, the 
13 See footnote 18, p. 41. CLOTHING 
43 
American soldier was clothed in a uniform which, with the exception of a 
moderate trend towards making it suitable for dress and garrison use, was the 
same as that in use at the end of World War I.20 The last development in 
arctic clothing before the war was in 1928. Little attention was given to special 
types of clothing for unusual military uses. Some observations were made 
upon the relative desirability of cotton versus wool uniforms for wear in the 
field in the tropics. The physiologic implications of these observations, how- 
ever, were on an unsound footing because of the conviction on the part of com- 
manders in general that soldiers fared better on restricted water intake during 
periods of heavy physical activity. In September of 1936 at Fort Riley, 
Kansas, field tests were made of clothing impregnated against vesicant gases,21 
The tests, however, were limited to observations on four men and were made by 
a contract surgeon, rather than under the auspices of trained research personnel. 
The need for a field jacket to replace the service coat was established in the 
middle 1930’s. Development began in 1935, ended early in 1937, and after 
much delay resulted in the adoption of the olive-drab field jacket in November 
1939. Lightness of weight, water-repellency, and tightness of weave for wind 
resistance characterized this garment which might be considered the initial 
step toward the development of the specialized uniforms required for World 
War II,22 
The Chemical Warfare Service laboratories at Edgewood Arsenal, Mary- 
land, maintained a Medical Research Division which stimulated interest in the 
protection to be derived from clothing or specially treated clothing. A manual, 
“Prevention and Treatment of Casualties from Chemical Agents,” was pre- 
pared in 1940 with assistance from the Medical Department and included refer- 
ences to the uses of impregnated clothing.23 In December 1940, the Training 
Division of the Surgeon General’s Office recommended that the 5th Medical 
Battalion, assigned to the 5th Division at Camp Custer, Michigan, be used as a 
unit for winter training and testing. Study was limited to medical care in 
the cold, and protective clothing suitable for the wounded to wear during 
evacuation was included.24 
Isolated medical problems did receive some attention, as is illustrated by 
the concern over the possibility of pathogenic anaerobic bacteria said to have 
been found in samples of woolen clothing.25 Samples of woolen clothing from 
various sources, including quartermaster stocks, were tested for pathogenic 
Clostridia. The Army Medical School laboratories came to the conclusion 
20 See footnote 11, p. 35. 
21 Ltr, J. R. Fuchlow, Contract Surg USA, to SG thru Surg, Ft. Riley, Kans., 10 Sep 36, sub : 
Medical officer’s report on soldiers during a test wearing of impregnated uniforms. SG : 421—1. 
22 See footnote 11, p. 35. 
» WD TM 8-285, 10 Jul 41. 
24 Memo, Capt T. J. Hartford, SGO, for Gen Love, SGO, 11 Dec 40. HD: 353 (Chron). 
25 Ltr. Dir Army Med School to SG, 13 Sep 41, sub : Anaerobic bacteria in woolen fabrics. SG : 
700.2-1 (AMS). 44 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
that woolen clothing uncontaminated by soil was not a significant source of gas 
gangrene or tetanus. Clothing contaminated by the soil of European battle- 
fields or in some training areas in the Midwestern States, might contain enough 
viable Clostridia to cause gas gangrene or tetanus. 
In such important items as work clothing, medical opinion was not obtained 
prior to the adoption of herringbone twill, and there is no record that considera- 
tion was given to the use of this cloth in the tropics, either as to its qualities of 
protection against insect bites or its undesirable characteristics in the dissipation 
of heat. One- and two-piece herringbone twill fatigue suits were authorized 
for Army use to the exclusion of denim in February 1941.26 
A member of the Quartermaster Corps Technical Subcommittee on Combat 
Winter Clothing tested Army items of winter clothing on an annual hunting 
trip of a party in the Maine woods in the fall of 1941, and submitted practical 
recommendations on the defects and good points of the articles tested.27 
These examples serve to illustrate the uncoordinated approach to the study 
of combat clothing. As late as the latter part of 1941, an adequate research 
program had not come into being. Prior to this time, the development of 
clothing had been largely the responsibility of the Quartermaster Corps Tech- 
nical Committee on Clothing and of the Quartermaster Corps School in Phila- 
delphia, located in the Quartermaster Depot. Newly developed items of 
clothing, however, were submitted to the Infantry Board, and to other Service 
Boards, including the Medical Board, for field trials. The failure to develop 
better Army clothing in the period between the wars cannot be attributed 
entirely to lack of foresight or appreciation of the need for versatile combat 
uniforms. Great emphasis had been placed upon economy by Congress, and 
funds were not available to establish the research facilities or to train specialized 
personnel necessary for the required researches. 
Medical interest in clothing was largely centered in the Training Division 
of the Office of The Surgeon General and at the Medical Field Service School 
at Carlisle Barracks, Pennsylvania. The trend of this interest, however, was 
focused upon the care of the wounded, and protective clothing for patients 
during evacuation from combat areas, rather than the prevention of disease and 
injury through the development of appropriate, flexible, well-designed uniforms 
based upon the physiologic characteristics of man operating in extremes of 
climate, and exposed to the hazards of insect vectors of disease. The greatest 
emphasis had been placed upon the development and testing of field equipment 
for the Medical Department in the Equipment Laboratory at the Medical Field 
Service School and in field maneuvers and unit exercises. 
28 Memo, TAG to QMG, 5 Apr 41, sub ; Adoption of herringbone twill clothing. SG : 421.-1. 
37 Ltr, M. E. Barker, CWS Member QM Subcommittee, 8 Dec 41, sub : A study of the requirements 
of winter clothing. SG : 421.-1. CLOTHING 
45 
Development of Medical Research on Clothing 
No agency within the Office of The Surgeon General was by directive 
assigned the responsibility for the study and development of clothing. Because 
of the role of clothing in the protection of the health of the soldier, this respon- 
sibility quite logically came to rest with the Preventive Medicine Service, and 
more specifically, the Sanitation Division. Under the direction of its chief, Col. 
William S. Stone, MC, clothing came to be considered a part of man’s environ- 
ment which might aid materially in the protection of his health or jeopardize his 
chances of survival. 
Sanitary reports from the Panama Canal Department and other tropical 
areas motivated the chief of the Sanitation Division to call upon The Quarter- 
master General’s Office to review the entire problem of adaptation of clothing 
to the physiologic requirements of the soldier.28 Conferences resulting from 
this action brought the program under review. It was recommended that The 
Quartermaster General establish a research program fashioned after that of the 
Harvard Fatigue Laboratory, which had been studying physiology in relation 
to fatigue and the stresses of heat, cold, and altitude, under the direction of Dr. 
David Bruce Dill. The Harvard Fatigue Laboratory was requested to begin 
a series of tests of clothing as it influenced man’s ability to function in extremes 
of climate. Pilot investigations already had been stimulated by The Surgeon 
General at this laboratory. Early in February 1941, the National Research 
Council approved support of investigations by this laboratory on “clothing, 
fatigue, and supplementary substances.” 29 The director of the Harvard Fa- 
tigue Laboratory addressed a letter to the Chief, Supply Division, Office of 
The Quartermaster General, outlining the researches approved for the labora- 
tory under Army auspices, and requested certain equipment and soldier per- 
sonnel as subjects for the experiments. The request was supported by The 
Quartermaster General and in turn by The Surgeon General, in consequence 
of which The Adjutant General directed the action and authorized the Com- 
manding General, First Corps Area, to give full cooperation in supplying 
equipment and subject personnel. This marked the beginning of physiologic 
researches on clothing, and a coordination of effort on this problem between The 
Quartermaster General and The Surgeon General.30 
Simulated cold, hot dry, and hot moist climates were established in the 
laboratory in which treadmill and other tests were used to study the effects of 
clothing already adopted, and to determine the physiologic principles on which 
28 Gen Sanitary Rpt, Trinidad Base Comd, 31 May 41, with 2d ind, SG to TAG, 30 Jun 41, and 3d 
ind, TAG to CofEngrs and QMG, 23 Jill 41. SG : 721.1 (Trinidad) F. 
29 Ltrs, Chairman, Div Med Sciences NEC, to Dr. D. B. Dill, Harvard Fatigue Lab, 6 Feb 41 and 11 
Feb 41. SG: 421.-1 (Uniforms). 
34 Ltr, Actg Dir, Harvard Fatigue Lab, to Chief Supply Div OQMG, 13 Mar 41, with 1st ind, QMG 
to TAG thru SG, 28 Mar 41, and 2d ind, SG to TAG, 28 Mar 41. SG : 421.-1 (Uniforms). 46 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
to base further development of fabrics and design. The first report upon the 
relation of clothing to fatigue from the Harvard Fatigue Laboratory was 
transmitted to The Surgeon General by the Chairman, Division of Medical 
Sciences, National Research Council, on 8 July 1941,31 Eventually other 
laboratories, notably the John B. Pierce Laboratory of Hygiene at New Haven, 
Connecticut, and the physiology departments of various universities were 
brought into an extensive program of research and testing. 
As an outgrowth of the conferences and researches already noted, it became 
obvious that sound studies on clothing could not be made without a comprehen- 
sive knowledge of climatic conditions in all parts of the world where military 
operations of American forces might be expected to take place. Knowledge of 
the climates of cold regions and dry and moist hot regions was limited. The 
chief of the Sanitation Division, Office of The Surgeon General, suggested these 
studies and vigorously supported their development. The Quartermaster Gen- 
eral obtained the services of Dr. Paul A. Siple, meteorologist and geographer, 
who had accompanied the Byrd expedition to the Antarctic. Dr. Siple was 
commissioned in the Quartermaster Corps and made the director of a climatic 
research unit in the Special Forces Section and took an active part in the pro- 
gram for the study of clothing in relation to climates.32 
Acting upon the recommendation of the chief of the Sanitation Division, 
plans were made for establishing a climatic research laboratory in which could 
be brought together the skills and knowledge of the physician, the physiologist, 
the textile expert, specialists in the design of clothing, and the meteorologist for 
the comprehensive and thorough scientific study of clothing. This culminated 
in the Climatic Research Laboratory at Lawrence, Massachusetts, which was 
housed in the plant of the Pacific Mills.33 Three highly qualified medical offi- 
cers were assigned for duty in this laboratory, one of whom had had experience 
in testing clothing in the Panama Canal Department, and the other two quali- 
fied in physiology or other research skills related to clothing and climatic 
studies. One of these officers, Lt. Col. (later Col.) John H. Talbott, MC, 
directed the medical phases of the research work at this laboratory and event- 
ually was designated official representative of The Surgeon General as well as 
The Quartermaster General in tests conducted on clothing and equipment.34 
While the National Research Council had been active in establishing 
research projects on clothing, this organization came to take a very much 
more active part in the scientific study of this difficult technical problem. 
31 Ltr, Dr. L. H. Weed, Dlv Med Sciences NRC, to SG, 8 Jul 41, with incl, sub : Preliminary report 
on experiments on soldiers and their clothing under different climatic conditions. SG : 421.-1 (Uni- 
forms). 
32 See footnote 11, p. 35. 
33 Physiological testing. Textile Research 14 : 222-227, July 1944. 
34 (1) Ltr, QMG to SG, 28 Aug 42, sub: Physiological and climatological research program of the 
QMC. SG: 421.—1 (Uniforms). (2) Semimonthly Rpt, Sanitation and Hygiene Div SGO, 16-31 
Dec 44. HD. Clothing 
47 
The Surgeon General of the Navy early in June 1942 called to the attention 
of Dr. E. F. DuBois, Chairman of the Committee on Aviation Medicine, the 
unsatisfactory state of aviation clothing. This served as the basis for the 
creation of a subcommittee under the Committee on Aviation Medicine which 
had as its terms of reference the study of clothing for the aviator. The Sub- 
committee on Clothing was organized on 12 June 1942. Members of the sub- 
committee were Dr. L. H, Newburgh, Chairman, Dr. E. R. Schwartz, Dr. L. P. 
Herrington, and Dr. W. H. Forbes. The initial interest of the subcommittee 
was the development of lightweight functional flying uniforms for aviators, 
so constructed as to protect against cold, flexible enough for wear in the heat, 
and embodying protective features against fire and drowning. Development 
of satisfactory headgear, gloves, and shoes was also considered. An electri- 
cally heated aviator’s suit had been developed by the Canadians, wTho also had 
produced a satisfactory helmet. The electrically heated suit, however, was 
heavy, and required too great a load on the electrical output of the plane to 
make it practical. A comprehensive research program on physiologic regu- 
lation of heat, characteristics of fabrics, design of the uniform, thermal in- 
sulation, flash protection from fire, and flotation garments was instituted. 
The initial meeting of the subcommittee brought together representatives of 
the Committee on Medical Research of the Office of Scientific Research and 
Development, the Committee on Aviation Medicine of the National Research 
Council, the Canadian Research Committee, the British Medical Research 
Council, the National Bureau of Standards, the National Institutes of Health, 
and the Textile Research Institute. Armed Forces’ members included repre- 
sentatives from the Office of The Quartermaster General; the Materiel Labora- 
tory, the Equipment Laboratory, and the Aero-Medical Center of Wright 
Field; and the Bureaus of Supplies and Accounts, Aeronautics, and Medicine 
and Surgery of the United States Navy.35 Subsequently, there were repre- 
sentatives from the Office of The Surgeon General, the Air Surgeon’s Office, 
and the Armored Force Medical Research Laboratory (later redesignated 
Armored Medical Research Laboratory) at Fort Knox, Kentucky, as well as 
liaison personnel from the Royal Air Force, the Rochester Desert Laboratory, 
the Harvard Fatigue Laboratory, the Textile Foundation, and others. In- 
cluded in the makeup of the subcommittee and its liaison group were the many 
skills and sciences having a bearing upon the development of clothing. The 
subcommittee had been reorganized by the fourth meeting on 17 June 1943, 
and had brought into its membership Dr. Milton Harris, Dr. Sid Robinson, 
and Professor C. P. Yaglou. At the same time, its terms of reference were 
expanded to include consideration of the clothing problems of ship and ground 
forces, as well as air forces, and researches were initiated on hot weather 
35 Minutes of Meeting, NRC Subcommittee on Clothing, Committee on Aviation Medicine, 17 Jun 
42. HD; 040. 48 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
clothing, comfort at low temperatures, especially as related to electrically 
heated clothing, cooling characteristics of air, decontamination clothing and 
footwear, textile materials, and clothing as related to exposure to water.36 
Because of the urgency of developing satisfactory clothing for operations 
in the jungle, a series of special meetings was held by the subcommittee to 
coordinate knowledge and findings on this problem and to push forward the 
research phases which were not then well developed. The studies initiated 
and coordinated by the subcommittee, together with the field and combat test- 
ing resulting from their findings, were responsible for major advances in 
adaptation of clothing to the physiologic needs of the soldier and for develop- 
ment of fabrics and design of uniforms which were durable and efficient for 
combat and, at the same time, contributed to the comfort, efficiency, and well- 
being of the soldier. Through its efforts, the science of clothing had been 
launched and was thoroughly established by the end of the war. 
The results of the intensive studies guided by the subcommittee have been 
brought together in one volume by Dr. L. H. Newburgh and his associates 
under the title of “Physiology of Heat Regulation and the Science of Cloth- 
ing.” 37 Despite the depth and range of these far-reaching investigations, 
Newburgh and his collaborators repeatedly stressed the point that many phases 
of clothing in relation to man are not understood, and that there is a need for 
continued basic and applied research. 
The Armored Force Medical Research Laboratory, initiated by the Pre- 
ventive Medicine Service, the Surgeon General’s Office, was established at Fort 
Knox, Kentucky, in September 1942 with the specific mission of conducting 
research on physiologic problems of practical significance to the Armored Force. 
Special attention was directed to the study of the soldier in relation to his 
duties. The aim of the laboratory was:38 
To obtain the basic data on selection and training of personnel and performance of 
equipment, from which conclusions may be drawn which will enable the individual soldier 
to perform his duties with maximum obtainable efficiency for the longest possible time, 
and to determine these limits imposed upon personnel so that they may be used to the 
best advantage by commanders and tacticians. 
With this objective, the study of clothing in relation to the functioning soldier 
became of necessity an important part of the program. 
While the Armored Medical Research Laboratory was not a testing organ- 
ization, its researches nevertheless were largely applied, rather than basic. Its 
work, therefore, complemented rather than duplicated the studies of the Sub- 
committee on Clothing. After June 1942, close liaison was maintained with the 
laboratory staff of the British Fighting Vehicle Physiological Laboratory. In 
“Minutes of Meeting, NRC Subcommittee on Clothing, Committee on Aviation Medicine, 17 Jun 
43. HD: 040. 
87 See footnote 1, p. 31. 
88 Historical Bpt, Armored Med Research Lab, 3 Oct 45. HD : 319.1-2. CLOTHING 
49 
the summer of 1942 temporary laboratory facilities were established at the 
Desert Training Center, Camp Young, California, for the study of the effects 
of dry heat on personnel operating in tanks.39 
As the program of the Armored Medical Research Laboratory progressed, 
climatic studies were made which included the protective efficiency of cold 
weather clothing, the physiologic effects of cold, observations of men in con- 
trolled chambers simulating humid jungle heat, ranges of use of clothing for 
jungle operations, the effects of impregnated and impervious clothing upon the 
efficiency of personnel, environmental heat and humidity in relation to accli- 
matization, anthropometric measurements of groups of men in an effort to fit 
tanks to men and to develop their clothing and equipment for efficient use in 
tanks, tests of flame-proofed clothing, and the design and fit of army shoes. 
The findings in this laboratory greatly influenced the fabrics and designs for 
clothing ultimately developed, especially for hot weather operations. 
The impregnation of clothing for protection against vesicant gases, fire, 
and insects necessitated the use of chemicals which to accomplish their primary 
purpose also had to be nonirritating and nontoxic to the w7earer. Testing for 
toxicity and allergic manifestations therefore became an important part of the 
development of special types of protective clothing. In the early phases of the 
program, much of the testing wTas done by the Medical Division of the Chemical 
Warfare Service Laboratory, Edgewood Arsenal, Maryland. Subsequently, 
the Army Industrial Hygiene Laboratory assumed the responsibility for this 
phase of the work on clothing.40 While this laboratory came into operation 
late in the war, it carried out many thousands of tests on the skin toxicity of 
various materials treated with waterproofing, fireproofing, and fungicidal 
agents. Additionally, a safety shoe program and various types of protective 
clothing used in Army-owned or Army-operated industrial plants were subjects 
of study at this laboratory. 
Both the Armored Medical Research Laboratory and the Army Industrial 
Hygiene Laboratory wTere initiated by and came directly under the control and 
guidance of the Preventive Medicine Service, Office of The Surgeon General. 
Specifically, their functions were the responsibility of the Division of Occupa- 
tional Health and Industrial Medicine. 
The primary responsibility for the development and production of clothing 
of all types rested with the Office of The Quartermaster General. Failure to 
appreciate fully the medical aspects of clothing and the necessity for the 
adaptation of clothing to the physiologic needs of man under a variety of stress 
circumstances, before and during the early phases of the war, was responsible 
for the loose organization and integration of the research and testing agencies 
previously discussed. Because of the sequence of their establishment, there 
38 Ibid. 
40Rpt, Army Industrial Hygiene Lab SGO, 17 May 45, sub: Toxicity of tropic-proofed equipment. 
HD : 422.3 Protective Clothing. 50 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
was considerable overlap of function and lack of coordination of purpose. 
Some duplication of effort was inevitable throughout the program, but by the 
end of 1942 there was a general understanding of the role each had to play and 
a mutually accepted division of responsibility. The roster of attendance at 
meetings of the Subcommittee on Clothing was proof of the interest in integra- 
tion of effort in the development of military clothing. Further, these com- 
bined efforts extended to the research facilities of American Allies, the 
Canadians and the British. 
Field Testing. As the program developed, field testing became an increas- 
ingly important practical necessity before adoption of clothing items. Exten- 
sive tests were carried on by the Quartermaster Board at Camp Lee, Virginia; 
representatives of the Medical Department frequently served as observers and 
participants. Testing of jungle clothing was done in the Panama Canal De- 
partment, in Florida, and in the Pacific theaters. Similarly, winter and arctic- 
type clothing were tested in the Rocky Mountain area by organizations operat- 
ing in the northern part of the United States, in Alaska, and in Canada. 
Durability as a military characteristic of clothing was tested on the Quarter- 
master Board combat course and shoe test track, but combat testing required 
the concurrence of the Army Ground Forces. 
In the early phases of the war, the Office of The Quartermaster General 
worked on the theory that combat clothing needs could best be met by develop- 
ment of a series of special types of clothing to meet a variety of combat require- 
ments. As the war progressed this point of viewT changed. The principal 
objective became the development of the fewest possible items with the greatest 
possible flexibility to reduce the number of special clothing units to the mini- 
mum.41 Field testing in theaters involved sending teams of qualified Quarter- 
master Corps clothing experts to observe the use of clothing items by soldiers 
under as many conditions as possible. These teams went to great lengths to 
sample soldier opinion as to desirability and utility of individual clothing 
items and equipment. Further development often was decidedly influenced by 
the results of these surveys. While this fair and impartial practice produced 
a wealth of practical information, the results often appeared to have more 
influence on change of policy and clothing development than they merited. 
This defect emphasizes the need for greater training of the soldier in what he 
may expect from clothing and especially the efficient use of clothing assemblies 
for protection of his health in extremes of climate. 
Medical Problems Associated with Clothing in World War II 
On that part of the chronicle of clothing which follows, no effort will be 
made to detail one by one the failures and successes incurred in providing 
satisfactory military clothing. Neither will detailed theater experiences be 
41 See footnote 11, p. 35. CLOTHING 
51 
recorded, but rather examples will be given to illustrate pertinent problems 
involving principles, major developments, and significant trends. Review of 
the source material has dictated the advisability of considering the subject on 
the basis of climatic extreme and special problems. If the reader fails to 
detect sufficient reference to the tedious negotiations, the slow progress, and 
the frustrations that often accompany the development of new programs in the 
military forces, it is not because they may not have existed, but rather that the 
author feels that they are not apropos to the purpose of this history and would 
add unnecessary detail to an already over-long story. 
CLOTHING FOR HOT CLIMATES 
Relation of Clothing to Heat Regulation, 
Comfort, and Efficiency 
Clothing is thermal barrier. In hot climates, it interferes with efficient 
dissipation of body heat under most circumstances. The initial impetus in 
embracing this concept provided by the Office of The Surgeon General was 
soon reinforced from other sources. A study on protective clothing was begun 
in the fall of 1941 at the United States Department of Agriculture Laboratory 
at Orlando, Florida, at the request of The Surgeon General.42 Tests of several 
fabrics for bite resistance to mosquitoes were carried out in 1943 as a part of 
the jungle clothing program of the Subcommittee on Clothing. Aedes taenio- 
rhynchus, A. aegypti, and Anopheles quadrimaculatus mosquitoes were used. 
It was found that Byrd-cloth offered the best protection, followed by poplin and 
Army twill. Nylon, British cellular-weave, and herringbone twill were unsatis- 
factory. Thse findings had a great bearing upon the work which had already 
been initiated to improve adaptation of the uniform for hot climates.43 Even- 
tually, field tests of developmental uniforms were established. Field tests in 
the jungle in Panama under simulated day and night combat conditions demon- 
strated the protection to be had from the tightly woven fabrics, such as Byrd- 
cloth.44 Even more important were the observations in the Everglades of 
Florida 43 and a provisional test in the Southwest Pacific area which corrob- 
orated the effectiveness and utility of the lightweight, tightly woven fabrics 
and established the criteria for adoption of the World War II jungle uniform.46 
42 Man and Animal Document No. 5174, Mar 1942. USDA Bureau of Entomology and Plant 
Quarantine. 
43 Minutes of 7th Meeting, NRC Subcommittee on Clothing, Committee on Aviation Medicine, 
15 Dec 43. HD: 040. 
44 Rpts, Maj C. H. Kearny, Inf, Mobile Force, Panama Dept, 1944. SG : 426.-1. 
45 Minutes of 4th Meeting on Jungle Clothing, NRC Subcommittee on Clothing, Committee on 
Aviation Medicine, 6 Oct 43. HD : 040. 
“(1) ETMD, Caribbean Def Comd, Mar 1944. HD; 350.5. (2) QMG Rpt, Mosquito proofing 
the jungle soldier. SG: 725.11 (1945). 
346336 0—55—5 52 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Great interest in improving the jungle uniform is evidenced by the following 
radio from General MacArthur:47 
For jungle warfare, British grenfell, or material equivalent weight, found best on 
provisional test because they are lighter, wet or dry, easier to launder in the field, and 
absorb less water or sweat. Herringbone twill absorbs large quantity of moisture which 
fatigues wearer, and is very uncomfortable. Advise durability test light material for 
possible ultimate adoption in the field. 
It was determined that the desirable properties of jungle clothing should 
be:48 
(a) Minimum resistance to heat loss, 
(b) Maximum resistance to mosquitoes, 
(c) Maximum resistance to other insects, 
(d) Camouflage, 
(e) Abrasion protection, 
(f) Durability, 
(g) Flexibility (that is, it should be possible to open or remove parts during the day 
when the mosquitoes are not present), and possibly, 
(h) Minimum weight when wet. 
Tightly woven fabrics were found to give the best protection against mosquitoes 
and on the basis of subjective comment, it was observed that the lightweight 
fabrics, although tightly woven, were preferred for comfort as well as their 
light weight when wet. 
The Armored Medical Research Laboratory set up projects, in conjunction 
with programs as directed by Office of Scientific Research and Development, to 
determine the relative physiologic load imposed by various types of clothing 
upon acclimatized men working in simulated jungle environment and concluded 
that;49 
a. Acclimatized men work with greatest effectiveness and comfort and least burden 
upon their heat regulating, cardiovascular and sweat mechanisms and have the lowest 
water requirements when unclothed (wearing only shorts, socks and shoes). 
b. Any garment covering a major portion of the body adds a definite and measurable 
burden which is manifested by marked increases in heart rate; rectal temperature and 
sweat loss, and by subjective sensations ranging from moderate to extreme discomfort. 
c. In order of magnitude of the added load and the undesirable effects produced, the 
tested garments or ensembles are as follows: (1) British fireproof overalls, tank crews, 
one-piece manufactured by T. Ravden and Sons, Ltd., 1942. (2) U. S. Army Suit, one- 
piece, herringbone twill, protective modified with overlapping flaps; union suit, cotton, 
protective two-piece; socks, wool, light, protective; hood, wool, O. D., protective and 
gloves, cotton, protective, (Leggings canvas, M19S8, 0. D., dismounted, protective, and gas 
mask not worn). (3) U. S. Army fatigue coveralls, Suit, one-piece, herringbone twill, 
made fire-resistant at M. I. T. by C. W. S. .process of impregnation with 22% antimony 
oxide and 12% Yinylite VYHH resin. (4) U. S. Army Suit, one-piece, herringbone twill, 
17 Quoted in report cited as footnote 40 (2), p. 51. 
48 See footnote 45, p. 51. 
49 Rpt, Armored Med Research Lab, 1942-46, Project 2, sub: Operation at high temperatures, 
p. 1. AFML. CLOTHING 
53 
unlaundered. (5) U. S. Army Suit, one-piece, herringbone twill, worn 2-6 months and 
laundered repeatedly. (6) U. S. Army Shorts, Cotton. 
d. When items (3), (4), and (5) above, are wetted with unevaporated sweat the 
differences between them become insignificant. 
Accordingly, the laboratory recommended:50 
(a) That all clothing to be issued for jungle operations be tested on standardized test 
subjects before acceptance, to determine the physiological burden which is imposed upon 
the wearer. 
(b) That all jungle clothing (wool excluded) be thoroughly laundered before use in 
hot humid environments. 
(c) When the military situation permits, and when there are no hazards from 
fauna, flora or solar radiation, men in hot humid climates be permitted to work in 
minimum amount of clothing. 
Further studies in the Physiology Department at Indiana University quan- 
titatively demonstrated that,51 
Coolness of clothing is directly related to the thinness of the fabric (not to fabric 
weight) ; inversely related to weight of suit; inversely to the amount of water required 
to saturate the suit or to the time required to dry the saturated suit, and directly to the 
amount of ventilation by openings. The coolness of any design is directly related to the 
percent of skin surface exposed. The coolness is not related to the permeability of the 
fabric to air under pressure, for low rates of air movement (% mph) ; for 1 to 2 mph 
a small effect was seen. 
Thus porosity of clothing came to be regarded as of little importance so 
long as the fabric was permeable to water vapor. It was also determined that 
impregnation of lightweight, tightly woven fabrics with insect repellents, in- 
secticides, and protective agents against vesicant gases or fire had little or 
no effect on the comfort and effectiveness of uniforms made from these 
materials. 
The results of these researches and field tests justified the conclusion that 
thin, tightly woven fabrics were best for the jungle uniform. Nylon and Byrd- 
cloth appeared to give the best physiologic results which, however, were almost 
equaled by poplin and Army twill. The insect type of bite resistance of the 
nylon fabric tested was unsatisfactory. Production of poplin and twill in 
quantities was practical, whereas Byrd-cloth and nylon would have required 
additional industrial facilities. For this reason, poplin and twill were adopted 
for further severe testing under jungle combat conditions. 
This recommendation, based almost entirely upon the physiologic and 
health protective characteristics of clothing, was accepted by The Quartermaster 
General. The Quartermaster Board conducted severe tests on its combat course 
and indorsed the feasibility of a jungle combat uniform made as a two-piece 
suit: jacket of 5-ounce poplin, and trousers of 8.2-ounce cotton uniform twill. 
“ Ibid. 
51 Minutes of Meeting, NRC Subcommittee on Clothing, Committee on Avaiatlon Medicine, 6 May 44. 
NBC Med Records Sec. 54 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Combat testing was initiated by The Quartermaster General in the spring 
of 1944. Extensive tests were carried out in the Southwest Pacific area, the 
China-Burma-India theater, and the Central Pacific area. The Surgeon Gen- 
eral opposed this action on the basis that the uniform was urgently needed for 
the prevention of malaria and was suitable for this purpose. It was a com- 
mand decision that combat testing should be carried out, following which The 
Surgeon General contributed full support.52 The Commanding General, Army 
Service Forces, authorized the tests and subsequent reports from the theaters 
concerned indorsed with few modifications the tropical combat uniform thus 
developed.53 
Dr. Sid Robinson, a member of the Subcommittee on Clothing, after an 
extensive field study in the China-Burma-India theater made the following 
report on 24 October 1945:54 
The design of the U. S. tropical combat uniform in its latest model is probably not 
perfect, but there are no major modifications necessary. Particularly advantageous 
design features are the shirt which can be worn with the tail in or outside the pants. . . . 
Other properties of clothing which are important to the combat soldier are the ease with 
which it can be kept clean, rapid drying, smoothness on the skin, and warmth at night 
when he has to sleep without shelter. Experiments and field tests have shown that the 
lightweight, smooth fabrics (Byrd-cloth, poplin, and Oxford cloth) are all definitely 
superior in the first three of these properties. 
Difficulties in the adaptation of the uniform for use in a combat theater 
are illustrated by a report of the observations in the South Pacific by Lt, Col. 
(later Col.) David Bruce Dill, MC:55 
In rear areas the 6-oz. khaki shirt and 8.2-oz. trousers are usually worn, with no 
undershirt by about half of the men. The rest wTear the dark herringbone twill, with no 
jacket, and no undershirt, acquiring a beautiful tan. The trousers are often cut off to 
make shorts. The fighting Infantry wear HBT—all of it, day and night. It is impreg- 
nated with dimethyl phthalate against the mite. The suggested new tropical uniform 
was tested on Bougainville, Biak, and Leyte, and was approved by the men wearing it. 
The reasons for approval were not altogether expected. Mosquitoes were not a con- 
sideration, for insect bites were not numerous, and the men have insect repellent. The 
tight woven uniforms were distinctly cooler. The weight was favorable, % that of HBT. 
Ease of washing and the fact that dirt does not penetrate so readily, were important in 
the soldiers’ minds. 
“Memo, SG for CG ASF, 5 Jun 44, sub: New tropical combat uniform, with 1st ind, CQ ASF to 
SG, 10 Jun 44. HD : 422.3 Protective Clothing. 
» (1) Ltrs, QMG to CGs SWPA and CBI, 1 Jul 44, and to CG CPA, 17 Jul 44, sub : Tests of jungle 
combat clothing. SG : 421 Boots. (2) In the Pacific Ocean areas, the uniforms were issued to soldiers 
functioning in combat and later, by questionnaires and interviews, the combat adaptability and effi- 
ciency of the uniform was determined as well as the likes and dislikes of the soldiers and their criti- 
cisms concerning this uniform. It was recommended that a uniform of 5-ounce poplin made from the 
design of the experimental jacket and trousers, combat, tropical, with certain modifications resulting 
from the tests be standardized Immediately and put into quantity produclon as expeditiously as 
possible. In Ltr, Surg POA to SG, 4 Mar 45, sub: Tests of jungle combat clothing. SG: 421. 
54 Minutes of Meeting, NRC Subcommittee on Clothing, Committee on Aviation Medicine, 24 Oct 
45. HD : 040. 
56 Minutes of Meeting, NRC Subcommittee on Clothing, Committee on Aviation Medicine, 26 Jan 
45. HD: 040. CLOTHING 
55 
Studies on clothing for hot dry climates did not produce such concrete 
results. Adolph56 reported no differences in rates of evaporation of sweat from 
men in hot dry environment wearing various types of light clothing. Solar 
radiation was the important factor. Protective clothing, even though it be 
only a thin white garment, was found to reduce materially the effects of solar 
radiation, and clothing was advantageous in hot sunshine only when the degree 
of work was moderate. The principle was established that lightweight uni- 
forms so constructed as to facilitate free ventilation were best adapted for 
desert use. Color was an important factor and, ideally, white would be desir- 
able. The deeper shades, best for camouflage purposes, absorbed heat, added 
to the heat load of the soldier, and thus more readily exposed him to the danger 
of heat exhaustion. Differences of opinion existed as to the advisability of 
special headgear for desert wear. The consensus was that a loosely fitted 
helmet which allowed free circulation of air provided the best protection.57 
Likewise, footgear with porous uppers facilitated heat loss. Traumatism from 
thorns of cacti and other desert plants was an important factor. It was neces- 
sary that clothing be sturdy enough to reduce injury from these sources to a 
minimum. Adolph,58 towards the end of the war, summarized the status of 
clothing and the understanding of acclimatization of men to hot dry climates 
by noting that knowledge of these subjects was limited and that further long- 
continued studies of climate, physiologic reactions of men to heat, and fabrics 
and design of clothing would be necessary. 
In summary, men are more comfortable when wearing uniforms made of 
thin, tightly woven fabrics, so designed as to facilitate ventilation in the moist 
tropics. During activity, work, or combat, the greatest working efficiency goes 
with the fewest clothes. In hot dry climates, working efficiency at moderate 
degrees of activity is highest when lightweight clothing, preferably light in 
color, is worn. Clothing appears to have little relation to acclimatization. 
Heat exhaustion is the end point of stress to heat. Susceptibility to heat 
exhaustion in general is greater when clothing is worn; design, color, and 
weight of fabrics are important factors in its prevention. 
Clothing and Vectors of Disease 
Clothing remained the first line of defense against the biting of adult 
mosquitoes during World War II despite the development of efficient repellents 
and powerful insecticides. The Office of The Surgeon General and malariolo- 
gists in the field consistently stressed the importance of developing mosquito- 
proof uniform fabrics. Following studies in the China-Burma-India theater, 
88 Adolph, E. F.: Desert. In Newburgh, L. H., ed., op. cit., pp. 330-338. 
87 Ltr, SG to QMG, 6 Mar 43, sub : Sun helmets. HD : 422.3 Protective Clothing. 
68 See footnote 56. 56 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
a representative of the Subcommittee on Clothing of the National Research 
Council reported:50 
Protection against mosquitoes is a property of clothing which all malariologists with 
whom I talked in military establishments and civilian laboratories and other medical 
authorities in Delhi, Calcutta, Rangoon, Colombo, Kandy and Bombay, agreed should be 
provided for military personnel in malaria zones. 
Before the war, considerable study had been given to the development of 
efficient head nets, mosquito gloves, and bed nets. Because the bed nets and 
head nets were of small mesh, interfered with air movement, and therefore 
were uncomfortable, it was difficult to obtain the cooperation of the soldier in 
using them.60 The development of repellents greatly reduced the need for 
head nets and even for bed nets and netted hammocks for field use, also mosquito 
gloves. Repellents functioned satisfactorily in tests on head nets up to 14-inch 
mesh construction, which would have resulted in greater visibility, improved 
ventilation, and marked savings in materials and production costs. The 14- 
inch mesh head net was never issued, however, since its effectiveness depended 
upon re-treatment every few days. With the development of satisfactory 
repellents, an effort was made to improve the insectproofness of the uniform 
by impregnation. Experimentally, it was possible to provide effective repel- 
lency for periods up to 1 week.61 Impregnation produced no significant differ- 
ence in heat exchange through the fabric.62 The method, however, was never 
used on a large scale against mosquitoes in the field. Reliance was placed 
upon use of repellents on the skin of exposed parts of the body and at clothing 
openings. In practice the duration of effectiveness of repellents was found to 
be short, 4 to 6 hours, and was materially reduced by exposure to wet during 
rains and stream crossings. 
Research on insect repellents and insecticides carried out during the first 
months of the war came to have a significant bearing on the role of clothing in 
the protection of the health of the American soldier. In training areas in the 
United States, mites, or common “chiggers,” caused much discomfort and dis- 
ability secondary to infections at the site of bites. In the summer of 1941 The 
Surgeon General requested the Orlando laboratory of the United States De- 
partment of Agriculture to study means and methods for controlling mites by 
repellents or insecticides, or a combination of both. This work led to the con- 
sideration of other insects and resulted in the development of dimethylphthal- 
ate, Indalone, Rutgers 612, and later dibutylphthalate. Madden, Lindquist, 
and Knipling of the Orlando laboratory successfully demonstrated the protec- 
tive value of dimethylphthalate and Indalone for troops in the Louisiana 
w See footnot 54, p. 54. 
80 Annual Rpt, Surg Panama Canal Dept, 1942. HD. 
01 See footnote 43, p. 51. 
82 (1) Minutes of Meeting, NRC Subcommittee on Clothing, Committee on Aviation Medicine, 10 
Mar 44. HD : 040. (2) See footnote 51, p. 53. CLOTHING 
57 
maneuvers in 1942. In 1943 these results were corroborated by an Australian 
medical officer, Capt. R. N. McCulloch, MC, who used dimethylphthalate and 
Indalone against New Guinea species of mites. McCulloch demonstrated that 
dimethylphthalate and dibutylphthalate also were actually effective miticides.63 
Extensive tests in New Guinea and in the Far East showed that clothing 
impregnated with dimethylphthalate or dibutylphthalate was a potent weapon 
in the control of scrub typhus.64 The urgent need for the protection of troops 
against this disease hastened the development of practical improvised field 
methods of impregnation, but not without opposition.65 It was claimed that 
the GI soap used as an emulsifying agent in the process was conducive to 
fungus infections.66 One precaution was noted; nonimpregnated shorts were 
to be worn to prevent irritation of the scrotum.67 No primary irritation of 
the skin was found to result from wearing impregnated clothing and the im- 
pregnates did not aggravate fungus infections of the skin.68 Later, a con- 
centrate embodying an emulsifying agent (Triton-X-100, Tween 20, Span 20) 
simplified the field impregnation of clothing with miticides. Subsequently, 
benzyl benzoate wTas used as a miticide because of its easy availability and the 
short supply of some of the chemicals required to produce dimethylphthalate.69 
The impregnates were lost from the clothing through successive launderings. 
Dibutylphthalate and benzyl benzoate appeared to withstand the greatest num- 
ber of launderings and were favored for that reason. Field tests on benzyl 
benzoate showed that it could be carried through five launderings, but dibutyl- 
phthalate gave longer sustained protection. For practical purposes, however, 
it was recommended that reimpregnation be carried out after each laundering.70 
In the early phases of the war, there was neither vaccine nor an effective 
lousicide for the prevention of epidemic typhus fever. In view of the historic 
wartime havoc from this disease, The Surgeon General instituted a search for 
improved methods of destroying lice. Tests of fumigation gases, such as chloro- 
picrin, eventually resulted in the adoption of methyl bromide for both individ- 
ual and mass delousing of clothing. Considerable question arose as to the 
83 (1) Bushland, R. C: Tests against chiggers in New Guinea to develop a practical field method 
for impregnating uniforms with dimethylphthalate for scrub typhus prevention. Am. J. Hyg. 43; 
219-229, May 1946. (2) Rpt, Capt R. N. McCulloch, 3d Australian Mob Ent Sec, 10 Oct 43, sub ; 
Trombiculid mite control. HD: 710 Typhus (Rpts). 
84 Ltr, Dr. F. G. Blake, Dir USA Typhus Commission, to CG USASOS, 11 Dec 43, sub: Scrub 
typhus in New Guinea—preliminary report and recommendations. HD: 710 Typhus (Rpts). 
65 Rpt, Brig Gen G. B. Denit, Chief Surg USASOS, sub: Mite protection of military personnel 
by simple clothing treatment. HD : 710 Typhus (Rpts). 
86 Ltr, Lt Col C. B. Philip, SnC, to Surg USAFPE, 5 Aug 44, sub : Scrub typhus on Owl and Biak 
Islands. HD : 710 Typhus (Rpts). 
87 Ltr, Maj R. R. Kierland, MC, to Surg Base F SWPA, 31 Jul 44, sub : Investigation of clothing 
impregnated with dimethylphthalate in an emulsion of Q. I. soap. HD: 710 Typhus (Rpts). 
88 Ltr, SG to Chief Surg USASOS, 6 Sep 44, sub : The effect on the skin of clothing impregnated 
with soap—dimethylphthalate. HD: 710 Typhus (Rpts). 
88 Semimonthly Rpt, Prev Med Serv SGO, 16-31 Mar 45. HD. 
70 Ltr, Capt R. C. Bushland, SnC, USA Typhus Commission, to Brig Gen S. Bayne-Jones, USA 
Typhus Commission, 22 Mar 45, sub: Field tests on clothing treatment. HD: 710 Typhus Reports. 58 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
possibility of toxic effects from clothing treated by methyl bromide, but were 
not substantiated. 
Concurrently, the search for a more practical individual method produced 
MYL powder. The Orlando laboratory conducted tests with MYL powder 
on Negro volunteers. Underwear impregnated with this powder remained 
lousicidal for periods up to 160 days.71 Prior to the development of DDT, MYL 
dusted into the clothing and on the underwear was widely used by United States 
Forces in North Africa. 
The researches on DDT began in the fall of 1942. It was soon apparent that 
an insecticide of wide range and multiple usages had been discovered. Tests 
at the Orlando laboratory demonstrated its effectiveness against lice when 
dusted into clothing. Its role in mass delousing was conclusively proved in the 
Naples typhus epidemic. Clothing thus dusted was shown to be lousicidal for 
periods of a month or longer provided it was not laundered. So effective was 
the method for mass delousing that Quartermaster Corps fumigation and bath 
companies were reequipped with hand and power dusters for use with American 
troops if necessary, but pointed primarily at the prevention of typhus fever by 
delousing prisoners of war, refugees, displaced persons, and populations of 
liberated or occupied territories.72 
Efforts were made to impregnate clothing with DDT. It was found that 
the impregnation of underwear was sufficient. A practical field test was at- 
tempted in December 1943 when DDT-impregnated underwear was forwarded 
to the North African theater where it was issued to selected companies of 
French Goums. The test could not be followed to its ultimate conclusion because 
of movement of personnel and loss in supply channels of some of the underwear, 
but it was noted that the troops observed were still free from lice at the onset 
of warm weather. It was concluded that the DDT-impregnated underwear had 
been responsible for drastically reducing the louse infestation of persons who 
normally are constantly infested with lice.73 
Experimental work continued under the auspices of the Preventive Medi- 
cine Service, Office of The Surgeon General. It was announced on 31 May 1944 
that impregnation of underwear was a practical procedure and that an emulsion 
had been found which retained its effectiveness against lice after the clothing 
had been laundered 8 times over a period of 2 months.74 The DDT emulsion 
concentrate for impregnation consisted of DDT, 25 percent; Triton X-100, 10 
percent; and Xylene, 65 percent.75 By dilution with water, any strength of 
71 Knlpling, E. F.: Insect control Investigation of the Orlando, Fla., laboratory during World 
War II. In Annual Report of the Smithsonian Institute, Washington, Government Printing Office, 
1948, pp. 331-348. 
73 ETMD, ETO, Jun 1944. HD : 350.05. 
73 Ltr, Surg NATO to SG, 1 Jul 44, sub : Testing of DDT impregnated underwear. SG : 421 Boots. 
74 Speech by Lt Col A. L. Ahnfeldt, SGO, at press luncheon, Hotel Pennsylvania, New York, under 
auspices of Gelgy Company, Inc., 31 May 44. HD: 700.7. 
75 Semimonthly Rpt, Sanitation and Hygiene Div SGO, 16-30 Sep 44. HD. CLOTHING 
59 
DDT desired could be prepared. In practice, 1 part of concentrate to 11 parts 
of water was found desirable and gave a DDT-dosage of slightly over 2 percent 
of the dry weight of the garment. Underwear impregnated with this material 
was worn in field tests and found to retain its lousicidal effect for periods of 
1 to 4 months without toxic effects or skin irritation. There was some danger 
to personnel handling fuel or lubricating oils while wearing clothing impreg- 
nated with DDT. The practical hazard was incurred when oil which was 
spilled on the clothing would dissolve the DDT and might be absorbed through 
the skin.76 The critical supply situation for Triton X-100 necessitated the use 
of other emulsifiers. Span 20 and Tween 20 proved to be the equal of Triton in 
fresh water, and better as an emulsifying agent in salt water. 
Appropriate clothing acted as a barrier against the cercariae causing 
schistosomiasis. The summary of a report of the 5th Malaria Survey Detach- 
ment and Medical Research Unit is representative of the experimental work 
done.77 
(a) Cercariae of Schistosoma japonicum did not penetrate O. D. woolen trouser 
material within 2 hours in any of a large, series of experiments both when the cloth 
was tested untreated and impregnated with either emulsified dimethyl phthalate, dibutyl 
phthalate, or benzyl benzoate. No cercariae passed through untreated Byrd-cloth. Uni- 
formly, untreated old suntan and fatigue trouser material allowed more cercariae to 
penetrate. 
(b) In rigorous washing tests clothing impregnated with dibutyl phthalate was most 
resistant to penetration by cercariae. 
(c) In continuous water immersion tests, benzyl benzoate impregnation prevented 
penetration one day longer than dimethyl or dibutyl phthalate. 
(d) Woolen sock material did not prevent the passage of cercariae even when 
impregnated. 
Practical considerations dictated that schistosomiasis control was best 
obtained by remaining away from infested water. For engineers, signalmen, 
and others required to work in water at times, waterproofed clothing and boots 
were desirable but not always practical. By the end of the war no effective 
impregnating agent for clothing had been discovered and attention had been 
turned to research on cercariacidal agents and snail control.78 
Leeches were prevalent in the jungles of the Pacific and Far Eastern areas. 
It was necessary to wear trousers inside combat boots to prevent ingress of 
leeches through upper shoelace eyelets or around tops of the boots. 
78 TB MED 194, 17 Aug 45. 
77 Ltr, 5th Malaria Surv Det and Med Research Unit AFWESPAC to SG, 16 Jul 45, sub: In 
vitro experiments on the penetration of cercariae through untreated and Impregnated cloths. SG : 421. 
78 (1) McMullen, D. B., and Graham, O. H. : The control of schistosomiasis japonlca II. Studies 
on the control of Oncomelania quadrasi, the molluscan intermediate host of Schistosoma japonicum 
in the Philippine Islands. Am. J. Hyg. 45 : 274-293, May 1947. (2) McMullen, D. B., and Ingalls, 
J. W. : The control of schistosomiasis japonlca IV. The effect of various chemicals on cercariae of 
Schistosoma japonicum. Am. J, Hyg. 45: 294-298. (3) Army Epidemiological Board: Collected 
Reprints. Washington, Government Printing Office, vol. IV, 1946 ; vol. V, 1947. 60 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
The Quartermaster General was placed under considerable pressure to 
develop a tropical uniform consisting of shorts and shirts with short sleeves. 
A precedent had been set by the British who had used uniforms of this type 
in their tropical stations for a number of years. The Army Air Forces were 
foremost in pressing for the adoption of such a uniform as “special items over 
and above minimum issue of long sleeved and long trousered cotton uni- 
forms.” 79 In response to a request for the procurement of 800,000 of these 
uniforms, the Air Corps was required to substantiate the need. The Surgeon 
General considered that such a uniform was not necessary; it exposed the 
soldier to the hazard of mosquito bites and, for the infantrymen, materially in- 
creased the incidence of skin trauma and infections. An indorsement to this 
correspondence quite clearly states his position:80 
1. The policy of this office on the issue of short sleeved shirts and short pants as 
items of equipment for troops has been there is no objection to the issue of this type of 
equipment provided it is in addition to the standard clothing issued to troops in the field. 
However, it must be pointed out that the short pants and short sleeved shirts if issued 
should be authorized only for wear in daylight hours because of the danger of contracting 
malaria in most tropical stations when protective clothing is not worn after dark. In 
addition, there will be a great increase in the number of skin infections, and traumatic 
skin lesions, as well as lesions due to leeches and other noxious parasites. 
2. The British Army is abandoning the use of short pants and short sleeved shirts 
for most theaters of operation. In those theaters where this clothing is authorized there 
are strict orders that it must not be worn after sunset or before sunrise in the 
morning. . . . 
3. In the Malayan and Burma campaigns from 50%-90% of the English troops 
engaged contracted malaria. The type of clothing and equipment possessed by a large 
proportion of these troops consisted of short pants and short sleeved shirts. Due to the 
high incidence of malaria, orders were issued during the campaign to discontinue the 
wearing of this type of equipment, but due to the shortage of supplies it was impossible 
to comply. Medical authorities assigned to these forces considered the high incidence 
of malaria to be blameable to a large extent upon the nonprotective type of clothing 
possessed by the troops. 
4. The only advantage that can be claimed for the short sleeved shirts and short 
pants is the coolness of this type of equipment and the ability of the wearer to withstand 
high temperatures as compared with wearing the conventional long sleeved shirts and 
long-legged trousers. That there is considerable erroneous Information in this respect 
is evidenced by investigations recently completed under the auspices of the Committee 
on Medical Research of the Office of Scientific Research and Development by the Harvard 
Fatigue Laboratory. . . . “Results of these experiments indicate that the standard sum- 
mer outfit of 8.2-ounce cotton shirt and ankle length trousers does not limit to any 
important degree the capacity for elimination of body heat. Such an outfit is well 
adapted for use of troops since it is durable and affords necessary protection from sun, 
wind, insects and possible chilly nights. Small but measurable increases in coolness may 
be obtained by omitting the undershirt, opening the neck of the shirt, and rolling sleeves 
and pants legs.” 
78 Memo, CG AAF for CG SOS, 8 Oct 42, sub: Uniform for wear in tropic and semi-tropic 
climate. HD: 421.-1 (Uniforms). 
80 Ltr, CG AAF to QMG, 17 Oct 42, sub : Procurement of tropical clothing. SG : 421.-1 (Uniforms) CLOTHING 
61 
5. It is therefore recommended that the short pants and short sleeved shirts not be 
issued to troops unless they are issued as additional items of equipment, and restrictions 
are placed on their use so that these items of clothing are not worn after sunset or before 
sunrise in any malarious area. 
Shorts were never an item of issue by the quartermaster. Several theaters 
permitted local purchase of shorts and shirts with short sleeves. In these the- 
aters, the wearing of shorts was permitted between sunrise and sunset. An 
additional problem of discipline, training, and inspection was thus created and 
undoubtedly was a factor in the prevalence of malaria. 
A consensus of theater reaction to the question of shorts is expressed in the 
report of the Air Surgeon after an extended tour of forces located in malarious 
areas:81 
Standing orders in malarious areas prescribe long-sleeved shirts and long trousers 
for all American military personnel. The same is true in the Australian Army. The 
reasons are summarized in the following statement of the Combined Advisory Committee 
on Tropical Medicine, Hygiene and Sanitation: “In the opinion of the Committee, it is 
essential, not only for malaria protection, but also for protection against other diseases, 
such as dengue fever and scrub typhus, and against skin injuries, insect bites, septic 
sores, tropical ulcers and blast burns that long-sleeved shirts and slacks be worn on all 
occasions.” There have been complaints of heat rash ascribed to the wearing of such 
garments. 
As a result of their experiences in New Guinea, the Australian Army au- 
thorities prohibited the wearing of shorts, day or night.82 
Clothing and Skin Diseases 
Clothing in relation to skin diseases was an unsolved problem. It was the 
experience in all theaters located in hot climates that skin diseases were an im- 
portant cause of disability and loss of time. Dr. Sid Robinson, after spending 
5 weeks in India, Burma, and Ceylon, reported that:83 
The most difficult and most prevalent problem confronting the ground forces in 
Burma and India is skin trouble. Beginning with prickly heat as the most universal 
disturbance, a long list of troubles could be listed including tropical sores, ringworm, 
blisters, toe rot, athlete’s foot, scabies, dhobie itch, etc. Infections of the feet and legs, 
jungle or tropical sores being quite common, were the most disabling skip infections 
of the front line troops in Burma. . . . All medical and operational personnel in the 
theater recognize skin trouble to be a major problem. 
This was borne out by the experience in other theaters in the tropics, notably 
the Southwest Pacific area.84 Skin diseases as influenced by clothing appeared 
81 Rpt, Inspection Trip SWPA, [Mar 1943] Brig Gen D. Grant, Air Surg. HD: 333. 
82 Tidy, Henry L., and Kutschbach, J. M. Browne: Inter-Allied Conferences on War Medicine. 
London, Staples Press Limited, 1945, p. 88-100. 
88 See footnote 54, p. 54. 
84 (1) Skin diseases in the tropics. Bull. U. S. Army M. Dept., No. 80: Sep 1944. (2) Clark, 
T. W. : Treatment of skin diseases in the tropics. Bull. U. S. Army M. Dept., No. 87 : 70-76, Apr 1945. 
(3) Dermatological problems in tropical theaters. Bull. U. S. Army M. Dept. 4: 299-300, Sep 1945. 
(4) Epstein, E.: The lichen planus - eczematoid dermatitis complex of the Southwest Pacific, a study 
of 65 cases. Bull. U. S. Army M. Dept. 4 : 687-694, Dec. 1945. 62 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
under three main considerations: footgear and trichophytosis; the wearing of 
the uniform to prevent insect bites, scratches, abrasions, and cuts which, when 
they occurred, often became secondarily infected; and miliaria, or prickly heat, 
which may have been made worse by clothing covering the major portions of 
the body. So many variables influenced the prevalence of dermatophytosis that 
it was impossible to define the precise role of clothing. The experience of the 
war established that type of footgear was an important consideration, and 
especially incriminated the combat boot.85 The protection afforded by clothing 
against skin trauma is a part of many records. In the Middle East, annual 
admission rates per 1,000 for miliaria for the months July, August, and Septem- 
ber 1944, were 4.88, 5.39, and 9.05 respectively, and in the China-Burma-India 
theater, 2.47, 3.16, and 2.09 during the same months. Rates for cases severe 
enough to affect efficiency but not made of record will never be known, but 
undoubtedly were high. Dr. Robinson noted the prevalence of prickly heat in 
the Pacific theater and pointed out that the University of Queensland, Aus- 
tralia, had sponsored the organization of a research team for work on the 
fundamental aspects of skin physiology. He recommended the initiation of 
research on the same problem by American scientists. 
Footgear 
The leather combat boot of World War II was not satisfactory for jungle 
operations. In addition to its probable role in trichophytosis, it did not stand 
up well under use in the wet jungles. The Surgeon General encouraged devel- 
opment of special footwear for the tropics which would combine protection 
against biting insects, ventilation of the feet, and comfort. The Quartermaster 
General developed a rubber-soled boot with permeable duck-fabric upper and 
stitched tongue that was impermeable to mud, insect bites, and leeches, but at 
the same time provided ventilation. A removable fabric insole was a feature 
of the boot, and when worn with a cushion-soled sock, sweat from the feet was 
dissipated by evaporation.86 The feet dried more rapidly whether wet by 
perspiration or water. The leather service shoe, on the other hand, was found 
by the Armored Medical Research Laboratory to permit dissipation of only 
a relatively small amount of foot moisture to the exterior.87 
The advisability of developing a mosquito boot for the protection of the 
American soldier against malaria was considered by The Surgeon General and 
discarded as impractical and unnecessary, a decision that proved to be sound 
as the tropical uniform and insect repellents came into use. The need for this 
85 (l) Quarterly Rpt, 144th Sta Hosp SWPA, 1945-3. HD. (2) Quarterly Rpt, Med Det 
839th Engr Avn Bn SWPA, 1945-3. HD. 
86 Pitkin, T.: Quartermaster equipment for special forces. QMC Historical Studies No. 5, OQMG, 
Feb 1944. 
87 Rpt, Armored Med Research Lab, 4 Dec 45, sub: Study of sweating of the feet of marching 
troops. HD : 421 Shoes. CLOTHING 
63 
item for use by officers, nurses, and troops, however, was insisted upon by Air 
Force personnel stationed in Africa. British practice had set the precedent, 
and Pan-American Airways had used a similar item with satisfactory results. 
Extra length boots were recommended for members of the Army Nurse Corps. 
The Surgeon General’s policy and opinion on the development of this boot is 
expressed as follows:88 
1. This office does not consider the issue of mosquito boots to troops and/or nurses as 
satisfactory or desirable for the protection of the health of the individuals concerned, 
provided all troops are furnished standard long trousers and canvas leggings, and nurses 
are provided with uniform, one-piece, coverall type with canvas leggings. The canvas 
leggings and long trousers afford adequate protection against mosquito bites and greater 
protection than mosquito boots against the bites of crawling insects such as chiggers, 
fleas, and ticks. They also prevent the ingress of leeches which abound in most tropical 
jungle areas in Africa and Asia. For the same reasons, the one-piece uniform, coverall 
type, with canvas leggings, affords much greater protection for nurses than mosquito 
boots. The mosquito boot affords no protection for nurses against crawling insects and 
leeches. It is extremely uncomfortable to wear, fatiguing, and practically impossible to 
keep in place during operations in jungle territory. 
2. The use of mosquito boots at fixed camps and stations may have some value, but 
for all-around military purposes, it is felt that this type of equipment is undesirable as 
an item of issue to troops in tropical regions. 
3. It is strongly recommended that mosquito boots not be standardized for issue to 
troops and nurses. 
Development of the item was subsequently discontinued by The Quartermaster 
General.89 
CLOTHING FOR COLD CLIMATES AND/FOR WINTER OPERATIONS 
IN TEMPERATE CLIMATES 
Development of Research and Field Tests 
Provisional data recorded approximately 90,536 cases of cold injury for 
United States Forces operating in all theaters during World War II.90 This 
experience has been summarized in a study at the Harvard University School 
of Public Health in which the role of clothing as one of a number of environ- 
mental factors was demonstrated.91 The history of the development of cold 
weather clothing has been carefully prepared by the Office of The Quarter- 
master General,92 the physiologic adaptation of man to cold has been briefly 
** 4th ind, SG to Dir Regmts Div SOS, 15 Aug 42, on Ltr, CO SOS USAF Central Africa to CG 
SOS, 22 Jul 42, sub : Mosquito boots. SG : 421.-11 Shoes. 
13th ind, CG SOS to QMG, 2 Jan 43, on Ltr, QMG to CO SOS USAF Central Africa, 11 Aug 42, 
sub: Mosquito boots. SG : 421 Boots. 
80 Information supplied by Medical Statistics Division, Office of The Surgeon General, 22 Mar 55. 
81 Whayne, Tom F.: Cold Injury in World War II, A Study in the Epidemiology of Trauma. 
Thesis, Harvard School of Public Health, 1950. 
82 See footnote 86, p. 62. 64 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
summarized above, and Newburgh and his associates93 have made a thorough 
review of the literature and of the results of research during World War II. 
Cold injury in World War I was minimal, and affected American troops 
only in the last weeks of the war. Training maneuvers in the cold climates 
between the wars and early in World War II did not provide sufficient exposure 
to alert those responsible for preventive medicine to the casualty-producing 
potentiality of cold and wet. The history of wars fought in winter cold, 
however, were a continuing story of crippling losses from cold injury. 
The Surgeon General was not active in the development of cold weather 
clothing during the early phases of the war. The chief of the Sanitation 
Division, Preventive Medicine Service, in his recommendations that led to the 
study of the physiology of man in relation to clothing, had included adaptation 
to cold. In 1941 The Surgeon General advised The Quartermaster General 
that semi-impervious ski clothing was satisfactory for arctic wear provided 
provision for adequate ventilation wTas made during periods of physical 
exertion. Isolated activities were initiated, but were not included in the pre- 
ventive medicine program. An opportunity to take part in special projects 
in a cold climate that involved the use of clothing was declined in the fall of 
1942.94 
Consideration of plans for cold weather operations emphasized the lack 
of knowledge of arctic clothing, medical equipment, and supplies. The Sur- 
geon, Headquarters Alaskan Department was ordered to the Office of The 
Surgeon General for consultations on clothing, hospitalization and evacuation, 
medical equipment and supplies, housing, and arctic sanitation in 1942. Upon 
his return to Alaska, field studies were begun which included observations upon 
clothing.95 The Surgeon General initiated action for the procurement of arctic 
clothing for nurses early in September 1942.96 Changes in the basic list of 
items and standardization with men’s arctic clothing where possible delayed 
procurement beyond the period of the Attu operation. 
Investigations on protection for the extremities by footgear and gloves 
of improved design were carried out by the Armored Medical Research Labor- 
atory, in the summer of 1943, and were expanded to include tests of the adequacy 
and ranges of use of winter combat clothing in subsequent research.97 The 
Surgeon, Headquarters, United States Air Forces, Central Canada, repotted 
upon the inadequacies of winter clothing in August 1943 and continued cloth- 
03 See footnote 1, p. 31. 
M 1st Ind, SG to CG SOS, 30 Oct 42, on Memo, CG SOS to SG, 19 Oct 42, sub : Arctic clothing. 
SG: 422.-1. 
96 Memo for record, Col T. F. Whayne, MC, 17 Oct 50, sub: Conference with Col W. S. Stone on 
the development of cold weather clothing. HD: 422.3 Protective and Special Clothing. 
96 Ltr, SG to CG SOS, 5 Sep 42, sub: Arctic clothing and equipment for nurses. HD : 421 Uniforms 
(Nurses). 
97 Annual Rpt, Armored Med Research Lab, 1945. HD. CLOTHING 
65 
ing observations into 1945.98 A study of the effect of climate on protective 
clothing for personnel was made a joint project between the United States 
Army, the Canadian Army, and British Army in 1944." Two expeditions 
to Alaska, one in 1943, and one in 1944, tested mosquito repellents, mosquito 
head nets, mosquito gloves, mosquito socks, and certain fabrics to determine 
clothing and procedures best adapted for protection against pest insects in the 
North.100 
Surgical consultants of the Professional Service, Surgeon General’s Of- 
fice, shared the interest in prevention of cold injury with the Preventive 
Medicine Service, while at the same time placing much emphasis upon treat- 
ment, rehabilitation, and reconditioning. It was not until after the losses of 
the first winter in Italy that an energetic effort was brought to bear upon the 
prevention of trenchfoot and other cold injuries.101 
Representatives of the Office of The Surgeon General participated actively 
in the proceedings of the Subcommittee on Clothing, National Research Council, 
the studies of which embraced cold wTeather clothing. Research by Newdmrgh 
and his associates was far reaching in its approach to the problem of man and 
his clothing in relation to cold. Physical responses, physiologic adjustment, 
and emotional reactions of man to the stress of cold were studied. Regional 
heat loss, the range of physiologic response to climatic cold, indices of comfort 
and the physical properties of clothing fabrics, clothing in relation to climate, 
and protection from clothing against the extremes of climate in the field were 
investigated. 
Textile research and development produced no synthetic fibers and fabrics 
which were superior thermal insulators to wool and alpaca pile materials or 
to the fur of northern animals such as the caribou. The development of pile 
fabrics as clothing insulation for arctic climates made possible for the first 
time in history the fabrication of washable combat garments which approached, 
in the protection they afforded, the fur parkas used by the Alaskan scouts before 
World War II. A tightly woven, wind-resistant 9-ounce Oxford cloth was 
developed as the best of the wind-protective fabrics which were practical from 
the standpoint of mass production and combat-wear life. The combination 
of pile insulators and wind-resistant outer covers was one of the major advances 
in cold weather clothing development. Several types of arctic footgear were 
developed. Fur, wool, and other fibers were used in various ways, including 
felts, without producing an entirely satisfactory item. For winter operations 
in temperate climates, the shoepac, as finally designed was considered satis- 
88 ETMDs, USAF Central Canada, 2 Aug 43, 19 Mar 45. HD : 350.05. 
89 See Minutes of Meetings, NRC Subcommittee on Clothing, 1944, 1945. HD : 040. 
100 Rpt, 2d Arctic mosquito test expedition, 1944. SG : 725.11. 
101 Rpt, Lt Col M. Ladd, JAGD, to SG, 9 Jun 45, sub; Study of records and of investigation rela- 
tive to trench foot. . . . HD: 710 Trench Foot. 66 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
factory when fitted loosely over two pairs of wool ski socks in graduated sizes 
and worn with a felt insole in the bottom of the boot. 
Experiments with impervious latex rubber socks gave promise of much 
improvement in protection of the feet. A wool sock next to the foot, covered 
in turn by a rubber sock, a second wool sock, and finally a second rubber sock, 
experimentally gave greatly improved protection, but in field tests was not 
readily accepted by the soldier. 
The end of the war brought promise of the development of better pro- 
tective fabrics with the studies on silica aerogel. First studied as a water- 
repellent agent of great buoyancy for use in flotation suits, it was also 
discovered that aerogel had great thermal resistance. In the form of a powder, 
it was first used as insulation in sleeping bags, certain types of experimental 
jackets, and blankets. Later, through a bonding process with latex, it was in- 
corporated into certain types of fabrics by laminating techniques and designated 
under the name “Aerobond.” Experimental use in antiexposure suits, ponchos, 
parkas, and trousers for wet weather wear, waders for the prevention of 
schistosomiasis, arctic clothing, gloves, and liners for combat boots, gave con- 
siderable promise.102 However, while silica aerogel in its pure unbonded form 
has a superior thermal insulation value to that of still air, serious problems 
arose due to the difficulties of anchoring the powder in place without destroy- 
ing its desirable properties. In addition, no successful, practical methods 
were found for containing the aerogel in vapor permeable materials, so this 
project was abandoned. 
These researches and developments in clothing were carried out during 
the war period. Consequently, preparations for combat in the cold lagged 
despite the great efforts that were made to translate the results of these studies 
into practical protection for the soldier in the field. 
Clothing and Cold Injury 
Many American soldiers suffered unnecessary cold injury on Attu, in the 
Mediterranean theater, and in Western Europe for lack of adequate types and 
supplies of clothing or because their training in the use of clothing had been 
incomplete. 
On Attu, troops were largely equipped with high-topped, laced leather 
boots. Among those so equipped, trenchfoot developed in large numbers, 
whereas those with the shoepac were much better protected.103 When the 
Attu task force was getting ready to depart, in May 1943, Quartermaster Corps 
cold-climate specialists had recommended shoepacs to the commanding general. 
102 (1) Minutes of Conference on Hydrophobic Silica Aerogel, NRC Subcommittee on Clothing, 
Committee on Aviation Medicine, 30 Sep 44. HD: 040. (2) See footnotes 54 and 55, p. 54. 
103 Annual Rpt, 183d Sta Hosp Alaska, 1943. HD. CLOTHING 
67 
Instead of the shoepac, he had chosen a 12-inch leather Blucher boot, which 
was perhaps a more comfortable item but not so well insulated nor so efficient 
as the rubber-footed shoepac would have been in the slush of Attu.104 In an 
after-action report dated 10 June 1943, the surgeon of the forces on Attu 
stated:105 
The large number of casualties due to foot trouble were the result of damp feet, 
added to cold and the inability of men pinned down in foxholes or other cover to keep up 
proper circulation by exercise. A waterproof type of footgear would probably have 
prevented the occurrence of disability in many of these cases. 
For the Attu action, the annual rate for total cold injury for the 22-day period 
was 1,301.2 per thousand per year. This figure reflects the task force’s unpre- 
paredness for winter combat and their deficiencies in training and clothing. 
The principal problems of protective clothing in relation to cold injury in the 
Mediterranean Theater of Operations were summed up by the Fifth United 
States Army Surgeon in his annual report for 1944;106 
The Winter Campaign of 1943-44 found Fifth Army troops poorly equipped to meet 
the dangers of trench foot. Troops were provided only with the Standard Army shoe 
or combat boot and a light wool sock. These shoes and boots became water-soaked and 
the light wool sock offered no protection against either wet or cold. The shoe or combat 
boot fit so snugly that a heavy wool sock could be worn only by issuing a larger size 
shoe. Supplies were not adequate for such a readjustment, nor were heavy wool socks 
available for issue early in the winter. Apart from these deficiencies, neither officers nor 
enlisted men were alert to the dangers of trench foot, or adequately indoctrinated in 
preventive measures. Trench foot was a new experience to Fifth Army troops and the 
preventive measures urged by the Surgeon were difficult to put into effect. 
Recommendations were made for a daily change in socks, but at first there were 
not sufficient socks on hand to enable their being “issued with the rations.” . . . 
In the winter of 1944—45, Fifth Army troops were better equipped and trained to 
prevent the occurrence of trench foot. All combat troops were issued shoe pacs to be 
worn with two pairs of heavy wool ski-socks and a pair of felt innersoles. All divisions 
made provisions to supply front-line troops with an exchange of socks and to provide 
warming and drying stations near the front lines. . . . 
When, despite the issuance of shoe pacs, a flood of trench foot cases occurred in 
Fifth Army troops in the month of October 1944, the Office of the Surgeon prepared a 
questionnaire for every trench foot admission to a Fifth Army Hospital to determine the 
cause for this influx of cases. It was discovered that a number of the troops had not been 
properly instructed in the use of the shoe pac, nor had they been issued proper sizes. 
The shoepacs as originally issued in the Mediterranean theater in the fall of 
1943 were unsatisfactory. They had neither heel nor arch support, traction was 
poor, and the combat soldier felt they were a hindrance in combat.107 Studies 
104 U. S. Army In World War II. The Quartermaster Corps: Organization, Supply, and Services, 
vol. I, p. 106. Washington, Government Printing Office, 1953. 
10B After-Action Rpt, Surg Attu Force, 10 Jun 43. HD: 319.1-2. 
10# Annual Rpt, 5th Army Med Serv MTO, 1944. HD. 
107Memo, Dir Sanitation and Hygiene Div SGO to Chief Prev Med Serv SGO, 20 Jun 44, sub: 
Immersion (trench) foot problem. HD:350.05 (NATOUSA, Mar 1944). 
346336 0—55 6 68 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
of footgear conjointly made by the Surgeon, Mediterranean Theater of Opera- 
tions, United States Army, and Chief Quartermaster prior to and during the 
Anzio beachhead operation were forwarded to the War Department through 
Quartermaster Corps channels and recommended heels, arch supports, and sole 
traction for the shoepac, and an adequate supply of the heavy wool ski sock. 
The necessity for a heavier sock was further supported by a comparison of the 
American and British experiences. By 20 December 1943, the Fifth United 
States Army had had over 900 cases of trenchfoot, whereas a like number of 
British troops experienced only 50 cases. The principal difference was that 
American troops were issued 20-percent wool smooth-ribbed, lightweight socks, 
whereas the British wore a heavy-ribbed, pure wool sock. French troops wear- 
ing the American issue likewise had high rates for trenchfoot.108 Adequate 
supplies of heavy wool socks did not begin to reach the theater until late in 
the winter. The essential technical medical data report for March 1944 re- 
ported tests of heavy socks in the 3d Infantry Division and supported their use 
as a “definite step in the right direction in the prevention of trench foot.”109 
The supply of socks was greatly improved before winter operations late in 
1944. The entire Fifth Army had shoepacs by the middle of October, but it 
was not until December that the desirable ski sock was available for general 
issue.110 The essential technical medical data report for the month of January 
1945 stated that:111 
Shoepacs when properly worn, appear to be a real protection against trench foot 
since only 11 percent of cases in December were wearing shoepacs with the two pair of 
ski socks as recommended. A total of 38 percent were wearing shoepacs but 27 percent 
were wearing the wrong socks. Fitting of shoepacs is now better, but there is still a 
shortage of smaller sizes. The most frequent complaint against shoepacs as noted on 
trench foot questionnaires is that feet perspire in them and then get cold. The solution 
is to change socks frequently allowing the damp socks to dry against the body. There 
is also some difficulty in maintaining stocks of ski socks so that men can always wear 
two pair and carry two pair. 
The German troops were reported not to have suffered severely from cold 
injury in the Mediterranean theater. They attributed this to excellent foot 
hygiene and discipline, easily removable high leather German field boots, and 
the four pairs of thick, but loosely woven, all-wool high stockings provided to 
German troops in forward areas in the winter.112 
Some shortages of other items of the uniform existed in the Mediterranean 
theater in the winter of 1943-44, but footgear was cause for the greatest concern. 
At the end of December 1943 only 50 percent of nurses in the North African 
ins ETMD, NATOUSA, Dec 1943. HD : 350.05. 
loo ETMD, NATOUSA, Mar 1944. HD : 350.05. 
no ETMD, MTO, Dec 1944. HD: 350.05. 
in ETMD, MTO, Jan 1945. HD : 350.05. 
H2 ETMD, MTO, May 1945. HD : 350.05. CLOTHING 
69 
theater were equipped with woolen uniforms.113 In the fall of 1944 many troops 
were issued standard War Department uniforms including the jacket, field, 
M-1943; trousers, field, cotton; shoepacs; ski socks; and the high-necked 
sweater. Initially, this uniform was not well accepted by troops. Investiga- 
tions revealed that these uniform items had not been well fitted and were not 
being worn in the manner for which they were designed. Training classes and 
a refitting program indoctrinated troops with the proper use of the uniform 
and resulted in a general acceptance. Training programs stressed that any 
constriction of clothing should be avoided, that perspiration was dangerous in 
the cold, that tight closures at neck, wrist, waist, and ankles were essential for 
maximum warmth, and that damp socks should be changed regularly. 
In the European theater, planning, training, and stockpiling of clothing 
and footgear failed to take full cognizance of the clothing lessons learned in 
Italy. Confidence born of the rapid sweep across Europe in the summer of 
1944 and the conviction on the part of many that the successes of Allied arms 
would be rewarded by victory before the onset of winter contributed to the 
unpreparedness for winter combat. Under these circumstances, command, 
training, and technical directives initiated by the Preventive Medicine Division 
of the Office of the Chief Surgeon, European Theater of Operations, produced 
few results. The onset of trenchfoot early in November 1944 could be likened 
to the situation in the Mediterranean theater in the fall of 1943. The greatest 
defects as to clothing were insufficient supplies, inadequate footgear, improper 
sizing and fitting, and failure to train the soldier in the proper use of 
clothing.114 
Only the Seventh United States Army, which had previously served in 
Italy, was supplied with shoepacs by the middle of November 1944.115 The 
Annual Report, Division of Preventive Medicine, Office of the Chief Surgeon, 
for 1944 reported:llfi 
Clothing and Equipment; The most outstanding deficiency in respect to clothing has 
been that related to overshoes and shoepacs. Shortage of these items has contributed 
to the incidence of trench foot. The following were apparent reasons for insufficient 
supplies: (a) Troops embarking to this theater equipped with overshoes were required 
to turn them in prior to departure, the understanding being that they would be similarly 
equipped upon arrival overseas, (b) There was a critical shortage of these items which 
was alleviated in part by air shipment from the United Kingdom, (c) There was an 
overage of smaller sizes of overshoes which further complicated the overall basis of 
allowance and issue, (d) Priority in issue was justly given to combat troops at the 
expense of service units. The latter troops were many times working continuously in 
the rain and mud without suitable foot cover. 
113 See footnote 108, p. 68. 
114 (1) Rpt, 3d Army Trench Foot Control Team, 10 Apr 45. HD: 710 Cold Injuries (ETO). 
(2) Rpt, 1st Army Trench Foot Control Team, 7 Apr 45. HD: 710 Cold Injuries (ETO). 
lwLtr, Lt Col R. P. Mason, MC, to Chief Surg ETOUSA, 11 Jan 45, sub: Report on study of 
trench foot in Seventh Army. HD: 710 Cold Injuries (ETO). 
113 Annual Rpt, Chief Surg ETO, 1944. HD. 70 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Many reports of medical officers stated that the soldiers were inadequately clothed 
to withstand the severity of the European winter. It is felt that the M-39 field jacket 
normally issued is not practicable and cannot be compared with the British woolen battle 
jacket as regards warmth. The garrison cap, OD, worn by many troops in the rear, 
is worthless as headwear in that it neither keeps the rain from the face, the sun from 
the eyes, nor affords protection to the ears. Many units such an anti-aircraft gun crews 
who have to stand watch in fixed positions should be issued subarctic clothing for com- 
fort since they have little opportunity for movement and the wearing of such apparel 
will not interfere with their work. 
Blankets were in short supply during the early autumn, many units having but two 
per individual. The authorized issue of 4 per man still cannot be provided in many 
instances. Sleeping bags are heartily received by the troops, and no adverse comments 
relative to their use have been heard. 
The shoepac was not considered entirely satisfactory for western European 
winter operations.117 A variety of expedients in footgear were tried, some of 
which were deemed satisfactory. Blanket-strip wrapping and socks, made 
from blankets and worn inside the arctic overshoe, were among the most effec- 
tive of these.118 
Unit shortages in the supply of footgear, especially the arctic-type over- 
shoe, form a part of too many of the official records of units to be detailed. A 
study made by the Preventive Medicine Division, Office of the Chief Surgeon, 
showed that in November 1944, only 3 divisions were completely equipped with 
overshoes; in December, 9 divisions were still incompletely equipped; and in 
January 1945, 7 still lacked overshoes for their entire commands. When rates 
for cold injury were related to supply of overshoes, it was found that divisions 
fully equipped in November had an average rate of 4.3 per thousand per annum; 
those not fully equipped until December, a rate of 10.5; and those not fully 
equipped until January 1945, a rate of 11.7.119 Soldiers often declined to wear 
overshoes into combat because of weight and poor traction and some divisions 
ordered overshoes left behind when combat activities took place.120 By Janu- 
ary 1945 both shoepacs and overshoes were in much more generous supply. 
Woolen socks were never in critical shortage, but difficulty was experienced by 
many units in getting them forward for daily exchange.121 
Tariffs for shoes and overshoes were predominantly in the small sizes 
because they had not been established with the view to the extra sizes required 
to fit footwear over two pairs of wool socks. Correspondingly, overshoes were 
not available in the required large sizes. Many men had not been resized since 
passing through reception centers.122 
117 See footnotes 17, p. 40 and 114, p. 60. 
118 (1) Semiannual Rpt, Surg 3d Armored Dlv ETO, 1945-1. HD. (2) Semiannual Rpt, Surg 
44th Cav Recon Sq (Mecz) ETO, 1945-1. HD. 
119 See footnote 91, p. 63. 
120 Rpt, Maj. P. A. Siple, QMG Tech Observer, 12 Apr 45, sub : Report on adequacy of winter 
clothing in ETO, winter 1944-45. HD : 710 Cold Injuries (ETO1). 
121 See footnote 114, p. 69. 
122 See footnote 114 (2), p. 69. CLOTHING 
71 
In addition to the difficulties with fitting, the M-3 and the field combat 
boot were poorly constructed for the prevention of trenchfoot. The welt-type 
sole leaked, there was too little room in the vamp, and the uppers were so 
scantily cut around the ankles and above, that properly fitted shoes could rarely 
be laced together without causing some constriction. With the bulk of extra 
socks, these defects were particularly objectionable and some constriction from 
lacing the shoe was the rule. These basic defects were recognized by The 
Quartermaster General. Based on a special report by Mr. Lawrence B. Shep- 
pard,123 Assistant Director of the Leather and Shoe Division, War Production 
Board, after a survey of footgear requirements in the theater, the Chief Quar- 
termaster, European Theater of Operations, United States Army, made several 
recommendations. He suggested that a combat boot similar to the one used 
throughout the war be maintained but that a change be made from a welt con- 
struction to a more waterproof type; that the last fits too closely and therefore 
requires further development; that better fitting devices and procedures be 
executed, especially at reception centers.124 
In February 1945, a representative of the Quartermaster General’s Office 
was sent to the European theater to observe the adequacy and use of winter 
clothing. He reported that the complete clothing assembly as developed by 
The Quartermaster General was adequate for frontline troops, but was provided 
in insufficient quantities and in many cases so late in the season that it was not 
available for winter combat. The winter campaign in Europe was fought 
by most combat personnel in a uniform that did not give proper protection. 
The principal weaknesses described were insufficient insulation, poor balance 
of insulation, lack of windproofness, lack of water repellency, and faulty clos- 
ures. The report further pointed out that the clothing initially provided for 
the European theater could not afford sufficient insulation because of poor 
balance, insufficient overall thickness, and the inefficiency with which it was 
worn.125 
Clothing conferences were held by the Chief Quartermaster, European 
Theater of Operations, and attended by Quartermaster Corps representatives 
from major forces and units on the Continent in January and March 1945. The 
purpose was to determine which articles of clothing were best adapted for 
preservation of the health of the combat soldier, for combat adaptability, and 
for durability. They also considered the service uniform for service troops 
and for all troops after the cessation of hostilities. The keynote of the con- 
ference was the provision of a simple and practical uniform and the reduction 
of the number of different uniform items. The winter combat jacket was unani- 
mously favored and the wool and combat trousers met acceptance. Little 
123 See footnote 15, p. 40. 
124 Memo, Chief QM ETO to QMG, 23 Mar 45, sub: Footwear and socks for use In the European 
Theater of Operations. HD: 332.81 (ETO) (Winter Clothing). 
125 See footnote 120, p. 70. 72 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
change in underwear, shirts, hand gear, and headgear was thought necessary, 
but modifications of the combat boot, service shoe, overshoe, and shoepac were 
recommended. It was thought that socks should undergo some modification; 
sweaters should be unchanged; and the overcoat be limited to the poncho, light- 
weight, nylon type and the overcoat, field, trenchcoat type. The Chief Sur- 
geon, European Theater of Operations, favorably indorsed these recommenda- 
tions to the War Department.126 
The role of protective clothing was emphasized in a period report for 1 
January to 30 June 1945 by the Surgeon, Third United States Army:127 
It was self-evident that cold type injuries were preventable in seventy-five to ninety 
percent of the cases. Prevention depends upon a combination of factors: 
1. Adequate, properly fitting winter clothing. 
2. Adequate, properly fitting footgear or combination footgear (shoepacs, regulation 
shoes, combat boots, and overshoes). 
3. Adequate, properly sized socks. 
4. Continuous, daily sock exchange to combat troops during the winter months. 
5. Rotation of small and large units of combat troops out of the line at frequent 
regular intervals to enable warming, drying and changing of individual soldier’s wet 
shoes and socks. Providing tents, huts, etc., wherein these things may be done. 
6. Instruction and training of troops in the early recognition of signs and symptoms 
preceding injury of tissue due to cold and dampness and the individual precautions 
necessary to prevent frostbite. 
7. Continued emphasis of the command responsibility for the above items. 
8. Frequent inspections (at least once weekly) of feet and footgear of the command. 
Necessary corrective action, insofar as possible, must be taken on the spot. 
So many factors combined to produce the approximately 64,008 American 
casualties128 from cold injury in Western Europe that it is impossible to estimate 
accurately what proportions could have been prevented, or the relative weight 
of one factor such as clothing. 
Several important principles, however, did evolve from the wartime re- 
search and theater experiences on clothing for the cold regions. 
1. Clothing is one factor among several which influenced noneffectiveness 
from cold injury. In a conference of trenchfoot control officers, held in Paris, 
21 April 1945, these experienced officers placed the following factors in the 
prevention of trenchfoot in the order of their importance as follows:129 
126 Memo, Chief QM ETO to QMG, 9 May 45, sub : Winter uniform, with 1st ind, Chief Surg BTO 
to CG ComZ ETO, 12 May 45. HD : 332.31. The chief surgeon’s indorsement contained the following 
statement: “Subsequent to the above meeting, a general conference of all trench foot control teams 
of armies was held in Paris. The line was principally represented, together with medical officers 
responsible for preventive medicine. It is significant that this group came to essentially the same 
conclusion in respect to clothing as did the Quartermaster conference.” 
127 Semiannual Rpt, Med Sec 3d Army, 1945-1. HD. 
128 This constitutes more than four 15,000-men divisions. Approximately 90 percent of cold 
casualties Involved riflemen and there were about 4,000 riflemen per infantry division. Thus closer to 
13 divisions were critically disabled for combat. For further details see volume on Cold Injury, 
History of Medical Department, United States Array, World War II, to be published. 
120 See footnote 100, p. 65. CLOTHING 
73 
a. Individual foot care. 
b. Clothing and equipment. 
c. flotation. 
d. Weather. 
2. No clothing developed during the period could be considered as complete 
protection against cold. 
3. Properly designed and effective clothing covering the torso is just as 
important as protective clothing items for the feet in the prevention of trench- 
foot. Loss of heat from any part of the body predisposes the cold injury of 
another part. This concept was dramatized by the Chief of the Preventive 
Medicine Service, Office of the Chief Surgeon, European Theater of Operations, 
when he said: “When a soldier takes off his hat, his feet begin to get cold.”130 
4. The most effective clothing for cold climates embodied layering of wool 
clothing underneath an outer garment of tightly woven windproof, water- 
repellent, durable fabric. This principle made the maximum use of the in- 
sulating properties of still air.131 
5. For maximum protection against the cold, the various items of clothing 
must be worn for the purposes for which they were designed. The Quarter- 
master General developed groups of clothing items appropriately called “cloth- 
ing assemblies.” Unless utilized as a total assembly, the degree of protection 
was materially reduced. This could be accomplished only by adequate supplies 
to forward elements of all components of the assembly, and by careful train- 
ing of all personnel in the utilization of the winter clothing assembly to pro- 
vide maximum protection. 
6. Prevention of trenchfoot required waterproofed footgear worn over 
sufficient insulation by air and wool as provided by at least two pair of heavy 
woolen socks. Since wetness destroyed the insulation thus provided, oppor- 
tunities for a change to dry socks must be provided daily and certainly within 
the average incubation period (3 days) of trenchfoot.132 
7. Loose fit of clothing and footgear to avoid constriction of the parts and 
unnecessary friction, and to provide freedom of action is essential for full cloth- 
ing protection against cold. 
SPECIAL CLOTHING PROBLEMS 
A number of special problems arose in connection with clothing, some prin- 
cipally medical in character, others obliquely so because specialized protective 
techniques introduced health hazards in themselves. 
130 Sec footnote 100, p. 65. 
331 See footnote 120, p. 70. 
132 See footnote 91, p. 63. 74 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Impregnation of Clothing 
Impregnation of clothing is patently a responsibility of the Chemical 
Corps. Toxicity, skin irritation, and added physiologic heat loads produced 
by the impregnates in clothing were of pertinent medical interest. Clothing 
impregnation with insecticides has been discussed in the section on clothing in 
the hot climates. Although plans for testing wool impregnated with these 
agents were made in the summer of 1945,133 no evidence that they were carried 
out has been found. 
The medical aspects of fireproofing and water repellency techniques came 
under the surveillance of the Subcommittee on Clothing, National Research 
Council, as early as 1 September 1942.134 Pursuing the concept of developing 
clothing in accord with physiologic demands, The Surgeon General in the fall 
of 1942, called to the attention of the Chief of Staff the probable hazards from 
clothing impregnated against vesicant gases to soldiers operating in the tropics. 
In January 1943 a directive from the Chief of Staff to the Chief, Chemical War- 
fare Service, set up the requirement that all overseas troops were to be equipped 
for chemical warfare by that spring, and pointed to the doubts that had arisen 
over the suitability of impregnated clothing for the tropics. By direction, a 
committee to study this problem was established, participation by The Surgeon 
General directed, and arrangements made for studies in the John B. Pierce 
Laboratory of Hygiene, New Haven, Connecticut, and for tests to be conducted 
in a tropical region (Panama and, if practical, in Liberia or the Southwest 
Pacific as well).135 The National Institutes of Health investigated the effects 
of chemical warfare protective clothing upon the efficiency of soldiers in tropi- 
cal climates. Early tests at the Pierce Laboratory concluded that the impreg- 
nating agent CC-2 imposed no unusual physiologic load nor impairment of 
efficiency, and recommended additional field testing.136 Interim reports from 
the Panama tests confirmed these observations, and the final report on 15 June 
1943 recommended that clothing impregnated with CC-2 was satisfactory for 
use by troop personnel under combat conditions in tropical climates. The water- 
suspension process of impregnation was favored. It was found that clothing 
should be reimpregnated or replaced after 14 days’ wear and that laundering of 
impregnated clothing in the tropics should be kept to the minimum compatible 
with reasonable standards of cleanliness. Skin-patch testing had not been 
completed and further studies were required as to abrasiveness, porosity, flexi- 
133 Semimonthly Rpt, Prev Med Serv SGO, 16-30 Jun 45. HD : 024. 
134 Minutes of Meeting, NRC Subcommittee on Clothing, Committee on Aviation Medicine, 1 Sep 42. 
HD: 040. 
136 (1) Memo for Record, 25 Jan 43, sub: Expedited tests of permeable protective clothing. SG : 
421.-1. (2) Ltr, CG SOS to SG, QMG, and Chief CWS, 13 Feb 43, sub : Committee for controlling 
tests for permeable protective clothing. SG : 334.8-1. 
136 Ltr, SG to Dir Reqmts Div SOS, 27 Feb 43, sub: Expedited tests on permeable protective 
clothing. SG: 421.1. CLOTHING 
75 
bility, weight, comfort, fatigue, wear, and functional restrictions.137 Further 
testing showed that impregnation of the underwear worn under the herringbone 
twill one-piece suit was almost as effective as when both outer and under gar- 
ments were impregnated.138 
The impregnation of women’s clothing was made the subject of a separate 
study. It was concluded that protective clothing impregnated with CC-2, 
either by the solution or the water-suspension method, is physiologically satis- 
factory for constant wear over a period of at least 4 weeks by women engaged 
in moderately strenuous activity in temperate climates. Occasional dermatitis 
resulted, but it was concluded that the skin of women is no more sensitive to 
clothing than the skin of men.139 
In December 1943 the Armored Medical Research Laboratory was re- 
quested by The Quartermaster General to test a group of flameproof treatments 
for clothing, notably fire-retardant, CM, manufactured by the DuPont Com- 
pany, an ammonium sulfomate type, and “Flame-Out,” manufactured by 
Treesdale Laboratories, a borax-boric acid type.140 The DuPont product 
was recommended and approved for limited use. Coveralls treated with the CM 
fire retardant were to be issued to tank and other vehicle crews, gasoline and 
ammunition handlers (first echelon), personnel handling or using incendiary 
agents, including flamethrowers, and other personnel designated by unit com- 
manders because of exposure to fire hazards. Some skin irritation was seen, 
but the protection afforded the personnel noted was considered to outweigh 
disability likely to arise from skin irritation.141 
Studies on protective clothing against chemical agents and fire continued 
into 1945. In November 1944, the Chemical Warfare Service requested the 
services of the director of the Armored Medical Research Laboratory for 
cooperative special studies on protective clothing.142 These studies resulted 
in tests on “Banflame” and the initiation of field tests of garments impregnated 
with this agent by the Army Ground Force Boards. 
The Subcommittee on Clothing in March of 1944 recorded that, “Mosquito- 
repellant impregnation of clothing seems to produce no difference in heat 
exchange. This is also true of water-repellency treatments, and Chemical 
Warfare Service impregnations, which are themselves water-repellent.”143 
137 Rpts, Lt Col T. H. Marshall, CWS, Lt Col W. S. Stone, SCO, Mr. H. A. Secrlst, QMGO, to CG 
ASF, 29 Apr 43, and 15 Jun 43, sub : Protective value, life span and physiological effects of impreg- 
nated cotton clothing in tropic zone. SG : 421.1. 
las CWS Rpt, M. Sullivan and- C. M. Hunt, 28 Mar 44, sub : A comparison of the penetration of 
measured droplets of H through CC-2 Impregnated and unimpregnated clothing worn by men. Filed 
at Army Chem Ctr, Md. 
139 Memo, 1st Lt M. Hayes, MC, for SG, 10 Nov 43, sub: Test of clothing, women’s, protective, 
QMBT-1305. SG: 421.1. 
140 Ltr, QMG to SG, 28 Dec 43, sub : Test of flameprooflng for clothing. SG : 421.1. 
141 (1) Rpt, Project 27, 13 Mar 44, sub: Fire resisting compounds for clothing, in Annual Rpt, 
Armored Med Research Lab, 1945. HD. (2) See footnote 120, p. 70. 
142 Ltr, Chief CWS to SG, 21 Nov 44, sub : Investigation on protective clothing. SG : 421 Boots. 
143 See footnote 62 (1), p. 56. 76 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
The development of the foam-impregnation technique for clothing im- 
proved the heat dissipation characteristics of impregnated clothing, simplified 
the problem of laundry,144 and made possible the impregnation and reimpreg- 
nation of clothing during the laundry process in both fixed and mobile laundries. 
The multiple impregnation of clothing with insecticides and flame and chemical 
protective agents, while comprising technical difficulties, did not materially 
affect clothing in relation to the physiology of man. 
Dubbin 
The use of dubbin for shoes is a form of impregnation. The procedure 
was important medically only in that the dubbin allegedly waterproofed shoes 
and improved their wearing qualities and comfort, and aided in protection 
against cold injury. Dubbins containing anti vesicant impregnates were used 
for protection against chemical warfare agents. Based on complaints from the 
field that dubbin makes shoes colder in the cold and hotter in the heat, a series 
of laboratory tests were made in which it was shown that dubbin did not 
significantly affect the thermal insulation of leather, but did reduce porosity. 
Dubbin was ineffective in improving the performance of shoes in protection 
against cold injury.145 Dubbins containing impregnates were overrated and 
a series of tests by the National Bureau of Standards revealed that there was 
little difference between the impregnated and unimpregnated dubbins in their 
ability to protect against vesicant agents.146 
Since there was considerable demand for dubbin, a decision was made late 
in 1943 to issue both types indiscriminately for normal use. Development of a 
new and improved dubbin impregnate against chemical warfare agents was 
initiated.147 
Special Gas Masks 
The development of the gas mask for World War II has been recorded in 
reports of activities of the Chemical Warfare Service. In the European the- 
ater, certain hospitals were considered to be vulnerable to gas attack from the 
air. A head wound gas mask appeared desirable. Upon receipt of the recom- 
mendation from the European Theater of Operations, the War Department 
canvassed other theaters to determine the desirability of the item. All advised 
development. The Surgeon General had such an item under study, but even- 
144 (1) Ltr, Chief CWS to CO Armored Med Research Lab thru SG, 14 Apr 45, sub: Heat load 
studies on clothing flameproofed by foam impregnation method. SG : 421. (2) Ltr, Chief CWS to CO 
Armored Med Research Lab thru SG, 20 Jul 45, sub : Laboratory tests on worn flameproof protective 
clothing. SG : 421. (3) Filler, L.: Laundry and Related Activities of The Quartermaster General. 
QMC Historical Studies No. 13, Washington, Government Printing Office, 1946. 
145 See footnote 114 (2), p. 69. 
149Rpt, QM Climatic Research Lab, 17 Apr 46, sub: Dubbin on footgear, heat and cold effect of. 
SG: 400.112. 
147 Ltr, QMG to CG ASF thru Chief CWS, 2 Mar 44, sub; Study of dubbing and shoe impregnate. 
SG: 400.112. CLOTHING 
77 
tually the Chemical Warfare Service took over this responsibility, together 
with that for requirements, storage, and issue.148 
Allergy to Clothing 
Allergic manifestations and skin irritation resulting from fabrics, dyes, 
and impregnating agents were not a significant medical problem. Tests of the 
standard uniform in producing allergic dermatitis were negative. Some reac- 
tion to the cushion-soled sock was reported by the Armored Medical Research 
Laboratory.149 In March 1943, the senior consultant in dermatology in the 
European theater noted an increasing number of men with sensitivity of the 
skin to dye, wool, and other materials in uniforms, severe enough at times to 
be disabling. Issue of long cotton underwear upon the recommendation of 
the Office of the Chief Surgeon was authorized for these patients. Likewise, 
he reported that patients with skin disease apparently had been made worse by 
contact with the general issue, blue-gray woolen pajamas used in Army hos- 
pitals.150 In the China-Burma-India theater, a dermatitis venanata, or 
“Dhobie-mark dermatitis,” resulted from the use of “bichi” nut ink used for 
laundry marking.151 
Tropic-Proofed Clothing and Equipment 
Mildew formed by fungi affected many types of fabrics, leather, and equip- 
ment. Tentage, bed clothing, canvas linings of the combat shoe and shoe 
leathers were the items of clothing, or related to clothing, that were affected. 
In the early phases of the war, toxicity of the mildew-proofing agents under 
study was tested by the Chemical Warfare Service Laboratory and by the 
Armored Medical Research Laboratory. With the establishment of the Army 
Industrial Hygiene Laboratory in Baltimore, Maryland, this function became 
a part of its responsibilities. Many fungicides and mildew-proofing agents 
were patch-tested on human volunteers without reference to ultimate adoption 
by the developing agency. These chemicals were classified according to the 
degree of exposure or contact of the soldier with the agent.152 
Footwear 
Byes and Finishing Material. With the cessation of European hostilities, 
improvement in the appearance of the flesh-side out shoe became a matter of 
some importance. Toxicity from unauthorized shoe dyes was cause for the 
148 (1) Ltr, Chief Surg ETO to SG, 16 Feb 44, sub: Development projects. SG ; 470.7. (2) Ltr, 
SG to CG ASF, 7 Aug 44, sub : Standardization of mask, gas, head wound, M7-11-9. SG : 470.7. 
140 Appendix B to Annual Report cited as footnote 96, p. 64. 
160 Ltr, Lt Col D. M. Plllsbury, Senior Consultant in Dermatology ETO, to Chief QM ETO, 4 Mar 
43, sub : Long cotton underwear for use on patients with sensitivity to wool uniform. HD : 422 (ETO). 
151 CBI Field Med Bulls, vol. 2, No. 6, Jun 1943 ; vol. 3, No. 6, Jun 1944. 
152 See footnote 40, p. 49. 78 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
testing of a number of products by the Army Industrial Hygiene Laboratory. 
A War Department circular in May 1945 directed use of dubbin or shoe impreg- 
nate, and prohibited the application of dyes, coloring, or finishing material on 
combat boots and service shoes without specific authorization or approval by 
the War Department.153 
Plastic Insoles {Saran). A variety of materials were used as insoles for 
shoes. Felt eventually was adopted and was further improved after the war 
for use with shoepacs. Plastic-mesh net soles were given trials both by the 
Quartermaster Board and in the Mediterranean Theater of Operations. Being 
impervious to water and because the mesh construction provided airspace and 
a bellows action, it was hoped that these insoles would prove of benefit for both 
cold weather and tropical wear.154 Troop trial in the Mediterranean theater 
both supported and criticized the device. Medical officers indicated that they 
added to marching comfort when fitted with the proper size shoes, kept the foot 
warmer in moderately cold weather, and aided in drying of socks. The con- 
sensus of opinion was that Saran insoles were a comfort in cold wet weather, 
but would not greatly influence the incidence of trenchfoot.155 A supply of shoes 
big enough to fit over the necessary socks and the insole was a practical con- 
sideration. Tests at Camp Lee, Virginia, early in 1944 caused the Quarter- 
master Board to recommend “that the Saran insoles be considered as not pos- 
sessing sufficiently outstanding or clearly evidenced value to warrant their issue 
for general use of troops in temperate climates with the service shoe or combat 
boot.”156 
Sizing md Fitting of Footgear. In March 1945, the Chief Surgeon, 
European Theater of Operations, in commenting upon improvements in the 
uniform recommended by the Chief Quartermaster, European Theater of 
Operations, stated, “In almost thirty years of service, I have rarely seen shoes 
fitted with the care and expertness that this function deserves.”157 “Improper 
Fitting of Shoes” was the subject of a War Department memorandum published 
on IT September 1942, which called attention to the fact that enlisted men were 
being issued shoes at reception centers and elsewhere in the sizes they requested, 
a practice which resulted in many improper fits. Commanding generals of all 
service commands were directed to see to the fitting of shoes in compliance with 
the provisions of Army Regulations (AR) 850-125.158 Fitting of shoes for 
Wacs was unsatisfactory for the same reason. Women preferred fits over thin 
hose and resisted sizing by fitting machines. Eventually correct sizes were 
prescribed and issued without consideration of the Wac’s choice. Inspection 
163 WD Cir 137, 8 May 45. 
1M Ltr, SG to QMG, 5 May 43, sub: Insole, ventilating, experimental. SG ; 421.11 (Shoes). 
155 Ltr, SG for QMG, 15 May 44, sub : Insoles, ventilating, lab test No. AMRL3. SG : 421.-1. 
158 Rpt, The QM Board, 30 Jul 44, sub: Report of test of Insole, ventilating, Saran : fused edge 
type and fused and bound edge type. SG: 400.112. 
157 1st ind, Chief Surg ETO to CG ComZ ETO, 26 Mar 45, on basic ltr cited in footnote 124, p. 71. 
158 AG Memo S850-2-42, 17 Sep 42, sub: Improper fitting of shoes. AG : 333.1. 79 
CLOTHING 
to insure the fitting of clothing and directing that woolen and other winter 
clothing issued during warm weather was to be tried on and inspected for 
proper fit in compliance with AR 850-126 was the subject of another War 
Department memorandum in December 1942.159 
The medical implications of the misfitting of shoes were recognized in the 
research project carried out at the Armored Medical Research Laboratory in 
the spring of 1943. The report of the findings recommended: 
a. That a thorough study of foot disabilities resulting from misfitted shoes be 
undertaken. 
b. That anthropometric measurements of soldiers’ feet be secured to provide a basis 
for the design and fitting of Army shoes. 
c. That certain recommended changes in the structural characteristics of Army shoes 
be given consideration. 
Further action on these recommendations approved anthropometric studies of 
measurements by this laboratory. Results of these preliminary studies showed 
that the design of the army shoe was not altogether in accord with shape and 
size of feet, and that procedures for fitting soldiers’ feet were not satisfactory. 
The laboratory believed that this situation contributed in no small measure to 
foot disabilities and that further study of the problem could result in marked 
improvement.160 
Improper fitting and the sizing of combat boots and shoepacs in Italy in 
the winter of 1943-44 contributed to trenchfoot prevalence and complicated the 
problem of control. There was much improvement by the winter of 1944-45.161 
In the European theater, the long wait in England before the assault on 
the Continent saw little emphasis upon the fitting of clothing and footgear, 
especially as it related to combat activities in the cold. The importance of fit, 
however, was stressed in a headquarters circular prepared in the Office of the 
Chief Surgeon in October of 1944.162 
Numerous essential technical medical data reports and sanitary reports 
from the European theater pointed out deficiences in the fit of shoes, shoepacs, 
and overshoes, and their relation to cold injury.163 The importance of proper 
fitting of shoes was stressed in War Department Circular 312, 22 July 1944. 
The headquarters of the Ground Forces Replacement System in the European 
theater drew attention to the urgency of the proper fitting of shoes in their 
Circular 55, dated 13 December 1944.164 
Investigation of clothing problems in the spring of 1945 led the Chief 
Quartermaster, European Theater of Operations, to the conclusion that shoe 
lasts fit too closely, that better fitting devices and procedures must be found, 
169 AG Memo W3Q-15-42, 26 Dec 42, sub: Improper fitting of clothing. SG : 421.-1 (Uniforms). 
180 Appendix B to Annual Report cited as footnote 96, p. 
181 Simeone, F. A.: Trench foot in the Italian campaign. HD : 314.7-2. 
182 Hq ETOUSA Clr 108, 26 Oct 44, sub : Care of the feet. HD. 
183 (1) For example see footnote 17, p. 40. (2) ETMD, MTO, Oct 1944. HD: 350.05. 
184 See footnote 90, p. 63. 80 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
that shoe tariffs included far too many sizes, and that the tariff must be ex- 
panded upward to include larger sizes.165 The medical implications of im- 
proper sizing and fitting were summarized by the Chief Surgeon, European 
Theater of Operations, in an indorsement to the report of the above investiga- 
tions :166 
2. Insofar as cold injury (trench foot, frostbite, Immersion foot) is concerned, the 
generalization may be made that it is the direct result of lack of adequate circulation of 
the blood. With sufficient blood circulating at a temperature of 98 degrees Fahrenheit, 
little or no damage can be done to tissue by cold. 
3. It follows, then, that prevention of cold injury lies entirely in the maintenance 
of adequate circulation. The factors of decreased circulation, particularly in the extrem- 
ities, are: 
a. Loss of surface heat. As a defense mechanism against lowering the body tempera- 
ture as a whole, surface blood vessels are constricted reflexly when surface temperatures 
are lowered by exposure to cold. Surface temperature is lowered faster through a wet 
medium than through a dry medium. For this reason, extremities are injured at higher 
temperatures when wet than when dry; and trench foot occurs in higher temperatures 
than frostbite. 
Consequently, warmth and waterproofness in a shoe or garment is to be sought. If 
it be Impossible to waterproof an item, the skin should be further protected by a heavy 
layer of material which retains a large part of its insulating quality when wet—such as 
wool. 
b. Constriction of circulation. It is of the greatest importance that circulation be 
not constricted by tight shoes or clothing. A large proportion of patients with trench 
foot showed the marks of shoe laces over their insteps. Shoes that fitted too tightly 
were solely responsible for many cases of trench foot. 
It is impossible to fit shoes properly unless socks be of uniform thickness. 
Furthermore, the construction of both the Type III shoe and the combat boot— 
with quarters that are wide apart over the instep, invites tight lacing. 
c. Stagnation of circulation. Hours of inactivity promote stagnation of circulation, 
particularly in the extremities. One way to combat stagnation is to have the footwear 
fit loosely enough to permit of active movement of the foot within the shoes. 
Sizing of socks offered some difficulty, and some units requisitioned socks 
only in size 12 in order to have enough large sizes. Shrinkage of socks occurred 
as a result of the quartermaster laundry procedures, which complicated the 
satisfactory reissue of properly sized socks. This failing was critical enough 
to justify The Quartermaster General in instituting research to determine 
laundry procedures and treatments of wool to reduce shrinkage to a minimum.167 
Tariffs 
Complaints about the uniform, field investigations, and practical experience 
in the Zone of Interior and in the several theaters of operations, thoroughly 
185 See footnote 124, p. 71. 
See footnote 157, p. 78. 
167 See footnote 124, p. 71. CLOTHING 
81 
demonstrated that a scientific basis for design, sizing, and establishment of 
clothing tariffs had not been available to guide the provision of clothing stocks 
during the war. With a realization of this defect, The Quartermaster General 
in October 1945, authorized the Climatic Research Laboratory to conduct a 
series of anthropometric studies on a sufficiently large number of male and 
female Army personnel to establish authentic guides for design, sizing, and 
tariff determinations. Between May and November 1946, 105,062 men selected 
in accord with the population distributions prepared by the Bureau of the 
Census were subjected to detailed anthropometric measurements.168 Addi- 
tionally, over 8,000 women were measured. The data on males and females 
were subjected to statistical analysis. The distribution of body types was found 
to fall into distinct groupings that arranged themselves roughly into the form 
of a normal curve. These data, establishing type groups and distribution of 
body types within the military population, should materially improve fit, ap- 
pearance, tariffs, and stockpiling of the uniform. These studies have been 
continued into the postwar period.169 
Reconditioning and Reissue 
The reissue of salvaged clothing and textile items was not a matter of 
great medical concern. The Office of The Surgeon General adhered to the 
policy that ordinary laundering or dry cleaning offered sufficient sterilization 
and disinfestation. Exceptions were noted for the clothing of soldiers known to 
have been ill of communicable diseases or where the degree of louse infestation 
might require the use of methyl bromide disinfestation.170 Spread of fungus 
infections through reissued shoes came under consideration in 1941. Until 
the middle of 1943, the methods recommended or concurred in by The Surgeon 
General involved the use of chlorine as a fungicidal agent.171 Some question 
arose as to the necessity for sterilizing shoes under any circumstances. The 
Division of Medical Sciences, National Research Council, on 27 June 1944 made 
the following recommendations to The Surgeon General: 
1. Foot baths for the prevention of “athlete’s foot” are not prophylactic, not necessary, 
and their use should be discontinued by the Army. 
2. Shoe sterilization: 
a. For factory rebuilt shoes: Sterilization is desirable, at least until further 
information is available. 
108 QMC Climatic Research Lab, Rpt No. 122, 2 Jul 47, sub : Survey of body size of Army per- 
sonnel, male and female. QM : 420 Anthropometric Survey. 
ie* QMC Research Lab, Proposed Studies, 5 Oct 48, sub: Body size measurements of Inductees 
and body size measurement and clothing fitting tests on inductees. QM : 420 Anthropometric Survey. 
170 (1) Ltr, QMG to SG, 6 Oct 44, sub: Sterilization of clothing for reissue, with 1st ind, SG to 
QMG, 26 Oct 44. SG : 720.5. (2) Ltr, Dir Sanitation and Hygiene Dlv SGO to Mr. M. B. Kent, 
UNRRA, 4 Feb 44. SG : 720.5. 
171 Ltr, QMG to SG, 18 Apr 42, sub; Sterilization of class B shoes. SG : 421.-11. 82 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
b. For shoes turned in for exchange, but not requiring repair: There is not 
sufficient evidence that such shoes transmit fungus infection of the feet to warrant 
sterilization.”2 
Subsequently, a method of sterilization, using formaldehyde in 1-percent 
solution, followed by a soap solution, and finally immersion of the shoes in an 
oil emulsion with 5-percent pentachlorphenol173 came into limited use. 
Some soldier resistance to wearing rebuilt and reissued shoes because of foot 
complaints was observed. The large-scale program for the rebuilding of service 
shoes was so important that the adverse comments of the 326th Glider Infantry, 
Army Air Base, Alliance, Nebraska, was cause for thorough investigation by 
Quartermaster Corps and Medical Department consultants.174 The investiga- 
tion substantiated the wisdom of the rebuilt shoe program and further empha- 
sized the need for fungicidal treatment. Formaldehyde fumigation according 
to the method developed by Dr. Fred O’Flaherty, at the University of Cin- 
cinnati, was the basic sterilizing procedure used in the army shoe reconstruction 
factories. 
Transmission of trichophytosis through gymnasium shoes used in recon- 
ditioning facilities was cause for concern. The Preventive Medicine Service, 
Office of The Surgeon General, recommended a pair of shoes for each individual 
during hospitalization with fumigation before reissue by the O’Flaherty 
procedure.175 
Industrial Medical Aspects of Clothing 
Protective clothing in industrial operations in Army-owned or Army- 
operated industrial plants conformed largely to commercial practice. Among 
the most significant health problems was trinitrotoluene poisoning. Personnel 
handling toxic explosives were provided with powder uniforms, socks, suitable 
underwear, head coverings, powder shoes, and sweat shirts or sweaters as 
necessary. These articles of clothing remained in the plant. Freshly 
laundered uniforms were furnished each day. Each worker was required to 
have a bath and a complete change of clothing after the work shift. These 
were requirements that could be met only by careful supervision and main- 
tenance in the bath and change rooms. Special types of protective clothing 
were developed for workers involved in the application of radioactive luminous 
paint to instrument dials.176 
Appropriate protective clothing for service personnel engaged in handling 
heavy shipping on docks, in railway yards, and in similar operations received 
172 Ltr, NRC Dlv of Med Science to SG, 27 Jun 44. SG: 421.-11 (Boots). 
173 Ltr, QMG to SG, 2 Sep 43, sub: Disinfecting worn shoes for athlete’s foot. SG: 421.—11 
(Boots). 
174 Memo, CG ASF for SG, 9 Jul 43, sub: Rebuilt shoes. SG : 421.-11 (Boots). 
176 Semimonthly Rpt, Prev Med Serv SGO, 1-15 Jul 45. HD. 
179 Rpt, Army Industrial Hygiene Lab SGO, 9 Oct 50, sub : Relationship of clothing to industrial 
hazards including the use of protective clothing during World War II. HD : 422.3 Protective Clothing. CLOTHING 
83 
little medical attention, but was largely within the province of safety officers 
and safety engineers. The Surgeon General’s concern for the problem was 
expressed in an indorsement reporting standardization of safety working shoes, 
in which he noted that, while civilian employees were used whenever possible 
in storage, transportation, and repair of materials for war in the Zone of 
Interior, military personnel accomplished such work in the theaters. This 
personel should be protected by safety shoes wherever needed.177 
Miscellaneous 
Anti-Louse Suit. In 1942 an anti-louse suit was designed in the European 
Theater of Operations and submitted to the War Department for develop- 
ment.178 DDT modified the requirement. In October 1943, 2,000 suits were 
requested. Their use was to be limited to heavily exposed personnel and to 
sterilization and bath units.179 Subsequently, protection from DDT and vac- 
cination were considered adequate and the anti-louse suit was discarded. 
1771st ind, SG to QMG, 8 Jan 44, on Ltr, QMG to SG, 27 Dec 43, sub: Shoes, safety, working, 
composition sole. SG: 421.-11 (Boots). 
178 Ltr, Chief Surg ETO to Chief QM ETO, 8 Dec 42, sub : Anti-louse protective clothing. HD: 
422 ETO. 
178 Memo, Chief Surg ETO to Chief QM ETO, 17 Nov 43, sub : Anti-louse suits. HD: 422 ETO. 
346336 O—55 7 CHAPTER IV 
Nutrition 
John B. Youmans, M. D* 
The Medical Department of the Army has always been concerned with 
the feeding of the soldier as it affects health and effectiveness. This responsi- 
bility was given statutory status in 1863 (Act of March 3, 1863, 12 Stat. 744; 
U. S. Code (10:104). As revised in 1877 (Rev. Stat. 1174, February 27, 1877, 
Sec. 1174), it holds today as follows: 
The officers of the Medical Department of the Army shall unite with the officers of 
the line (under such rules and regulations as shall be prescribed by the Secretary of 
War) in superintending the cooking done by the enlisted men; and the Surgeon General 
shall promulgate to the officers of the said Corps such regulations and instructions as 
may tend to insure the proper preparation of the ration of the soldier. 
The application of the science of nutrition in the Army, both as a part of 
preventive medicine and as a therapeutic procedure for the sick and wounded, 
begun in World War I, was expanded in World War II. The developments in 
nutrition in relation to vitamins A and C, thiamine, minerals (especially cal- 
cium and iron), and the acid-base balance to the health of the soldier were 
appreciated during World War I. In addition, the loss of vitamin C and 
thiamine by heat, including considerable destruction of the latter in cooking, 
and the loss of nutrients in milling was known. On the other hand, the require- 
ments of the body for these vitamins, in fact the exact nature and identity of 
these vitamins, were unknown. Knowledge of the vitamin content of foods 
was in terms of the relative value of different foods for the various vitamins 
in general terms. The development in nutrition had increased the number of 
vitamins identified. It resulted in their isolation and synthesis so that the 
specificity of their action and the curative effects of some of them had begun to 
be determined before World War II. A greater appreciation of the effects of 
a lack or diminished intake of vitamins was more general. 
Every war brings many new and unsolved problems, particularly to a 
country which does not maintain a large preparedness program. Such was 
the case in nutrition in this country at the beginning of the war. Twm avenues 
of approach were used to solve problems as they arose. The first was to define 
problems and submit them through the Office of Scientific Research and Devel- 
opment to various university and industrial laboratories for solution. The 
second was to tackle them in military research organizations. 
•Dean, School of Medicine, Vanderbilt University. Formerly Colonel, MC, AUS, Chief, Nutrition 
Division, Preventive Medicine Service, Office of The Surgeon General. 86 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
By precedence since the Spanish-American War and by Army regulations 
after World War I, one of the duties of The Surgeon General has been to 
prescribe the basic standards of diet for the Army. By informal agreement be- 
tween The Surgeon General and The Quartermaster General, the recommended 
dietary allowances submitted by the Committee on Medicine, National Research 
Council, and later confirmed in the “Recommended Daily Dietary Allowances” 
of the National Research Council were accepted as the dietary standards of 
the Army at the beginning of this war. Although the standards selected were 
not designed for Army use, they had such a large margin of safety that they 
were deemed suitable and satisfactory. Later, at the request of The Surgeon 
General, the Subcommittee on Medical Nutrition, National Research Council, 
submitted minimum dietary allowances, prepared by the Food and Nutrition 
Board, for use under emergencies and in times of short supplies. 
Upon request by the Office of The Surgeon General the nutrition require- 
ments of troops were studied in detail. The nutritional value of food items 
being supplied to the Army was studied by the United States Food and Drug 
Administration and by many university laboratories. Nutrient cooking loss 
data were accumulated from a large variety of sources among which were the 
Bureau of Human Nutrition and Home Economics of the United States 
Department of Agriculture, and the Nutrition Laboratory of the Pentagon 
Restaurant Association. In addition, much technological wTork on food in 
relation to nutrition was done by the Quartermaster Subsistence Research 
Laboratory. The relation of nutrition to prevention and cure of disease was 
studied by medical officers in the field. 
Many studies of the relationship of protein metabolism to wound healing 
were done by both civilian and military hospitals in this country. One well- 
organized group was the Committee of the J osiah Macy Foundation, studying 
the relationship of metabolism to convalescence. There was also a subcom- 
mittee of the National Research Council which studied metabolism in relation 
to wound healing. The individual projects studied are too numerous to list in 
this history. Special diets made from Army rations were studied in the Army’s 
Medical Nutrition Laboratory at Chicago, as was the relationship of atabrine 
and vitamin A deficiency to the development of atypical lichen planus, a serious 
skin affliction of the Southwest Pacific theater. Nutrition in relation to the 
healing of acute decubitus ulcers was studied at the Wakeman General Hospital, 
Camp Atterbury, Indiana, under the direction of the Chief Nutrition Consul- 
tant, Fifth Service Command. 
Throughout the war, at a large number of military installations, the energy 
expenditure of troops in a wide variety of activities was studied. The method 
used was usually that of oxygen consumption. At Wright Field, Ohio, and 
at many of the subsidiary Air Force physiologic investigation centers, the NUTRITION 
87 
oxygen requirements of pilots and other crew members were determined for all 
types of aircraft at all altitudes. The Army Signal Corps determined energy 
expenditure in a variety of field tests at Fort Monmouth, New Jersey. Infantry 
troop and tank personnel energy expenditure was studied to some extent by 
the Medical Department in conjunction with the Quartermaster Board at Camp 
Lee, Virginia, and by the Armored Medical Research Laboratory at Fort Knox, 
Kentucky. Much work was done by the United States Navy at the Submarine 
Center in New London, Connecticut, also on board many training ships, and 
at the Naval Medical Research Institute at Bethesda, Maryland. 
To carry out an appraisal of the nutritional state of troops, in relation to 
the rations which they consumed, a controlled experiment was conducted on 
1,000 infantrymen in the mountains of Colorado in the summer of 1944.1 Here 
the technique for determining the nutritional state were standardized and 
critically studied. Subsequent to the standardization of these methods, a sur- 
vey team was sent to the Pacific theater to appraise the nutritional state of 
carefully selected samples of men from all arms and services in the major Army 
areas.2 This was done in an effort to determine wdiether or not the troops who 
had lived on the B ration, C ration, K ration, and ten-in-one ration for periods 
of time up to 3 years were, in fact, properly nourished. The findings of this 
survey indicated that the nutritional state of a vast majority of the troops in 
this theater, whether they were fresh from the United States or had been there 
for long periods of time, was satisfactory. The same approach was used in 
China in the winter of 1944 as a basis for determining the supply requirements 
of Chinese troops under American supervision.3 
THE RATION 
Training Camp and Garrison 
Formal improvements in the ration have been slow. The training camp 
and garrison ration was based on the quantities of standard foods consumed 
by 400 messes, obtained by nutritional surveys between 1917 and 1918. A pro- 
posed training ration was presented by the Chief, Food and Nutrition Division, 
Office of The Surgeon General,4 at the close of World War I, with suggestions 
for a revision, but no immediate action was taken. As the result of the inability 
to purchase a satisfactory dietary with the money provided by the garrison 
1 Rpt, Armored Med Research Lab, Proj. 30, 22 Nov 44. HD: 430 (Rations). 
J Rpt, Nutrition Dlv SGO, 22 Aug 45, sub : Nutrition survey in the Pacific Theatre of Operations. 
HD: 720.1. 
8 Memo, Col J. B. Youmans, MC, to CG China Theater, 20 Jan 45, sub: Report on the nutritional 
status and requirements of Chinese troops, the adequacy and availability of food supplies, and their 
procurement, distribution, storage, and issue. Filed in Nutrition Div, OTSG. 
* (1) Murlin, J. R., and Miller, C. W. : Preliminary results of nutritional surveys in United 
States Army camps. Am. J. Pub. Health 9 : 401-411, Jun 1919. (2) Chamberlain, W. P., and 
Dunham, G. C. : The well balanced ration. The Quartermaster Review 1 : 16—17, 52-58, Jan-Feb 1922. 88 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
ration, the Quartermaster Corps, with the advice of the Medical Department,5 
accomplished a revision in 1927 to increase the money value of the ration. The 
intent of the changes was to permit the purchase of supplementary food to 
provide variety. While the nutritive value of the ration was considered by the 
Office of The Surgeon General, the higher money value of the ration received 
by the Navy at the time was an important factor in the decisions. A large 
proportion of the changes in food were in animal products, some of which, par- 
ticularly meats, were expensive and also beyond the normal consumption by the 
Army. The normal use of these foods allowed ration savings for the purchase 
of fresh vegetables, fruits, and milk. The result of this abnormal distribution 
of foods in calculating the money value of the ration was evident in the de- 
pression of the 1930’s when the cost of meat decreased out of proportion to 
vegetables, and the Army was again faced with an unsatisfactory dietary. As 
the result of nutritional surveys, a proposal was made to the Quartermaster 
Corps that a ration be set up that would represent fairly satisfactorily the food 
needs and nutritive requirements of a hard working man. It was also desired 
to develop some, method of determining the money value of the rations from 
such a ration rather than to obtain additional money by introducing quantities 
of food out of proportion to those which a suitable dietary should contain. It 
was indicated that a ration to be successful must have the following char- 
acteristics :6 
1. A ration must be defensible from a nutritional standpoint. 
2. When issued in kind, it must afford sufficient quantities of each item of 
the various classes of foods to allow the preparation of adequate, varied, and 
balanced menus. From the standpoint of supply agencies, it must be capable 
of issue in kind. 
3. The relation of the various groups to each other should be such that it 
can be used to determine the adequacy of the rations actually consumed. 
4. When commuted into money, it should furnish sufficient money to buy 
the various kinds of food necessary to provide nutritionally adequate meals 
sufficient in quantity and of suitable variety and balance. Providing sufficient 
money for food purchases does not assure suitable variety, caloric content, 
vitamin sufficiency, et cetera; only competent personnel can insure this. 
The ration approved in 1932, while showing much improvement in the 
variety, quantities, and distribution of food, still required slight adjustment 
especially in meat (reduction) and milk (increase) and sources of vitamin C, 
for adequacy and normal distribution of food. Furthermore, the primary 
B (1) Ltr, Lt Col H. L. Cooper, Inf, to Chief of Infantry, 26 Jun 23, sub: Difference in the value 
of the ration between the Army and Marine Corps, with inds. SG : 246.4-1. (2) Memo, Brig Gen 
B. H. Weils, ACofS, for SG, 23 Dec 26, sub : Increase in the ration allowance-—Regular Army and 
Philippine Scouts, with inds. SG : 430.2-1. (3) Ltr, Lt Col P. B. Howe, SnC, to Col J. F. Siler, 
SGO, 11 Jan 27. SG : 430.2-1. 
8 Ltr, Lt Col Paul E. Howe, SnC, to SG, 27 Oct 32. HD : 720.1. NUTRITION 
89 
consideration was still the money value in spite of the recommendation of the 
Office of The Surgeon General. 
During the mobilization of troops for defense in 1940, a “menu” plan of 
prescribing rations was introduced for trial in 1941 and adopted with changes 
from time to time.7 The basis of this field ration wTas a monthly menu to be 
prescribed for all stations operating on a field ration system within a corps or 
service command area (the hospital phases of this plan will be discussed later). 
The menus were required “to indicate the components of each of the three 
daily meals, and a daily recapitulation of the total quantity of units of purchase 
of each item required to feed the prescribed menu to 100 men.” Provision was 
made that “care will be exercised to see that the menu is nutritionally balanced,” 
and by implication, adequate, “ample variety provided, and full utilization 
made of seasonal fresh fruits and vegetables.” 
The latter statement is the first formal statement in War Department 
directives that required that the dietary to be fed to the soldier be 
nutritionally balanced. In the final adoption and revision of War Department 
circulars relating to the menu plan of field rations, the following was included 
as the result of suggestion of The Surgeon General:8 “. . , that consideration 
be given to evaluation of vitamins and minerals. ... In its preparation, con- 
sideration should be given to the quantities of food necessary to meet nutritional 
requirements consistent with the prescribed training program.” 
The concept of the menu plan of prescribing and issuing rations was excel- 
lent and generally successful. The chief difficulties arose from the problems 
of any ration that is prescribed for troops with units having variable degrees 
of activity and a variety of food habits and operating in areas with different 
supplies of perishable foods such as meats and vegetables. There are three 
possibilities that might meet the problem of variable activity—to prescribe food 
for (1) the maximum activity contemplated; (2) the minimum activity with 
regard to caloric content and protein, vitamin, and mineral requirements, and 
additional food for more active units to meet the increased caloric requirements 
and to carry the additional vitamins associated with the use of carbohydrate 
or fat; and (3) the average activity of a camp or corps area and provide for 
adjustment of the distribution of food between organizations with high and 
low degrees of activity, or extra food for organizations with activity greater 
than the average. No definite policy was expressed, however, in the various 
directives relating to field rationing. The tendency wras to provide for average 
activities. War Department Circular 208,13 September 1943, at the insistence 
of the Surgeon General’s Office, provided for more active troops as follows: 
In instances where the field ration is insufficient in certain components to provide 
adequate sustenance for certain organizations, station commanders may, on request of the 
7 (1) WD Cir 28, 17 Feb 41. (2) WD Cir 16, 11 Jan 43. (3) WD Cir 208, 13 Sep 43. 
8 Ltr, SG to TAG, 1 Jul 41, sub : Comments and recommendations on the field ration system 
in effect since May 1, 1941. SG : 430.2. 90 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
commanders thereof and with the approval of local medical authorities, authorize the 
issue of additional quantities of grain products (including bread and flour), legumes, 
potatoes, etc., and such additional fats, spreads and seasoning as may be required to 
make the additional foods palatable and to insure their consumption, provided the cost 
of such increases will not cause the value of the rations for the station to be greater 
than the value of the garrison ration for the same month. 
Measures were taken to correct problems that resulted from too much food 
(because prescribed in greater amounts than some organizations could consume, 
kinds of food that were not generally eaten, or due to variable attendance at 
the mess), and that created new problems. A plan introduced to correct varia- 
tions in attendance was to issue rations in accordance with a count of the number 
of individuals who actually ate meals, combined with a percentage reduction 
in the number of rations drawn with increase in the size of the mess. This 
plan produced a situation in which some organizations would not have received 
sufficient food had the requirements of the directive been followed explicitly.9 
With suitable adjustment at the camp or station level and the resource- 
fulness of the Army mess sergeants, the menu plan of field rationing in the 
United States generally supplied adequate and acceptable rations. Master 
menus were ultimately prepared in the Office of The Quartermaster General, 
with adjustments made at the corps area, camp, or station level. Medical 
Department officers, particularly food and nutrition officers at the various levels 
of command, especially corps area and camp or station, reviewed the adequacy 
of the quantities of food prescribed to prepare the menus and offered valuable 
suggestions with regard to changes and adjustment to particular conditions. 
Nutritional surveys were conducted from time to time to determine whether the 
soldiers were actually consuming an adequate dietary. 
No special provision was made to assure an adequate dietary for troops 
subsisting on the garrison ration as suggested by The Surgeon General. One 
step in such a direction was the classification of foods into groups having 
roughly similar nutritive value and the suggestion that garrison ration accounts 
provide for nutritional as well as financial accounting of the food purchased 
with the garrison ration. All foods in nutritional accounts used were listed 
according to groups instead of only the more perishable foods. Such informa- 
tion reduced to a pound per man per day basis provided an excellent first ap- 
proximation as to the adequacy of the food used. The foods prescribed in 
master menus were then classified and properly arranged and offered future 
possibilities for practical evaluation of the food provided for troops living on 
garrison rations. 
At the end of the war the Army had a variety of rations, all of which met 
the nutritional requirements of the published basic dietary standards. They 
were the A ration, which was used in the Zone of Interior and which was made 
fi ASF Monthly Progress Rpt, Sec. 7, Health, 31 Aug 43. NUTRITION 
91 
up of the best fresh and canned food that it was possible for The Quarter- 
master General to procure. The quantity of food required was so enormous 
that it was necessary to limit the variety of choices of any given post in terms of 
the national supply. Hence, the War Department master menu was prescribed, 
the component parts of which were determined by food availability in the 
nation. The B ration was essentially the same as the A ration except that 
nearly all of its components wTere canned. It was used in communications zones 
and, as far as practical, in combat zones. 
The C ration, K ration, and ten-in-one ration were designed for the various 
phases of an assault and were intended to be used only for short periods before 
adequate cooking facilities could be brought forward. It wTas thought that the 
K ration should be used in the early days of an assault where no facilities or 
time for preparation were available. In the next few days, the C ration, wdiich 
required only heating, and could even be used cold, was indicated. In the next 
phase, where small groups could eat together, the ten-in-one ration was to be 
used and finally, when kitchens could be set up, the B ration was indicated. 
In practice, however, because of the ease of issue, the lack of necessity for 
bringing up troop kitchens and other complicated requirements of more normal 
messing, commanders used these battle rations for much longer periods than 
that for which they were designed. In many instances the problems of supply 
necessitated such use. For that reason there was much discontent and often 
failure to consume the rations because of their monotony and lack of accepta- 
bility. The rations themselves were wholly adequate to maintain health and 
a high degree of combat efficiency when issued and consumed in sufficient 
amounts to cover the caloric requirements. The rations failed, however, in 
some campaigns. Most of the defects described were results of improper use 
rather than defects in the ration itself. From one point of view, these rations 
were too good because they did permit commanders to use them for too long 
periods of time. 
Troops in training were fed the A ration. Commanders were urged to 
teach their men the value of eating properly and there is every evidence that 
this program was generally very effective. Careful nutrition surveys indicate 
that the American Army was, in fact, the best fed Army in the world and that 
the nutritional state of troops was far superior to that of American soldiers 
in previous wars. Also, surveys indicate that it was as optimal as it is possible 
to measure in our present state of nutritional knowledge. 
As indicated above, the packaged rations were often used for excessive 
periods of time and the men frequently ate too little and lost considerable 
quantities of weight. Satisfactory procedure for supplying at least one hot 
meal per day to troops in actual combat in cold theaters were never well or 
generally developed. Some units wrere successful and others were not. It is 
apparent, from discussing this matter with infantry commanders, that success 92 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
was a result of the interest of the command. Many tests were devised to study 
this problem but none of them were satisfactorily carried out. Furthermore, 
it appeared to be the attitude of the Office of The Quartermaster General at 
times that combat feeding was one problem with one solution. It is apparent 
from study of the actual procedures used by units in the various theaters that 
there were many problems, depending upon the area in which the troops 
operated. In some cases, it was necessary to supply troops by night (Europe), 
and in others food could be supplied only by day (New Guinea). For security 
reasons some units were not permitted to make fires and in others the com- 
manders stated that fire made no difference. There was general agreement 
among commanders that the morale value of at least one hot meal a day was 
of real importance in all theaters and that it is imperative in cold theaters.10 
This is one of the problems of the future which should not be overlooked. 
Because of the emotional stress of battle, troops fail to consume the avail- 
able food even when other factors, such as acceptability of the food, are satis- 
factory and lose weight during the very active stages of combat regardless of 
the ration they are fed. For that reason, the concept of rehabilitation feeding 
at the end of each active combat period developed in all theaters. Commanders 
gradually became aware that men could go for days or weeks on slightly in- 
adequate rations provided that they were very well fed during their rest periods. 
This concept is of real importance and needs additional study. 
At the beginning of the war, feeding on troop trains and troopships was 
very haphazard and men frequently received unsatisfactory meals. By the end 
of the war, largely as a result of the efforts of the Food Service Program in the 
Office of The Quartermaster General, troop train and troopship feeding was 
almost as satisfactory as garrison feeding. In general, the A ration was used 
for such activities. 
There was much interest during the war in the matter of feeding Air Force 
personnel in flight, particularly at very high altitudes. Investigative work 
in high altitude chambers indicated that men could not eat at 30,000 feet because 
unconsciousness occurred as soon as the oxygen mask was removed. However, 
in practice, it was found that men did eat at such altitudes and that, almost 
invariably, they carried some kind of lunch in their pockets. The first real 
study of the problem was made by the nutrition officer of the Eighth Air Force 
in England. He found that men on bomber missions were happier, remained 
more alert, and came home less exhausted if they had something to eat while 
in flight. The first flight lunch which he designed consisted almost exclusively 
of small bits of candies and it was very well accepted. 
This problem was also studied by a medical officer from the headquarters of 
the Second Air Force at an experimental laboratory, Smoky Hill Airbase, 
10 Wardlow, Chester ; The Transportation Corps : Responsibilities, Organization, and Operations. 
In United States Army in World War II. Washington, Government Printing Office, 1951, p. 16. NUTRITION 
93 
Salina, Kansas. Here he studied not only the ability of men to eat at high 
altitudes on long flights but the effectiveness of food on their normal activities 
under such conditions. His work, also, indicated that food was desirable in 
flight, particularly for flights which exceeded 5 hours. His work bore out 
the contention of investigators of the Nutrition Foundation in New York that 
high carbohydrate diets were better for flight crews than high protein diets, 
but the differences were of small magnitude. In general, the nutrition require- 
ments of men in flight are identical to those of ground troops and sea troops. 
With the beginning of the bombing of Japan by B-29’s, in which the dura- 
tion of flight missions ranged from 8 to 20 hours, feeding of Air Force personnel 
in flight became imperative. Also, proper management of preflight and post- 
flight feeding became more important. The men going out on long missions 
were under severe emotional strain and frequently did not eat well before the 
takeoff. After such missions men were frequently too tired to eat satisfactorily 
and the frequency with which such missions were flown sometimes resulted in a 
gradual decline in the nutritional state of personnel. For the above reasons, 
preflight and postflight feedings were carefully studied and adequate procedures 
worked out for them, particularly by the Twentieth Air Force. Records 
of their experiences and requirements will be found in the Office of the Air 
Surgeon. In general, in-flight feeding became satisfactory when properly made 
sandwiches, containing highly acceptable foods, plus hot drinks, were made 
available. Schedules were altered to permit proper feeding before takeoffs 
and the frequency of missions was altered to allow adequate rehabilitation after 
long flights. Feeding of relatively long-mission fighter pilots while in flight 
was not adequately solved. 
OVERSEAS HOSPITAL RATION 
In 1942, in connection with the development of expeditionary menus for 
temperate, tropical, and frigid climates, the medical staff at Headquarters Army 
Ground Forces suggested that provision should be made for the patients in 
hospitals. As a result, 10-day rations were planned for regular, light, soft, 
liquid, and special diets for overseas hospitals. Maximum use was made of 
foods in the Expeditionary Menu No. 1 (revised 1 June 1942) and No, 2 (re- 
vised 27 August 1942). With suitable changes in quantity or the addition of 
supplementary foods it was possible to provide a reasonably satisfactory diet 
for patients. It was assumed that hospitals would have the first chance at 
satisfactory perishable foods whenever available. There were basic menus 
related to the food supplied. It was assumed and suggested that there could 
or should be changes in the use of foods in different hospitals. 
Data with regard to the preparation of the different types of diets to be 
expected were not available. There were no records of hospital diets used or 
methods of providing for hospitals in the history of World War I. As the 94 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
result of suggestions from Walter Reed General Hospital, Washington, D. C., 
a percentage distribution of diets was made for purpose of procurement and 
issue, as follows:11 regular diets, 85 percent; light diets, 3 percent; soft diets, 
6 percent; liquid diets, 4 percent; and special diets, 2 percent. 
Copies of the overseas hospital menu were prepared and distributed by The 
Quartermaster General to port commanders for reproduction and issue to all 
outgoing task force shipments. This method of distribution was not entirely 
satisfactory because there was insufficient indoctrination of personnel in the 
subsistence offices and hospital personnel in the field. Until indoctrination was 
accomplished and special items reached the hospitals, results wTere rather 
unsuccessful. In some instances, especially where some local foods were avail- 
able, special plans had been developed previously and there was difficulty in 
obtaining sufficient interest to give the plan a trial. 
The emergency combat rations, C, K, and ten-in-one, proved to be inade- 
quate for sick and wounded soldiers at clearing stations and evacuation hos- 
pitals. They were dehydrated rations, in part, and it was difficult to make 
acceptable liquid and soft diets from them. For that reason two ration sup- 
plements were standardized. The first was an aid station beverage pack and 
consisted of soluble coffee, tea, soup, and fruit juices to make hot drinks for men 
wounded or in shock. The requirement for it developed in the theaters of 
operations and many supplements of this sort were used before the official 
standardization of the pack in 1944. The second pack, the hospital ration 
supplement, consisted of components for making liquid and soft diets from the 
C ration and the ten-in-one ration. It contained soups, fruit juices, additional 
beverages, and some cereal components. To supplement this pack, some in- 
vestigative work was done in the Medical Nutrition Laboratory in Chicago by 
the dietetics branch which developed a wide variety of acceptable diets that 
could be made from the packaged rations plus the hospital supplement. These 
diets may be found in the records of the Medical Nutrition Laboratory.12 
There were several other types of Army food, sometimes erroneously 
called “rations,” which were to be used for special purposes and in the event 
of severe emergencies. They were not rations in the true sense because they 
did not contain adequate nutrients for a soldier for 1 day. Examples of these 
are the D bar which was a type of chocolate bar, the Air Corps flight lunch 
which was a box of mixed candies, the parachute ration which was a small 
packaged ration equal to approximately one-third of the K ration, the life raft 
11 Ltr, QMG to Port Comdrs, 25 Nov 42, sub : Overseas hospital ration menu, with incl. SG ; 
430.1 Boston. 
12 Rpt, Med Nutrition Lab, 1 Sep 45, sub: Project MNL-3, Hospital special diet modified from 
expeditionary forces ration. AFML. NUTRITION 
95 
ration which appeared in at least five forms, made up mostly of candies and 
raisins, and a number of others. None of these emergency type, lifesaving 
rations was satisfactory but their use for the purposes for which they were 
designed turned out to be infinitesimally small, so the deficiencies in them were 
of little importance. 
At the end of the war representatives of the Office of The Surgeon General, 
Office of The Quartermaster General, Army Air Forces, and Army Ground 
Forces met in Chicago on IT August 1945 to determine the direction which 
research should take in the future with regard to pure emergency, survival 
type rations. It was generally agreed that a survival ration should be a part 
of the equipment of each soldier, just as a first aid pack is a part of his basic 
equipment. It was agreed that this ration should contain not less than 25 
percent of the probable emergency requirements of a soldier for 1 day and that 
it should be packaged in a watertight container which would fit into a pocket 
of the soldier’s uniform. No consideration need be given to vitamin content 
because vitamin deficiencies are not a consideration in an acute, lifesaving type 
of ration. Since most of the use of such a ration is by Army, Navy, and Air 
Force troops lost at sea, arrangements were made to include apparatus which 
would supply 800 cc. of water daily with the ration. Careful analysis of all 
available data indicated that less than 0.05 percent of the troops would ever be 
required to use such a ration for a period in excess of 48 hours. It was agreed 
that food was not essential for the maintenance of life in such a short period 
of time but that its morale value was worthwhile.13 
NUTRITION SURVEYS 
Throughout World War I, the interval of peace, and up until the middle 
of 1944 there was a strong feeling on the part of the Subsistence Division, Office 
of The Quartermaster General, that if a nutritionally adequate diet was sup- 
plied it naturally followed that men consumed an adequate diet. The Food 
Division, Office of The Surgeon General, in World War I and the Nutrition 
Division, Office of The Surgeon General, in World War II have correctly in- 
sisted that an appraisal of the dietary of the Army must be on an “as consumed” 
basis if nutritional adequacy is to be determined. The nutrition officers began 
early to conduct nutrition surveys of the adequacy of the diet as consumed and 
indoctrinated troops and commanders in the importance of this concept. This 
is a proper function of The Surgeon General and supplies essential data to 
Subsistence Division, Office of The Quartermaster General, upon which to base 
food procurement. 
13 Interim Rpt, QMC Subsistence Research and Development Lab, Aug 1945, sub : Survival ra- 
tions : a critical review. HD : 720.1. 96 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
The nutritional state of troops is an important part of the general respon- 
sibility of The Surgeon General for the preservation of health and the preven- 
tion of disease. It is also of paramount importance to commanders because it 
determines much of the fighting efficiency of combat troops. One of the reasons 
for the reorganization of the Nutrition Division in the spring of 1944, placing 
at its head a medical officer, was to implement The Surgeon General’s respon- 
sibility in the maintenance of an optimal nutritional state in all troops. This 
is a medical officer’s job because it requires a physical examination and in some 
instances a laboratory study of certain body tissues. 
Nutrition surveys of messes, lasting from 7 to 10 days, were conducted in 
various camps and stations for periods usually of 30 days, to supply information 
on the nutritional adequacy of the food consumed by the soldier as compared 
with that planned or issued. The factual data obtained gave confidence in the 
rationing procedures or brought out difficulties and served as a sound basis for 
recommendation. Particular attention was given to the selection and handling 
of food because the maltreatment of food in storage, cooking, and serving or the 
failure on the part of the soldier to consume food because of dislike or poor 
preparation could render an originally adequate dietary inadequate. Lacking 
actual data on losses of vitamins in such procedures, such data were obtained 
through the Office of Scientific Research and Development for the losses under 
good, poor, and very poor conditions of storage and preparation characteristic 
of the Army. Corrections were then applied to the calculation of nutritional 
content of the dietary in accordance with the methods used in a kitchen or with 
the average of Army methods. 
Nutritional surveys had a secondary and often very useful purpose under 
conditions where the causes, of apparent difficulties were hard to detect or where 
there was some uncertainty as to the success of messing operations. This was 
true because, in the course of collecting data, food and nutrition officers were in 
constant contact with the personnel of a mess and were usually able to gain 
their confidence and thus obtain a background to the problems confronting the 
mess that was not possible on inspection with its usual formality. 
Surveys were made by food and nutrition officers before and upon com- 
pletion of their training and before assignment and afterwards when required 
in the course of their duties. A simultaneous survey of 99 Ground Force 
organizations was made in June 1943,14 when it appeared that the plan of 
determining the number of rations to be drawn might result in an inadequate 
dietary for some organizations if followed as prescribed. A second simulta- 
neous survey was conducted in 1945. 
14 (1) Howe, P. B., and Berryman, G. H. : Average food consumption In the training camps 
of the United States Army, 1941-1943. Am. J. Physiol. 144 : 588-594, Sep 1945. (2) See footnote 9, 
p. 90. NUTRITION 
97 
The early surveys in 194115 represented roughly the concept of Army 
personnel with regard to the kinds and quantities found required for a satis- 
factory dietary based on experience with the garrison ration and information 
in technical manuals at that time. Subsequently the use of the master menu 
prepared by the Quartermaster General’s Office tended to modify slightly the 
choice of foods. The chief differences in the quantities of food consumed in 
1941 and subsequently were that in the later period there were less meats and 
citrus fruit and greater quantities of all other classes of food, particularly 
sugar, cereal grains, and potatoes. 
The various types of organizations or units surveyed had a wide range of 
duties and levels of activity. They included infantry, artillery, cavalry, quar- 
termaster, military police, ordnance, engineering, medical, air, chemical war- 
fare, tank, induction center troops, and others. The number of each type of 
unit differed widely (from 1 chemical warfare unit to 77 infantry units), and 
the caloric value of food consumed likewise differed over a wide range (from 
3,132 for 5 induction centers to 4,135 for 3 demolition units). The average 
caloric value of the food consumed in the average mess, when properly weighted, 
was almost 3,700 calories (3,694) by calculation. This agrees closely with the 
estimate reported by Murlin and his associates16 during the last war (3,633). 
As was also observed in World War I reports, the calculated caloric value of 
food consumed in the ordinary mess rarely lies outside the range of 3,000 to 
4,000 calories. 
The data examined in terms of seasons gave results that are again similar 
to those reported in 1919. The caloric intake was highest during the fall 
(September-November, 3,960 calories), dropping in the spring (March-May, 
3,570 calories) and rising slightly during the summer (June-August, 3,790 
calories). The observation by Murlin that seasonal variation, caused no more 
than a 400 calorie deviation (in food consumed in the mess only) is corroborated 
by these data. 
The simultaneous surveys carried out in 99 messes at 38 Ground Force 
stations during the first week of June 1943, represented approximately 130,000 
rations consumed. They included a study of: the food planned and consumed; 
the number of men present for rations (rations due) ; rations drawn; average 
number of men eating (the basis on which rations were drawn according to 
War Department Circular 16, 1943) ; table waste, i. e., food left on plates and 
total edible waste; the cooking and standing time for classes of food that might 
be seriously affected in nutritional value by long cooking and standing. 
15 (1) Howe, P. E. : Nutritional problems of the Army. Mil. Surgeon 90: 253—266, Mar 1942. 
(2) Howe, P. E. : The dietaries of our military forces. Ann. Am. Acad. Polit. & Social Sc., Jan 1943, 
pp. 72-79. (3) Howe, P. E.: Effect of recent developments In nutrition on the rationing of the 
Army. Connecticut M. J. 6 : 157-161, Mar 1942. 
18 Murlin, J. R., and Hildebrandt, F. M. : Average food consumption in the training camps of 
the United States Army. Am. J. Physiol. 49 ; 531-556, Sep 1919. 98 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Table 1 presents composite data on the quantities of food consumed, and 
wasted, by classes of food having similar nutritive value.17 “Food consumed” 
represents the average amounts of food eaten in the mess. It does not include 
waste. The data on waste refer to the quantities of edible food fit for human 
consumption but not eaten by the soldier, or prepared or discarded in the 
kitchen. The food waste has been corrected to the equivalent original form, 
i. e., as purchases, for the purpose of comparison. (The data on waste of in- 
dividual classes of food represent averages of averages. Such data might be 
open to serious question because of irregular weighting. It is justified here due 
to the fact that the kinds and amounts of food and the size of organizations 
were similar.) Edible table waste is the waste of food, corrected to its pur- 
chased form, taken on the soldier’s plate and not consumed. Total edible waste, 
including this waste and all other edible food prepared or discarded, was 0.39 
pounds per man per day. 
Table 2 is based upon the June 1948 survey of 99 messes and relates to the 
extent of overcooking or preparation or standing before serving the foods that 
Table 1. Average Quantities of Food Consumed in Army Messes (As Determined in 
455 Messes During 1941-43) 
Food groups 
Consumed 
(pounds per 
man per day) 
Percent 
edible waste4 
Meat, fish, and poultry 
0. 909 
7. 5 
Eggs 
. 149 
6. 2 
Milk and milk products (fluid milk equivalents) 
1. 016 
1. 6 
Fats, butter, and spreads 
. 083 
. 7 
Fats, other 
. 069 
4. 5 
Sugar and svrups 
. 262 
1. 0 
Cereals and grain products 
. 567 
11. 1 
Beans; other legumes, dry; nuts, dry 
. 055 
10. 5 
Vegetables, leafy green or yellow 
. 359 
16. 4 
Tomatoes _ 
. 155 
3. 5 
Citrus fruits 
. 248 
1. 3 
Potatoes 
. 561 
12. 9 
Vegetables, other than leafy green or yellow 
. 252 
10. 8 
Fruits, other than citrus 
. 358 
2. 0 
Fruits, dried 
. 026 
4. 7 
♦Average edible food wasted in messhall and kitchen s, 
Average total edible food Issued to organization 
Source: Howe, P. E., and Berryman, O. N.: Average food consumption in the training camps of the United States 
Army, 1941-1943. Am. J. Physiol. 144 : 588-694, Sep 1945. 
17 See footnote 14 (1), p. 96. NUTRITION 
99 
Table 2. Observations on Length of Time Taken in Preparing or Cooking Food 
and on Standing Time 
Preparation or cooking time 
Standing time 
(percent 
standing 
more than 
half hour) 
Type of food 
Nominal 
Percentage requiring 
allowance 
in hours 
Less than 
1 hour 
1 to 2 
hours 
2 or 3 
hours 
Meats __ 
2 
60 
0 
40 
62 
Vegetables, leafy green or yellow 
1 
31 
43 
26 
76 
Salads ___ 
1 
8 
17 
75 
100 
Potatoes 
1 
24 
61 
15 
27 
Vegetables, other 
1 
52 
15 
33 
61 
Source: Howe, P. E., and Berryman, G. H.: Average food consumption in the training camps of the United States 
Army, 1941-1943. Am. J. Physiol. 144 : 588-594, Sep 1945. 
result in serious destruction of vitamins. The period of “ample cooking or 
preparing time” is an arbitrary value which may be longer than desirable. 
The data on rations drawn were studied in relation to the caloric content of 
the food planned and consumed. They were divided into two groups as 
follows: 
1. Messes that consumed less calories than were planned. In this group 
63 messes consumed an average of 3,MO calories against 3,710 calories planned. 
They had an average attendance of 161 men and drew 171 rations (10 extra 
rations per day). The latter represents 106 percent of the attendance. The 
attendance was 86 percent of the morning strength report. There was 0.15 
pound edible table waste and 0.36 pound total edible waste. In addition to 
the above there were 19 messes that drew fewer rations than indicated by the 
attendance. These messes consumed 2,780 calories against 3,620 calories planned. 
They had an average attendance of 176 men and drew 169 rations representing 
96 percent of the morning strength report. There was 0.13 pound edible table 
waste, 0.24 pound total edible waste. 
2. Messes that consumed more calories than were planned. In this group 
15 messes consumed 3,940 calories against 3,690 calories planned. They had an 
average attendance of 158 and drew 180 rations (22 extra rations per day), 
representing 120 percent of the attendance. The average attendance was 77 
percent of the morning strength report. There was 0.17 pound edible table 
waste, 0.30 pound total edible waste. Two organizations in this group drew less 
rations than the number of men eating. 
The general conclusions to be drawn from these data are as follows: 
1. Organizations drew more rations than they were entitled to according 
346336 0—55 8 100 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
to War Department Circular 16, 1943, when followed exactly. In 17 percent 
of the cases extra food was needed if the caloric intake can be taken as an index 
of the requirements of the messes. On the average, the organizations were 
receiving barely enough food for their needs if the rations were drawn according 
to regulations. In no case were more rations drawm than represented by the 
number of rations to which the organizations would have been entitled according 
to the number of men present for rations without the deductions made for 
strength according to Army Regulations (AR) 30-2210. 
2. The total edible waste was fairly high, 0.32, approximating the waste in 
1917-18,0.38 pound per man per day. It is possible under very close supervision 
to reduce edible waste as it is prepared to 0.1 pound per man per day or even 
less. Table waste was approximately 50 percent of the total edible waste, indi- 
cating that the soldier in his eating habits is not more wasteful than the 
kitchen personnel. That is, waste that occurs to a considerable extent occurs 
in the administration and preparation phases of mess operation. Waste did 
not bear a marked relation either to caloric intake or the excess number of 
rations drawn. It is obvious, however, that if more perishable food is issued or 
excessive quantities prepared than can be consumed there will be more waste. 
Excess issue of staple foods should not have as great effect on waste as perishable 
foods since the former can be stored for future use or returned to the sales 
officer. There were indications that the relatively high waste of vegetables 
was needlessly cutting into civilian supplies of vegetables through a lack of 
local administration of supply and planning of menus in relation to the dietary 
habits of the troops. 
3. The caloric intake showed a considerable range and varied from approx- 
imately 2,774 to 4,644 calories. The average caloric consumption, 3,468 calories, 
was less than the soldier had been consuming in previous surveys (4,100 calories 
supplied and 3,888 calories consumed in 1941-42, and 3,900 calories supplied 
and 3,633 calories consumed with approximately 365 calories in the post ex- 
change in 1917-18). Since the ration was usually planned for the average of a 
station, some organizations will require less and some more food. This means 
that food, particularly the staple energy foods, should be distributed according 
to the needs of the various organizations or additional quantities of these foods 
be made available to organizations that need them. The differences between 
caloric intake observed, in relation to past experience, indicated that the soldier 
may depend upon the food eaten outside the mess to complete his caloric require- 
ments. Troops were less active than they were formerly, or they ate more food 
in the past than was required. It is not possible from these data to determine 
which factor or factors were operating. There was considerable use of excess 
water and overcooking and the service of food was delayed to such an extent NUTRITION 
101 
that serious losses were occurring in the labile vitamins and soluble minerals, 
which tend to invalidate the careful planning of rations. 
A comparison of the food issued and consumed by Negro soldiers as com- 
pared with white troops indicates that the consumption of the two sets of 
soldiers was essentially the same. 
Material was developed to aid food and nutrition and Medical Department 
officers in the evaluation of rations, including data on food consumption. The 
general principles of an adequate acceptable dietary were prepared in mimeo- 
graph form and distributed, and finally published in War Department Tech- 
nical Bulletin (TB MED) 23, 23 March 1944. A rapid, fairly accurate method 
of determining the approximate nutritive value of dietaries was developed from 
the experience of the Bureau of Nutrition and Home Economics, United States 
Department of Agriculture.18 The weighted average composition of roughly 
similar classes of foods was represented in tables. It was only necessary to 
apply the values to the weights of particular classes of food as used or pro- 
vided. Distributions of food were studied for the fall-winter and spring- 
summer periods of the year. The tables proved to be very useful and these 
percentages were used in weighting the composition of the various classes of 
food. Tables for classifying foods and factors for conversion of unit packages 
to pounds for use in dietary analysis of rations were also developed and pub- 
lished in TB MED 25, 28 March 1944. The use of the per capita consumption 
of the various classes of food which follow a given food pattern in relation to 
the per capita consumption of a given mess may also be used as a first approxi- 
mation of adequacy of dietaries or rations. 
Motorized troop energy expenditure in all varieties of tanks, and to a 
limited extent also for artillery troops, was determined at Fort Knox, Kentucky. 
Many universities doing experimental work for the Army made contributions. 
Much of these data were brought together and summarized by the Chief, 
Chemical Section, Armored Medical Kesearch Laboratory, and his report was 
made available to The Surgeon General and to The Quartermaster General. 
At the end of 1944 it was possible to make reasonably accurate estimates 
of the caloric requirements of troops in all kinds of activities and to arrive at a 
reasonably, properly weighted estimate of a mean value which was applicable 
to the whole Army. To support this evidence another simultaneous nutrition 
survey of the actual food intake of troops at a large number of camps scattered 
over the entire United States was made in the spring of 1945.19 
18 (1) Berryman, G. H., and Chatfleld, C. : A short method of calculating the nutritive value of 
diets. J. Nutrition 25: 23-37, Jan 1943. (2) Berryman, G. H., and Howe, P. E.: A short method 
of calculating the nutritive value of diets. J. Nutrition 27 : 231-240, Mar 1944. (Erratum p. 434, 
May 1944.) 
1BRpt No. 36, Med Nutrition Lab, 5 Apr 48, sub: Simultaneous survey of food consumption in 
various camps of the United States Army, 22—28, May 45. AFML. 102 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Table 3 shows the average quantities of the various food groups consumed 
in the mess per man per day during the period under survey; for comparative 
purposes, food consumption figures as reported in 1943 by Howe and Berry- 
man 20 are shown in column 2 of this table. In order to determine the nutri- 
tional adequacy of the food consumed it was necessary to estimate not only the 
amounts of food prepared but also the amount of each food item wasted and 
subtract the nutrients contained therein from the nutrients in the food pre- 
pared. To obtain data on food wastage, all plate waste was segregated by 
food groups and weighed, and all kitchen waste was also segregated and 
weighed. The range of food wastage in the different messes was from 0.08 
pound to 0.66 pound per man per day, resulting in an overall average of 0.24 
pound of edible food per man per day or approximately 5 percent of the food 
issued by the Quartermaster Corps. This figure, as compared with an average 
edible food waste of 0.38 pound per man per day reported in 1919, 0.39 pound 
per man per day in 1941, and 0.32 pound per man per day in 1943, indicates the 
creditable strides made by the Army in food conservation. 
Table 3. Average Quantities of Food Consumed in 44 Army Messes 
During the Period 22-28 May 1945 
Food groups 
Pounds consumed per man 
per day 
1945 
1941-43* 
Meat, fish, and poultry 
0. 834 
0. 909 
Eggs 
. 165 
. 149 
Milk and milk products (fluid milk equivalents) 
1. 260 
1. 016 
Fats, butter, and spreads. 
. 070 
. 083 
Fats, other 
. 044 
. 069 
Sugar and syrups 
. 280 
. 262 
Cereals and grain products _ _ 
. 512 
. 567 
Beans; other legumes, dry; nuts, dry ... 
. 036 
. 055 
Vegetables, leafy green or yellow 
. 302 
. 359 
Tomatoes 
. 162 
. 155 
Citrus fruits 
. 332 
. 248 
Potatoes 
. 562 
. 561 
Vegetables, other than leafy green or yellow 
. 248 
. 252 
Fruits, other than citrus 
. 211 
. 358 
Fruits, dried 
. 028 
. 026 
*For comparative purposes, average food consumption in Army messes as reported by Howe and Berryman in 1943, 
Am. J. Physiol. 144; 588-594, Sep 1945. 
Source: Rpt No. 30, Med Nutrition Lab, 5 Apr 1948, sub: Simultaneous survey of food consumption in various camps 
of the United States Army, 22-28 May 1945. AFML. 
1,0 Sec footnote 14 (1), p. 96. NUTRITION 
103 
During this study, data were also obtained on messing practices, i. e., total 
elapsed preparation times. The methods of cooking and preparation of food 
were satisfactory in the majority of messhalls. In some instances, however, 
improper preparations and cooking practices were employed, resulting in 
lowered nutritive value of the food consumed. The most common infraction 
of good cooking practices was poor timing of food preparation: meat was cooked 
and salads prepared too far in advance. Another factor, also having bearing 
upon the amount of food left over, and wasted, was the overdrawing and under- 
drawing of rations. A comparison was made of rations drawn with the number 
of men actually fed, based on head counts made by each nutrition officer and a 
compilation of rations drawn. Of the messes surveyed, 79 percent overdrew 
rations and 20 percent underdrew rations. Overdrawing rations to the extent 
of 5 percent was the average for the 44 messes surveyed. 
The approximate nutritive value of the food consumed for the period is 
shown in Table 4. It will be noted that the quantities of essential nutrients as 
calculated are liberal, and exceed, in every instance, the National Research 
Council’s recommended dietary allowances for moderately active men. 
Table 4. Calculated Nutritive Value of Average Food Consumed Per Man Per 
Day as Determined in 44 Army Messes During the Period 22-28 May 1945 
Nutrients 
Consumed 
Standard 
Deviation 
NRC* 
3, 744 
299 
3, 000 
127 
11 
70 
181 
28 
411 
54 
1. 3 
. 2 
. 8 
2. 2 
. 2 
Iron mgm 
23. 3 
2. 1 
12. 0 
10, 042 
1, 960 
5, 000 
1. 6 
. 2 
1. 5 
2. 9 
. 4 
2. 0 
23. 0 
2. 4 
15. 0 
89. 0 
12. 6 
75 
*1945 National Research Council recommended daily allowances for a moderately active man. 
Source: Rpt No. 36, Med Nutrition Lab, 5 Apr 48, sub: Simultaneous survey of food consumption in various camps of 
the United States Army, 22-28 May 45. AFML. 
The various organizations and units surveyed were of widely different 
composition and had a broad range of duties and levels of physical activity. 
Included were artillery, cavalry, engineer, infantry, medical, military police, 
quartermaster, signal, tank transportation, replacement center, and miscel- 104 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
laneous troop units. The average caloric value of food consumed by the 
various types of units ranged from 3,471 calories for 2 basic training units to 
4,078 calories for 2 quartermaster units, with a total average of 3,744 calories 
per man per day. These figures, when considered in terms of the strength of 
the various units, indicate there was no significant variation of the average 
caloric intake with degree of activity of troops. The estimated average caloric 
intake (3,744) agrees closely with the estimate of the previous simultaneous 
survey in World War II in 1943 (3,694) and with Murlin and his associates 
in World War I (3,633). The observation by Howe and Berryman that the 
calculated caloric value of food consumed in the mess rarely lies outside of the 
range of 3,000 to 4,000 calories was corroborated by these data. 
Similar surveys were made in isolated camps periodically throughout the 
war. Nutrition surveys of the actual food consumption of carefully selected 
representative samples of troops in most of the larger bases of the Pacific 
theater were made in the spring and summer of 1945. In the summer of 1944 
a controlled experiment was carried out in the Tarryall Mountains at Camp 
Carson, Colorado. Its primary purpose was to test ration acceptability but 
at the same time very precise records of the actual caloric intake of troops 
were maintained. These troops (a battalion of infantrymen) were on very 
rigid advanced infantry training. 
There was good, general agreement from all of the sources of information 
concerning the caloric intake of American soldiers and it was, therefore, possible 
to write a prescription for the diet of the Army based upon scientific appraisal 
of soldier requirements.21 There may appear to have been some unnecessary 
delay in getting this prescription written but as a matter of fact much of the 
information was used informally by The Quartermaster General in setting up 
both the master menu of the A ration and the components of the various expe- 
ditionary forces’ rations for many months before the official prescription was 
published. The errors in diet construction were always on the high side prior to 
the publication of these standards. 
A national food shortage and the tremendous food requirement of Europe 
and the Orient were in part responsible for the publication of this diet at the 
relatively low level of 3,600 calories. Previous to this time all of the rations 
of the Army ranged from 3,750 calories up to over 4,500 calories. 
The content of other nutrients which go to make up a diet were arrived at 
by using the National Research Council standards as a guide but lowering the 
amounts to what was deemed to be safe but satisfactory levels after carefully 
studying nutrition survey data in many parts of the world. For example, it 
will be found that the thiamine requirement of the Army ration is considerably 
lower than that of the National Research Council. The Ai;my figure was 
arrived at by studying troops in the Pacific who had lived on a B ration, much 
21 WD Clr 33, 5 Feb 46. NUTRITION 
105 
lower in thiamine content than the requirements of the National Research 
Council, for a period of over 2 years and showed no detectable evidence of 
thiamine deficiency. The same applied to the other components of vitamin B 
complex. The figures actually used were also supported by experimental data, 
particularly that from the University of Minnesota22 and by information 
obtained from other investigators. 
It was the opinion of the officers of the Nutrition Division, Office of The 
Surgeon General, that a single dietary standard for the Army was a fallacious 
concept and that the various components of the Army should be fed in the terms 
of their physiologic needs. Such a procedure would call for a diet of nearly 
5,000 calories in some engineering organizations and for approximately 2,500 
in many headquarters. However, the administrative mechanism for handling 
such a plan was not well worked out. Although covered in effect in War De- 
partment Circular 208, 13 September 1943, the new concept was never put into 
effect except as a trial proposition in the feeding of prisoners of war. The 
actual dietary prescription was a mean value wThich could be raised or lowered 
by local commanders with Medical Department approval. 
Realizing that under certain circumstances rations may be inadequate be- 
cause of the inability of troops to consume them or to get all of the normal 
components, policies were written permitting the supplementation over and 
above the basic standards as required—the requirement being determined by 
Medical Department officers. 
PRISONER OF WAR FEEDING 
Providing food for German prisoners of war in the Zone of Interior created 
many problems. If the number of prisoners had been small the feeding problem 
would have been of minor importance. But on V-E Day there were between 
300,000 and 400,000 prisoners of war distributed in main and branch camps in 
the Zone of Interior. The first prisoners of war were received in the United 
States in May 1942. Their presence in the Zone of Interior posed many ques- 
tions of feeding. The most important was how much and what items of food 
should be used in the dietary of the German prisoners of war. Answering this 
question required the interpretation of that part of the Geneva Convention 
article pertaining to the feeding of prisoners of war. The Geneva Convention 
reads, “The food ration of Prisoners of War shall be equal in quantity and 
quality to that of troops at base camps.” The obvious way to conform to this 
was to feed prisoners the same items and amounts of food as American troops 
received. 
So, from 1942, when the first German prisoners of war were received until 
1944 when the first directive on prisoner of war feeding w7as issued, German 
22 Keys, A. : Human starvation and its consequences. J. Am. Dietet. A. 22 : 582-587, Jul 1946. 106 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
prisoners were fed approximately the same ration as American troops or, 
namely, the foods listed on the service command menu for troops. 
The first circular on prisoner of war feeding was published 1 July 1944.23 
This circular was not very forceful. Some of the pertinent provisions con- 
tained therein were: 
.... In no case will the issue of critical or rationed items exceed quantities stipu- 
lated in the Office of The Quartermaster General master menu. . . . 
.... The menu board may find it necessary to alter the percentage of increases, de- 
creases, or the deletion suggested, based upon experiences in feeding the prisoners in their 
particular camp. If, for example, it is known that prisoners will consume the regular 
post menu issue of apple butter, beets, carrots, or tomatoes1 without waste, the regular 
issue should be made. The value of the garrison ration must not be exceeded, how- 
ever. . . . 
Thus, it can be seen that no restrictions of consequence were made. As long 
as the prisoner of war menu did not exceed the value of the garrison ration or 
the amounts of rationed items on the Office of The Quartermaster General menu, 
it was satisfactory. Also, it can be seen that in some instances prisoners of war 
could be fed a ration equal or greater than that of United States enlisted men. 
This was found to be true in some cases. In 1945 four circulars on prisoner 
of war feeding were published, namely, Army Service Forces Circulars 39, 72, 
150, and 191. Parts of the first three circulars were in effect at the same time; 
this caused confusion. 
It can be safely said that serious, effective attention on a wide scale was never 
given by anyone to the maximum usage of noncritical foods in prisoner of war 
feeding until the following occurred: First, the Allied armies overran prison 
camps in Germany and found in them starving, malnourished prisoners of war, 
Americans and others; second, civilians in the United States protested vigor- 
ously when they learned through newspaper accounts and radio commentators 
that the German prisoners of war were being fed a diet luxurious in comparison 
with the one they (housewives) could provide for their families. Response 
by the War Department to the foregoing protests was immediate: All agencies 
involved in feeding the prisoners of war were instructed to cut the use of 
civilian-scarce food to a minimum and to substitute civilian-plentiful food. 
The Geneva Convention was reinterpreted by joint agreement of the Office of 
The Surgeon General, Office of The Quartermaster General, and Office of The 
Provost Marshal General, with concurrence of the Commanding General, Army 
Service Forces, as follows: The word “equal” does not mean “identical,” there- 
fore, if American troops were fed 100 gm. of protein in the form of grade A 
beef, while German prisoners had to be fed the same amount of protein, it did 
not have to come from the same part of the carcass. Furthermore, while troops 
23 WD POW Clr 35, 1 Jul 44. NUTRITION 
107 
were authorized from 3,600 to 4,000 calories per day their actual consumption 
was a function of their energy requirements (the work they did) and might be 
considerably lower than the authorized figure. It was, therefore, agreed to feed 
prisoners of war in terms of their energy requirements and to feed them low-cost 
nonrationed foods which were nutritionally adequate, as determined by ac- 
cepted American standards. (See Army Service Forces Circular 235, 1945.) 
In haste, as a stop-gap measure, Army Service Forces Circular 150, 
27 April 1945, was written, principally by the Office of The Quartermaster 
General, and dispatched to the field accompanied by a menu guide for prisoners 
of war. This circular and menu required that use be made of the following 
or similar items: pig’s snouts, pig’s feet, pig’s tails, green bones, hearts, and 
similar items of meat in amounts not to exceed 4 ounces per man per day (this 
did not mean inedible meat), bread in amounts up to 130 pounds per 100 men 
per day and flour in addition. They would not eat this much bread. No sub- 
stitutions were permitted. This resulted in a sad state of affairs: (1) The 
items specified in the menu could either not be obtained at all by market centers 
or in only limited quantities, (2) inability to obtain the foregoing items resulted 
in an inadequate diet, and (3) some thought the dietary standards were too 
low when, as a matter of fact, this was not the trouble—the trouble was in the 
unavailability of foods and a poorly planned menu. Soon there were reports 
of prisoners of war fainting on the job, inability to meet established work 
quotas, and loss of weight. Then the public again bombarded the War Depart- 
ment, this time the letters stating, in effect, that to starve the Germans was 
to lower ourselves to the same level as the Germans who starved their American 
prisoners in Germany. 
At this point, a joint meeting of representatives from the Office of The 
Quartermaster General, The Surgeon General, and The Provost Marshal Gen- 
eral was held to consider what could be done to feed the German prisoners a 
nutritionally adequate diet with noncritical items of food. This meeting was 
called by the Office of The Quartermaster General. It marked the first time 
that joint consideration by all interested agencies was given to the prisoner of 
war feeding problem. Preceding this first meeting most of the directives on 
prisoner of war feeding had been written by the Office of The Quartermaster 
General with the approval of The Provost Marshal General. In this joint 
meeting several decisions were made: 
1. To have teams make brief surveys of the status of prisoner of war sub- 
sistence—the teams to consist of representatives of The Surgeon General, The 
Quartermaster General, and the Director of Food Service from the headquarters 
of the service command in which the surveys were conducted or, namely, the 
First, Second, Fourth, Fifth, and Sixth Service Commands; 
2. To have a committee review existing directives on prisoner of war feed- 
ing and to formulate recommendations concerning them; and 108 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
3. To have a committee make a survey of previous surveys of prisoner 
of war feeding and to render a report thereon. 
There were, therefore, three committees at work simultaneously: (i) the 
survey teams at work in the service commands; (2) the committee to review 
existing regulations; and (3) the committee to review reports of previous sur- 
veys, which had been conducted by both nutrition officers and food service 
officers. The findings of all these committees were briefly as follows: The 
committee surveying prisoner of war camps in the Zone of Interior found, in 
general, noncompliance with the existing directives. The committee which 
studied existing directives found that specificity was lacking and the mere 
existence of such a large number of directives confused the officers in the field 
responsible for implementing the directives. The report of the committee to 
review previous surveys revealed that the findings of the committee working 
in prisoner of war camps merely substantiated previously reported findings. 
These committees brought to a focal point conditions of long standing pertain- 
ing to prisoner of war feeding. Not of minor importance was the sale of scarce 
food items not available to the civilian public from the post exchange to 
German prisoners. 
The second joint meeting of representatives of the interested agencies was 
held to discuss the results of the survey and to map out the general plan for a 
single new directive to supersede all existing directives. The real problem 
was one of policy on nutrition standards for prisoners of war. The Office of 
The Surgeon General contended that the terms of the Geneva Convention 
article were met when the standards of the National Research Council were 
attained and that prisoners of war should be fed according to their degree of 
activity. These two contentions were upheld and became a part of the directive, 
Army Service Forces Circular 191,29 May 1945. 
The directive stated specifically the duties of all concerned with the feeding 
of German prisoners of war. Some of the more important duties to be dis- 
charged by the Medical Department through nutrition officers in conformance 
with Army Service Forces Circular 191 were: to assist in the formulation of a 
service command prisoner of war menu; determination of the caloric expend- 
iture of energy by prisoners of war—the results would indicate to the sales 
officer the amounts of food to issue; and frequent inspection of feeding and 
sanitation. The provisions of this circular were carefully worked out and, 
with a few exceptions, proved satisfactory. 
The Nutrition Division, Office of The Surgeon General, published a set 
of criteria by which prisoner of war camps could estimate the caloric require- 
ments of troops and by the simple process of periodic weighing could determine 
the adequacy of the ration issue. 
It should be made clear here that the key to feeding the prisoners properly 
with food not in short supply was a well-planned menu composed of food NUTRITION 
109 
procurable by market centers in proper amounts. Procurement of food items 
not commonly used in GI rations was very difficult, as aforementioned, for 
market centers to effect. For example, to procure enough pig’s tails to make 
one issue of them to German prisoners of war was an almost insurmountable 
task, particularly when the number of German prisoners of war to be fed was 
large. Many items of this sort were never used; instead other meats (non- 
rationed) such as fish, bologna, et cetera, were issued. There was a lag period 
between the time when the circular was written and when procurement could 
be effected. As soon as procurement “caught up” with the circular the plan 
devised jointly by the Office of The Surgeon General, the Office of The Quar- 
termaster General, and Office of The Provost Marshal General worked 
satisfactorily. 
Everyone who assisted in writing the directive was cognizant of the fact 
that the circular could not possibly be perfect. In order to find out as soon 
as possible its faults and to correct them a study was to be conducted in 
prisoner of war camps by a survey team planned as soon as Army Service 
Forces Circular 191 was put into effect. The teams consisted of representatives 
from the Office of The Surgeon General and the Office of The Quartermaster 
General. Surveys were made and reported but the number of recommendations 
was small. Y-J Day occurred before action could be taken on these recom- 
mendations. V-J Day had an immediate effect on the whole outlook of prisoner 
of war feeding inasmuch as plans were made at once for the return of the entire 
number to Germany by March 1946. 
A record to indicate what the German prisoners of war needed, on the 
average, is as follows: a ration providing 3,400 calories was usually sufficient; 
a ration providing as much as 4,000 calories was permitted for prisoners of 
war laboring in lumber camps, in beet harvest, or in other arduous work when- 
ever it was determined by the proper medical authority that there was a need 
for it; a low-calorie ration, 2,500 calories, was issued to those German prisoners 
of war who refused to work. To some it may seem that the German prisoners 
of war were overfed. The fact that they afforded the primary source of labor 
in Army camps, harvest fields, pulpwood mills, and other locations should not 
be overlooked when considering whether prisoners of war were fed too liberally. 
To produce efficient work any personnel must be well fed and it was on this 
hypothesis that the Office of The Surgeon General recommended feeding of a 
ration equal calorically to the caloric expenditure of energy. 
CIVILIAN FEEDING IN LIBERATED 
AND OCCUPIED AREAS 
With the cessation of hostilities in Germany it became the duty of the 
Army to maintain law and order and to prevent the spread of disease. The 110 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
food problem in Europe was acute. The Office of The Surgeon General supplied 
five nutrition survey teams for the purpose of appraising the nutritional state 
of the civil populations in the occupied countries. The purpose of this appraisal 
was to determine the minimum food requirements for all groups of the popula- 
tion. It was believed that only by this technique could the inadequate supply of 
food be distributed equitably in the best interest of the Army, and also the 
quantity of food available through all sources, including the black market, be 
estimated. Invariably, actual measurement of people showed 500 calories more 
food intake than agriculture supply surveys indicated was available. Failure 
of populations to lose weight proved the correctness of the survey findings and 
saved millions of dollars in rations. By 15 August 1945 more than 40,000 
people had been examined in Germany. This group was a carefully selected 
miniature sample of the population of 20 of Germany’s most important cities. 
A similar procedure was planned for Japan, provided the food supplies of that 
country were inadequate to meet the needs of the occupying forces. There was 
no effort to supply an optimal diet to these people but rather to supply a diet 
which would prevent civil unrest, the spread of disease, and would allow the 
civil populations to carry out such work as might be necessary for the effective 
running of the country by American forces. Further details of this program 
and the nutritional state of civil populations in occupied countries will be 
found in another volume in this series. 
REGIONAL FOOD HABITS AS RELATED 
TO FOOD ACCEPTANCE 
Food acceptance is tied up with many factors which are largely psychologi- 
cal—the strongest is probably the food habits of the family from which an 
individual comes. Here, unfortunately, methods of food preparation, good 
or bad, play a significant role. Food habits of a locality in the United States 
are undoubtedly based on two major factors: (1) the predominating nationality 
of the country from which the people come, and (2) the food available in the 
community. Even in the latter case the methods of preparation characteristic 
of the nationality of origin modify the use of the abundant foods of a region 
and introduce a secondary factor in the acceptance of the same foods by persons 
of another region. 
Factual evidence of the effect of previous food habits on the acceptance 
of food in the Army is very limited. The failure to accept new foods or methods 
of preparation is so much more obvious that it is much easier to notice and 
relate than the lack of effect or acceptance after a period of exposure to 
particular foods. 
An example is the method of preparation of a meal at Fort Meade, Mary- 
land, where parts of two companies messed together—one largely from the 
New England States with a New England mess sergeant and the other from the NUTRITION 
111 
South with a mess sergeant from the same region. The mess sergeants super- 
vised the cooking on alternate days. In a survey of the mess it was noted that 
the consumption of food was greater by the men from the region from which the 
mess sergeant came on the days he was in charge of the kitchen. 
There were many cases of failure to accept fresh vegetables other than the 
standard potatoes, tomatoes, corn, string beans, spinach, and cabbage. In some 
cases even some of these foods were not accepted. In the case of other vegetables, 
they were well prepared even when the cook knew that only a small portion of 
the quantity he was preparing would be eaten, the rest to go into the garbage 
or elsewhere if the garbage can was under close scrutiny. 
Regional food habits are very definite with regard to certain basic carbo- 
hydrate foods—rice and potatoes, and individual foods—cornbread and beans. 
Lamb, or as it is usually called, mutton, is also a regional problem. In the 
latter case the difficulty in acceptance may be due to the small size of the bulk 
and consequently the difficulties of getting full-sized slices of meat. 
At times variety or greater profusion of so-called acceptable foods was 
resorted to when all that was needed was a slight variation in method of 
preparation and good cooking. 
The psychological conditions under which food is eaten plays a part in food 
acceptance. It has been noticed in Army messes that were not consuming certain 
foods satisfactorily that, while at most of the tables there would be considerable 
waste, at an occasional table there was no waste and the serving dishes were 
completely emptied. One possible explanation is that someone showed an 
interest, no one objected, and the rest fell in line. This is, in effect, the condition 
that determines the food habits in youth. 
From a national point of view, a British officer engaged in studying the 
nutritional problems of the Royal Air Force told of the delight certain Royal 
Air Force troops had in our rations when they first lived on them. Later their 
established habits prevailed and they insisted on returning to British rations. 
It is obvious that regional food habits, in the broadest sense, are a factor 
in the acceptance of foods and that such habits persist for a long time. The 
opinion has been expressed that the soldier after a year or so gradually becomes 
accustomed to the foods he obtains in Army messes and accepts them. 
There are two or three phases of the extent to which regional food habits 
interfere with or promote the eating of basic foods or unusual foods: (1) when 
they first are presented or after they have been presented for a relatively short 
time, and (2) when they have been presented for a season or longer. The ulti- 
mate test of acceptance might well be when two foods or methods of prepara- 
tion are presented simultaneously and the individual eats the new food or 
method of preparation in preference to the one to which he was previously 
accustomed, or at least 50 percent of the time. 112 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Since previous food habits do influence acceptance of food, at least tem- 
porarily, profitable studies might well be conducted with individuals from 
different regions on such questions as to the best methods to modify acceptance 
of foods, the classification of foods and methods of preparation that present 
the least and most difficult problems of acceptance, the extent to which texture 
(fine, coarse, soft, or hard), color (colorless, colored, and the kind of color), 
and flavor (acid, sour, sweet, strong, milk, highly flavored, or bland) affect 
acceptance, and which of the factors have the greatest influence. Along with 
such studies could well be included studies of the qualities of food that promote 
the acceptance of the same foods for long periods of time and those that cause 
early dissatisfaction and even rejection under conditions of monotony. While 
subjects from the United States are rather well conditioned to variety there is 
evidence that some types of food are acceptable over longer periods of time than 
others. Results on studies of the effect of regional food habits in relation to 
food acceptance can be useful in the development of a sound nutritional pro- 
gram for the country as a whole. They should reveal nutritional deficiencies 
and their causes. As a member of the Food and Agriculture Organization of 
the United Nations, the United States agreed, at the first conference at Quebec, 
Canada, “to take all measures within its power to raise the level of nutrition 
and the standard of living of the people under their jurisdiction” and “to report 
to one another ... on the measures taken and progress achieved.” 
THEATERS OF OPERATIONS 24 
Overseas Problem 
The feeding of the soldier in the overseas areas was essentially one of 
supply, experience of mess personnel in the preparation and serving of the field 
ration, and the use of the packaged rations, C, K, and five- or ten-in-one. The 
character of the rations was determined in the Zone of Interior. Supplemen- 
tation of the ration from sources within or near the field of operations was not 
the policy of the Army. In the China-Burma-India theater, this policy was 
modified to some extent before supplies of the B ration reached the authorized 
level. Troops were fed the British field service ration, supplemented by fresh 
supplies purchased locally and by available items of the B ration. 
The basic major difficulty in the adequacy of the diets was failure to con- 
serve the food available, whether the field or B ration or the packaged rations. 
The length of the supply line and the rapid movement of troops into new areas, 
which characterized amphibious operations, resulted in unbalanced rations. 
The rations were unbalanced in relation to the articles of the ration, more than 
in actual nutritional adequacy. This was not true of the packaged rations, 
u This section was prepared by Dr. Audrey A. Bill from historical reports and other archival 
material. NUTRITION 
113 
which were units in themselves but also restricted in caloric content. The 
problem of acceptance was more pronounced, however, with the packaged ra- 
tions, which were planned for short periods of time. Their convenience in 
transportation, distribution, lack of need for kitchen facilities for preparation, 
and relative nonperishability or difficulties of supply resulted in their continu- 
ous use, without relief with the B ration, for longer periods than contemplated. 
Under these conditions the soldier chose the parts in which he was most inter- 
ested and discarded, bartered, or gave away the others. The result was a low- 
ered caloric intake and some slight malnutrition. 
Nutrition in North African Theater25 
The Consultant in Medicine, Office of the Surgeon, Headquarters, North 
African Theater of Operations, functioned as the nutrition officer from 3 
January 1943 until the responsibility for this subject was transferred to the 
section of preventive medicine on 1 August 1944. At the time of his arrival at 
Allied Force Headquarters in Algiers on 3 January 1943, the American forces 
in North Africa had been engaged for less than 2 months. A short review of 
the tactical situation as it existed at that time will aid in the understanding of 
certain of the problems of nutrition encountered by the American forces in 
forward areas. 
In the original planning for the OPERATION TORCH, it was con- 
templated that while there would be a considerable number of personnel of the 
Air Forces east of Algiers, the Ground Force component in that area would 
be relatively small. However, due to changes in operational plans, by January 
the bulk of the Tactical and Bombing Air Force, one regimental combat team, 
and numerous smaller units were in Eastern Algeria and in Western and 
Southern Tunisia; one regimental combat team was guarding the line of 
communications from Algiers to Souk-Ahras; and II Corps and its attached 
troops were moving into Southern Tunisia. This meant that a sizable incre- 
ment of the American forces in North Africa were east or south of Constantine, 
Algeria. As far as supply lines were concerned, 3 small, frequently bombed 
ports (Bougie, Philippeville, Bone), 1 single-tracked railroad from Oran to 
Constantine, and 1 fairly good road from Algiers east were available for 
supplying this force and for the British First Army and troops along the line 
of communications. The American supply lines which stretched primarily 
from Casablanca and Oran were long and tenuous, and it is not strange that 
during this period of time the combat forces operated on a “shoestring” basis 
insofar as supplies were concerned. 
25 This section is based on material submitted by Perrin H. Long, formerly Colonel, MC, Consultant 
in Medicine, Office of the Surgeon, Headquarters, North African Theater of Operations. Material was 
originally presented in Long, P. H. : The History of nutrition in the North African Theater of Opera- 
tions, 3 January 1943 to 1 August 1944. HD ; 314.7-2. 114 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
In the course of a tour of inspection of British hospitals in North Africa 
made by the consultant in medicine with the British consulting surgeon and 
physician from 13 to 20 January 1943, complaints were heard from American 
troops about their rations. Many of them were receiving the British Composite 
Pack which they stated did not “fill them up” and which contained items 
foreign to the American dietary and, hence, disliked. The C and K rations 
also came in for criticism because of the tastelessness and their monotony. 
However, on this trip no evidence of nutritional disturbances were seen in 
American troops. 
During a tour of inspection in II Corps which was made in February 1943, 
the Consultant in Medicine, North African Theater of Operations, heard further 
complaints about the inadequacy of the “Compo,” C, and K rations which 
were being issued to American troops. During this month, reports began to 
reach the Office of the Surgeon, Headquarters, North African Theater of 
Operations, from Ground and Air Force units concerning alleged deficiencies 
in the rations which they were receiving. However, it was not until April 1943 
that evidence was obtained by the Consultant in Medicine in the course of a 
tour of II Corps, in Northern Tunisia, of the development of definite nutritional 
disturbances in the troops of that Corps. He observed that instances of 
avitaminosis had been noted in patients received from II Corps. As far as 
could be ascertained, these disturbances occurred in individuals who were sup- 
posed to be on full C rations, but there was no way of telling whether or not 
they had consumed their rations. There seemed to be general agreement 
among those concerned that cold C rations were unpalatable for prolonged con- 
sumption and if the statements of the enlisted men were correct, cold C rations 
produced certain digestive disturbances. Because the problem involved various 
interested sections of the headquarters and because of its importance, he recom- 
mended that a board consisting of representatives from G-l, G-4, the Quarter- 
master, the Surgeon, and an infantry battalion commander from either the 1st 
or 9th Divisions be created for the purpose of ascertaining the facts and 
making recommendations concerning the diets of combat troops. 
The recommendation in respect to the forming of a board of officers to 
survey the rations was favorably considered by the Surgeon, North African 
Theater of Operations, and was forwarded as a memorandum to the Deputy 
Theater Commander on 15 May 1943. It was returned with the suggestion 
that the difficulty lay in the misuse of the C ration, rather than with the ration 
itself. In his reply the Surgeon, North African Theater of Operations, pointed 
out that this was well understood by him, and that his proposal was in part 
made to explore methods by which the responsibility for the proper use of 
rations could be impressed upon the command, as well as any other methods 
which would result in an improvement of the nutrition of troops in combat. NUTRITION 
115 
The Deputy Theater Commander was not impressed by this reply and the 
board was not appointed.26 
Late in May 1943, as a result of discussions which had taken place in the 
conference of the Chief Administrative Officer (British), Allied Force Head- 
quarters, the Deputy Theater Commander suggested to the Chief Administra- 
tive Officer that a joint Anglo-American committee be set up to explore the 
possibility of devising a common Anglo-American ration scale for Allied Force. 
The Chief Administrative Officer acceded to this request and the following 
committee was appointed: 
Brigadier H. M. Hinde, OBE, DST (Chairman) 
Col. T, Young, DDH, Allied Force 
Lt. Col. E. R. Herbertson, ADST 
Lt. Col. R. F. Locke, QMC, North African Theater of Operations 
Lt. Col. Perrin H. Long, MC, Consultant in Medicine, Allied Force, and 
Capt. P. F. Stannard, RASC (Secretary). 
After a considerable amount of w’ork upon the part of British and Ameri- 
can medical officers in the Allied Force Medical Section, an agreement on a 
common ration scale was reached and presented to the committee. The circum- 
stances surrounding this agreement are perhaps best described in a report en- 
titled “A Personal Memorandum Upon the Nutritive Value of Existing and 
Proposed Army Rations, Together with Comments upon the Utilization of 
Rations in NATOUSA and the Adequacy of Existing and Proposed Rations” 
which was made by the Consultant in Medicine to the Deputy Theater Com- 
mander on 29 June 1943. The common ration scale suggested was considered 
possible of implementation without sacrifice of American dietary standards. 
The common ration was broken down into its components and was finally 
approved by the whole committee and forwarded to the Deputy Theater Com- 
mander on 28 July 1943. This ration was never adopted because at the time 
it was made, the two branches of Allied Force were separating into their com- 
ponents, and each was developing its own line of communications and sources 
of supplies. The introduction of the common ration at this point probably 
would have increased the difficulties which each force was experiencing in the 
problem of procuring and distributing rations. It was, however, an interesting 
idea and one well worth considering, even though it was never realized. 
The period between the end of the Tunisian campaign and the amphibian 
assault upon Sicily was one of intense activity, especially in the Eastern Base 
Section, as men were being trained and retrained and supplies were being built 
up in “dumps” for use during the coming attack. It is not surprising there- 
fore, that the B ration became unbalanced during this period of time, and that 
by July due to “elimination and substitution” of the various items, the caloric 
31 Annual Rpt, Surg NATOUSA, 1943. HD. 
346336 0—55 9 116 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
value of this ration had fallen to a level which fluctuated between 1,800 and 
2,700 calories per day, with the average daily ration for that month having a 
value of 2,400 calories. During this time three divisions and attached 
troops, which had been engaged in Tunisia, were undergoing amphibian train- 
ing in the course of which emergency C and K rations were used. Thus when 
II Corps entered Sicily, a number of its component troops had been for a 
considerable period of time on rations which were deficient in calories. 
The troops had better and more varied food during the 38-day campaign in 
Sicily than at any other period of combat up to that time. This resulted from 
the fact that five-in-one rations were widely used, a considerable number of 
first-class German rations were captured, lemons and certain other fresh fruits 
and vegetables were fairly abundant and were procured in considerable amounts 
in one way or another. Because the campaign was short and troop reliefs 
frequent, the individual soldier had an opportunity “to stoke up” in a manner 
which had been denied him in North Africa. 
Despite the fact that there had been some improvement in the level of 
nutrition in the ground combat troops engaged in the Sicilian campaign, reports 
of varying degrees of undernutrition were constantly being received from com- 
ponents of the Army Air Forces, together with requests that multivitamin 
capsules be issued to these units. During the absence of the Consultant in 
Medicine in Sicily, the Surgeon, North African Theater of Operations, took 
cognizance of these demands, and upon his recommendations, the issue of such 
vitamin concentrates was authorized in Section III, NATOIJSA Circular 153, 
7 August 1943. The phrasing of this section in which it was stated that no 
requests for vitamin concentrates would be submitted until “a medical officer 
or nutritionist has analyzed the diet provided from the menu in use,” produced 
many administrative difficulties because it was obvious that a unit medical 
officer who lacked scales and nutritional charts and tables would have a diffi- 
cult time in analyzing the diet of his unit. This, coupled with the fact that 
vitamin concentrates were frequently in short supply, made their distribution 
a problem. At about this same time, and without consultation with or advice 
from the Consultant in Medicine, Section III, NATOUSA Circular 164, 
29 August 1943, which directed that the part of War Department Circular 208, 
1943, dealing with the percentage reduction in rations would be in force in 
the North African Theater of Operations, was issued. This action was ill- 
timed and badly conceived because it not only cut down the caloric value of 
the total rations for any one unit, but also, as it was shown later, penalized the 
soldier in combat severely. 
The opening of the campaign on the mainland in Italy with its attendant 
logistic problems created an unbalance in the rations. This was due to the fact 
that the bulk of the ground forces was removed from the neighborhood of the 
fixed bases in North Africa, large numbers of service forces were likewise sent NUTRITION 
117 
to Italy, the tactical air force, which when Sicily had been secured had moved 
there, quickly followed the ground forces into Italy, and the strategic air force 
moved from its bases in North Africa to the eastern side of Italy. These move- 
ments of large numbers of men and supplies necessitated the building up of 
new lines of communications and of new “dumps” in remote and often in- 
accessible places. It soon became apparent from reports reaching the Office 
of the Surgeon, Headquarters, North African Theater of Operations, that the 
rations in certain parts of Italy were badly unbalanced and that nutritional 
disturbances were occurring. In November 1943, the theater was fortunate 
in having as its guest Col. Paul E. Howre, SnC, then the nutrition officer in the 
Office of The Surgeon General. Colonel Howe, in company wdth the Consult- 
ant in Medicine, made a tour of inspection, in the course of which studies upon 
nutrition were carried out in the base sections, Fifth United States Army and 
in the Fifteenth Air Force. It was concluded that the ration as issued to 
troops in the Fifth United States Army during the past 3 months had been 
inadequate. This was demonstrated from calculations of the nutritive values 
of the rations as issued and from evidence of weight loss and other nutritional 
deficiencies which had been noticed especially in forward divisional troops. 
It was realized that this inadequacy had been in part the result of the tactical 
situation, in part the result of difficulties and failures in transportation, and in 
part the result of the increased nutritive requirements associated with cold, wet 
weather. 
The recommendations made on the basis of these studies reflect the nature 
of the observations made. In order to improve conditions found in the Fifth 
United States Army, it was advised that hot food be supplied to combat in- 
fantry for at least one meal a day whenever the tactical situation permitted 
the use of stoves; that unit commanders be impressed with the necessity for 
the consumption of “Lemon Juice Powder Synthetic,” a chief source of vitamin 
C; and that, because of nutritional inadequacy, C and K rations which were 
used of necessity under certain combat conditions not be utilized without sup- 
plementation for more than 3 days. Because of the estimated daily caloric 
requirement of Fifth United States Army personnel at that time, it was recom- 
mended that five-in-one ration be issued to 4 instead of 5 men per day. For 
the same reason, it wras suggested that ten-in-one ration be issued to 8 men 
daily. Issuance of the full allowances of food for B ration was advised, in- 
cluding all components necessary to make bread when bread per se could not 
be provided. Supplementation of B ration was considered necessary for serv- 
ice troops involved in strenuous work. It was deemed desirable that a nutrition 
officer be provided for duty with army troops and that one be assigned to each 
corps. Nutritional rehabilitation was urged for organizations which had been 
subsisting continuously or largely on C and K rations when troops wrere with- 118 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
drawn in reserve positions or regrouping areas. For this purpose, B ration, 
supplemented for strenuous work, was advised. 
Problems in nutrition of Army Air Force troops which were disclosed by 
these studies included those which arose from “improper substitution and 
eliminations of ration components” of B ration. Heavy bomber groups were 
voluntarily eliminating “gas-producing components of the diet such as cabbage, 
beans, etc,,” from the ration consumed because of gastrointestinal discomfort 
during long missions. The caloric value of the ration consumed was thereby 
lowered, and weight loss ensued. Missions of 7 to 8 hours in length made it 
impossible for fighter pilots to eat for that period of time; and as for bomber 
personnel during such lengthy missions, “the cold . . . makes it difficult and 
dangerous to open ‘K’ rations because fingers are frost bitten quickly at such 
altitudes.” In areas out of normal lines for supply, Army Air Force units 
had to subsist on emergency rations for periods up to some 5 months at a time. 
Menus were scarce in some units, and there were difficulties due to percentage 
reduction in rations. 
Upon receiving the recommendations made on the basis of these studies, 
the Surgeon, North African Theater of Operations, sent a memorandum out- 
lining the damage which was resulting from the percentage reduction in rations, 
to the Deputy Theater Commander. The latter, after a careful consideration of 
all of the factors involved, called a meeting of the Chief of Staff, the Quarter- 
master, and the Consultant in Medicine, North African Theater of Operations. 
In the course of the meeting the decision was taken not only to do aw’ay with 
the percentage reduction in rations, but also to activate that part of War Depart- 
ment Circular 208, 1943, which permitted the drawing of excess rations under 
special conditions. The immediate promulgation of this policy in the theater 
was welcomed by all who were engaged in heavy work. It was a step in the 
right direction towards providing a more adequate diet for members of units 
whose duties were of a strenuous nature. 
In January and February 1944, the Chief Nutrition Officer, Office of the 
Chief Surgeon, European Theater of Operations (Lt. Col. W. H. Griffith, 
SnC), paid a visit to the North African theater. His observations were 
recorded in a report made to the Surgeon, North African Theater of Operations, 
on 18 February 1944.27 “No evidence of nutritional inadequacy (was) observed.” 
However, it should be made clear at this point that when Colonel Griffith was 
discussing “evidence of nutritional inadequacy” in his report, he was referring 
to frank nutritional disturbances and not to weight loss, minor anemias, et 
cetera. It is also of interest to note that the forces on the Anzio Beachhead 
were subsisting on emergency rations, while along the front west of Cassino, 
B-type rations were in general use, due to the stalemate in that area. 
27 Gordon, J. E.; History of preventive medicine in the European Theater of Operations, United 
States Army, 1941-1945. HD: 314.7-2. NUTRITION 
119 
There can be little doubt about the improvement in the B ration as issued 
in the North African theater during December 1943 and January 1944. Frozen 
meat and butter were ordinarily available for three or more meals a week, fresh 
vegetables, nuts, and a certain amount of fruit became surplus as far as civilian 
needs were concerned in Italy and North Africa, and hence were procured by 
the Army. Fresh eggs were also in fairly good supply. Local shortages in 
certain items existed due to planning mistakes and to transportation failures, 
but the bulk of the troops who were not actually in frontline duty received a 
much more nutritious, palatable and varied diet than they had at any previous 
period in the North African theater. That this was true was shown by a study, 
initiated by the Consultant in Medicine, North African Theater of Operations, 
of the nutrition of “trainees” in the North African Disciplinary Training 
Center. The study was carried out by a board of medical officers during the 
summer of 1944. The Disciplinary Training Center was at that time located in 
a very torrid section of North Africa about 25 miles southwest of Oran, and 
the “trainees” were being put through 16 hours of strenuous exercises each day. 
One hundred general-service men were studied. The results of this study 
were of interest because despite very heavy exercise over the 90-day period, the 
average “trainee” in the group lost only 3 pounds of weight, none developed 
anemia, and no other evidence of nutritional deficiencies was noted. 
The situation in respect to rations for prisoners of war in the North African 
theater after the surrender in Tunisia, and subsequent to that time, was always 
relatively good. Of course, local shortages in food did occur from time to time 
when unexpected numbers of prisoners were taken, but this existed only until 
they arrived at the permanent cages. The ration for prisoners of war was 
essentially a modified American B ration with fresh vegetables and fruits added, 
when such items were in surplus in quartermaster supplies. The ration was 
modified on a sliding caloric scale so that it provided between 2,500 and 3,000 
calories a day for idle prisoners, and up to 4,000 calories a day for prisoners who 
were engaged in strenuous labor. Sick, wounded, or injured prisoners of war 
who required hospitalization received the diet provided for American sick, 
wounded, or injured. 
Another problem of rations which was of considerable interest in the North 
African theater was that of the hospital ration. Because of logistic reasons and 
the tactical situation, the hospital ration was not widely distributed in the 
early days of the theater, and was used only in the Mediterranean and Atlantic 
Base Sections. The hospitals in Eastern Base Section were forced to use the 
B ration. When dysentery and malaria became prevalent in May and June 
1943 it was noted that not only the B ration but also the hospital ration was 
inadequate because the content of such components as fruit juices, custards, and 
cocoa was not great enough, and the desired special diets could not be prepared. 
Coupled with this deficit in the content of the interesting items of these diets 120 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
was the fact that as a result of the supply situation which existed in Eastern 
Base Section, the B ration was short in calories due to eliminations and substi- 
tutions, averaging but 2,500 calories a day during June, July, August, and 
September 1943. In view of this, and with the knowledge at hand which had 
been gained during the campaign in Sicily in respect to the difficulties in placing 
the hospital ration where it was needed, it was decided to abandon this ration in 
the North African theater, and as a substitute, to provide the B ration, plus a 
purchase allowance of 35 cents a day per patient with which to purchase from 
the Quartermaster Corps those items necessary to prepare the required diets. 
This was authorized in Section III, NATOUSA Circular 179, 13 September 
1943, and was amended to include patients occupying beds in dispensaries, by 
Section IV, NATOUSA Circular 199,10 October 1943. 
In general, it can be said that this plan was satisfactory and especially so 
in newly created base sections and in forward areas in which, as experience had 
previously shown, great difficulties were encountered in maintaining the hos- 
pital ration. It also provided a means of augmenting the standard B ration for 
those patients who did not require special diets, but in whom a state of under- 
nutrition had developed because of the prolonged consumption of C, K, ten-in- 
one, or unbalanced B rations. This system of providing diets for hospitalized 
personnel, while approved by Col. Paul S. Howe, did come in for a certain 
amount of criticism from Lt. Col. W. H. Griffith. At the time this criticism 
was made, part of it was considered valid, but that part which dealt with the 
automatic issue of the hospital ration was thought unjustifiable because experi- 
ence within the theater' had always demonstrated that the automatic issue 
system for rations, sooner or later, broke down. It was considered that the 
plan for building up the ration which had been devised, met the conditions as 
they existed in the North African Theater of Operations, and that these con- 
ditions were different from those encountered by Lt. Colonel Griffith in England. 
One of the major disease problems in the North African and Mediterranean 
Theaters of Operations was infectious hepatitis, in which a special problem in 
nutrition was presented because of the anorexia, nausea, vomiting, and loss of 
weight which are characteristic of the disease. It was noted in the winter of 
that difficulties were being encountered in preparing appetizing and 
tempting diets for these patients out of the items in the rations which were 
available, and that most of the patients convalescent from the disease were 
definitely underweight. That this should have occurred is not extraordinary, 
if one remembers that many of the patients were underweight at the time they 
contracted infectious hepatitis. In a planned series of dietary tests which were 
carried out early in 1944, it was show n that patients with hepatitis would con- 
sume a diet high in certain proteins and carbohydrates, but low in fats, wfith 
avidity. Further experiments showed that their dislike of fats was probably 
based on the fact that under the conditions which existed in the theater, fats NUTRITION 
121 
were very likely to be slightly rancid, and hence not well tolerated by these 
patients. As a result of these studies a special diet which contained 200 or more 
grams of protein, 25 to 50 gm. of fat and 400 or more grams of carbohydrate 
was devised for patients with hepatitis. By special arrangements made with 
the Quartermaster Corps, amounts of lean frozen beef and of dried skim milk 
were obtained which were adequate to provide the protein component of the 
diet, and patients with hepatitis had the first call upon all fresh fruits and 
vegetables procured by the quartermaster. Proper menus covering a 10-day 
cycle were prepared for the basic diet, and hospital dietitians throughout the 
theater were instructed in its preparation. This diet was very successful (if 
its success can be judged by its consumption) and was relished, with the result 
that most patients suffering from this disease showed a gain in weight at the 
time they left the hospital.28 
The question of the waste of food was brought out in the report of Lt. 
Colonel Griffith29 and there can be no question but that much food was wasted 
in the North African Theater of Operations. Two factors were responsible 
for this waste: Poor menu planning and preparation of the ration as issued, and 
the high percentage of unacceptable items within the B ration. Interested 
members of the staff of the 17th General Hospital conducted a study in 1944 
upon the acceptability of the ration as offered to patients. It is of interest that 
sources of protein showed a very high percentage of waste. Hospital patients 
were found to waste up to 25 percent of food offered, and ambulatory patients, 
17 percent. A fresh educational campaign was found to reduce food wastage 
markedly. It was concluded that:30 
These studies definitely indicate that one evaluation of certain items of the Expedi- 
tionary Force “B” Ration for temperate and tropical areas should be made. The 
palatability and acceptability of the items just reviewed are low and the waste from them 
considerable. It seems likely that the percentage waste noted for ambulatory patients 
quite accurately reflects the waste occurring when the “B” ration is consumed by field or 
service troops. Hence, the waste, in terms of total food and money value is enormous. 
With a full realization of the difficulties of planning for procurements, processing and 
distribution of the “B” ration, it is still considered that an intransigent point of view 
in respect to changing these items should not be taken, and that every effort should be 
made by experiment and trial to replace them with satisfactory items in order that the 
world’s largest “swill” barrel may be eliminated. 
Little can be said about this report because, first, it is true, and secondly, 
the Quartermaster Corps had been long aware of the unacceptability of certain 
of the items in the B ration, but had done nothing about them in the period 
in which the Consultant in Medicine was acting as a nutrition officer in the 
North African theater. 
28 Ltr, Col M. H. Barker, MC, to Surg NATOUSA, 2 Nov 44, sub: Dietetic studies with suggestions 
for Infectious hepatitis. HD: 710 Jaundice. 
23 See footnote 27, p. 118. 
30 ETMD, NATOUSA, 1 Jul 44. HD : 350.05. 122 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
The general level of the preparation of food in the North African theater 
was low, and menu planning was essentially a lost art. In the recollections 
and experiences of the Consultant in Medicine there were but three good messes 
in the theater, and these were good because they were frequently illegal in 
respect to the types of food served and because they had capable cooks. The 
fault for the poor planning and preparation of food can be about equally dis- 
tributed among command, mess officers, and cooks. The higher echelon of 
command in this theater, because of military exigencies, had little time to be 
interested in the details of unit mess operations. Such personnel, because of 
their position and responsibilities, usually ate in small well-operated messes. 
On the other hand, many mess officers were inadequately trained for their re- 
sponsibilities and lacked the fundamental knowledge required for excellent 
mess operations. Few properly trained cooks were available, and these were 
most frequently found in kitchens of higher echelons. Poor selection of menus 
and poor preparation of food was generally responsible for the waste of food 
which occurred in the North African theater. 
In summary, it can be said that many factors contributed to the problem 
of nutrition in the North African theater. Among these were: 
1. The use of canned rations which were unpalatable, monotonous, and 
nutritionally deficient. 
2. The misuse of emergency rations, a factor which was most difficult to 
eliminate, because logistically the compact emergency ration was the planner’s 
delight, as so much else could be placed in the space which was saved by the 
use of emergency rations. 
3. The utilization for more than a year of the Expeditionary Force Menu 
No. 1, B ration, which was finally shown in the Camp Lee, Virginia, tests to be a 
deficient menu. 
4. The substitution and elimination of items in the rations. 
5. The inexpert procurement of rations by mess officers. 
6. The poor preparation of food. 
7. The percentage reduction in rations for a 3-month period. 
Nutrition in the European 
Theater of Operations 31 
A nutrition branch was established in the Division of Preventive Medicine 
of the Office of the Chief Surgeon, European Theater of Operations, late in 
August 1942. The branch began activities, therefore, early in the history of 
the theater and at a period when the ration scale for troops in the European 
Theater of Operations was still a subject of discussion. From that time it set 
81 This section is based on material submitted by Wendell H. Griffith, formerly Colonel, SnC, Chief 
of Nutrition Branch, Division of Preventive Medicine, Office of the Chief Surgeon, European Theater 
of Operations. The material was originally presented a.s a part of Gordon, J. B.; History of pre- 
ventive medicine in the European Theater of Operations, United States Army, 1941-1945. HD: 
314.7-2. NUTRITION 
123 
the dietary standards for rations provided by the Quartermaster Corps and 
determined the nutritional needs of the Army personnel. The nutrition branch 
grew with the theater, as did also the magnitude of its responsibility for the 
nutritional health of troops and of hospital patients and the variety of its in- 
terests in all phases of Army messing. It was recognized that the functions 
of nutrition officers were investigative and advisory and that the accomplish- 
ment of the mission of the nutrition branch depended upon complete coordina- 
tion with commanding officers, responsible for mess operation, and with officers 
of the Quartermaster Corps, responsible for the procurement and issue of 
rations and for the training of mess personnel. 
Activities of the nutrition branch centered on the preventive aspects of 
sound nutrition but included the nutritional rehabilitation of malnourished 
recovered American prisoners liberated from German stalags, a problem which 
turned out to be one of the most important purely medical problems confronted 
by the Chief Surgeon’s Office, European Theater of Operations. Field tests of 
the suitability of standard operational rations for combat troops in Europe were 
planned and directed, an activity of especial importance in the case of the new 
ten-in-otie ration which had not previously been subjected to trial under field 
conditions. As a result of these trials and of other accumulated experience, 
pertinent recommendations were made concerning the composition of C, K, 
and ten-in-one rations and particularly concerning desirable changes in the B 
ration. The unofficial move to supply a so-called Americanized version of the 
British Army ration to American forces in the United Kingdom was opposed 
and new ration scales for troops and hospital patients were pioneered. A troop 
ration was described in terms of groups of foodstuffs, in accordance with their 
nutritive significance, for the first time in a theater of operations of the United 
States Army; and, for the first time, hospitals were issued a type A patients’ 
ration which did not require an added monetary allowance. The nutritional 
welfare of troops in combat was constantly emphasized in theater directives 
and by personal contact with officers of combat units. This was doubly neces- 
sary because of the tendency to exaggerate the value of convenience of transport 
and issue of operational rations with resulting potential damage to the nutri- 
tional fitness of soldiers. This program, which was actively supported by 
the Chief Quartermaster, European Theater of Operations, was so successful 
that the great majority of combat units received the modified type A ration 
rather than C or K rations, even when in contact with the enemy. Nutrition 
officers were particularly prominent in the supervision of special procedures 
which were designed to maintain mess operation on a high level in the marshal- 
ling areas from which troops embarked for the liberation of France. Partici- 
pation in programs to prevent waste of food and to develop a sense of in- 
dividual responsibility for proper eating was encouraged. 124 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
TROOP RATIONS IN THE UNITED KINGDOM 
British and British-American Rations. The first American units which 
arrived in Northern Ireland on 26 January 1942 were issued British rations and 
were loaned British Army cooks who familiarized American cooks with the 
ration components and with the stoves and other kitchen equipment. The same 
procedure was used as additional forces reached Ireland and England. The 
British Home Service ration included a cash element of 2y2d (pence) per day 
which was used by British messes in the purchase of condiments and other 
items. This dietary was soon found unsuitable for the American Army and 
the amounts of meat, grain products, sugar, evaporated milk, and dried fruit 
were increased. Troops engaged in hard labor were authorized a 15-percent 
increase in this augmented British or so-called British-American ration. 
According to American standards and tastes, the British ration was un- 
satisfactory because of its low caloric value and low content of milk, egg, beef, 
pork, tomato products, canned fruits and fruit juices, and coffee. On the basis 
of consumption, it failed to provide the levels of calcium, riboflavin, and ascor- 
bic acid recommended by the National Research Council. The inadequacy of 
the Home Service ration for British troops was recognized by the British War 
Office and improvements were made in 1943. The British-American ration was 
more than adequate in calories but was deficient in tomato products, fruits, and 
fruit juices. Its nutrient supply was greater than that of the British Home 
Service ration but, on a consumption basis, it failed to supply the recommended 
levels of calcium, riboflavin, and niacin. 
Early Development of the American Ration. American rations were 
authorized on paper in February 1942 but no menu was published and troops 
continued to receive either the British ration or the British-American ration. 
The components of the authorized type A field ration were the same as those 
of the garrison ration except that 4 ounces of wheat flour and 8 ounces of bread 
replaced 12 ounces of wheat flour. The listing of the garrison ration as the 
basic field ration in an overseas theater is inexplicable in view of the fact that 
the garrison ration was designed for the calculation of the monetary value and 
not for the issue of a ration. There was concern over the authorization of this 
ration because of its weight (4.55 pounds) and caloric value (5,127 calories), 
and in May a revised ration was published in which beef was decreased from 
7.43 to 5.20 ounces, potatoes from 10 to 8 ounces, sugar from 5 to 4 ounces, bread 
from 8 to 7 ounces, and flour from 4 to 3 ounces. These changes lowered the 
caloric value from 5,127 to 4,562 but still left the ration far in excess of the 
British Army ration so that pressure was continued to decrease the difference 
between the rations of the 2 armies. Undue attention was paid at this time to 
the weight of the authorized ration and to the shipping which would be required 
to transport it across the Atlantic. No consideration was given the fact that NUTRITION 
125 
the list of components did not constitute an acceptable ration nor the fact that 
the weights were not significant because boneless meat would be shipped rather 
than carcass meat, dehydrated potatoes rather than fresh potatoes, evaporated 
and dried milk rather than fresh milk, et cetera. On 28 July 1942 the first 
menu was published by the Office of the Chief Quartermaster, European 
Theater of Operations, and this served as the tentative basis of issue to units 
adjacent to the relatively few depots which were in operation at that time. 
The activation of quartermaster depots proceeded rapidly during the early fall 
and units were transferred from the British-American ration to the American 
ration accordingly. This changeover was nearly complete by the end of Octo- 
ber except for those units of the Army Air Forces which shared stations with 
the Royal Air Force. At these stations either British or American rations 
were issued depending upon which force was numerically greater. It is inter- 
esting that neither group was satisfied with the ration to which it was unac- 
customed. American Air Force enlisted personnel at stations issued the British 
ration (not the British-American ration) were particularly unhappy and re- 
quests for supplementation of the ration with canned fruits and fruit juices 
were not infrequent. Supplementation in these instances was impracticable 
and was not approved. Fortunately this situation did not continue long be- 
cause incoming Air Force personnel made possible the general issue of Amer- 
ican rations. 
The first menu for the type A field ration (Table 5), which was published 
on 28 July 1942 as a tentative basis of issue, was authorized by the Commanding 
General, European Theater of Operations, United States Army, on 6 Septem- 
ber 1942. The letter of authorization directed that the services of the newly 
assigned nutrition officer would be utilized to make the best possible use of 
subsistence and that the contents of the proposed menu should be modified 
when justified by further study. It became the first duty, therefore, of the 
nutrition branch to determine the adequacy of the ration prescribed by menus 
prepared by the Subsistence Division, Office of the Chief Quartermaster, Euro- 
pean Theater of Operations, and to recommend improvements, if necessary. 
The reports of the resulting studies of the first menu authorized on 6 September 
1942 and of the second menu (Table 5) authorized on 12 October 1942 paved 
the way for the subsequent complete revision of the ration scale upon which 
these menus were based. The reports, which were forwarded to the Chief 
Quartermaster and which served as a basis for the first of many regularly 
occurring conferences at which theater rations were discussed and evaluated 
during the ensuing 3-year period, emphasized the following points: 
1. The caloric levels of the first and second menus were approximately 
4,800 and 4,500 respectively, both of which were in excess of the actual energy 
requirement of troops. Adjustment of this level should not be accomplished 
at the expense of the nutrients of the ration. 126 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Table 5. Nutritive Value of Troop Rations in the United Kingdom, With and 
Without Correction for Minimum Losses During Issue, Storage, Preparation, 
and Service of Food 1 
Nutrients 
British8 Home 
Service ration 
1942 
British- 
American 
ration 1942 
United States 
ration 
August- 
October 1942 
United States 
ration 
November- 
December 
1942 
United States 
ration 
January 1943- 
January 1945 
Energy, cal 
3, 060 
4, 182 
4, 766 
4, 465 
4, 049 
(2, 776) 
(3, 704) 
(4, 170) 
(3, 940) 
(3, 624) 
Protein, gm 
96 
124 
149 
136 
130 
(91) 
(118) 
(142) 
(129) 
(123) 
Fat, gm 
117 
197 
215 
205 
165 
(97) 
(156) 
(164) 
(161) 
(132) 
Carbohydrate, gm 
406 
478 
557 
519 
536 
(385) 
(457) 
(532) 
(494) 
(486) 
Calcium, gm 
0. 63 
0. 77 
0. 88 
0. 87 
0. 96 
(0. 60) 
(0. 73) 
(0. 84) 
(0. 82) 
(0. 91) 
Iron, mg 
19 
25 
29 
28 
27 
(18) 
(24) 
(28) 
(27) 
(25) 
Vitamin A, I. U _ 
3, 050 
1, 233 
1, 503 
2, 474 
2, 448 
(Animal) 
(2, 890) 
(1, 170) 
(1,428) 
(2, 350) 
(2, 330) 
Carotene, I. U 
4, 647 
9, 695 
9, 638 
9, 842 
11, 482 
(Plant). . 
(4,415) 
(9, 200) 
(9, 156) 
(9, 350) 
(10, 910) 
Thiamine, mg 
1. 98 
2. 69 
3. 01 
3. 05 
2. 61 
(1. 50) 
(1. 99) 
(2. 18) 
(2. 13) 
(1. 88) 
Riboflavin, mg 
1. 83 
1. 97 
2. 43 
2. 42 
2. 40 
(1. 58) 
(1. 71) 
(2. 11) 
(2. 08) 
(2. 07) 
Niacin, mg 
20 
24 
32 
28 
27 
(16) 
(19) 
(26) 
(22) 
(21) 
Ascorbic acid, mg . _ 
100 
147 
134 
164 
167 
(45) 
(69) 
(104) 
(97) 
(96) 
1 Uncorrected and corrected values represent “as issued” and “as consumed” values respectively. Corrected, or “as 
consumed” values, are estimated by making the following deductions from “as issued” values: 
a. Deduction of 5 percent to cover wastage loss during issue, storage, preparation, and service of ration components. 
b. Deduction of 25 percent of meat and cooking fat which is assumed to be uneaten. 
c. Deduction of nutrient losses. 
The corrected value in the table is the value in parenthesis. 
8 This value was calculated according to the procedure used in estimating caloric values of U. S. Army rations. The 
British War Office estimates the average value of the monetary allowance as 214 calories, thus increasing the total ration 
value to 3,274. The energy content of the ration was increased 284 calories in May 1943 and an additional allowance of 
200 calories was authorized troops undergoing hard training. 
2. Forty percent of the calories were from fat, a large part of which would 
not be eaten. Special measures to salvage unused fat were therefore necessary. 
3. The substitutive table which was patterned after the one described for 
the garrison ration listed vegetables, in general, as substitutes for plant sources 
of vitamin A. In order to safeguard the adequacy of the ration it was essential 
that substitutes for leafy, green and yellow vegetables should be limited to NUTRITION 
127 
vegetables in that category. Similarly, substitutes for tomatoes should be 
limited to tomato or citrus fruit products. 
4. Increased issues of fresh cabbage and potatoes, milk and tomato products 
were necessary in order to provide an acceptable ration. 
5. Menus should be used as an instructional medium for mess personnel 
and should include data on methods of conserving nutrients during the prepara- 
tion of food, on the necessity of complete utilization of the nutritionally 
important foodstuffs, and on other pertinent phases of mess operation. 
Waste of Food in 191$. During November 1942 an extensive survey of 
American units in the United Kingdom was made by representatives of the 
Nutrition Branch, Office of the Chief Surgeon, of the Subsistence Division, 
Office of the Chief Quartermaster, and of the British Army Catering Corps. 
This investigation demonstrated that the issue of excess food was resulting in 
widespread wastage because of failure to use the ration economically and to 
return unused items to depots. It not only represented financial loss and the 
futile transportation of supplies across the Atlantic but also had an unfortunate 
effect on the British who were campaigning for the maximum prevention of 
waste. 
Revision of Ration Scale. On 12 December 1942 the chief of the Nutrition 
Branch, Office of the Chief Surgeon, was specifically ordered to recommend 
whatever changes in the current directives on rations were deemed appropriate 
as a result of his investigations in the theater. As a matter of fact, the third 
menu, published 22 December 1942, was satisfactory in most respects because 
most of the earlier recommendations of the branch had been approved by the 
Subsistence Division, Office of the Chief Quartermaster, and incorporated in 
the menu. The caloric level had been decreased temporarily to 3,800 as a means 
of emphasizing the necessity of complete utilization of the ration. None of 
these changes were in accordance with the theater ration directive so that there 
was need of a restatement of the basic components and allowable substitutive 
items of the rations. Advantage was taken, therefore, of this opportunity to 
describe the field ration in terms of food classes composed of nutritionally 
similar foodstuffs. Substitutive items w7ere rigidly restricted to those of 
nutritional equivalence and both basic components and substitutes were limited 
to those known to be available. The proposed new directive on rations was 
published on 11 February 1943, Only minor changes in the troop ration scale 
were necessary in subsequent revisions of this circular. 
Average Type A Menu in the United Kingdom.. The composition of the 
average type A field ration issued in the United Kingdom between 1 January 
1943 and 1 February 1945 was adequate in all nutrients except riboflavin which 
was 10 percent less than the recommended allowance. This was not believed 
significant and there was no evidence of ariboflavinosis in the troops. It is 
highly probable that 2.0 mg. of riboflavin daily are more than sufficient. From 128 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
a practical standpoint it is very difficult to provide this level even in a varied 
diet containing meat, milk, and eggs without occasional servings of liver and 
without riboflavin-enriched flour and bread. Worthy of emphasis is the fact 
that United States Army rations in the United Kingdom contained neither 
white flour (70 percent extraction) nor white bread. British flour (85 percent 
extraction) and British bread were used and the consumption by the troops was 
very satisfactory (0.424 pound daily). The average intakes of evaporated 
milk and of dried egg were the equivalent of one pint of whole milk and of one 
egg daily. Servings of cabbage and of brussels sprouts were in excess of 
American food habits. The average daily issue of all fresh vegetables, other 
than tomatoes and potatoes, amounted to 0.375 pound, 28 percent of which 
consisted of cabbage and sprouts. 
Hospital {Patients1) Ration. The first theater directive on hospital ra- 
tions in February 1942 authorized one field ration plus a monetary allowance 
of one shilling (approximately 20 cents) for the feeding of patients. Quar- 
termasters were directed to procure the extra foodstuffs, requisitioned by hospi- 
tal commanders, from “any available source.” Later, hospitals were allowed 
to purchase food supplies for patients from local civilian sources as well as 
from the quartermaster. The monetary allowance was unsatisfactory in the 
United Kingdom because of the very limited number of foodstuffs which could 
be procured by local purchase. The theater abolished the monetary supple- 
ment in February 1943 and adopted a special patients’ ration at the same time 
that the revised troop ration was authorized. 
In November 1943, the availability of supplies permitted revision of the 
hospital ration scale and small increases were authorized in meats, milk prod- 
ucts, fruit juices, and potatoes. These additions wrere offset by decreases in 
legumes and grain and the energy content remained approximately 4,000 cal- 
ories. Up to this time the majority of patients consisted of sick individuals 
without particularly hearty appetities. As more and more wounded Air Force 
personnel arrived in the hospitals, the ration which heretofore had been ade- 
quate required supplementation. Provision was therefore made for significant 
augmentation whenever necessary. Prior to D-day, increases w-ere authorized 
in the hospital ration in anticipation of the expected change in the type of 
hospital patient. The greater appetite and food consumption of average battle 
casualties compared with average patients is noteworthy. 
The hospital ration in the United Kingdom was never the same as that 
issued on the Continent because of the greater supply of fresh meat and vege- 
tables in England. Menus described the regular patients’ diet only. Provision 
was made for modification of the ration issue whenever the need for special diets 
increased above 20 percent. This was the case if certain hospitals specialized 
in specific types of patients, such as those with hepatitis, with jaw injuries, 
et cetera. Provision was also made for the feeding of soup, sandwiches, egg- NUTRITION 
129 
nog, fruit juices, and coffee at airstrips receiving casualties by plane from the 
Continent. Similar arrangements were made at so-called “transit hospitals” 
receiving casualties transported by water. 
The special hospital ration used in the United Kingdom was composed of 
the items appearing in the troop ration, plus skimmed milk powder (for fat- 
free diets), malted milk powder, egg noodles, brown sugar, canned soups, 
purees, et cetera. It supplied 100 percent more chicken and fruit juices, 65 per- 
cent more milk, 20 percent more eggs, and 40 percent more fruit than the troop 
ration. 
Planning for Rations in Combat. The continuation on the Continent of 
the excellent ration supplied in the United Kingdom was impossible for many 
months after the establishment of a beachhead. The enormity of the problem 
of transport across the channel and from beach depots to rapidly moving 
armies demanded the temporary use of nonperishable, conveniently packed, and 
easily prepared rations. Operational rations, such as C, D, and K, and the 
nonperishable type B ration were already stocked in depots in the United 
Kingdom. Because the latter ration consisted of more than 100 different food- 
stuffs in as many different containers, the Chief Quartermaster, European 
Theater of Operations, proposed the preparation of a so-called twelve-in-one 
ration which would supply in a single box an assortment of type B components 
sufficient for 1 day’s supply of food for 12 men. Before more than a few units 
of the twelve-in-one had been assembled, the theater was informed of the avail- 
ability of the new ten-in-one ration in the United States. The ten-in-one 
appeared to fill the need for a ration intermediate between C and K and the 
type B ration, and plans for the twelve-in-one were therefore dropped. 
In order to familiarize the theater with the advantages or possible disad- 
vantages of operational rations, a ration board headed by the chief of the 
Nutrition Branch, Office of the Chief Surgeon, was appointed in 1943 and 
directed to conduct comprehensive field tests on rations which would be used 
later in combat. In the first of these field tests it was noted that troops 
remained in reasonably good physical condition during a 10-day period on C, 
K, and five-in-one rations but that the rations were deficient in calories, espe- 
cially for large men. The report listed the following recommendations: The 
use of the D ration as a supplement only; the restriction of the use of C and K 
rations to 5-day periods unless supplemented; the replacement of the wholly 
unsatisfactory dextrose and malted tablets of the K ration with a desirable 
confection; the replacement of the fruit powder component of C and K rations 
with a source of ascorbic acid which would guarantee the utilization of this 
nutrient; and, the addition of cigarettes, gum, matches, and toilet tissue to the 
rations which lacked these articles. 
The report of the second trial noted the acceptable quality of the majority 
of the components of the recently developed ten-in-one ration and the excellence 130 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
of its packaging but emphasized its marked inadequacy in calories (3,300-3,400) 
for troops during 15-day maneuvers in moderately cool weather (35°-55° F.). 
The following recommendations were made: An increase in caloric value to 
3,900 calories; a limitation of 30 days in its issue and of a total of 40 days in 
the issue of ten-in-one and unsupplemented B rations; the replacement of the 
dehydrated baked beans, the fortified fruit powders, the K-l biscuits, and the 
dextrose and malted milk tablets; and the addition of cocoa beverage powder, 
pea or bean soup powder, extra cereal mixture with increased sugar in the 
mixture, components for hot drinks twice daily, heating units, and extra 
paper tissues. 
The conception of the ten-in-one ration was basically sound but it was 
obvious that it was developed for use in warmer areas than Western Europe. 
Because of the demonstration of the marked caloric deficiency of this ration, 
the theater decided to use it on an 8-man basis or to supplement it with addi- 
tional food if it was issued on a 10-man basis. 
Specific recommendations were made to the Chief Quartermaster, European 
Theater of Operations, with respect to feeding troops on the Continent: 
Shipment of bakery units and of fresh meat to the Continent at the earliest 
possible moment after D-day so that the maximum period for subsistence of 
troops on wholly processed rations (D, C, K, ten-in-one, and B) would not 
exceed 40 days; substitution of canned roast beef or canned meats for less 
desirable components of the B ration; replacement of the butter substitute; 
modification of the ten-in-one ration; supplementation of C and K rations with 
miscellaneous nonperishable foodstuffs (sardines, peanuts, jam, et cetera) as a 
means of avoiding monotony; supplementation of C and K rations with multi- 
vitamins after 15 days in the event these were the only rations available; and 
provision of individual heating units, preferably tablets of the hexamine type. 
These efforts to improve the quality of processed operational rations were 
supported by the Chief Quartermaster and were successful insofar as the 
ten-in-one ration was concerned. The theater was informed in April 1944 that 
the caloric value of the ten-in-one had been increased from 3,400 to 3,700 and 
that in future procurement in the United States the ration would provide 3,900 
calories. These improved types were received before the termination of hostili- 
ties on the Continent but improved C and K rations were not available until 
the later spring of 1945. Additional type B meat components, such as canned 
beef and gravy, pork and gravy, sardines, et cetera, were received but not until 
after the type B ration had been replaced by the A ration with its fresh food- 
stuffs. Individual heating units of the wax candle type were received but were 
little used because of their unsatisfactory character. 
A supplementary ration for the nourishment of casualties in beachheads 
was essential because C or K rations were wholly unsatisfactory for this pur- 
pose. The procurement of such “patient’s operational ration” was one of the NUTRITION 
131 
first activities of the Nutrition Branch, Office of the Chief Surgeon. The 
Office of the Chief Quartermaster agreed to prepare cases, each containing 
fruit juice, milk, sugar, and coffee for 20 men, if an equivalent ration could not 
be procured from the United States. Subsequently, the 25-in-l hospital sup- 
plement was developed in the United States and was used with great benefit 
in Italy and in France. Procurement of this supplement from the United 
States became impossible in the spring of 1945 so that an additional quantity 
assembled from supplies in the United Kingdom for use by the armies in 
Europe. 
In addition to the 25-in-l, a second supplement, the B-C pack, was 
requested by the theater and supplied from the United States. This unit con- 
tained bouillon cubes and cigarettes and was designed for issue to aid stations. 
These components were selected following a survey of battalion medical officers 
in experienced divisions which had arrived in England from the North African 
theater. The value of this supplement was questionable, mainly because of the 
successful provision of other nourishment to frontline units. 
RATIONS ON THE CONTINENT 
Type C and K rations, supplemented with the D chocolate bar, were used 
on the Continent until D-day plus 5, at which time ten-in-one rations were 
available for issue to troops in rear areas. The latter ration was widely used 
until D-day plus 33 when type B components were distributed. By D-day plus 
40 fresh bread and meat were issued in limited quantities. The supply of bread 
increased rapidly as new bakery companies arrived and went into production. 
The early establishment of bakeries on the Continent and the movement of 
these with the armies contributed immeasurably to the maintenance of the 
nutritional health of the troops. 
Operational rations were supplemented with captured enemy foodstuffs 
and with fresh vegetables and eggs which were surplus in many districts of 
Normandy and Brittany. Shipments of potatoes and carrots were received 
from the United Kingdom after D-day plus 90 and, at the same time, arrange- 
ments were made with French authorities to obtain tomatoes, onions, celery, 
and cabbage whenever these wrere in surplus of civilian requirements. The list- 
ing of fresh meat and vegetables in monthly menus of the modified type A 
ration possible starting with the September menu. It is estimated that 
about one-half of the meat and vegetable issue during the fall and winter 
consisted of fresh items. Combat troops and hospital patients were given first 
priority on fresh meats. The meat issue in the armies was augmented by the 
capture of large cold storage plants well stocked with carcass beef. As an 
illustration, the After-Action Report of the Third United States Army, 
1 August 1944 to 9 May 1945, states that the army captured 2,600,000 pounds 
of frozen beef and 500,000 pounds of canned beef, property of the German 
Army, and issue to frontline troops was started at once. 
346336 0—55 10 132 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Vigorous efforts were made by the Nutrition Branch, Office of the Chief 
Surgeon, and by many Quartermaster Corps officers to minimize the use of 
operational rations, except as emergency rations for frontline troops. Supply 
officers were inclined to overemphasize the convenience of transport and issue 
of the C, K, and ten-in-one rations at times when convenience was not a tactical 
necessity. The justification for the use of the modified A ration with its hot, 
varied meals did not depend on a theoretical effect upon physical fitness and 
morale. These positive effects were real and were recognized by the personnel 
of experienced divisions. The contrast between old and new combat divisions 
in this respect was most enlightening. Table 6 shows the proportional use of 
operational rations on the Continent. The extent of issue of nonoperational 
rations to combat, as well as service troops, was most gratifying. It is sig- 
nificant that the Battle of the Bulge, which occurred in an area easily supplied 
with A rations, did not increase the issue of operational rations (December 
1944 and January 1945, Table 6). This is in contrast to the requirement of 
these rations in the period of rapid movement away from supply depots during 
the overrunning of Germany (April-May 1945). 
Table 6. Issue of Operational Rations 
Percent of Rations Issued 
Period 
A or B 
Operational rations 
rations 
c 
K 
Ten-in-one 
Total 
1944 
June 
0 
14 
15 
71 
100 
July 
57 
6 
9 
28 
43 
August _ _ 
52 
14 
14 
20 
48 
September 
58 
18 
10 
14 
42 
October 
79 
7 
5 
9 
21 
November _ 
88 
3 
5 
4 
12 
December 
87 
3 
5 
5 
13 
1945 
January ______ 
91 
2 
3 
4 
9 
February 
91 
2 
4 
3 
9 
March _ _ _ 
88 
4 
5 
3 
12 
April 
74 
8 
7 
11 
26 
May ______ _ _____ 
87 
2 
4 
7 
13 
June 
94 
1 
3 
2 
6 
July ___ 
96 
1 
2 
1 
4 
Source: Data supplied to author by Office of the Chief Quartermaster, Headquarters, European Theater of Opera- 
tions, United States Army. NUTRITION 
133 
Troops were on a diet practically devoid of ascorbic acid whenever they 
subsisted on unsupplemented C, K, or ten-in-one rations in the cold weather 
which was general in Europe. This resulted from the refusal to prepare and 
drink the lemonade which may be made from the fortified lemon or other fruit 
powders. Kevised forms of the improved C and K rations were on hand late 
in the war but the bulk used between D-day and April 1945 consisted of 
unimproved types. These were unpopular and were poorly utilized. Limited 
experience with the newest C ration indicated that troops preferred it to the 
K ration. The K ration appeared more desirable than the unimproved C ration 
except in units which made provision for heating the C ration. These units 
set up field ranges as close to the front as was feasible, heated the meat com- 
ponents of the C ration in boiling water, repacked the hot cans in cases and 
sent them forward for distribution. The taste of the C ration meat component 
wras greatly improved if wTarmed. 
The deficiency in thiamine and the questionable deficiency in riboflavin in 
the type B ration was corrected as quickly as fresh items became available. 
The ration was adequate by October 1944 and by February 1945 was superior 
in its content of nutrients to that supplied in the United Kingdom before 
D-day. The difference was primarily due to enriched flour, which was used on 
the Continent and which had a higher content of thiamine and riboflavin than 
the British National flour. 
Extra ration allowances were authorized combat units occupying positions 
in contact with the enemy. These augmentations included a 10-percent overall 
increase for units receiving the A or B ration and additional meat, jam, bread, 
and coffee ingredients for troops receiving operational rations. Full advantage 
was taken of these authorizations and the service of sandwiches and coffee to 
frontline troops as supplements to C and K rations was a common occurrence. 
In June 1945, rations for personnel engaged in nonarduous duties, except 
patients, were automatically decreased 10 percent. Fortunately the ration was 
rich enough in nutrients so that minimum allowances wTere still supplied. 
Overall deductions are hazardous because of the failure to distinguish between 
foods of high and low nutrient content. The decrease in June was necessitated 
by the theater shortage in rations. It should be noted in this connection that 
the average ration was insufficient for units performing very heavy labor and 
required augmentation. 
Hospital Rations. The feeding of battle casualties wTas quite satisfactory. 
The rapid evacuation to the hospitals in the United Kingdom, both by air 
and by water, materially eased the load on the medical units which preceded 
general hospitals to the Continent. The result that operation hospital 
rations were only required in the early stages of the invasion. Most of the 
casualties arrived very quickly in areas where type B or A components were 134 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
available. The hospital ration on the Continent differed from that in the 
United Kingdom in that the continental ration consisted of the troop ration 
plus a supplementary list of foodstuffs, whereas patients in the United Kingdom 
were supplied a separate special ration. The continental issues were generally 
excessive unless hospital mess officers refused components of the troop ration 
which were not needed. The authorization for the use of the special hospital 
ration on the Continent wTas refused by Headquarters, European Theater of 
Operations, United States Army, for the reason that depots would find it too 
difficult to provide 2 rations rather than 1 ration plus a supplement. 
AUGMENTATION AND REDUCTION OF RATIONS 
In August 1942 authority was granted the Commanding General, Services 
of Supply, European Theater of Operations, to increase the augmented British 
ration (British-American ration) 15 percent if not less than 75 percent of an 
organization was engaged in hard physical labor for 10 or more hours daily, 
6 days per week. This augmentation ceased as troops received the American 
ration in September and October of 1942. 
Early in 1943, upon the request of the Air Surgeon, members of air combat 
crews on operational status were authorized 8 fresh eggs and 3 oranges per 
man weekly and 0.0625 pounds of powdered whole milk daily. Later, Air 
Force combat and repair crews on operational status were allowed an addi- 
tional augmentation. The request for shell eggs and oranges was approved by 
the Office of the Chief Surgeon, European Theater of Operations, as a morale 
measure and not because of nutritional necessity. The request for components 
for a fourth meal was granted without the reference of the matter to the 
Chief Surgeon for investigation and recommendation. 
In view of the increasing number of requests for augmentation of rations, 
mainly from port and engineer battalions, an extra allowance for units per- 
forming arduous tasks was written into the theater directive on rations. Nu- 
trition officers had been assigned to the staffs of base section surgeons by this 
time so that it was possible to make the augmentation contingent upon an in- 
vestigation which “shows that the authorized ration issue is properly prepared, 
served and eaten and that a need for additional food still exists.” The aug- 
mentation, which supplied approximately 400 calories, was purposely limited 
to bread or flour, potatoes and lard, although most units which requested extra 
food desired more meat. The basic ration was adequate in nutrients and gen- 
erous in its meat components and it was believed to be sound policy, therefore, 
to confine supplements to reasonably available foodstuffs which provided the 
necessary calories. Units which were not interested in eating more bread and 
potatoes were not considered to be suffering from a shortage of food. As a 
matter of fact, few of the requests for augmentation were found to be justified. NUTRITION 
135 
These investigations by nutrition officers did prove to be excellent opportuni- 
ties for instruction of untrained or careless mess personnel. 
The above procedure which provided for a thorough survey of the physical 
well-being of troops as well as a determination of the adequacy of the quantity 
of the ration issue was a most satisfactory method of controlling the vexing 
problem of insuring that soldiers were well-fed without incurring the risk of 
waste of food because of oversupply. Unfortunately, it became necessary in 
July 1944 to replace this system with one which liberalized the issue of aug- 
mented rations and recognized the fact that it was easier to supply extra food to 
a unit than it was to insist upon efficient mess operation. Prior to the invasion 
of France requests for augmentation of the ration increased enormously due 
to the number of depot and port units which ran day and night shifts. Some 
units attempted to feed sandwich meals at night rather than hot meals prepared 
by a night shift in the mess. The ration was not adapted for sandwich meals. 
Night feeding was poor, therefore, and vegetables, canned fruits, et cetera, ac- 
cumulated in storerooms. In other units, which served regular hot meals at 
midnight, men on the night shift were permitted to get up and eat the midday 
meal with the day shift. The total daily food intake of these men was no 
greater but this practice did deprive the day shift of its normal share of the 
more desirable components of the ration, especially of its share of the meat issue. 
Artificial shortages of certain ration items developed from these failures of 
mess officers to insist upon mess discipline and proper mess operation. During 
this period the Commanding General, Services of Supply, European Theater 
of Operations, believed it necessary to authorize many augmentations without 
the usual preliminary survey. All investigations were therefore discontinued 
and augmentation requests were approved as they were received. As soon as 
the emergency created by the main invasion operations had passed, the aug- 
mentation procedure was brought under control again by a new directive which 
rescinded all previous written and verbal authorizations for extra rations and 
which described the specific types of augmentation which might be requested. 
The ration increases for the Air Forces, referred to above, were reaffirmed. 
An automatic increase of 10 percent was allowed messes serving less than 50 
men in order to provide adequately for the many isolated antiaircraft and 
similar groups consisting of 5 to 20 men. The Chief Quartermaster, European 
Theater of Operations, was authorized to grant extra food to troops engaged 
in hard labor, to noncombat sectors, to troops returned to rest camps after 
combat, and to troops operating under exceptional circumstances provided the 
Chief Surgeon recommended the augmentations as essential for the maintenance 
of physical fitness. 
In June 1945 the theater ration and augmentation directives were drasti- 
cally revised. The new directive, which took into consideration the cessation 136 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
of hostilities and the critical shortage of rations within the theater, included 
the following provisions: 
1. All augmentations were discontinued except the 10-percent increase for 
small messes (under 50) and increases for crews of small watercraft. The way 
was left open for augmentations which were approved by the Chief Surgeon, 
European Theater of Operations, but it wTas emphasized that nutritional neces- 
sity, and not convenience in mess operation, would be the sole factor governing 
the approval of an augmentation request. 
2. Decreases in normal ration issues were authorized for the first time in 
the theater: 
a. Rations for all military personnel engaged in sedentary duties were 
automatically reduced by 10 percent. 
h. Base section and other commanders were directed to review constantly 
troop lists in their respective commands and to apply reductions up to 10 per- 
cent for all troops engaged in light or moderately active duties. 
c. A percentage reduction, as follows, was directed for all messes not 
affected by the provisions of paragraphs a and h, above: 
Percentage 
Strength of mess: 
reduction 
Over 1,000 
7 
300-1,000_ 
5 
Under 300 
- _ 0 
None of the above reductions applied to ration items, such as shell eggs or 
fruit, issued on the basis of one per man. Furthermore, personnel in the fol- 
lowing categories were exempted from all reductions: Hospital patients, troops 
undergoing vigorous training or engaged in hard labor, troops on leave or in 
officially designated rest areas, messes serving less than 50 men, and recovered 
Allied military personnel (RAMP’s). 
Vitamin Supplementation. The supplementation of rations with multi- 
vitamins was a relatively unimportant feature of rationing in the European 
Theater of Operations except in the case of hospital patients and Air Force 
personnel. The former required extra vitamins if the food intake wTas insuffi- 
cient to provide the necessary levels of these nutrients. Combat crewTs were 
supplied multivitamins at the request of the Air Surgeon. This may have 
been justified as a preventive measure related to a possible greater need of 
certain nutrients by aviators. The basis of such a need was never demonstrated. 
In February 1944 a survey of the dietary histories of the personnel of small 
detachments (1-15 men) of the Corps of Military Police, Finance Department, 
and Transportation Corps, located in cities, towns, and villages throughout the 
United Kingdom, showed that the intake of vitamins was well below the mini- 
mum standards. These men were isolated from United States Army messes 
and received a monetary allowance in lieu of rations. Obviously no control 
of their purchase of food was possible except that of the British rationing NUTRITION 
137 
regulations. Arrangements were made to supply multivitamins to these detach- 
ments although no evidence of nutrient deficiency was uncovered. 
Provision was made for distribution of vitamins to combat troops in the 
event subsistence on unsupplemented rations continued for periods in excess of 
15 days. Fortunately, few units were ever in this category. Conferences with 
division surgeons disclosed that few believed that vitamin supplementation was 
necessary. These conferences always served the purpose of reemphasizing the 
desirability of extending even more the common practice of augmenting opera- 
tional rations with sandwiches and other items. 
The initial survey of German stalags at Limburg, Zigenheim, and Heppen- 
heim by the Nutrition Branch, Office of the Chief Surgeon, revealed the magni- 
tude of the RAMP problem. It furnished the background for the measures 
adopted to insure nutritional rehabilitation of the men who required immediate 
hospitalization, or who were hospitalized during or after evacuation to the camps 
in the rear areas, and of the men who, although suffering from malnutrition, 
were not hospitalized and remained under the control of the Provost Marshal, 
European Theater of Operations. A directive was immediately distributed to 
hospitals outlining therapeutic dietary procedures for the various categories 
of malnourished patients. The nutritional care of nonhospitalized RAMP’s 
was effected by the authorization of a special bland, high protein, high calorie 
ration for use in RAMP camps. Conferences were held with base section 
surgeons and with medical officers in these camps in order to guarantee the 
proper use of the bland diet. This dietary regime was necessary because of 
the extreme gastrointestinal sensitivity which characterized RAMP’s. Diarrhea 
was almost universal before corrective measures were instituted. It was neces- 
sary to prohibit the distribution to RAMP’s of peanuts, candy bars, doughnuts, 
et cetera, by the Army Exchange Service and by the Red Cross because it was 
evident that these well-intended measures were in reality harmful. Studies of 
nutritional rehabilitation in the RAMP camps were not undertaken because 
it was the original policy of the theater to evacuate these troops to the United 
States immediately. Provision was made for the continuance of the bland 
ration on the ships carrying them home. 
OTHER RATION PROBLEMS 
Milk and Ice Cream. Milk issues consisted almost exclusively of evaporated 
and dried whole milk. Small amounts of skimmed milk powder were included 
in the hospital ration for use in lowT-fat diets. One shipment of 3,200 quarts of 
frozen whole milk was received in good condition in the United Kingdom 
in March 1945, and was distributed to hospitals. Beverage milk and eggnog were 
prepared and served in hospitals but no serious attempt was made to popularize 
the use of beverage milk in troop messes although suitable instructions for its 
preparation were published in mess bulletins. The dried whole milk was very 138 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
acceptable, however, and yielded a reasonably good fluid milk if care was used 
in its rehydration and particularly if the product was flavored with chocolate 
or vanilla. In view of the lack of apparatus for the large-scale reconstitution 
of fluid milk from milk powder, emphasis was placed on the utilization of dried 
and evaporated milk in cooking, in cocoa, on cereal, and in similar ways. 
Consumption of the milk component of the ration was satisfactory. This would 
not have been the case in the absence of an intensive educational program. 
Early ration directives authorized the daily issue of the equivalent of 5 
ounces of evaporated milk per man. This was not considered sufficient and 
the Nutrition Branch, Office of the Chief Surgeon, was instrumental in having 
the allowance increased to 7 and 10 ounces, and later to 8 and 12 ounces, for 
troops and hospital patients, respectively. Thus, troops received the equivalent 
of 1 pint of whole milk daily. The additional milk added greatly to the ac- 
ceptability of the ration and assisted materially in assuring satisfactory intake 
of calcium and riboflavin. The use of fresh milk from local sources in the 
United Kingdom and on the Continent was restricted and later prohibited be- 
cause of the medical hazard involved and because of the scarcity of the supply 
for civilian use. 
The manufacture of ice cream by British concerns was prohibited by gov- 
ernmental order as a means of conserving materials and of insuring a uniform 
distribution of available milk. The American Army supported this policy 
and ice cream was not supplied except as it was prepared by hand freezing in 
small quantities in a few messes. The British restriction was removed after 
the liberation of France and Belgium, and in January 1945 the use of ice 
cream by United States Army units in England and on the Continent was 
authorized and encouraged. It was specified, however, that ice cream would be 
prepared from ration components exclusively and that civilian manufacturing 
agencies must maintain United States Army standards of sanitation. In 
August 1945, ice cream mix became a normal component of the ration issue. 
Dehydrated Foods. The issue of dehydrated foods was not a serious prob- 
lem in the European theater because these items never predominated in the 
ration. Dried milk was acceptable. Dried egg was not received enthusiasti- 
cally but it was a useful item if used as an ingredient. The wastage was ex- 
cessive whenever it was served as an omelet or as scrambled egg because of the 
inability or refusal of cooks to prepare it properly. Onion was very satis- 
factory if used with ground beef. It was unsatisfactory if used as a vegetable. 
Potato was acceptable if reconstituted properly. Sweet potato was a good 
product but the amount in the B ration was excessive for the average soldier. 
Carrots and beets were reasonably satisfactory. Obviously, none of these dried 
foodstuffs was a good substitute for the canned product. The problem of dehy- 
drated foods was worsened by the fact that relatively few cooks had received 
sufficient training on the handling of this type of foodstuff. NUTRITION 
139 
Local Procurement of Foodstuffs. The general policies governing the 
procurement of foodstuffs from sources within the theater were designed to 
save transoceanic shipping by the maximum use of local surpluses and, at the 
same time, to protect the food rationing programs of the British and other 
Allied governments by restrictions on miscellaneous purchases by individuals 
and units of the American forces. The British Ministries of Food and of 
Agriculture made available large quantities of such foodstuffs as flour, bread, 
prepared cereals, rolled oats, tea, marmalade, syrup, condiments, potatoes, and 
vegetables. Procurement through authorized quartermaster purchasing officers 
wTas also authorized on the Continent but this was limited largely to fresh 
vegetables and the supply permitted only occasional issue. The supply of 
potatoes, cabbage, carrots, beets, rutabagas, and brussels sprouts was prac- 
tically unlimited in England. Tomatoes and lettuce were only abundant 
during short seasons so that the dietary was generally lacking in fresh salad 
components. Fresh fruits were notably lacking in the American ration. 
Seasonal apples and pears were unrationed in England and the same was true of 
apricots and grapes in France, but the former were of inferior quality and the 
latter were readily available only in southern France, Shipments of oranges, 
wUich were received occasionally in 1944 and 1945, were therefore especially 
appreciated by the troops. 
The purchase of meals in public restaurants was prohibited on the Con- 
tinent. No such restriction prevailed in the United Kingdom although the 
demand for meals sometimes exceeded the supply. The American Red Cross 
provided snack bars which were well patronized. These were limited to British 
sources of supply and to British rationing in the United Kingdom but were 
allowed to purchase quartermaster subsistence supplies on the Continent. 
RATIONS FOR PRISONERS OF WAR 
A small number of German and Italian prisoners of war were brought to 
the United Kingdom from North Africa in 1943. Prisoners captured in Nor- 
mandy in 1944 increased the number but the total in the United Kingdom under 
the control of the United States Army was never large. These prisoners of 
war were issued a ration which did not differ greatly from that supplied Ameri- 
can troops. No distinction was made in the rations for working and non work- 
ing prisoners. 
Prisoners of war on the Continent were issued a similar ration until 7 De- 
cember 1944, except that nonworkers received 20 percent less than workers. 
At this time the worker’s ration was reduced from 3,860 to 3,258 calories; non- 
workers received 10 percent less. Another reduction was made in April 1945. 
For the first time separate rations were authorized non workers because it was 
not feasible to make an overall percentage deduction in the worker’s ration to 
bring the caloric level down to the 2,000 calorie level ordered by the theater 140 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
for non workers. These ration decreases were the result of the disparity between 
tremendous numbers of captured prisoners and the relatively small stocks of 
available foodstuffs. Furthermore, the 2,000-calorie ration was authorized as 
the theater ration for displaced persons and others whose subsistence was the 
responsibility of Allied Military Government. The earlier rations supplied 
nonworkers were in accordance with the Geneva Convention and were in excess 
of the actual requirements of the prisoners. This original policy was bitterly 
criticized by Allied civilians because nonworking prisoners had more to eat 
than Allied workers. Following the German surrender in May 1945, prac- 
tically all the prisoners held by the armies inside of Germany were classified as 
“disarmed forces” and their subsistence became the responsibility of the civilian 
food administration. Prisoners of war in the communications zone remained 
on the prisoner of war ration. 
In February and March 1945 the Nutrition Branch, Office of the Chief Sur- 
geon, was directed to investigate the nutritional status of prisoners of war in 
American custody. The survey team, consisting of 2 medical and 2 nutrition 
officers examined 800 prisoners in representative work camps and enclosures. 
The results showed that the nutrition of prisoners who had been in American 
hands for 50 days or more was satisfactory and considerably superior to that 
of newly captured Germans. This indicated that the prisoner of war ration 
in use during the early part of 1945 was superior to the ration of the German 
Army. 
In August 1945 the Nutrition Branch, Office of the Chief Surgeon, was 
directed to make a second theater survey of the adequacy of the feeding of 
prisoners of war and of German disarmed forces. The 2,000-calorie ration was 
found to be insufficient for German prisoners under 21 years of age and for 
others who were classed as nonworkers but whose caloric needs were signifi- 
cantly increased by fatigue duties, calisthenics, or marching. The 2,000-calorie 
ration was adequate for individuals who were inactive in fact. The German 
civilian ration issued to disarmed forces varied from 1,200 to 1,500 calories at 
that time and was inadequate. This was especially true because there was no 
opportunity for the men in the enclosures to supplement their rations as German 
civilians were able to do from gardens, household supplies, et cetera. 
Nutrition in the 
Persian Gulf Command 
In the noncombat or less active areas such as the Persian Gulf Command 
and China-Burma-India theater, the problems in nutrition were of a different 
nature. In the Persian Gulf Command, troops were stationed primarily in 
fixed installations. The field ration wTas used throughout 1943, and supple- 
mented by vitamin tablets up to June of that year when the practice was dis- 
continued because the ration was felt to be nutritionally adequate. Local NUTRITION 
141 
produce could not be fed to soldiers because of the native’s custom of using night 
soil for fertilizer. No fresh meat was provided for the command until just 
prior to the Teheran conference. No master menu was ever prepared in this 
command, the menu being largely dependent upon the arrival of reefer ships. 
There was some inequitable distribution of food; however, no vitamin deficiency 
diseases were known to have existed. 
The problem of feeding Army employees who were local inhabitants of 
various religious faiths and food habits was encountered in the Persian Gulf 
Command. For example, Mohammedans were provided goat meat in lieu of 
pork. The problem also arose in the China-Burma-India theater, where nutri- 
tional deficiency disease developed among Chinese troops stationed in a training 
center at Ramgarh, India. 
Nutrition in the China-Burma-India Theater32 
The establishment of a theater of operations by the United States Army 
in India and Burma presented peculiar subsistence problems. Our forces were 
not invading a hostile country where subsistence could be requisitioned from 
the populace and where supply lines could be appropriated and set up without 
regard for the native population. They came as “guests” to a densely populated, 
Allied country in the throes of political unrest. Furthermore, a large propor- 
tion of the population was on the brink of a great famine which was to destroy 
by starvation a million and a half people in 1943. The United States troops 
could not be concentrated within a few well-consolidated areas, but because of 
military necessity were scattered in small groups separated by thousands of 
miles. The existing ground lines of communication between these areas were 
extremely primitive or nonexistent. Rations of the British or Indian Armies 
were not acceptable to our troops. It was intended, however, for these troops 
to “live off the land.” 
When the first contingent of troops arrived in India from the United States 
early in 1942, no provision had been made for the continuous supplying of these 
troops with subsistence from the Zone of Interior. A reserve stock of B rations 
was sent to the theater, but these were not to be used except in emergencies. It 
was intended that these troops should be fed on supplies obtained from local 
markets and on rations obtained through the British Army. In October 1942, 
a theater policy was adopted governing the subsistence of United States troops 
in India and Burma.33 The ration consisted of the British troops field service 
ration obtained through the Royal Indian Army Service Corps, supplemented 
by local purchase of fresh supplies and by the issue of excess stocks of the 
reserve B ration. These reserves were augmented from time to time by ship- 
32 This section is based on material submitted by Karl J. Koehn, formerly Captain, SnC, Nutrition 
Consultant, Indla-Burma theater. The material was originally presented In Van Auken, H. A. : A 
history of preventive medicine in the United States Army Forces of the Indla-Burma theater, 1942 
to 1945. HD : 314.7-2. 
33 CBI Memo 120, 30 Oct 42, sub : Rations for U. S. Forces in CBI. HD. 142 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
ments from the Zone of Interior which permitted rotation of stocks to prevent 
spoilage and which provided a reserve for subsequent incoming troops. 
Unfortunately the excess stocks of B-ration reserve were slow to ac- 
cumulate and confusion existed as to what constituted an emergency. It was 
often difficult to maintain the reserve at the authorized level because of the 
rapid expansion of the theater. The British troops field service ration was 
found to be unsuitable for United States troops because many items such as 
pork and soya links, corned beef and mutton, were not acceptable and hence 
were not eaten. The milk allowance received from the British Army amounted 
to only 2 ounces of tinned milk per man per day, which is not considered to be 
adequate for United States troops. Practically no fresh milk was available 
because of the insanitary conditions under which it was produced. Fresh meat 
was scarce and of inferior quality, because of the Government of India law 
which prohibits the slaughter of bullocks in good state of health under 10 years 
of age, pregnant cows, or cows in milk. Other fresh meats were not available. 
Difficulty was also encountered in obtaining sufficient quantities of high quality 
fresh fruits and vegetables. These were available to troops in the metropolitan 
areas such as Karachi, New Delhi, and Calcutta, but were scarce in isolated 
regions such as the Brahmaputra River Valley. Menus were prepared in the 
various section headquarters located in the above mentioned cities but these 
could only be used in the immediate vicinity because of difficulty of distribution. 
Numerous complaints were received by the Surgeon of the theater that the 
dietary of the troops was deficient in calcium, thiamine, riboflavin, and vitamin 
C. Medical officers reported a reduction in the efficiency of the command which 
they attributed to malnutrition. A large proportion of the troops reporting 
for sick call complained of weakness, insomnia, lassitude, and gastric complaints 
which were suggestive of a deficiency state. An increase in the occurrence 
of gingivitis was also observed which may have been precipitated by a vitamin C 
deficiency.34 
The situation became serious enough to warrant careful study of the ade- 
quacy of the ration and means of improving the nutritional status of the troops. 
In midyear of 1942 a nutrition officer, Capt. (later Maj.) M. J. Babcock, SnC, 
was assigned to the theater as Nutrition Consultant to the Surgeon, Head- 
quarters, Services of Supply, China-Burma-India. He made a thorough study 
of the dietary of the troops and concurred in the opinion that the ration was 
deficient in calcium, thiamine, and riboflavin. Dietary studies of the troop 
ration continued throughout the autumn and winter and were summarized in a 
report in January 1943.35 On the basis of these studies, the Surgeon 
recommended that: 
Surg 45th Engr Regt (GS) to Food and Nutrition Off CBI, 26 Apr 43, sub: Inadequacy 
of diet. HD : 720.1. 
36 Rpt, Capt M. J. Babcock, SnC, 14 Jan 43, sub : Nutrition of U. S. Army Forces in India and 
Burma. AG: 331.4. NUTRITION 
1. The allowance of canned milk obtained from the United States be in- 
creased to supplement the 2 ounces received from the British Army; 
2. Troops in Base Section No. 3 (Ledo area) be issued the B ration instead 
of the British Troops Field Service Ration; and 
3. The ration of other troops stationed in Assam be supplemented with 
canned fruits and vegetables. 
Troops in the forward areas deserved preference in subsistence because 
they were fighting and doing heavy work under very adverse conditions and 
because local supplies were not available. These recommendations were put 
into effect. Stocks of B rations which were beginning to accumulate in excess 
of the authorized reserve were diverted to the use of hospitals and combat 
aircrews. The Surgeon, China-Burma-India, recommended that the Expedi- 
tionary Force Menu No. 1 (Tropical and Temperate Climate) be adopted as 
the field ration for this theater. No action was taken on this recommendation 
at that time and the policy of “living off the land” was continued except in 
the Ledo area. 
As a result of the complaints that the ration was nutritionally inadequate, 
many requests for the issue of multivitamin tablets to supplement the ration 
were received by the Surgeon’s Office. Since this item was in critical supply 
at that time, it was necessary to establish a theater policy governing the issue of 
multivitamin tablets to supplement the ration in order to insure expeditious 
use of available supplies. The issue of multivitamin tablets was authorized to 
supplement the ration of troops only upon certification by the unit medical 
officer that a specific deficiency existed and that no foods were available to 
correct this deficiency. Requisitions accompanied by the certificate were re- 
quired to be submitted to the Surgeon, Headquarters, Services of Supply, 
China-Burma-India, for final approval. Later in 1943 this policy was liberal- 
ized to include the issue of multivitamin tablets to combat aircrews and units 
subsisting on emergency rations. 
At this time an outbreak of nutritional deficiency disease occurred in the 
form of beriberi among Chinese troops at the Chinese Training Center at 
Ramgarh, India. This outbreak was investigated by the nutritional con- 
sultant.36 Between 8 August and 25 September 1943, 199 patients were hos- 
pitalized with beriberi as the primary cause of hospitalization. Many patients 
were not admitted to hospitals but were treated as outpatients at dispensaries. 
Other symptoms of deficiency diseases such as night blindness, cheilosis, 
glossitis, and osteomalacia were also observed. These troops had recently ar- 
rived from China and most of them had a background of chronic malnutrition. 
The rice eaten by some of them had spoiled and required much washing which 
39 Rpt, Capt M. J. Babcock, SnC, 30 Sep 43, sub; Investigation of dietary deficiencies among 
Chinese troops at Ramgarh Training Center. HD : 314.7-2 Ref. 144 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
caused the extraction and loss of nutrients. The diet prescribed for Chinese 
enlisted men in India at that time had the following composition: 
Item 
Amount 
Rice, polished 
Meat _ _ 
Vegetables, fresh (y3 green) _ _ _ 
8 ounces 
Oil, cooking 
— _ 5 gallons per 1,000 men 
Salt _ _ 
Tea _ 
Firewood 
. 3 pounds 
A nutritional analysis of this ration made at that time showed the follow- 
ing daily allowances of nutrients: 
Nutrient 
Chinese troop 
ration 
Recommended 
Calories 
3,950 
4, 000 
Calcium, mg 
170 
800 
Iron, mg _ 
16. 2 
12 
Vitamin A. I. U _ __ 
2, 570 
5, 000 
Thiamine, mg 
.57 
1. 8 
Riboflavin, mg 
1. 46 
2. 40 
Niacin, mg 
22. 5 
20. 0 
Ascorbic acid, mg _ _______ 
38. 6 
75. 0 
This dietary was obviously deficient in calcium, vitamin A, thiamine, 
riboflavin, and ascorbic acid. The ration was changed as follows: iy2 pounds 
of undermilled rice was substituted for the 2 pounds of polished rice, and 
one-half instead of one-third of the vegetable allowance was prescribed as 
green. The following ingredients were added: 2 ounces of dried beans, 2 
ounces of peanuts, and 4 ounces of atta (whole wheat flour). Subsequent to 
these changes, no further widespread incidence of nutritional disease occurred 
among troops of the Chinese Army in India or Burma. 
With large numbers of troops moving into Assam during the latter part 
of 1943 and in early 1944, the problem of supplying subsistence from the port 
of Calcutta became acute. The Bengal-Assam Railway system was sorely 
overtaxed and since the trip from Calcutta to Assam took 12 days, only non- 
perishable items were so shipped. Barges carrying supplies up the rivers of 
East Bengal were often stranded for days because of the great variations in 
the flow of water. There were no roads connecting Calcutta with Assam, 
so motor transport could not be used. Because of the uncertainty of supply, 
it was impractical to prepare a menu in advance for the forward areas. The 
local markets were quickly depleted of foods, and the reserve of B rations was 
seriously unbalanced. It was necessary, therefore, to employ airlift to trans- 
port much of the subsistence from Calcutta to Assam. 
As the combat troops and those engaged in the construction of the Ledo 
Road, petroleum pipeline, and signal communications moved forward from 
Ledo into Burma, many of the units had to be supplied by airdropping. An NUTRITION 
145 
airdropped ration was formulated of B-ration components which was nutri- 
tionally adequate yet light in weight. This was accomplished by the full 
use of dehydrated products. C and K rations were also used for this purpose. 
Airdropped rations were always supplemented with multivitamin tablets. 
Supply to the forward areas was always uncertain under optimum con- 
ditions, but it became precarious during the spring-summer season of 1944, 
It became necessary, therefore, to liberalize the theater policy on the issue of 
multivitamin tablets to supplement the ration. This was done by authorizing 
the issue of one tablet per man per day to all troops stationed in Assam and 
Burma until such time as transportation would allow the supplying of ade- 
quate subsistence to all units. 
Early in 1944 Col. Paul E. Howe, Chief of the Nutrition Division, Office 
of The Surgeon General, visited the theater and studied the ration problems. 
In his report Colonel Howe attributed the inadequacy of the ration to the 
attempt to “live off the land,” to dependence on British supplies which were 
often not available or acceptable, and to inadequacy or failure of transporta- 
tion. He recommended that the theater adopt the Expeditionary Force Menu 
No. 1 (revised 1 October 1943) as the basic field ration. He also recommended 
that additional nutrition officers be assigned to the theater to work with the 
troops in the field.37 
In March 1944, four nutrition officers were assigned to this theater. The 
following were their assignments: (1) Air Transport Command installations 
in India and China; (2) Services of Supply installations around Ledo and the 
Ledo Road as far as Myitkyina; (3) the eastern half of India; and (4) the Air 
Force installations in Northern Burma. The duties of these nutrition officers 
were to conduct nutritional surveys in troop masses in the field to determine 
the nutritional adequacy of the dietary consumed by the troops, to advise the 
surgeon in matters pertaining to nutrition, and to assist the quartermaster in 
preparing menus and in selecting nutritionally equivalent substitutes for 
unavailable items. 
In July 1944, the Expeditionary Force Menu No. 1 was adopted as the 
basic field ration for this theater in accordance with Colonel Howe’s recom- 
mendation. Such components as were available from the British were procured 
in bulk from the Royal Indian Army Service Corps under reverse lease-lend 
agreement. These items included flour, salt, sugar, condiments, fresh eggs, 
meats, fruits, and vegetables. Components not available locally were imported 
from the Zone of Interior and a 90-day reserve stock level maintained. The 
indigenous products were of low quality compared with United States Army 
standards. The flour was particularly subject to criticism by United States 
troops. It was not enriched and therefore was low in vitamin content, was 
heavily infested with weevils, and, because of its low gluten content, it was 
37 Ltr, Col P. E. Howe, SGO, to Surg CBI, 11 Mar 44. HD : 720.1. 146 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
unsuitable for breadmaking. The fruits were of fair quality, but many species 
were previously unknown to the troops and were not well received, for example, 
mangoes, papayas, and leechie nuts. The vegetables were generally of poor 
quality, picked after the optimum stage of maturity and were usually wilted or 
spoiled upon arrival at their destination. As in the case of fruits, many of the 
vegetables were unknown to the cooks who were at a loss to know whether a 
new botanical specimen issued to the mess should be boiled, fried, or baked; or 
whether it should be seasoned with salt or sweetened with sugar. The resulting 
product was usually highly unpalatable. 
The troops in this theater subsisted for several months on the ration as 
prescribed by the Expeditionary Force Menu No. 1, supplemented with such 
indigenous fresh produce as could be obtained from the Royal Indian Army 
Service Corps. During that time complaints about the quality and quantity of 
the ration became more and more numerous. The following were the most 
commonly expressed complaints: (1) the caloric value of the ration was inade- 
quate ; (2) the canned meat components became monotonous, were unacceptable, 
and were not eaten by the troops; (3) the dried eggs and whole milk powder 
were rancid and therefore were not consumed; (4) insufficient bread and spreads 
were issued; and (5) cereal products were heavily infested with weevils. 
The complaint that the caloric value of the ration was inadequate as 
prescribed by the Expeditionary Force Menu No. 1 was justified in many in- 
stances. The food prescribed by this ration contained 3,945 calories whereas 
nutritional surveys conducted in hard-working units such as port battalions and 
truck companies revealed that food actually consumed exceeded 4,000 calories 
if it were available. The port battalions and aviation engineer battalions, 
which worked three 8-hour shifts daily, often served as many as 6 meals a day. 
This was very difficult to accomplish with the food prescribed by the Expedi- 
tionary Force Menu No. 1. The canned meat components of the B ration were 
highly spiced and quickly became monotonous and therefore unacceptable. 
Much of the meat was not consumed, and therefore the ration as consumed 
was lowered in nutritional value. 
The dried eggs and powdered whole milk components of the B ration were 
too perishable to be sent to a tropical theater so far from the source of supply. 
It required from 60 to 90 days’ travel time to ship subsistence from the Zone 
of Interior to India and for most of that time the temperature was around 100° 
Fahrenheit. An additional 30 days were required to unload and transport the 
supplies to the various subdepots where they were stored for an additional 90 
days at a temperature of 100° F. or higher. This latter storage was necessary 
for the proper rotation of the 90-day reserve stocks. Thus it was necessary 
to subject these products to high temperatures for a minimum of 6 months 
before they could be used. Actually they were from 1 to 2 years old before they 
were issued. The powdered eggs were discolored and had a disagreeable taste NUTRITION 
147 
which was difficult to disguise; consequently the mess personnel seldom bothered 
to prepare them as a breakfast dish and when they did, most of them were 
discarded. The powdered eggs, however, were extensively used in baking and 
cooking. The whole milk powder could not be made into a palatable beverage 
unless it was mixed with chocolate or some other flavoring to mask its disagree- 
able taste. It could be used satisfactorily, however, in cooking and baking. 
Because of the long storage at high temperature, the dehydrated vegetables 
had deteriorated considerably. Many of the cooks in the theater had not had 
previous experience in the preparation of dehydrated vegetables and, therefore, 
were not adept in preparing appetizing dishes from them. Consequently the 
dehydrated vegetables were not acceptable and considerable waste resulted. 
This had a deleterious effect on the nutritional adequacy of the ration. The 
surgeon recommended that a food service program be established in this theater 
to correct these difficulties, but the recommendation was not favorably con- 
sidered at that time. 
The hospitals found it difficult to operate on the field ration and hospital 
supplement ration as prescribed by the Issue Chart to Expeditionary Force 
Menu No. 1. The hospital ration did not furnish adequate subsistence for 
patients under the climatic and epidemiologic conditions of this theater. The 
high proportion of patients admitted with febrile and diarrheal diseases resulted 
in the use of a large percentage of special or restricted diets. The subsistence 
issued was particularly deficient in fruit juices and the more acceptable canned 
meat items. An attempt to correct this was made in Base Section No. 2 
(eastern half of India) by issuing one field ration for each patient and allowing 
the hospital a monetary credit with the quartermaster equal to one-half the 
cost of the field ration for each patient in lieu of the automatic issue of the 
hospital supplemental ration. This did not work out satisfactorily because the 
purchase of certain items of the hospital supplemental ration in excessive quan- 
tities by some hospitals quickly depleted stocks of these items, which were being 
sent to the theater on the basis of troop strength as prescribed by the Issue 
Chart to Expeditionary Force Menu No. 1. Thus, many hospitals were not 
able to obtain the subsistence items required for the formulation of the special 
or restricted diets. 
In September 1944, the Surgeon, Headquarters, United States Forces, 
India-Burma Theater, requested that the ration scale for troops in the theater 
be revised, that a more liberal hospital supplemental ration be provided, and 
that a uniform ration system be adopted for all hospitals. The Nutrition 
Consultant to the Surgeon assisted by the nutrition officers of the base sections 
and hospital dietitians, in cooperation with the Quartermaster, drew up a new 
ration scale in the form of the Basic Subsistence Issue Chart for India and 
Burma and also set up a uniform ration system for hospitals. This was accom- 
plished in October 1944, and the new policy submitted to the Commanding 
346336 0—55 11 148 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
General, India-Burma Theater, for approval in November. It was put into 
effect 1 January 1945.38 
The revised ration provided a maximum of 4,500 calories with a greater 
variety of meats including canned ham (to increase the thiamine content of 
the ration), canned pork and gravy, frozen boneless beef, and lamb carcass. 
The frozen and fresh meats provided more of the B vitamins than the canned 
beef components of the Expeditionary Force Menu No. 1. An increase in 
juices, fruits, bread, and spreads were also provided. 
All hospitals in the theater were authorized to draw one field ration for 
each patient plus an automatic issue of the revised hospital supplemental ration 
prescribed by the Basic Subsistence Issue Chart for India and Burma. This 
revised hospital supplemental ration prescribed more liberal allowances of 
canned meats, milk, fruit juices, and canned vegetables than the Expeditionary 
Force Menu No. 1. The quantities of the less useful items such as dehydrated 
soups and vegetables purees were reduced. 
Early in November 1944, Captain Babcock was returned to the Zone of 
Interior under the theater rotation policy and he was replaced by Capt. (later 
Lt. Col.) K. J. Koehn, SnC, as Nutrition Consultant to the Surgeon. 
With the adoption of the Basic Revised Subsistence Issue Chart for India 
and Burma it became necessary to publish a monthly master menu for the 
theater. The preparation of this menu was undertaken jointly by the Quarter- 
master and the Surgeon, India-Burma. The menu was used as the basis of 
issue of subsistence to all unit messes in the theater. This was necessary to 
insure equitable distribution of all ration items, particularly the fresh and 
frozen meat components. The menu was also used to exercise control over the 
stock levels of subsistence items. For example, if it appeared that the supply 
of a certain item was diminishing at such a rate that it would be exhausted 
before the supply could be replenished from the Zone of Interior, the quantities 
prescribed by the menu would be reduced so that the supply would last until 
replenished. Conversely, if stocks of an item greatly exceeded the reserve level, 
an increased issue would be prescribed. If stocks of certain items began to 
accumulate in the messes, the rate of issue would be reduced in the menu. The 
master menu was subjected to nutritional analysis each month before publica- 
tion to insure that the optimum quantities of nutrients were prescribed with 
the available foods. 
The increase in the ration, particularly for hospital patients was very well 
received in the field. Some difficulties were encountered, however, in making 
adjustments to the new ration scale. Subsistence supplies due in to replenish 
stocks depleted by the increased issues failed to arrive when expected. Ship- 
ments of canned ham were cancelled. This deficiency of supply was apparently 
38 Cir 21, Hq India-Burma Theater, 15 Dec 44, sub; Rations for U. S. Forces, India-Burma 
theater. HD. NUTRITION 
149 
related to increased demands by other more active theaters. Fortunately the 
shortage of subsistence was confined to staple and nonperishable items. The 
supply of frozen boneless and imported carcass beef was uninterrupted. This 
issue of fresh meat boosted the morale of the troops more than any other factor 
connected with food. It served to break the monotony of an otherwise tiresome 
ration. 
The frozen boneless beef, obtained from the Zone of Interior via reefer 
ships, was conveniently packed in 50-pound boxes and was separated into three 
cuts: roasts and steaks, stewing and boiling meat, and ground meat. These 
were unloaded from the ships at Calcutta to a nearby cold storage warehouse 
where they were kept frozen while awaiting transshipment. They were then 
loaded into cargo planes and flown to the general depots and subdepots in the 
forward areas. Here the meat was kept frozen in cold storage plants until 
picked up by unit ration trucks. This system worked remarkably well and 
very little meat was lost through spoilage. All of the meat received from the 
Zone of Interior was shipped to the forward areas. The frozen boned and 
carcass meat obtained through the British Army was distributed in the 
rear areas. 
Some difficulty was encountered in the feeding of Chinese patients in 
American hospitals in the forward areas. The basic ration for Chinese enlisted 
patients was the revised Chinese troop ration described earlier in this discus- 
sion. The components of this ration were obtained through the Royal Indian 
Army Service Corps and were prepared by the Chinese themselves. Cooking 
was done in large drums or tubs over an open fire where they prepared their 
rice, stews, and soups. An attempt was made to exercise supervision over the 
cooking and serving of the food by United States personnel, but it was almost 
impossible to change centuries’ old customs. For example, when fresh meat 
was issued, it was necessary to cut it up and issue it to each patient. The patient 
then cooked it himself according to his particular custom or entrusted its cook- 
ing to some friend. Because of their customs of cooking their foods in large 
volumes of water, many of the water soluble nutrients were lost. In order to 
prevent the occurrence of deficiencies, Marmite, a brewers’ yeast preparation, 
was added to the soups. To supplement the ration further, all of the hospital 
comfort items of the British troops field service ration were made available to 
hospital commanders who decided which items were necessary for the welfare 
of the patients. These items consisted of canned milk, meats, fruits, sugar, et 
cetera. Upon the insistence of the Chinese, these items were issued individually 
to each patient by an American in order to insure equitable distribution. It 
was over the issue of these comfort items that trouble arose. It was natural 
that hospital commanders had different ideas as to just which comfort items 
were necessary and in what quantities. A Chinese patient would find out that 
a neighboring hospital was issuing an item he was not receiving; he would then 150 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
complain that he was not getting what he was entitled to. This became wide- 
spread among the patients of all hospitals in this area and no hospital escaped 
criticism on one score or another. The Chinese found these tactics very useful 
in playing one hospital against another to secure more comfort items than 
were necessary. A patient would insist on going to one particular hospital and 
would boycott the others. Since all of the patients were well fed, this situation 
was absurd, but rapidly became intolerable. A meeting was called by the 
Surgeon, Advance Section, which was attended by the nutrition officer and the 
hospital commanders concerned. A uniform scale of hospital comforts was 
evolved which was put into effect in all hospitals caring for Chinese patients. 
After the Chinese were made to understand that the food was the same in all 
hospitals, the trouble subsided. 
Nutritional surveys conducted in Advance Section in 1945 showed that in 
spite of the more liberal ration prescribed, it was still deficient in thiamine, 
the average daily intake being 1 mg. per man. The riboflavin intake was also 
low. The ration as prescribed was low in these vitamins because of two factors; 
the lack of fresh pork, and the use of unenriched, indigenous flour which com- 
prised 40 percent of the issue. Although few cases of clinical avitaminoses 
were ever seen in United States troops in this theater, an increasing number 
of patients were seen in the forward areas who complained of vague symptoms 
suggestive of subclinical thiamine deficiency, i. e., anorexia, nervousness, indi- 
gestion, or fatigue. Some of these patients responded to therapy with thiamine 
hydrochloride although it was not proved that other factors coincident to 
hospitalization were not the cause of improvement. The use of thiamine prepa- 
rations by hospitals in the forward areas increased considerably in 1945 indi- 
cating that the long continued low intake of thiamine was beginning to show 
effects. 
Since lean pork products contain approximately five times as much thia- 
mine as lean beef, the Surgeon recommended that pork loins and hams be 
requisitioned in lieu of half of the beef being procured monthly from the 
Zone of Interior. He further recommended that the use of unenriched flour 
be discontinued and that 100-percent enriched flour be procured from the Zone 
of Interior. The former recommendation was acted upon and the first ship- 
ment of boneless pork loins and hams arrived in the theater in July 1945. 
This pork not only substantially increased the thiamine content of the ration 
but relieved the monotony of the previously predominantly beef dietary. The 
second recommendation was not favorably considered at that time because of 
the theater policy to procure as many items locally as possible to conserve 
shipping space. 
In April 1945 the War Department directed that the ration scale for this 
theater be reduced so that the total quantities of foods within the various food 
groups (with several exceptions) conformed with the quantities prescribed NUTRITION 
151 
by the Issue Chart to Expeditionary Force Menu No. 1. The revised ration 
provided approximately 4,150 calories, 2.06 mg. of thiamine, and 2.78 mg. 
of riboflavin daily. The increase in thiamine content of the ration in spite 
of the decrease in calories resulted from the inclusion of 0.13 pound per man 
per day of lean pork products. It was necessary to reduce the total weight 
of issue of leafy, green, and yellow vegetables, but this was compensated for 
by reducing the weight of the canned vegetables and increasing the dehy- 
drated. Since fresh vegetables were usually substituted for the dehydrated, 
the net result was an increase in this group. The reduction in calories was 
caused by the decrease in the issue of fats and potatoes. Adjustments were 
made between the various food groups so that the overall decrease in the 
ration could be accomplished without seriously affecting its nutritional value. 
The limitations placed upon the ration by the War Department also 
applied to the hospital supplemental ration. It was necessary, therefore, 
to place the hospitals back on the ration prescribed by the Issue Chart to Expe- 
ditionary Force Menu No. 1. Within 1 month, reserve stocks of supplemental 
items on hand in the hospitals were exhausted and the subsistence issued was 
insufficient to allow for the proper dietary management of patients. The 
Nutrition Consultant to the Surgeon and the quartermaster subsistence officer 
studied the situation very carefully in order to determine how the hospitals 
could be furnished adequate subsistence without exceeding the overall allot- 
ment of subsistence to this theater. They arrived at the following conclusions: 
Hospital supplemental ration items were allocated to this theater on the basis 
of troop strength, assuming 15-percent hospitalization of the command. Under 
the existing theater policy the hospital ration items received with 10,000 rations 
were, therefore, issued to 1,500 patients. Statistics revealed, however, that 
in this theater only 5 percent of the command was hospitalized. Thus, two- 
thirds of the items earmarked for hospitals remained in the depots unused. 
The problem could be solved, therefore, by prorating the essential hospital 
items received with 10,000 rations among 500 patients without exceeding the 
quantities of food allotted this theater. The hospital supplemental ration 
was revised, therefore, to increase the allowances of fruit juices, canned meat, 
and other essential items effective 1 August 1945. 
During the summer monsoon of 1945, nutritional surveys conducted in 
the forward areas indicated that the consumption of thiamine and riboflavin 
was not optimum. This was attributable to lack of fresh foods in the ration 
and to the impossibility at times of transporting fresh or frozen meats to the 
forward units along the road. Transportation failure resulted from tem- 
porary washouts of the Stilwell Road caused by torrential rains and from low 
visibility which grounded aircraft. The Surgeon, therefore, requested that 
the Commanding General, United States Forces, India-Burma Theater, obtain 
authority from the War Department either to procure vitamin preparations 152 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
containing thiamine, riboflavin, and niacin for the enrichment of the indigenous 
flour or to procure 100-percent enriched flour from the Zone of Interior. The 
authority for the procurement of bulk vitamins or 100-percent enriched flour 
was granted. 
The enriching of the indigenous flour appeared to be the most practicable 
means of increasing the vitamin content of the ration. Before requisitions 
were placed for the vitamins, theater headquarters was requested to allow the 
United States Army to provide bulk vitamins to the Indian mills furnishing 
us flour for the purpose of enriching this flour. This request was not favor- 
ably considered since the flour for United States troops and for the British 
and Indian troops all came from a common stockpile, and they considered it 
impracticable to enrich the flour for the United States troops without enriching 
all of the flour. The project, therefore, had to be dropped. Before the ques- 
tion of procuring 100-percent enriched flour from the Zone of Interior could 
be considered, the end of the war with Japan had occurred. Since early evac- 
uation of the theater was contemplated, reserve stocks of enriched flour were 
released for issue which were sufficient to provide 100-percent flour for the 
troops until evacuation of the theater had been accomplished. 
The difficulty in maintaining an adequate dietary arising from the use of 
unenriched flour is just one example of the problems encountered in an attempt 
to feed troops in a foreign country on indigenous foods. This applies not only 
to flour but to such foods as fresh vegetables, which are raised from undeveloped 
strains on infertile land, and meat from malnourished animals. A comprehen- 
sive nutritional survey of India and Burma prior to the entry of the troops into 
these areas would have allowed our forces to anticipate the difficulties later 
encountered and steps could have been taken to prevent them. The obvious 
course that would have been followed is the continuous supplying of these 
forces from the beginning with the balanced B ration. In case such items of 
this ration as flour were required to be obtained locally, arrangements could have 
been made to correct the resulting deficiencies. The most practical means of 
accomplishing this is by furnishing tablets containing thiamine, riboflavin, 
and niacin for use in enriching bread. The proper quantities and proportion of 
each vitamin could be incorporated into a tablet to be used for each unit of flour 
used in making bread. This can be dissolved in the water so that uniform 
distribution throughout the bread can be accomplished. 
Experience in this theater has shown that it is impracticable to send such 
dehydrated products as powdered eggs, whole milk powder, and dehydrated 
vegetables to a tropical climate unless a quick turnover can be arranged or 
facilities provided to store these items under relatively cool conditions. Surveys 
conducted in this theater showed that over 50 percent of all dehydrated vege- 
tables prepared in the messes were discarded, which represents a waste of effort 
in their manufacture and waste of the original product which could have been NUTRITION 
153 
used to feed the civilian population. If at all possible only canned foods should 
be sent to theaters in tropical climates. 
Although it may be economical to feed relatively small forces on the rations 
of Allied troops, this procedure was found to be highly unsatisfactory in this 
theater. There is a great difference in food habits between various countries, 
even between such closely Allied countries as the United States and England. 
The United States troops almost unanimously condemned the British rations. 
This is attributable to their dislike of such items as mutton, corned beef, and 
pork and soya links, and to the inferior quality of many foods. Since the 
United States standards and specifications for foodstuffs are the highest in 
the world, it appears unwise to attempt to subsist American troops on the 
inferior rations of other countries. 
Another cause of dissatisfaction with the ration among the United States 
troops in this theater was the lack of skill on the part of the cooks in preparing 
the B-ration components. Many of the men serving as cooks had no training 
in cooking and many of those who had, had left the Zone of Interior without 
learning how to prepare such foods as dehydrated eggs, vegetables, and the 
various stew and hash components of the ration. The Surgeon repeatedly 
recommended that a food service program be established in this theater to 
correct this deficiency. This recommendation was not favorably considered by 
the theater general staff, which was unfortunate because such a program would 
have allowed the training of competent mess personnel in the theater and 
would have provided competent supervision over the preparation of food for 
the enlisted men. It is strongly recommended that in future operations, a food 
service program be made an integral part of the organization of every theater 
of operations. 
In summary, it may be said that the history of nutrition in the India-Burma 
theater is one of constant struggle against odds to improve the nutritional ade- 
quacy of the ration. The difficulties encountered were the inability of India 
and Burma to supply appreciable quantities of acceptable subsistence to sustain 
our Army, the length of the supply line from the Zone of Interior which was 
the longest in the world, the priority in subsistence given the more active 
theaters of operations, the adverse climatic conditions encountered, and the 
inadequate transportation facilities in the interior. In spite of these difficulties, 
a slow but steady improvement in the nutritional quality of the ration was 
obtained. Except for the outbreak of beriberi among Chinese troops, there 
were no significant indications of malnutrition in this theater. 
Nutrition in the Pacific Area 
The problems experienced in Europe and Asia were often accentuated dur- 
ing amphibious landings in the Pacific area. Americans found the food pro- 
vided them by other nations to be often unacceptable and, in turn, met difficulties 154 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
in feeding their Allies an American ration unpalatable to those with different 
food habits. Varying local situations made procurement of native food difficult 
or inadvisable and supply lines not infrequently embraced great distances. 
Limitation of refrigeration for transport and storage resulted in spoilage, and 
the lack of ability to obtain perishables at times resulted in a monotonous diet. 
This situation was sometimes aggravated by climatic differences between source 
of food and forward bases. As in other parts of the world, problems at times 
arose on the basis of lack of personnel, or of their skill in the preparation of 
food, with the attendant complaints of unpalatability and failure to consume 
the ration served. Inspection was not always all it might have been under 
the circumstances, and there were occasional unfavorable comments on mess 
management. 
Difficulties were sometimes encountered in the preflight and in-flight feed- 
ing of Air Force personnel on long missions. Refusal by troops of certain 
items in the diet occurred. Dried and evaporated milk, and lemon crystals, 
were mentioned as such items. Comment was made on the loss of water-soluble 
vitamins during the handling and preparation of food, and the requirements 
for certain of them were felt to be in excess of supply in areas where troops 
were subjected for long periods of time to excessive heat and humidity. 
Special problems arose in respect to the hospital ration, the feeding of 
oriental laborers and troops of Allied countries, and in the provision of food 
to prisoners of war. Here, as elsewhere, hospitals received priority in the 
ration scale and hospital diet was supplemented by special purchase of food. 
However, the need for hospital dietitians was at times keenly felt. An un- 
favorable reaction on the part of troops from the Philippine Islands to a special 
ration scale was recorded. Nausea and vomiting among Philippine civilians 
was at one time felt to be due to the Army diet. 
However, in spite of not infrequent untoward circumstances in respect to 
food supplied or consumed which resulted chiefly from the great problem of 
supplying a nutritious and acceptable diet to troops operating in areas at long 
distances over water from the source of supply, and in tropical or semitropical 
areas where geographic and climatic factors considerably enhanced the prob- 
lem, there was remarkably little severe disability due to malnutrition. Weight 
loss by troops was often considerable. However, it should be remembered that 
psychic as well as dietary factors may affect the intake of food by troops under 
combat conditions or even during acclimatization in tropical areas. In addition 
to dietary inadequacy in calories, inadequacy of calcium and the water-soluble 
vitamins was most often commented upon in the Pacific area, as it was in other 
theaters of operations. Apparently, slow clotting time was encountered in at 
least one instance, and chronic fatigue, skin infection, untoward oral conditions, 
and other signs and symptoms suggestive of avitaminosis were noted by various 
observers. Beriberi and pellagra were regarded as principal causes of mor- NUTRITION 
155 
bidity and mortality due to disease among our citizens who were prisoners of 
the Japanese. 
Some of the observations of individual commentators on nutrition in the 
Pacific theater are recorded as examples of the type and number of problems 
in feeding troops and of their dispersal throughout the area. An interview 
with the Surgeon, 37th Division, stationed on Guadalcanal and New Georgia 
islands is illustrative of the situation in regard to nutrition encountered early 
in operations in the Pacific area.39 The surgeon believed that very few clinical 
signs of vitamin deficiency had been seen in troops of that division and that 
their supply of multivitamin capsules prior to combat had been adequate. How- 
ever, he recounted that the weight loss of the individual soldier during the 
battle of Munda had been in the neighborhood of 20 to 30 pounds. 
The C ration was used by this division in combat, and it was supplemented 
by D (chocolate) bars. Logistic difficulties arose out of the tactical situation, 
and the diet became unpalatable. On the whole, the surgeon thought that the 
ration had been low in calcium and inadequate in perishables, including fresh 
fruits, vegetables, meat, and fish. It was his impression that inspection of food 
obtained in New Zealand and the Fiji Islands had not met American desired 
standards, and that problems in refrigeration resulted in its improper freezing. 
Up to 40-percent spoilage of evaporated milk obtained from New Zealand was 
attributed to climatic factors. As a result of this experience, the division sur- 
geon believed that the use of powdered milk was preferable to that of evaporated 
in such a geographic area. Fish were simply not available. There was a 
relative shortage of water due to porous ground and no rivers, and it was 
necessary to collect rainwater or to obtain it from the United States Navy. 
Historical reports provide information on problems in nutrition related 
to island warfare, to meeting the special problems of hospitals, and to feeding 
natives of other countries. During the assault of Saipan, K, C, and B rations 
were used. The first fresh food received by troops on this island was a ship- 
ment arriving on D plus 136, a striking example of the adverse relation of the 
tactical situation to the feeding of soldiers. From 15 June to 31 December 
1944, only about 10 days’ supply of fresh food per man was provided, yet no 
nutritional disease was observed among troops in spite of their uniform weight 
loss. After the latter date, fresh food became available for a meal daily. 
Troops on the islands gradually took advantage of the fresh fish, vegetables, 
and fruits that were available from native and Foreign Economics Administra- 
tion sources. On Saipan fresh fish were accepted from native fishermen be- 
ginning in June 1945 and an average of 40 tons of fish was issued per month. 
Fresh fruits and vegetables produced under Foreign Economics Administra- 
tion supervision were accepted for quartermaster issue and the supply was 
adequate. Ice cream manufactured from standard ice cream mixture was a 
39 Interview, Dr. Bill with Lt Col Hobart Mlkesell, MC, Surg, 37th Div, 18 Nov 43. HD. 156 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
welcomed addition to the menu. The quartermaster bakery began functioning 
early and furnished good bread for all troops. Food poisoning which occurred 
was attributed to faulty handling of food and not to food defective when issued. 
An example of the priority for fresh food enjoyed by hospitals was that 
provided by USASOS Regulations 30-16, 20 February 1945. This regulation 
provided for a supplemental list of foods for special diets required in hospitals. 
Nutritional analysis of hospital diets so insured found them to meet National 
Research Council standards for nutritional adequacy. 
The regular Army menu was unpalatable to civilians in the Philippines, 
and many developed acute episodes of nausea and vomiting believed to be 
related to the high fat content of their unaccustomed diet.40 
Reports of inspection trips in the Pacific area provide information on 
nutrition there from persons variously oriented to the situation. Reports in- 
cluded comment on the adequacy of the Australian ration when perishables 
were obtainable, and the monotony of the diet when they were not. Weight loss 
but little clinical avitaminosis was seen in troops in forward areas. The trans- 
fer of procurement and distribution of food from Australian to American 
control was noted.41 
The report of another inspection trip made in 1943 by Brig, Gen. Charles C. 
Hillman, (MC), USA, included an account of the complaints which he heard 
in respect to hospital rations.42 These included reference to the inadequacy of 
the number and use of hospital dietitians, to the limited facilities for refrigera- 
tion available in hospitals, and to nutritional inadequacy of certain diets. 
Based on his observations, General Hillman advised provision of the Southwest 
Pacific and Pacific areas with more officers of the Veterinary Corps for the 
purpose of augmenting local meat and dairy inspection. 
Nutrition was often a subject of discussion in regularly recurring reports 
received from the Pacific area. In one, the problems in feeding which were 
encountered in New Guinea in 1942 and 1943 were described in some detail. 
As for nutritional adequacy of the diet, comment was made only on the prob- 
able loss of ascorbic acid and thiamine during the handling of food products. 
Problems in the handling of food included unsatisfactory inspection, lack of 
cool and cold storage, pilfering, spoilage in containers due variously to the 
geographical environment, distribution of food products, and mess manage- 
ment. On the whole, however, nutrition officers found the quantity and 
quality of food “very satisfactory” at the time of writing the report. 
At that time, fresh meats, fruits, and vegetables were being obtained from 
Australia, and a few gardens had been planted locally. Ninety percent of the 
«• (1) Quarterly Rpt, 168th Evac Hosp SWPA, 1945-1. HD. 
“ 2d Ind, Hq USASOS, SWPA, Office of the Surg, to CinC SWPA, 9 Mar 43 on Ltr, SG to CG 
Gen Hq SWPA, 4 Dec 42, sub: Information on adequacy and acceptability ol the ration. HD; 720.1 
(Food) SWPA. 
42 Observations, Brig. Gen. C. C. Hillman, SWPA, 12 Jul 43. HD; 333. NUTRITION 
157 
troops were receiving bread from field bakeries, although there was spoilage 
of flour. Canned fruits and corned beef, fresh boneless meat, ham, and bacon 
were readily available, but there was little fish. Army rations used included C 
ration, which had been shipped to New Guinea in large quantities in 1942 and 
early in 1943. Large amounts of this ration had deteriorated in cans which had 
been stored in the open and subjected to high temperatures. D ration of both 
American and Australian origin had deteriorated in open storage save when 
stored in sealed metal containers. There was pilferage of peanuts from the 
bulky jungle ration. Troops had found K ration just palatable and soon tired 
of it. Mountain ration had been issued in New Guinea only on a trial basis. 
It is evident that these difficulties were related more to matters of immediate 
concern to the Quartermaster than to the Medical Corps. 
Sanitary reports from the Pacific area contained references to calcium 
deficiency in certain troops, diagnosis of that condition having been based on 
the doubtful criterion of poor (carious) dentition, and on slow clotting time. 
Dietary intake low in ascorbic acid, thiamine, and riboflavin was described. 
There were descriptions of lack of desirable fresh meat, eggs, fruits, and vege- 
tables, and of problems related to supply, transportation, preparation, and 
palatability of food as well as its nutritional adequacy. However, observations 
on clinical evidence of malnutrition—with the exception of those noted above— 
and of weight loss were strikingly absent. 
At least one example of the reaction of those concerned with effecting action 
on the basis of these reports should be described because it is indicative of the 
different perspective of persons not then subjected to the conditions under 
which these reports were made and thus able to comment upon them from a 
dispassionate point of view. Such an example included acceptance of the 
factual basis of complaints that certain processed and fresh foods received 
from Allied Nations did not meet our best standards.43 However, it was pointed 
out that the reports came from troops who had been overseas for some 2 years, 
that their morale was lowered, and that their neuropsychiatric case rate was 
rising. It was advised that efforts be made to improve the quality and accept- 
ability of food in the Pacific area. 
Numerous surveys were made of the nutritional adequacy of food issued and 
consumed and of the nutritional status of troops in the Pacific area. Those 
available for perusal point to the same dietary and potentially nutritional 
deficiencies already described: calcium, thiamine, riboflavin, ascorbic acid, and 
total calories. For example, a quantitative study of diet provided and con- 
sumed on a small tropical island in a forward area in the tropics showed the 
primary deficiencies to be in calcium, and the vitamins listed above.44 A careful 
43 Ltr, Col J. B. Youmans, MC, to OQMG, 22 Sep 44, sub : Observer’s report on subsistence in 
SWPA. SG: 430.2. 
44 Rush, A.: A field study of the Army diet as provided to troops stationed in a forward area in 
the tropics. HD : 700.7. 158 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
study of Eighth United States Army messes for a period of 20 days, 20 February 
through 15 March 1945 showed less than desirable amounts of calcium, thiamine, 
and riboflavin.45 One such study reported the finding of nutritional inadequacy 
in ascorbic acid, a conclusion based on the determination of the plasma levels 
of that vitamin.46 
Major Problems in Nutrition Overseas 
To attempt to generalize the problems of overseas theaters in nutrition is 
to invoke a storm of criticism by those intimate with individual situations. 
However, certain of these problems were apparent at one time or another in all 
areas outside the United States. They evolved from difficulties in supply and 
in meeting demand. Problems in logistics derived from the tactical situation 
were not uncommon. Accordingly, rations designed for use over short periods 
of time were actually consumed over very long periods. Their caloric con- 
stitution was not always suited to the needs of troops under such circum- 
stances; their limited number of food items provided a very monotonous diet 
when unrelieved for many days or weeks; and the food habits of troops so fed 
varied markedly. Caloric inadequacy due to the constitution of the rations 
and to their rejection by the individual soldier resulted in weight loss. Diffi- 
culties met in the provision of fresh foods including meats, fruits, and vege- 
tables, and in the handling of food products, including their storage and prep- 
aration, not infrequently resulted in diets inadequate in calcium and the water- 
soluble vitamins. 
Certain special problems in nutrition were more or less common to all 
theaters. These included temporary or permanent need for nutritional officers 
or dietitians. The feeding of Air Force personnel on lengthy missions was 
rarely solved to the satisfaction of the personnel. Provision of special diets 
in hospitals often constituted a problem, in spite of the fact that it was general 
practice to give hospitals priority in respect to food. The feeding of Allied 
troops and civilians, and of prisoners of war raised many questions. Although 
these problems were considerable and their solution difficult of accomplishment, 
and although the feeding of troops overseas undoubtedly left something to be 
desired, the remarkably little evidence of deficiency states reported attests to 
the fact that on the whole the nutritional status of the Army overseas spoke 
well for the technical and professional skill of those concerned with its feeding 
during World War II. 
46 5th ind, Lt Col W. D. Cartwright, AGD, to CG 8th Army, on Sanitary Rpt, 8th Army, Apr 
1945. HD: 720.1 SWPA. 
40 Golden, W. R. C., and Schechter, M. S.; Evaluation of vitamin C status of troops in the 
tropics. HD: 700.7. CHAPTER V 
Malnutrition and Deficiency Diseases 
John B. Youmans, M. D. 
The record of World War II is notable for the virtual absence of nutri- 
tional disease among troops. The Army operated under a high standard of 
nutritional adequacy in the soldier’s diet (as set up by the Food Nutrition 
Board, National Research Council, together with a set of minimal allowances 
for short periods for use in emergencies), and an assumption that adequate 
nutrition is necessary for maximum efficiency and health. Concern was felt 
with regard to deviations from these standards—during the time the soldier 
drew upon his body reserves when there was a shortage of food, either because 
of logistic problems, or personal reactions to the food available as issued, 
prepared, and served. Under such circumstances frank nutritional disease, 
except for loss of weight, seldom occurred. This is in great contrast to 
what might have been expected and would probably have occurred only a 
few years earlier. The magnificient development and use of new knowledge of 
all matters concerned with nutrition made possible, and successful, operations 
of great magnitude, conducted under serious logistic difficulties occasioned by 
extremes of environment and distance, such as the tropical heat and humidity 
of the jungles of the South Sea islands and the frigid climate of Iceland. It 
is safe to say that many operations of World War II would not have been 
possible or could have been carried out only partially had it not been possible 
to prevent nutritional disease. 
Only under extreme conditions, mostly in prisoners of war subjected to 
the neglect and cruelties of their captors, and in sporadic instances of indi- 
viduals conditioned by injury, disease, or some personal peculiarity, did those 
terrible spectres of other wars—scurvy, dropsy, pellagra, beriberi, and 
xerophthalmia—return. Such was the achievement of preventive medicine. 
To refer, as will be done below, to the occurrence of an appreciable amount 
of nutritional deficiency is not the contradiction that it seems. It is to be 
explained by the changing concept of nutritional deficiency states, the recogni- 
tion of the fact that there are degrees of deficiency, insufficient to warrant such 
diagnoses as scurvy, pellagra, or beriberi which require a considerable period 
for development even under controlled conditions. Partial deficiency may 
exist to an extent sufficient to prevent the fullest state of health, physical 
strength, and fitness, without causing overt or gross disability. Such condi- 
tions existed in the general population before the war and their presence was 160 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
reflected in a similar occurrence in the troops under average conditions, although 
as their service lengthened it was decreased by the highly efficient control of 
food and nutrition in the Army. It is in this respect that preventive medicine 
finds its greatest opportunity in the field of nutritional deficiency disease and 
the opportunity to ensure optimal health and physical fitness as far as nutrition 
can secure them, by preventing even slight deficiencies. 
INCIDENCE AND EPIDEMIOLOGY 
It is impossible to state accurately the prevalence of nutritional deficiency 
in the Army as a whole or in any considerable portion of it. Fully developed 
clinical forms of the deficiencies such as scurvy and beriberi are reportable in 
rates, as hospital admissions, per annum, but these give but little indication of 
the actual prevalence of deficiencies. The prevalence of nutritional deficiencies 
below the level of the classical expressions of disease is uncertain because indi- 
viduals with deficiencies of these grades alone are not usually patients, nor 
are they considered ill; the opportunity and special needs for diagnosis are 
lacking and the conditions exist unknown and often unsuspected. 
Some idea of the prevalence of nutritional deficiency disease can be secured, 
however, from special research studies and from a search of hospital records. 
The special research studies were made on groups of presumably healthy troops 
under field conditions, giving information on the prevalence of the mild or 
slight forms of the deficiency, and on special groups such as prisoners of war 
and patients in hospitals with advanced deficiency disease. The latter will 
give only the incidence of advanced stages as they are recorded in hospital 
practice under the standard forms of diagnosis. 
MINOR NUTRITIONAL DEFICIENCY DISEASE 
It has been known for some time that a number of apparently well persons 
have minor grades of nutritional deficiencies, sufficient to present recognizable 
evidence on physical or laboratory examination. It was this group which was 
of particular concern from the point of view of preventive medicine because of 
the subtle effect of such disease on efficiency and morale. Also, a potential result 
could be a large number of troops who were “under par” and would be quick to 
succumb to severe disabling nutritional disease during periods of stress arising 
from injury and disease or temporary severe dietary restriction. It was clearly 
recognized that under some unavoidable circumstances severe undernutrition 
might develop despite all efforts to prevent it. It was known, however, that 
by proper care and attention good nutritional state and good reserve could be 
maintained in all but rare instances. Such action would lessen and prevent 
the frequency and severity of advanced deficiency states when circumstances MALNUTRITION AND DEFICIENCY DISEASES 
161 
tended unavoidably to produce them. Thus injury and disease may produce 
nutritional disturbances which in turn diminish the resistance to and recovery 
from illness and injury. Good nutrition prior to injury or illness offers some 
protection against the effects of such nutritional disease. Similarly, periods 
of severe restriction of food are less serious if nutrition is good before the 
starvation begins. 
Evidence of the prevalence of those milder forms of deficiency was found 
in the ration trials at Camp Carson, Colorado, May to August 1944.1 In this 
experiment, incident to the study of the effect of a variety of special rations, 
the test subjects were examined for evidence of nutritional deficiency disease by 
physical and laboratory examinations before the start of the experimental 
period. These troops consisted of a battalion, approximately 1,000 strong, 
undergoing rigid advanced infantry training, and may be considered fairly 
representative of a considerable number of similar troops training at that time 
in the western part of the Zone of Interior. The prevalence of minor nutri- 
tional deficiency, as interpreted from the physical signs, are shown in Table 7. 
Table 7. Men in Various Companies Showing Signs of the Deficiencies Listed 
Vitamin A 
Thiamine 
Riboflavin 
Niacin 
Ascorbic acid 
(number) 
(percent) 
(percent) 
(percent) 
(percent) 
E 
11 
6 
15 
1 
F 
8 
1 
2 
1 
G 
13 
4 
5 
0 
H 
7 
0 
8 
0 
19 percent 
X 
4 
2 
3 
1 
Y 
2 
5 
5 
3 
Source: Rpt, Armored Med Research Lab, Proj. 30, 22 Nov 44. HD; 430 (Rations). 
Data on the prevalence of these deficiencies under other conditions are 
available from a survey of nutrition of troops in the Pacific area made during 
April-June 1945.2 Troops examined in this study included selected samples of 
the garrisons of Hawaii, Guadalcanal, Guam, Iwo Jima; casualties from 
Okinawa; and combat troops on Luzon and Leyte. The details of the physical 
examinations were essentially the same as those of the Camp Carson experiment 
and, in addition, included a record of the dietary. The dietary was more 
nearly representative of that occurring under a variety of ordinary field condi- 
tions in that theater than was the dietary in the Camp Carson study. The 
1 Rpt, Armored Med Research Lab, Proj. 30, 22 Nov 44. HD: 430 (Rations). 
2 Rpt, Nutrition Div SGO, 22 Aug 45, sub; Nutrition survey in Pacific Theatre of Operations. 
HD : 720.1. 162 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
prevalence of the various deficiencies as determined by physical examinations 
is shown in Table 8. 
Table 8. Prevalence of Nutritional Deficiencies Among Troops in the Pacific as 
Shown by Physical Signs 
Location 
Vitamin A 
(percent) 
Thiamine 
(percent) 
Riboflavin 
(percent) 
Niacin 
(percent) 
Ascorbic 
acid 
(percent) 
Hawaii 
0 
0 
0 
0 
8 
Guadalcanal 
0 
0 
0 
0 
2 
Guam. 
32 
0 
0 
0 
0 
Iwo Jima 
12 
0 
0 
0 
0 
Okinawa casualties 
18 
2 
2 
0 
2 
Luzon _ _ _ 
12 
0 
0 
0 
2 
Source; Rpt, Nutrition Div SOO, 22 Aug 45, sub: Nutrition survey in Pacific Theatre of Operations. HD: 720.1. 
Certain differences in the various groups comprising the Pacific study are 
interesting and their significance and possible explanation is discussed in the 
report. In view of the great environmental and operational differences the 
groups involved are too small to permit general conclusions as to variations 
between broad classifications of troops, as between garrison and combat units. 
The situation is too likely to be modified by a great variety of local circum- 
stances. It is of interest, however, that the combat troops examined were in as 
good or better nutritional state than the garrison troops (except for body 
weight) and had the better physical fitness scores. 
Evidence of a somewhat different sort is attained from more detailed 
studies of small numbers, such as those of Kush,3 Beach and Miller,4 and Golden 
and Schechter.5 However, part of the evidence often interpreted as indicating 
nutritional deficiency disease was a discrepancy between the intake of various 
nutrients and the recommended allowances of the Food and Nutritidn Board 
of the National Research Council. It must be remembered that these allowances 
were liberal and had a large margin of safety. There is also the factor of body 
store to consider. Nevertheless, there may have been some reduction in tissue 
stores and, in these cases, actual mild deficiency, particularly of vitamin C. 
It would manifestly be unfair to use the evidence presented here to establish 
the prevalence of minor nutritional deficiency disease in the Army as a whole. 
The sample is too small and not sufficiently representative. Such data, except 
under conditions of great stability and uniformity, is of little value except for 
3 Rush, A.: Study of Army diet In the tropics. Bull. U. S. Army M. Dept. 2 : 43, 6 Nov 44. 
4 Beach, E. F., and Miller, O. N.: Chemical determination of nutritional state of full duty troops, 
Manila area, July and August 1945. HD; 720.1. 
B Golden, W. R. C., and Schechter, M. S.; Vitamin C status of troops in the tropics. Bull. U. S. 
Army M. Dept. 4 ; 711-717, Dec 1945. MALNUTRITION AND DEFICIENCY DISEASES 
163 
purposes of a broad comparison, as, for example, of overall prevalence by 
decades. The figures obtained suffer from all the disadvantages of an average 
value. The finding of an average value for the hemoglobin of 100 men of 14.5 
gm. (within the range of normal) does not reflect sufficiently the seriousness of 
the fact that an undetermined number may have had hemoglobin concentrations 
of but 10 grams. A prevalence of minor nutritional disease of only 5 percent 
in the Army as a whole is of little consolation if a task force of 25,000 fails 
because minor nutritional deficiencies have rendered 90 percent of the command 
incapable of putting out their maximum effort. Such an occurrence may be 
excused if it is clearly recognized at the time and is the result of circumstances 
beyond control. It is inexcusable if it exists unknown or unsuspected or, if 
known, without every effort having been made to prevent it. It can always be 
detected by proper inquiry and, with proper management, can often be predicted 
and prevented. 
Nevertheless, it seems fair to conclude that except for special instances, 
probably limited to small groups, and for short periods, the prevalence of 
nutritional deficiency disease in the troops, even in overseas theaters of opera- 
tions, did not exceed that presented in Tables 7-9. This may be compared with 
the prevalence among the civilian population from which these troops were 
drawn as shown in the following tabulation which was calculated for use in 
connection with the feeding of civilians in Europe. 
Deficiency 
Percent 
Protein 
4 
Vitamin A 
_ _ 10 
Thiamine _ 
2 
Riboflavin 
Deficiency 
Percent 
Niacin 
4 
Ascorbic acid 
10 
Vitamin D 
5 
Iron 
_ 10 
Table 9. Pbevalence of Nutritional Deficiencies Among Troops in the Pacific as 
Shown by Laboratory Tests 
Location 
Thiamine 
(percent) 
Riboflavin 
(percent) 
Ascorbic 
acid 
(percent) 
Hemo- 
globin 
(percent) 
Serum 
protein 
(percent) 
Hawaii 
0 
0 
2 
0 
0 
Guadalcanal 
2 
0 
45 
0 
0 
Guam 
2 
8 
2 
0 
0 
Iwo Jima 
2 
9 
5 
0 
0 
Okinawa casualties 
0 
6 
8 
0 
0 
Luzon 
0 
2 
4 
0 
0 
Source: Rpt, Nutrition Dlv SOO, 22 Aug 45, sub: Nutrition survey in Pacific Theatre of Operations. 
HD: 721.1. 
Some question may be raised concerning the validity of the criteria on 
which these diagnoses were made. It is recognized that none of the physical 
signs are pathognomonic in the degree of deficiency encountered. Some dis- 
346(336 0—55 12 164 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
agreement may be had with the criteria used for interpreting and evaluating 
the laboratory data. Nevertheless, these criteria have been employed by expe- 
rienced examiners in a large number of similar studies and have received fairly 
general acceptance. It should be noted that they at least set rather clearly 
the minimal amount of nutritional deficiency—more than there may have 
been if one accepts finer and less clearly established criteria, but there was 
probably no less. 
SPECIFIC DEFICIENCIES 
Mild caloric deficiency, due simply to an insufficiency of food, was fairly 
common in the Army under combat conditions. This was usually the result 
of a combination of causes—difficulties of supply, the necessity of using 
packaged rations calorically inadequate for the energy expended, and decreased 
consumption of food because of emotional strain, fatigue, and exigencies of the 
situation. Except among prisoners of war, however, such caloric deficiencies 
rarely were great enough over long enough periods to cause protein deficiency 
and physical disability. For example, the nutritional survey of troops in the 
Pacific theater showed that although troops fresh from combat had some 
caloric deficiency, as evidenced by loss of weight, their physical fitness was 
equal to that of troops in the Zone of Interior and in at least one instance, 
superior.6 Neither were these mild caloric deficiencies often accompanied 
by vitamin or mineral deficiencies. The reduced caloric intake lessened the 
need for vitamins and minerals, and the rations, even when only partly con- 
sumed, supplied a considerable amount. This circumstance, together with 
the fact that existing body stores under the system of Army feeding and 
practice were nearly always high at the outset of a campaign, was sufficient 
to prevent significant deficiencies except in occasional individuals in whom 
it could usually be classed as conditioned. 
Beriberi (Vitamin B1? Thiamine'). Beriberi, as a primary, idiopathic 
disease in noncaptured American troops was almost nonexistent. For exam- 
ple, in Cutts’ report of over 125 cases of beriberi,7 none occurred among Ameri- 
can troops. All cases were observed in Chinese troops. Although 5 cases 
in the entire Army were reported in admissions to hospitals in 1942, most of 
these must have been “conditioned cases.” Occasional reports, mostly rumors, 
of mild cases of deficiency were received, especially from the China-Burma- 
India theater, but in most instances the diagnosis was not sufficiently estab- 
lished and the evidence consisted of nonspecific signs and symptoms such as 
nervousness and fatigability. Such diagnoses were strongly controverted by 
evidence of a liberal intake of thiamine in the food. 
tt See footnote 8, p. 162. 
7 Cutts, F. B.: Observations on beriberi. Indla-Burma Field Med. Bull., vol. 2, No. 12, Dec 1943. 
HD: 461. MALNUTRITION AND DEFICIENCY DISEASES 
165 
Riboflavin. No outspoken cases of idiopathic riboflavin deficiency dis- 
ease were reported and the only possible instances of this deficiency were mild 
cases detected on special surveys and examination,8 in which careful examina- 
tion and laboratory tests were made. Even some of these may be considered 
doubtful in view of changing ideas of the specificity of certain signs such as 
cheilosis and vascularization of the cornea, previously thought to be due to 
this deficiency; also, because of a lowering of values formerly believed 
to represent intake requirements. 
Niacin. A few cases of pellagra in otherwise well individuals occurred 
from time to time in all theaters of operations. For the most part, these were 
caused by a deficient intake of proper food due to habit, food dislikes and 
prejudices, irregularities of eating related to duty assignments, and similar 
causes, such as could be ascertained by questioning the patients. These cases 
exhibited no differences from those observed in civilian practice. 
Vitamin C. A number of reports of scurvy and vitamin C deficiency as 
well as special studies of vitamin C nutrition were made.9 Some reason for 
concern and a suspicion of the existence of this deficiency were justified because 
in certain of the rations, particularly in the C, K, and ten-in-one, the source of 
most of the vitamin C was the synthetic fruit juice powders, which, on the 
whole, were not well consumed by the soldiers. It was often forgotten, how- 
ever, that the standard of daily requirements for this nutrient was set at a very 
high level, 75 mg. per day, an amount three times as great as that actually 
needed to protect against a state of true physiologic deficiency. It is, there- 
fore, not surprising that in many instances, reported cases and outbreaks of 
scurvy and vitamin C deficiency could not be substantiated when subjected to 
careful analysis. There was also some tendency on the part of medical officers 
to attach too much significance to such signs and symptoms as gingivitis and 
bleeding gums, which, while suggestive, are not very specific or reliable, 
especially in mild or early deficiencies. 
Vitamin A. Vitamin A deficiency, too, was very seldom seen, though it 
was often suspected, or diagnosed when it was not present-. Considerable 
anxiety was expressed concerning it, especially in relation to visual acuity in 
dim light or the dark (night blindness), particularly in the Air Forces. Again, 
it was forgotten that it takes months, probably over a year, to deplete a normal 
adult’s stores of vitamin A and that the diet of all troops before being sub- 
jected to any dietary shortages was high in vitamin A. It was also commonly 
forgotten, or not known, that much of the vitamin A is ingested in the form of 
carotene, obtained from such foods as green and yellow vegetables and that 
vitamin A is quite stable. It is not necessary to have all or even most of the 
5 See footnotes 1 and 2, p. 161. 
8 See footnotes 3, 4, and 5, p. 162. 166 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
vitamin A as such, as in animal foods. Finally, it is probable that the standard 
of requirements, 5,000 international units daily, which was in general well 
supplied and consumed even under conditions of difficult supply and feeding, 
was so high as to provide a large margin of safety. 
It is not surprising then that there was little or no primary vitamin A de- 
ficiency of a significant grade in American troops. This does not exclude the 
probability, however, of a slight dietary deficiency for long periods 'prior to 
Army service, and the existence of a chronic low-grade deficiency yet insuf- 
ficient to produce such classical disease as xerophthalmia. Some evidence of 
such a mild deficiency could be found in any body of troops if one was willing 
to take as evidence the presence of mild perifollicular hyperkeratosis of either 
the dry, horny, or the acneform type, which though not highly specific is 
suggestive. Such evidence can be found in any group of the population in 
this country. 
Vitamin D amd Calcium Deficiency. Much concern also was expressed 
concerning vitamin D and calcium deficiency. Such deficiency was not in- 
frequently reported in Essential Technical Medical Data (ETMD) reports. 
For the most part these reports came from the more distant or remote overseas 
theaters, especially the China-Burma-India, the Pacific, and some of the Arctic 
stations. This concern and such diagnoses were based largely on two circum- 
stances : the lack of milk and the presence of subjective symptoms, the latter 
usually highly unreliable and susceptible of numerous other explanations. In 
the Arctic, lack of sunshine was sometimes considered a factor. Again, the 
rations, even under restricted conditions, usually provided calcium in amounts 
equal or close to standard requirements which are probably very liberal. There 
were shortages as the result of difficulties in supply and failure of mess per- 
sonnel to incorporate the milk and milk products in the prepared foods. So 
far as it is known, no instances of idiopathic calcium or vitamin D deficiency, 
established by blood calcium studies, demonstration of significant deminerali- 
zation of bone, or the occurrence of tetany were observed. It should be remem- 
bered that the normal adult possesses a large reserve store of calcium in his 
skeleton and deficiency must be severe and long continued to produce an actual 
pathologic state of calcium deficiency in otherwise normal persons. Vitamin D 
requirements are, of course, very small in adults and deficiency of this vitamin 
is uncommon. 
Iron. Iron deficiency anemia is likewise very unusual in the normal adult 
male and in the nonchildbearing female because of the extreme conservation of 
iron by the body. Such iron deficiency anemia as might occur would most 
likely have existed before entry into the service and would have constituted a 
probable cause for rejection. 
Recent studies, however, particularly those on “folic” acid, have shown 
that an anemia of the macrocytic type might occur with a restriction of foods MALNUTRITION AND DEFICIENCY DISEASES 
167 
generally considered to furnish much of the B complex vitamins. The presence 
of troops in areas where tropical anemia (probably a macrocytic type) existed 
suggested such a possibility. Reports of anemia among Army nurses in the 
Pacific area led to the inclusion of an inquiry into this disease in a general 
survey of nutrition during March-May 1945 in the Pacific theater. However, 
a significant degree of anemia was found to be relatively uncommon, and its 
dependence on dietary factors was not established. 
As has been indicated, frank nutritional disease was extremely rare among 
the troops. It must be realized that these cases include only those of primary 
nutritional disease admitted with the diagnosis. Undoubtedly, additional cases 
of severe nutritional deficiency occurred as complications of other injury and 
disease and, even though recognized, failed to be included in the diagnosis 
because of the tendency to omit the diagnosis of complications. This is par- 
ticularly true of the less well-known and established deficiencies such as the 
protein, iron, and riboflavin deficiencies. Even sodium chloride deficiency is 
apt to be omitted. Therefore, even the hospital records will fail to give all of 
such cases. 
Prisoners of War 
The greatest incidence of evident nutritional deficiency disease occurred 
in recovered Allied prisoners of war and in civilians of liberated and conquered 
countries. In the Asiatic and Pacific theaters the number of instances of these 
diseases was much greater than in Europe. No reliable data are available as 
to the actual prevalence because of lack of records. The best sources of informa- 
tion in this field are the reports of the examination of prisoners of war made 
during the period of incarceration and following their release and return to 
this country.10 
These cases of deficiency diseases, while conforming in general to the 
pattern traditionally established, revealed certain characteristics of unusual 
interest, particularly in the cases of starvation edema and in cases of thiamine 
deficiency. In these subjects, both those in Europe and in the Pacific, loss of 
body tissues (emaciation) caused by inadequate caloric intakes was the most 
pronounced and most frequent deficiency state accompanying this starvation. 
There was, in many cases, an edema characteristic of starvation or famine 
edema. Such edema has ordinarily been considered in recent years to be a 
manifestation of protein deficiency dependent for its immediate production on 
hypoproteinemia. Studies in many of these subjects revealed normal serum 
protein concentrations. Furthermore, many of the subjects with extreme de- 
10 (1) Morgan, H. J. ; Wright, I. S., and van Ravenswaay, A. C.: Health of repatriated prisoners 
of war from the Far Bast. J. A. M. A. 130; 995-999. 13 Apr 46. (2) Musselman, M. M.; Nutri- 
tional disease in Cabanatuan. Wad Med. 8: 325-332, Nov—Dec 1945. (3) Navarro, M. D.: Observa- 
tions on vitamin deficiencies during the occupation. Santo Tomas J. Med. 2 : 205-208, Jul 1947. 
(4) Report of the Health Survey of Repatriated Prisoners of War from the Far East. HD : 383.6. 168 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
grees of emaciation failed to present edema. These discrepancies were also 
observed in experimental studies of nutritional deficiencies to be described 
below. 
In April and May 1945 a considerable number of Japanese prisoners of 
war suffering from nutritional deficiency disease were seen by the writer in 
Leyte. Among some 20 or 30 such patients the principal disease seemed to be 
starvation and protein deficiency. Though many had been diagnosed as beri- 
beri, the persistence of the tendon reflexes, the absence of significant sensory 
changes, and atrophy and muscle weakness, indicated that the edema present 
was more probably a result of caloric and protein deficiency. 
In attempting to discover the explanation for these observations, in ap- 
parent variance to previous concepts, the following facts must be kept in mind. 
In many instances the observations consisted of a single determination of the 
serum protein concentration which was interpreted in its relation to edema 
without consideration of such factors as salt and water intake, diarrhea, dehy- 
dration, physical activity, and other factors known to affect the relationship 
between serum protein concentration levels and the occurrence of edema. Never- 
theless, as will be discussed below, the observations were made so frequently 
and under so many independent circumstances that they strongly suggest an- 
other important factor in the production of edema in these persons. 
With the severe emaciation (caloric and protein deficiency) there were 
seen a percentage of other nutritional deficiency diseases as shown above. These 
were for the most part beriberi and pellagra. 
There was, however, a great difference in the two major theaters, European 
and Pacific, in this respect. The vitamin deficiencies in florid form appear to 
have been uncommon in the European theater but were fairly frequent in the 
Pacific. How much this was concerned with the factor of length of incarcera- 
tion is not clear. There appears to be no data available indicating the relation 
between the occurrence of these other diseases and the period of captivity. It 
might be suspected, however, that such a relationship was at least a partial 
explanation for the difference in the two theaters. In general, the feeding of 
prisoners of the Germans was more nearly adequate until the last fewT weeks 
before release. In general, the prisoners in the Pacific were badly fed during 
the entire period. 
Experimental studies as well as clinical observations suggest that the 
characteristics of deficiency disease resulting from relatively acute and chronic 
deficiency states vary considerably. This difference may be illustrated by some 
unusual features of the cases of thiamine deficiency from the Pacific. Among 
these, there occurred an unusual and unexpected number with evidence of MALNUTRITION AND DEFICIENCY DISEASES 
169 
involvement of the second (optic) and eighth (acoustic) cranial nerves.12 In- 
volvement of the optic nerve in thiamine deficiency had only rarely been observed 
and reported previously. The writer has seen two cases, apparently of this kind, 
with atrophy of the nerve head and at certain stages an optic neuritis character- 
izing the findings. While some doubt has existed as to the etiology, and a 
suspicion of a toxic optic neuritis from methanol poisoning existed in some, 
this does not seem to be an entirely adequate explanation. There is, further- 
more, the theoretical possibility that a primary thiamine deficiency may have 
predisposed and conditioned to an effect of methanol which would otherwise not 
have occurred. The cases in civilian life observed by the writer occurred in 
chronic alcoholics. So far the condition has remained stationary in most of 
these subjects with little or no evidence of improvement in function and no 
change in the morphologic appearance. Unfortunately, a variety of treatment 
and modification of the nutritional condition before studies were begun to 
determine the nutritional status and possible etiology made later studies essen- 
tially valueless. 
Much the same situation occurred in those subjects with involvement of 
the eighth nerve. Deafness, partial or nearly complete, of a “nerve” type, with 
little tendency to improve was the principal finding. 
Other findings of unusual interest in recovered prisoners from the Pacific 
suffering from nutritional deficiencies (thiamine) was a loss of libido, testicular 
atrophy, loss of hair (body hair in particular), and certain manifestations of 
feminization, particularly enlargement of the breast. These changes are of 
particular interest in view of recent work suggesting a relation between the sex 
hormones, liver function, and the B complex group of vitamins. Similar obser- 
vations were made in the experimental studies already mentioned. 
RESEARCH 
Although much of the research in nutrition dealt with such aspects of 
preventive medicine as the requirements of the various nutrients, considerable 
new knowledge of actual nutritional disease was added by studies conducted by 
the Office of The Surgeon General or under its auspices. 
Of these the most extensive was that conducted at the University of Min- 
nesota by Keys and his associates,13 supported in part by the Office of The 
Surgeon General. These studies consisted in the controlled production of 
starvation (caloric deficiency) in a group of young men. By careful adjust- 
12 (1) Bloom, S. M.; Merz, E. H., and Taylor, W. W.: Nutritional amblyopia in American pris- 
oners of war liberated from the Japanese. Am. J. Ophth. 29: 1248-1257, Oct 1946. (2) de Ocampo, 
G.; Yambao, C. V.; Managas, P. J., and Sevilla, C. L.: Epidemic retrobulbar neuritis in the Philip- 
pines during Japanese occupation. Am. J. Ophth. 30 : 698-704, Jun 1947. 
13 Keys, A.: Human starvation and its consequences. J. Am. Dietet. A. 22 : 582—587, Jul 1946. 170 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
ment, the caloric intake was maintained at a level sufficiently less than a planned 
energy output to cause a steady, progressive loss of weight. The energy 
output was maintained at a moderately high level (3,100 calories). Protein 
intake was minimum (40 gm.), but animal protein was very low, possibly 
inadequate in amino acids. Other nutrients, vitamins, and minerals were at 
levels judged to be minimally adequate. After an initial period of adjust- 
ment the subjects were maintained on this regime for some 3 to 4 months. By 
this time all had been reduced to a severe stage of starvation, and restoration 
was accomplished by successive increments of food in a manner designed to 
simulate relief dietaries. 
The results of these experiments, in addition to providing much new data 
on the physiology of such starvation, are of particular interest in comparison 
with the starvation observed in Allied and enemy prisoners of war, civilian 
inmates of prison and detention camps, and the general civilian populations. 
As in most of these latter examples, the outstanding deficiency disease was 
starvation (loss of weight) and loss of muscle tissue, presumably reflecting at 
least a relative protein deficiency. Evidence of other deficiencies were 
uncommon and minor in degree. Among the outstanding changes in both 
groups were the pigmentation, the loss of body hair, edema, bradycardia, 
hypotension, and muscular weakness, particularly that related to sustained or 
rapidly repeated acts. Changes in the emotions and psyche with a trend to the 
so-called psychoneuroses were observed. Rehabilitation was slower than 
might have been expected if all effects are included, and the most rapid and 
desirable rate of recovery required large feedings. There was some tendency 
to overweight with recovery. These studies have added much to the knowl- 
edge of the effects of starvation. CHAPTER VI 
Preventive Psychiatry During World War II 
Marvin E. Perkins, M. D * 
At the outset of World War II the psychiatrists in the United States Army 
had no organized program of preventive psychiatry or mental hygiene. In 
fact, the years preceding the war have been characterized as being ones in which 
psychiatry was practiced primarily for purposes of diagnosis and disposition; 
furthermore, it wras not until after the entry of the United States into hostilities 
that a separate branch for neuropsychiatry was established in the Surgeon 
General’s Office in February 1942.1 It was not until another year had passed 
that an officer was assigned to the Neuropsychiatry Division of the Office of 
The Surgeon General for the purpose of developing a program of preventive 
psychiatry.2 
The condition of military psychiatry with respect to its preventive orienta- 
tion was hardly less developed than that of the general practice of psychiatry 
in civilian medicine. For although such eminent psychiatrists as Adolph 
Meyer, William Alanson White, C. Macfie Campbell, Thomas W. Salmon, and 
Elmer E. Southard had emphasized the potential value of the wider application 
of psychiatry, preventive psychiatry as such could not be regarded as a clearly 
delineated discipline. Some psychiatrists were active in the mental hygiene 
movement, identified with the National Committee for Mental Hygiene, but 
the greater number were not associated with this type of psychiatric endeavor. 
EARLY DEVELOPMENT OF MENTAL HYGIENE 
Before attempting to trace the development in the Army during the war 
years of mental hygiene, or preventive psychiatry, as it was later designated by 
some, it is necessary to review briefly some earlier applications of the term 
“mental hygiene.” Both terms were expressions wdiich for most practicing 
psychiatrists had indistinct meanings; at least, it may be said that they were 
subject to variable interpretation. 
Deutsch3 has traced the variation in meaning of mental hygiene, since its 
introduction in this country in 1843 by William Sweetser. The original usage 
•Chief, Psychiatric Services Division, Department of Public Health, Government of the District 
of Columbia. Formerly Major, MC, AUS. 
1 Caldwell. J. M. : Organization and administration of neuropsychiatry in the Office of The Sur- 
geon General, 1942-1947. Mil. Surgeon 107 : 19-25 Jul 1950. 
2 Menninger, William C.: Psychiatry in a Troubled World. New York, Macmillan, 1948, pp. 327-337. 
3 Deutsch A. : The history of mental hygiene. In Bunker, H. A. : One Hundred Years of American 
Psychiatry. New York, Columbia University Press, 1944, pp. 325-365. 172 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
was intended to convey an approach to illness somewhat analogous to the cur- 
rent concept of psychosomatic medicine or comprehensive medicine. George 
Cook in 1859 used the term to embody the problems attendant on the promotion 
of mental health and the prevention of mental disease. Cook emphasized the 
importance of observations that the inception of mental disease was in child- 
hood. He also singled out the family unit as the proper focus for mental 
hygiene measures. During the Civil War, Isaac Ray issued a book in which 
he defined mental hygiene as “the art of preserving the health of the mind.” 
Ray’s presentation was one which attempted to give the individual a kind of 
prophylactic guidance. In 1876 the concept was expanded by John P. Gray 
to include not merely the individual application, but also the community aspects 
of mental hygiene, relating it to sociologic and social science studies. Thus, 
before the outbreak of the Civil War, the term “mental hygiene” had been used 
for two quite different purposes: (1) To define an approach toward the under- 
standing of the etiology of an individual’s illness in terms of the whole person 
(Sweetser), and (2) to indicate the practice of instituting measures in the 
family setting before illness affected an individual of that unit (Cook). These 
contributions had been made by institutional psychiatrists. Interest in mental 
hygiene continued to be manifest so that by 1880 two other usages had been 
introduced: (3) A formula for individual living (Ray), and (4) an approach 
to prevention of mental disease by the study of social problems and action 
taken at community level (Gray). 
These four concepts, different in focus and emphasis, may perhaps be con- 
sidered as phases in the natural evolution of the mental hygiene movement. 
The first requirement is an awareness by the physician that the patient’s symp- 
toms present something which has meaning in terms of the whole person; 
second, that current unhealthy symptomatic reactions follow a pattern which 
has had origin in the setting of early family experience; third, that such reac- 
tions may be adjusted for the better or avoided by providing individual guid- 
ance ; and, finally, that such personal problems have implications which extend 
beyond the individual patient, affecting the social group of which he is a part 
and also affected by measures taken through the group. 
The first step is the inquiring receptive attitude of the physician; the 
second, a conclusion regarding etiology based upon observation; the third, an 
effort at application of new-found knowledge in individual treatment based on 
etiology; and, finally, a recognition of the social factors and need for group 
preventive measures. These steps are analogous to the traditional pattern of 
the development of epidemiology.4 
Up to 1880 there was no organized effort among psychiatrists for a program 
of mental hygiene and no organized body of thought which could be called 
* Gordon, J. B.: Evolution of an epidemiology of health. In The Epidemiology of Health. New 
York, Health Education Council, 1953, pp. 24-73. PREVENTIVE PSYCHIATRY 
173 
preventive psychiatry. However, the increasingly comprehensive concept had 
made mental hygiene a subject of common interest among psychiatrists and 
social workers. The first mental hygiene organization in this country was a 
joint professional undertaking of psychiatrists, neurologists, and social workers, 
called the National Association for the Protection of the Insane and the Pre- 
vention of Insanity, which was established on 1 July 1880. The main effort 
of the organization was not the prevention of mental disease but, rather, the 
institution of reform measures of a humanitarian nature. The organization 
did not crystallize a “mental hygiene” or “preventive psychiatry” and, after a 
short controversial existence, disappeared sometime after 1886. Twenty-three 
years later, the National Committee for Mental Hygiene was organized, the 
result of Clifford Beers’ experiences as a patient in a mental hospital, his 
account of those experiences, and his recommendations for an organized effort 
to improve the lot of the mental patient. The efforts of this organization were 
of importance to various spheres of activity including the establishment of 
community child guidance clinics, in some ways a prototype for the military 
mental hygiene clinic.5 
MILITARY PSYCHIATRY AND MENTAL HYGIENE 
BEFORE WORLD WAR II 
The Civil War was a time of great ferment for the Army Medical Depart- 
ment. Many reforms were needed to meet the immediate problems of attending 
to the sick and wounded, and the term of office of William A, Hammond as 
Surgeon General was marked by vigorous action in instituting many of the 
necessary reforms. The important specialty of neurology had its beginning 
in the United States during the war as a result of the combined efforts of 
Hammond and S. Weir Mitchell. The former authorized the establishment 
of the Turner’s Lane Hospital in Philadelphia for the study of nervous dis- 
orders and injuries and the latter was assigned for that purpose. The classical 
monograph by Mitchell, Morehouse, and Keen 6 is an account of the neurologic 
studies made at Turner’s Lane Hospital. These studies embodied careful clin- 
ical observations of the injured nervous system and, important as they proved 
to be in the fields of neurology and psychiatry, they were not concerned with 
either of the concepts of mental hygiene which had been defined before that 
time. 
Early in World War I, Thomas W. Salmon, under auspices of the Rocke- 
feller Foundation, studied the experience of the British in the management 
5 Deutsch, Albert: The Mentally 111 in America. Garden City, N. Y., Doubleday, Doran, and 
Company, 1937, p. 325. 
8 Mitchell, S. W. ; Morehouse, C. R., and Keen, W. S., Jr.: Gunshot Wounds and Other Injuries 
of the Nerves. Philadelphia, Lippincott, 1864. 174 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
of psychiatric problems and submitted a report which contains the following 
comment:7 
Although it might be considered more appropriately under the heading of pre- 
vention than under that of treatment, the most important recommendation to be made 
is that of rigidly excluding insane, feebleminded, psychopathic, and neuropathic indi- 
viduals from the forces which are to be sent to France and exposed to the terrific stress 
of modern war. ... If the period of training at the concentration camps is used for 
observation and examination it is within our power to reduce very materially the 
difficult problem of caring for mental and nervous cases in France, increase the military 
efficiency of the expeditionary forces, and save the country millions of dollars in 
pensions. 
This recommendation, a relatively minor dictum in an important, 
thorough, and competent report, may wTell have been the basis for the practice 
of diagnosis and disposition referred to as in effect during the interim between 
the two World Wars. It may also have served as the basis for the optimistic 
opinion prevailing at the outbreak of World War II that effective prevention 
of psychiatric disorders would be accomplished by competent psychiatric 
screening. Lt. Col. Manfred S. Guttmacher, MC, who was assigned to the 
Neuropsychiatry Consultants Division during the latter part of World War 
II, for the purpose of providing professional supervision for the mental 
hygiene consultation services, made the following observation regarding pre- 
ventive psychiatry during the First World War as it was reported in the 
official history:8 
Chapter IV of the volume on the history of neuropsychiatry during World War I 
states that the cantonment neuropsychiatrist became the “guardian of the mental health” 
of his military organization. When one reads the entire chapter, it is apparent that this 
was in nearly every instance an ideal rather than a reality, since there was no formal 
organiaztion of psychiatric facilities that brought psychiatrists into really close contact 
with enlisted or with officer personnel in the training camps. It is, however, clear that 
by the end of the First World War, it was realized that the training camps were fruitful 
fields for the early treatment of maladjusted trainees and that many of them could be 
prevented from becoming ineffectuals. But, prevention of psychiatric disorders by 
effective general indoctrination of the officers and the trainees was not conceived. 
Psychiatry, in the interim between the two World Wars, suffered from 
several conditions. It lacked public acceptance and understanding to a large 
degree. As a specialty, it tended to be isolated from the general practice of 
medicine and, as specialists, psychiatrists had relatively little professional 
stature among other members of the medical profession. It was primarily 
interested in, if not preoccupied by, the problems of treatment. Little sub- 
stantial knowledge had been accumulated by psychiatrists on problems related 
7 Salmon, T. W. : The care and treatment of mental diseases and war neurosis (shell shock) 
in the British Army. In Medical Department of the United States Army in the World War. Wash- 
ington, Government Printing Office, 1929, vol. X, pp. 497-523. 
8 Guttmacher, M. S.: Army consultation services (mental hygiene clinics). Am. J. Psychiat. 
102 : 735-748, May 1946. PREVENTIVE PSYCHIATRY 
175 
to selection of men, occupational classification and placement, or the prevention 
of psychiatric disability.9 In such circumstances and without an adequately 
organized body of information, it is not surprising that there were no well- 
formulated plans for the application of psychiatry to the practical problems 
encountered in the military service. As a further handicap, many psychiatrists 
were either not accustomed to collaborative effort with clinical psychologists 
and psychiatric social workers or were actually unaware of the potential value 
of mutual participation. 
To recount the development of preventive psychiatry during World War 
II is to trace the changes in responsibility and utilization of three professionally 
allied disciplines: psychiatry, clinical psychology, and psychiatric social work. 
Psychiatrists, at the inception of the war, were predominantly engaged in diag- 
nosis and disposition in hospitals and induction stations; psychologists were 
utilized in personnel work as officers of The Adjutant General’s Department, 
but were not used in clinical activity;10 psychiatric social workers had no com- 
missioned or enlisted status at all in their professional capacity.11 Each of these 
professions came to be employed in significantly new7 roles for the military 
service during the course of the war. The remarkable transition in the military 
roles of the psychiatrist, clinical psychologist, and psychiatric social worker 
took place largely in the training centers. It was in the training centers that 
the members of these professions became integrated into the effective military 
psychiatric team. The organized unit which resulted in this setting came to 
be known as the mental hygiene consultation service; and here the practice of 
psychiatry in this setting came to be considered as preventive psychiatry. For 
purposes of following the development of preventive psychiatry in World 
War II, this account will deal almost exclusively with development in the 
training center setting. 
DEVELOPMENTAL PHASES IN 
REPLACEMENT TRAINING CENTERS 
It may facilitate a review of the development of preventive psychiatry in 
the training centers to divide the period into four transitional phases. Because 
the growth of the different mental hygiene consultation services showed definite 
variations, there was no completely consistent developmental pattern in the 
field, although there were certainly similar problems to be dealt with in each 
replacement training center. The course of development of the individual 
unit seemed to be most dependent upon the psychiatrist’s previous experience, 
8 Menninger, W. C.: The role of psychiatry in the world today. Am. J. Psychiat. 104 : 155-163, 
Sep 1947. 
10 Zehrer, F. A.: The clinical psychologist in the United States Army, 1953. HD : 730 Neuro- 
psychiatry. 
11 O’Keefe, D. E. : History of psychiatric social work in World War II. HD : 314.7-2. 176 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
his comprehension of the problems to be met, his preference in formulating a 
plan commensurate with his own abilities, his capacity to interpret these 
matters to command, and his ability to enlist the support of command in trans- 
lating the whole into effective action. Because of the importance of the indi- 
vidual in establishing a mental hygiene consultation service, the developmental 
pattern at a given post was likely to be distinctly different from that of another 
only a short distance away. One consequence of such variation was that in 
practice some part of the field was consistently ahead of official directives con- 
cerning nearly everything which finally became established as approved policy. 
When official policy was published, that part of the field which had lagged 
behind the others in development tended to be brought up to the standards of 
the more advanced practices as approved. For these reasons the phases which 
will be described are arbitrarily fixed to reflect the principal emphasis of the 
time as contained in official directives. 
Classification Phase 
The initial phase may be called the “Classification Phase” in which the 
primary interest was in getting the right man promptly into training for the 
right job with the least waste of time and money. This phase began during 
the mobilization period, before our entry into active hostilities, and was carried 
on for the most part by psychologists and classification specialists. 
One of the early steps in the development of consultation services for 
replacement training centers was initiated on 13 December 1940 when The 
Adjutant General sent a letter to the chiefs of arms and services proposing that 
the Adjutant General’s Office undertake the following:12 
1. Attempt to locate Reserve officers qualified in the testing field to permit 
assignment of one such officer to each replacement center after attendance at the 
replacement center school. 
2. Request an increase in commissioned officer quotas for each center, stating 
that G-l and G-3, informally, had indicated a favorable disposition toward 
an increase in authorized strength for this purpose. 
The letter pointed out that selectees wffio reported to replacement centers 
from reception centers would have received an initial classification, including 
General Classification Test 1A. However, it was anticipated that considerable 
reclassification would be needed during the period at the replacement center 
and it was considered that the services of psychologists who could administer 
and evaluate various aptitude tests would be useful in selecting students to 
attend various courses. The letter cited the earlier favorable experience of 
the Air Corps in selecting students for the technical school at Chanute Field, 
12 Ltr, TAG to Chiefs of Infantry, Cavalry, Field Artillery, Engineers, Signal Corps, Ordnance, 
Chemical Warfare Service, Coast Artillery, QMG, SG, CG Armored Force, 13 Dec 40, sub : Additional 
commissioned personnel for replacement centers. AG: 210.31 ORC. PREVENTIVE PSYCHIATRY 
177 
Illinois. Recommendations were requested as to whether the services of these 
specialists were desirable at the various replacement centers. With but one 
exception, all responded favorably to the proposal.13 
A radiogram was sent to the commanding generals of the nine corps areas 
requesting that they report names of available Reserve officers qualified as 
practical psychologists or classification experts. These men were to attend a 
30-day course of instruction and then be assigned to replacement centers.14 
As a result of this wire, 18 officers were reported to The Adjutant General as 
potentially useful in the contemplated assignments, including 5 captains, 11 
first lieutenants, and 2 second lieutenants.15 
During the same week, a memorandum mentioned that consideration was 
being given to the assignment of a second lieutenant Reserve officer to one of the 
Infantry replacement centers.18 This Reserve officer, a Regular Army master 
sergeant, was one of several considered for assignment to the Infantry replace- 
ment centers, the majority of whom were warrant officers and sergeants of 
the first three grades with considerable experience in administration. The 
plan at that time was to assign 8 such officers to the Infantry replacement 
centers as had been requested. 
Thus, in December 1940, at least 20 Reserve officers were being considered 
for assignments. This marks the first step in the direction of establishing an 
agency at replacement training centers to assist responsible commanders in the 
effective utilization of manpower. The development of the mental hygiene 
consultation services in part came from this early movement. Of these officers, 
7 held Reserve commissions in the Infantry, 5 in the Medical Corps, 3 in the 
Field Artillery, and 1 each in the Judge Advocate General Department, Advo- 
cate General’s Department, and the Quartermaster, Cavalry, and Sanitary 
Corps. 
The Adjutant General conducted the 30-day course of intensive instruction 
starting in January 1941. It covered the procedures of personnel administra- 
tion with particular reference to replacement centers. After attendance at 
the school17 these officers, who included practical psychologists, classification 
experts, and other administrative officers, went on to their variously assigned 
posts where some were assigned as classification officers. 
13 Ltr, Chief of Cavalry to TAG, 17 Dec 40, recommended that the assignment of such personnel 
be not considered for the Cavalry Replacement Center because . . it would appear that the 
services of a practical psychologist would \ be confined to assisting in the selection of individuals 
intended for horse elements and those intended for motor elements, which can be accomplished satis- 
factorily from individual classification cards.” AG : 210.31 ORC. 
Radio, TAG to CG each CA, 13 Dec 40. AG : 210.31 ORC. 
15 This does not Include Second and Fourth Corps Areas whose responses were not on file with 
the others. 
13 Memo, TAG to Chief of Infantry, 17 Dec 40. AG : 210.31 ORC. 
17 The training of commissioned classification officers preceded the formal organization of The 
Adjutant General’s School which was accomplished on 13 June 41. Hist Div WDSS. 178 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
The Engineer Replacement Training Center at Fort Leonard Wood, Mis- 
souri, received one of this first group of officers assigned to replacement training 
centers for the purpose of supplying expert guidance in the fields of classifica- 
tion and personnel counseling. This officer (1st Lt., AGD, later Maj., MAC, 
Francis P. Wickersham) was assigned first as a classification officer, but on 
3 December 1941 he was relieved of this duty and designated as psychologist 
to the Engineer Replacement Training Center. Thus was established the Office 
of the Personnel Consultant, as a branch of the Personnel Division. This 
officer was charged with the tasks of— 
1. Selecting men for special training. 
2. Maintaining a check upon individual progress while in special training. 
3. Advising as to the suitability for transfer of each man to the regular 
training company. 
4. Recommending separations from the service under Army Regulations 
(AR) 615-360, section VIII. 
The last function was an important one, initially, for it was the personnel 
consultant upon whom the major responsibility rested for such recommenda- 
tions. He soon sought the assistance and advice of psychiatrists in formulating 
such recommendations for discharge. Inasmuch as a psychiatrist was not 
immediately available for assignment to the Engineer Replacement Training 
Center, arrangements were made for consultations to be accomplished by the 
staff at the hospital.18 The wisdom of mutual effort in this area of activity was 
later to become generally recognized by making psychiatrists available for 
assignment to headquarters of each replacement training center. The basic 
directives during this period were concerned with establishing the necessary 
military occupational specialties19 and outlining the functions required to 
accomplish the mission of proper classification and assignment. Although the 
planning for this type of activity preceded our entry into hostilities, the com- 
prehensive regulation was not published until May 1942.20 
Classification was considered to be a means which would facilitate the 
placement of individuals in assignments which would be of most value to the 
military service. This would expedite unit training by proper utilization of 
various abilities and skills of the individuals. The anticipated objective was 
to be a substantial contribution to the production of an efficient combat or 
technical team in the shortest possible time. 
The primary objective in replacement training centers as explained in 
AR 615-28 was to assign each man properly to the type of training which he 
could best absorb. This was to be accomplished in the classification section by 
18 Davidoff, E. : A summary of the history and the program of the personnel consultation service 
at Fort Leonard Wood ASFTC. HD: 730 Neuropsychiatry. 
19 (1) WD Cir 12, 18 Jan 41. (2) WD Cir 269, 26 Dec 41. 
20 AR 615-28, 28 May 42. PREVENTIVE PSYCHIATRY 
179 
personnel, officer and enlisted, who had either psychological or personnel 
training, or both. 
The testing program designed to furnish an estimate of a man’s ability, 
included the Army General Classification Test, the nonlanguage test 2 abc, 
trade tests, aptitude tests, and individual tests. The latter were to be given 
as required to the men who were unable to adjust to the Army without assist- 
ance because of a low mental ability. It pointed out that such individuals 
may have been adjusted to a stereotyped mode of civilian living, but upon entry 
into Army life they experienced difficulties because of the sudden change. The 
individual testing of these men was to be accomplished only by a personnel 
consultant, because the result of such testing would be a factor in determining 
whether the man would be considered suitable for military service after train- 
ing in the special training unit, or whether discharge from the service should 
be effected without benefit of such training efforts. 
The function of the special training unit wTas to instruct enlisted men 
who were not immediately suited to assimilate regular basic training. Indi- 
viduals who were found in the course of regular training to require special 
assistance were assigned to the unit. This group included the illiterates, non- 
English-speaking enlisted men, and slow learners. Two other groups could 
be assigned also—the emotionally unstable and those physically unable to 
carry out assigned duties. 
It was pointed out in the regulation that personnel in this unit would have 
to be carefully selected for interest in the type of work of the unit and interest 
in the individuals who required such training. The only mention of the use 
of psychiatrists was in connection with their possible utilization in the special 
training units: “A personnel consultant will be assigned to each special train- 
ing unit and use will be made of psychiatrists or neuropsychiatrists who may 
be assigned to the replacement training center.” 
At Fort Monmouth, New Jersey, 1st Lt. (later Maj.) Harry L. Freedman, 
MC, was assigned to duty as assistant to the Personnel Officer, Headquarters, 
Eastern Signal Corps Replacement Training Center, on 23 December 1941. 
A short time later he was assigned to a position of direct responsibility to 
the commanding general (20 January 1942). From this staff relationship, a 
service wTas developed which was intended to be functionally distinct from the 
usual services supplied within the hospital or as an outpatient clinic of the 
hospital. Lieutenant Freedman stated it as follows:21 “Out of this relation- 
ship an organization and structure was conceived with functions which could 
be utilized as services to all sections of the Command. It was, therefore, pos- 
sible to develop a new resource to the Command, in a staff section to be known 
as the Mental Hygiene Unit.” 
21 Freedman, H. L., and Rockmore, M. J. : Developmental history of the mental hygiene unit In 
the Army, 1946. HD : 730 Neuropsychiatry. 
346336 0—55——IS 180 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Using the staffing pattern of the community psychiatric clinic as a guide, 
Lieutenant Freedman first obtained the assignment to his staff of an enlisted 
man who was a professionally qualified psychiatric social worker already on 
duty with the classification section. This was probably the first time that a 
social worker was assigned to perform primary duties of this profession in 
the Army. The unit was officially established at Fort Monmouth on 24 Feb- 
ruary 1942. It was called “The Classification Clinic” which clearly reflects 
the main emphasis of the period. The professional triad was completed 15 
March 1942 when a qualified clinical psychologist, an enlisted man, was assigned 
to the staff.22 
Concurrently, other psychiatrists in replacement training centers had 
been moving independently toward establishment of a psychiatric unit in 
response to local requirements and with the tacit approval of the Neuropsy- 
chiatry Branch of the Office of The Surgeon General. 
At the Engineer Replacement Training Center, Fort Belvoir, Virginia, an 
outpatient clinic had been established by Capt. (later Lt. Col.) Bernard Cruvant, 
MC, in May 1941 to meet the local needs for psychiatric services which could 
not be properly satisfied by hospitalization.23 A referral procedure was mimeo- 
graphed and distributed with a resultant increase in the number of psychiatric 
consultations. Liaison with the basic training supervisor was established in 
June 1941 and mutual effort was exerted toward solution of a problem having 
to do with the training program. As a result of this, a reclassification ques- 
tionnaire was formulated to assist in the function of the reclassification board, 
of which the psychiatrist was a member. The further development of staff 
responsibilities and function in the training program was hampered by the 
psychiatrist’s assignment to the station hospital which required more and more 
of his time. The result was that the main function of the psychiatrist was as a 
consultant in the outpatient clinic of the station hospital. The facility estab- 
lished at Fort Belvoir was the first in the Army to be called a “Consultation 
Service.” 24 
At the Antiaircraft Replacement Training Center, Camp Callan, Cali- 
fornia, Capt. (later Lt. Col.) Julius Schreiber, MC, inaugurated a program in 
June 1942 which at first had its primary mission as an outpatient clinic to keep 
down the number of psychiatric admissions to the hospital.25 A realization 
that more needed to be done led Captain Schreiber to work out a program which 
22 See footnote 21, p. 179. 
23 Cruvant, B. A.: Symposium on psychiatry in the Armed Forces; replacement training center 
consultation service. Am. J. Psychiat. 100 : 41-46, Jul 1943. 
24 See footnote 8, p. 174. 
26 (1) Stilwell, L. E., and Schreiber, J. : Neuropsychiatric program for a replacement training 
center. War Med. 3 : 20-29, Jan 1943. (2) Schreiber, J. : Psychological training and orientation 
of soldiers. Ment. Hyg. 28 : 537-554, Oct 1944. PREVENTIVE PSYCHIATRY 
181 
was meant to inform the soldier on the issues at stake and thereby contribute to 
his motivation and morale.26 
At the Ordnance Replacement Training Center, Aberdeen Proving Ground, 
Maryland, another station hospital physician had concluded that steps needed 
to be taken to assist in the adjustment period of the new soldier. A program of 
mental conditioning by means of lectures was recommended on 15 August 1942 
by Maj. (later Lt. Col.) R. Robert Cohen, MC. He conducted lectures to trainees 
on personal adjustment and emphasized the importance of an informed group 
of key personnel in the mental hygiene of trainees.27 
Meanwhile, other significant developments for military psychiatry were 
taking place. In the Office of The Surgeon General, establishment of the 
Neuropsychiatry Branch had been accomplished in February 1942 as a sub- 
division of the Medical Practice Division. Lt. Col. (later Col.) Patrick S. 
Madigan, MC, was the first chief of the branch.28 
At a Selective Service seminar for psychiatrists of the Medical Advisory 
Board and the Army Induction Board on 5 April 1941, Lt. Col. Madigan had 
emphasized the importance of screening:29 
In preparing for an adequate defense of our country in the present emergency, it is 
extremely important that we exercise meticulous care and precaution in selecting only 
those individuals whose mental, intellectual, and personality suitability can reasonably 
be expected to adequately adjust to the requirements of military life, not only for one 
year’s training, but for the following ten years as a reservist. Soldiering must be con- 
sidered as a possible vocation that is inherently and of necessity constricted in its 
requirements and standards. Those who do not fit into this general pattern because of 
personality traits or other indications of unsuitability may be quite adaptable to other 
pursuits in a civilian status in our general plan of a total defense of our country. There 
should, therefore, be no criticism of those who fail to meet the standards which experience 
has shown to be the best possible for an effective Army. 
He had concluded with the following admonition: 
The most important function of psychiatrists to the Advisory Board and induction 
centers is to keep in mind that the Army is one of the elements of national defense and 
its present mission is one of preparation for an offensive-defensive type of warfare. It 
is in no sense a social service or curative agency. It is neither to be considered a haven 
of rest for the wanderer or shiftless, or a corrective school for the misfits, the 
ne’er-do-wells, the feeble-minded, or the chronic offender. Furthermore, it is neither a 
gymnasium for the training and development of the undernourished or underdeveloped; 
26 Schreiber, J. : Morale aspect of military mental hygiene. Dls. Nerv. System 4; 197-201, 
Jul 1943. 
27 (1) Cohen, R. R. : Mental hygiene for the trainee; method for fortifying the Army’s man- 
power. Am. J. Psychiat. 100: 62—71, Jul 1943. (2) Cohen, R. R. : Factors in adjustment to Array 
life : a plan for preventive psychiatry by mass psychotherapy. War Med. 5 : 83-91, Feb 1944. (3) 
Cohen, R. R. : Officers and their relation to a mental-hygiene program for trainees. Ment. Hyg. 28 : 
368-380, Jul 1944. 
28 Annual Rpt, Neuropsychiatry Branch SGO, FY 1943. HD. 
29 Madigan, P. S.: Military psychiatry. Psychiatry 4 ; 225-229, May 1941. 182 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
nor is it a psychiatric clinic for the proper adjustment to adult emotional development. 
Therefore, there is no place within the Army for the physical or mental weakling, the 
potential or prepsychotic, or the behavior problem. If a person is a behavior problem 
in the civilian community, he will most certainly become a more intensified problem in 
the Service. 
A year later, Lt. Col. (later Col.) William C. Porter, MC,30 was warning 
of the “danger that we military psychiatrists may become psychiatrically over- 
zealous and reject men who are capable of performing satisfactory military 
service and who are legally liable for service in the Army.” Colonel Porter was 
pointing to the consequences of too fine a screening policy. Pointing out the 
need “to take stock,” he posed the problem as follows: 
.... Should we become more zealous in screening out potential and actual mental 
risks, or should we recognize that there is a field of usefulness in the Army for some 
persons who have theoretic disqualifications? Unfortunately, in our discipline we have 
no formula which may be applied in selection of mental risks. Each psychiatrist applies 
to his work such training, experience, and aptitudes as he may possess. He may have 
had no actual military experience and may be only indirectly aware of the psychologic 
hazards of the service and of the system of handling problem cases in a military organi- 
zation. Unless he is personally familiar with these factors, he is apt to judge a risk 
from the standpoint of his experience in nonmilitary hospitals or in private practice. 
Colonel Porter formulated the question, which had begun to create doubts 
among psychiatrists with regard to screening, thus:31 
.... Whether the neuropsychiatric examiners have rejected too many men who 
might have become satisfactory soldiers, whether by rejecting all questionable persons 
more harm has been done them than would have occurred if they had been exposed to 
military life, whether there is a place in the Army for certain types of mental deviants 
are cogent questions. 
In April 1942 Colonel Porter, Chief of Neuropsychiatry, Walter Reed 
General Hospital, sent a memorandum to Brig. Gen. C. C. Hillman, Chief of 
Professional Services, Office of The Surgeon General, outlining a plan for 
assignment of neuropsychiatrists to replacement training centers.32 This was 
proposed as being consistent with the opinion of certain psychiatrists that there 
was a need to provide psychiatric advice away from the hospital setting. The 
objectives were to be: to assist in the adjustment of the soldier to minor 
difficulties of maladaptation; to provide assistance to the unit commander by 
screening out “obvious mental defectives, psychopaths or prepsychotics” who 
presented administrative, disciplinary, or training problems; and to “sell 
practical psychiatry to the line.” Colonel Porter suggested that men between 
the ages of 30 and 40 be specially selected for this assignment and be given a 
6-week training course in “administrative duties, relationship to the line, 
military orientation and indoctrination in practical psychiatry.” 
30 Porter, W. C. : Military psychiatry. War Med. 2: 543-550, Jul 1942. 
31 Ibid. 
32 Memo, Lt Col W. C. Porter, MC, to Brig Gen C. C. Hillman, 3 Apr 42. SG: 211 Neuro- 
psychiatry. PREVENTIVE PSYCHIATRY 
183 
Colonel Madigan was favorably impressed by a report, made during the 
month of June, of the first 5 months of activities of the classification unit at 
Fort Monmouth. On 25 July 1942, The Surgeon General recommended that 
“qualified neuropsychiatrists be assigned to headquarters at each replacement 
training center.” 33 The Director of Training, Services of Supply, supported 
the recommendation.34 Following this, The Surgeon General recommended on 
20 August: “ . . . if the plan is approved, that the allotment of officers for 
duty at each replacement training center be increased by one Major, Medical 
Corps, to allow the assignment of a neuropsychiatrist.”35 
On 15 September, the Military Personnel Division, Services of Supply, 
initiated instructions to The Adjutant General through the Assistant Chief of 
Staff, G-l, to announce allotment of 1 major, Medical Corps, for each replace- 
ment training center under the Army Ground Forces.36 An announcement of 
a similar allotment for each replacement training center under Services of 
Supply was held in abeyance because of impending transfer of allotments under 
AR 170-10, 10 August 1942. At the time of the issue of this authorization 
Col. Roy D. Halloran, MC, had succeeded Colonel Madigan.37 
On 30 October 1942, The Adjutant General sent out the following letter 
as a result of having received requisitions for psychiatrists which had been 
previously authorized:38 
1. In connection with your recent requisition for a neuropsychiatrist, it is intended 
that this officer be used to establish a clinic or similar setup for the replacement training 
center in accordance with the following plan. 
a. The assignment of neuropsychiatrists to replacement training centers is intended 
to assist those normal individuals who may have correctible maladjustments to Army 
service and to eliminate those mentally unstable individuals who are or may become 
a distinct liability to military training, discipline, and morale during the early weeks of 
training. 
b. The general functions of the neuropsychiatrist will be as follows : 
(1) To Institute an advisory service, assisted by a qualified psychologist and 
such other personnel as may be made available, to aid the newly inducted soldier to 
make a satisfactory adjustment to his military duties. 
(2) To aid, by professional methods, individuals who have been brought to the 
neuropsychiatrist’s attention, in order to make full use of their training and capabilities 
or to recommend reclassification of those who are being trained in a skill beyond their 
capacities. 
(3) To study and recommend remedial measures for those individuals who 
manifest behavior problems. 
33 Ltr, SG to CG SOS, 25 Jul 42, sub: Assignment of psychiatrists to replacement training 
centers. SG : 211 Psychiatrists. 
34 Memo, Brig Gen C. R. Huebner to ACofS for Personnel SOS, 12 Aug 42, sub : Assignment of 
psychiatrists to replacement training centers. SG : 211 Neuropsychiatry. 
35 Memo, Lt Col P. A. Paden, MC, to Dir Mil Pers SOS, 20 Aug 42. SG : 211 Neuropsychiatry. 
36 Memo, Dir Mil Pers SOS to SG, 16 Sep 42, sub : Assignment of psychiatrists to replacement 
training centers. SG : 211 Neuropsychiatry. 
37 See footnote 28, p. 181. 
38 Ltr, TAG to CGs various Replacement Training Centers, 30 Oct 42, sub : Assignment of neuro- 
psychiatrists to replacement training centers. AG : 210.31. 184 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
(4) To recommend for immediate discharge from the service such men who, 
because of mental or emotional factors, cannot function adequately or who present a 
hazard to the other men. 
(5) To develop a liaison with line and medical officers for the purpose of 
instructing and developing a better understanding of the principles of mental hygiene as 
applied to the military service. 
(6) To aid in the morale program of the station by the use of the neuropsychia- 
trist’s specialized training and knowledge. 
o. Individuals will be referred to the neuropsychiatrist through the classification 
officer by any one of the following: 
(1) Staff sections. 
(2) School directors. 
(3) Chaplains. 
(4) Company, troop, or battery commanders. 
(5) Provost Marshal. 
All requests for action of the neuropsychiatrist will contain or be accompanied by 
a statement of the reasons therefor. 
d. The neuropsychiatrist will recommend disposition of the cases referred to him 
by any one or a combination of the following methods : 
(1) Reclassification, where considered advisable. 
(2) Special programs, corrective in character, cooperatively developed through 
conference with school directors, company, troop, or battery commanders, staff sections, 
and others. 
(3) Psychiatric observation and treatment. 
(4) Recommend admission to hospital with view to discharge on Certificate of 
Disability for Discharge because of disability (within this category are psychotics, severe 
psychoneurotics, epileptics). 
(5) Recommend disposition by a board of officers convened under Section VIII, 
AR 615-360 (within this category are psychopathic individuals, mentally deficient, chronic 
alcoholics, drug addicts). 
e. Cases scheduled for action by boards of officers will be handled as provided by 
pertinent regulations. 
2. It has been drawn to the attention of this office that certain replacement training 
centers already have similar facilities established which are operating satisfactorily. 
The special importance of this service during this critical training period and, therefore, 
the necessary careful selection of personnel, cannot be overemphasized. Since there 
is a shortage of officers with a suitable background for this duty, it is desired that 
duplication of experienced officers be avoided. 
3. In view of the above, it is requested that The Surgeon General will be informed, 
as early as is practicable, with the following information : 
a. Whether or not a similar service is now functioning under a neuropsychiatrist 
at your installation. 
b. The names and qualifications of the neuropsychiatrists. 
c. A recommendation as to the desirability of transferring that officer to fill the 
vacancy. 
This letter may be considered to mark officially the end of the classification 
phase. From the foregoing account, it is seen that individual psychiatrists had 
already exceeded the bounds of classification and were performing some of the 
functions outlined in the above letter. However advanced the application of PREVENTIVE PSYCHIATRY 
185 
psychiatry was in certain portions of the field, military psychiatry at large was 
not yet ready to exploit immediately the broad area of responsibility and 
activity as encompassed in this letter. A part of the difficulty, no doubt, rested 
with the traditional resistance of the military to innovations; part was lack 
of understanding by psychiatrists as to how to apply clinical experience in this 
broad way. Doubtless, also, there was some reluctance on the part of psychia- 
trists to give up the illusion of screening as the best contribution which psy- 
chiatry could offer. For although there was growing concern that psychiatry 
had failed at induction centers, it might yet succeed in screening at the next 
point of contact with the soldier—a better screening process might be accom- 
plished at the replacement training center. 
Notwithstanding the doubts of some experienced psychiatrists, the wis- 
dom of careful selective screening grasped the imagination of many and was 
a significant factor which had led to the assignment of psychiatrists to replace- 
ment training centers. In fact, to the new Chief of the Neuropsychiatry 
Branch, Office of The Surgeon General, Col. Roy D. Halloran, screening 
appeared to have accomplished almost all that had been expected in October 
1942:89 
Neuropsychiatric screening has been developed at induction centers to a far wider 
degree than during the last war, and neuropsychiatric service at this point is considered 
of paramount importance, however tedious and demanding. In spite of the relatively 
large and necessarily rapid mobilization, evidence already indicates that a greater 
percentage of potential neuropsychiatric misfits have been prevented from entering the 
armed forces than during a comparable period in the last war. 
He cited a need for a second echelon of screening to provide for the elim- 
ination of those who had been missed at the induction centers :40 
It is inevitable that under the most exacting examination possible some will be 
missed. An attempt must be made to weed these out during the training period. Ac- 
cordingly, steps have been authorized already to place well qualified neuropsychiatrists 
on the staff of replacement training centers. The soldier after induction goes to a 
reception center and spends anywhere from a few hours to a few days becoming oriented, 
getting his uniform and going through certain forms of introduction, and then proceeds 
to the replacement training center. Here for the first time the problems incident to the 
new life in the Army begin to appear. The function of the psychiatrist at the replace- 
ment training center will be concerned with adjusting normal individuals and detecting 
and eliminating the mentally unstable who are or may become a distinct liability to 
military training, discipline and morale during the early weeks of training. 
This was reiterated again approximately 6 months later by Colonel Hal- 
loran and Lt. Col, Malcolm J. Farrell, MC, at the 99th Annual Meeting of the 
American Psychiatric Association in May 1943.41 Maj, (later Lt. Col.) John 
39 Halloran, R. D.: Presentation of the subject of Symposium II. In Sladen, Frank J.; Psychiatry 
and the War. Springfield, Charles C Thomas, 1943, pp. 421-431. 
40 Ibid. 
41 Halloran, R. D., and Farrell, M. J.: The function of neuropsychiatry in the Army. Am. J. 
Psychiat. 100: 14-20, Jul 1943. 186 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
W. Appel, MC, ascribes the delay in recognizing the extent of the problem 
as being mainly due to the absence of reliable figures.42 
The difficulties in this matter were reported in July 1943:43 
Efforts have been made to improve screening at induction and training centers. 
At the induction centers large numbers of men are processed as rapidly as possible. 
But the time for examination is too short; psychiatrists lack adequate background 
information on the men; and psychiatrists are scarce. All these problems have been 
faced frankly, and appropriate measures instituted. But no test yet devised is so 
perfect that it can detect all the psychopaths and potential psychoneurotic individuals 
on brief examination. If a screen were tight enough to eliminate anybody who might 
possibly develop a nervous breakdown, it would be so tight as to eliminate nearly 
everybody. 
A second screening process is now instituted at the Replacement Training Centers. 
There, a trained staff of psychiatrists, psychologists, and psychiatric social workers, 
cooperating with line officers, chaplains and others, further observe the newly inducted 
soldier. 
From the foregoing, it is clear that there was strong impetus for assigning 
psychiatrists to replacement training centers for what was considered to be a 
need for more screening of unpromising individuals. 
Psychiatric Screening and Consultation Phase 
The second phase brought psychiatrists into collaboration with the psy- 
chologists and classification specialists. In certain instances competition 
rather than collaboration resulted. This was undoubtedly because of over- 
lapping areas of responsibilities outlined in The Adjutant General’s letter of 
30 October 1942 quoted above and AR 615-28. In most cases, this was satis- 
factorily resolved at the local level without benefit of clarifying directives from 
the War Department. The following letter illustrates that there were still 
ambiguities 2y2 years later:44 
I am enclosing a copy of our new SOP which came out yesterday as a result of 
further conference with the C. O. and is the culmination of nine months of interpretation 
of the function of a Mental Hygiene Division, the administrative keynote of which has 
been differentiating its function from that of the Classification and Personnel Con- 
sultant’s subsection of the Personnel Division. In this respect WD Cir 81 helped define 
both the administrative and functional relationship of this Division to the Command. 
This SOP now clears up the anomaly of having two Consultation Services existing side 
by side with overlapping responsibility. 
During this period, the function of the psychiatrist was initially to be the 
prevention of psychiatric casualties by a process of eliminating individuals 
during training who would not be likely to serve profitably in the military 
42 Appel, J. W. : Cause and prevention of psychiatric disorders in the U. S. Army in World War II. 
HD: 314.7-2. 
43 Annual Rpt, SG, FY 1943. HD. 
44 Ltr, Maj H. L. Freedman, Mental Hygiene Div ASFTC, Camp Plauche, La., to Maj M. S. 
Guttmacher, SGO, 18 Apr 45. HD : 730. PREVENTIVE PSYCHIATRY 
187 
service. This was, in essence, the type of activity that Maj. Thomas W. Salmon, 
MC, had recommended in his report in 1918. 
This phase began during a period when an increasing awareness was 
developing that two important tools were not accomplishing the hoped for 
results in meeting the manpower problem. Reaction against the classification 
and assignment system—“vocationalism”—mounted during 1942 in the Army 
Ground Forces because under the system a disproportionately large number 
of men in the lower mental groups were being assigned the combat arms for 
training.45 This produced many problems in the training situation in which 
psychiatric knowledge was deemed to be of value and, in some measure, helped 
to create a receptive attitude in the Army Ground Forces command toward 
establishment of the position of a staff psychiatrist. At the same time, realiza- 
tion grew that psychiatric screening as it was being performed at the induction 
stations would not alone accomplish the objective of prevention of psychiatric 
disorders and that psychiatrists could not be expected to eliminate all potential 
psychiatric casualties at the induction station. Without any intent to mini- 
mize the enormity of the task which was attempted, or reflect discredit upon 
those who labored conscientiously at it, it must be recorded that psychiatric 
screening at induction failed as a primary method of preventing the great 
majority of losses caused by psychiatric disorders. Although induction 
screening unquestionably served a useful purpose when individuals were elimi- 
nated who were mentally defective, overtly psychotic, psychopathic, or severely 
psychoneurotic, this group comprised only a relatively small proportion of the 
numbers who came to require psychiatric attention in the military service.46 
By the end of the first 2 weeks in November 1942,18 psychiatrists had been 
assigned to replacement training centers. In March 1943, there were 16 consul- 
tation services in the 33 training centers when Colonel Halloran recommended 
to Brigadier General Hillman that such units be established in all replacement 
training centers, including those of the Army Service Forces. By the middle 
of May 22 replacement training centers had neuropsychiatrists assigned and by 
the end of summer, all Army Ground Forces and Army Service Forces replace- 
ment training centers had consultation services.47 This condition did not per- 
sist, however, because the Army Service Forces had not yet published a 
directive making mandatory the establishment of mental hygiene consultation 
services in all Army Service Forces Training Centers. In this the Army 
Service Forces was more than 2 years later than the Army Ground Forces. 
46 Palmer, R. R.: The procurement of enlisted personnel: the problem of quality. In U. S. Army 
In World War II, The Army Ground Forces, The Procurement and Training of Ground Combat Troops. 
Washington, Government Printing Office, 1948, pp. 1-86. 
48 Farrell, M. J.; Psychiatric lessons learned in the Army. Rhode Island M. J. 30: 582-586, 
Aug. 1947. 
47 Semimonthly Rpts, Med Practice Dlv SGO, 1942 and 1943. HD: 024. 188 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
With the assignment of psychiatrists to replacement training centers, new 
problems came into relief which had not been previously encountered. Where 
the development of such a facility had proceeded spontaneously, it indicated 
a receptive attitude on the part of the command or medical officers. The papers 
of Lieutenant Freedman,48 Captain Cruvant,49 Major Cohen,50 and Captain 
Schreiber 51 indicate the importance of this factor. It is doubtful if such 
development could have proceeded without the wise leadership and support 
of responsible local commanders and senior medical officers. Such support, 
however, was not to be uniformly experienced by all psychiatrists in establish- 
ing new consultation services. 
Other difficulties arose, even when command support was satisfactory. 
Perhaps the first of these was because of a lack of clear understanding by both 
commanders (including medical) and the psychiatrist as to the psychiatrist’s 
place in the training situation, what his duties were to be, and how he was 
to implement them. 
The usual assignment procedure for the psychiatrist on orders to open a 
new consultation service was for him to report to the training center after 
spending a week of temporary duty at one of the established consultation serv- 
ices. Some were also briefly seen in the Neuropsychiatry Branch of the 
Surgeon General’s Office by Colonel Halloran. With an orientation thus 
acquired and armed with the only directive pertaining to his new assignment, 
the psychiatrist reported to the training center. 
The psychiatrist assigned to the Infantry Replacement Training Center, 
Camp Wolters, Texas, arrived on 27 November 1942 after having spent a week 
at the Engineer Replacement Training Center, Fort Belvoir, Virginia. He 
had conferred with Colonel Halloran and Colonel Farrell and was advised 
that his task was to organize and develop a mental hygiene consultation service 
for prevention, treatment, and disposition of maladjusted soldiers. Upon 
arrival he was first assigned to the special training unit several miles from the 
main camp. However, within the same day he was reassigned to the Infantry 
Replacement Training Center as Acting Assistant Classification Officer, with 
functions as an integral part of the Classification Section.52 At Camp Roberts, 
California, the psychiatrist arrived 6 December 1942 following 1 week of 
temporary duty at Camp Callan, California, Antiaircraft Replacement Train- 
ing Center. He was immediately assigned to S-l (Personnel) at Headquarters 
Field Artillery Replacement Training Center and given a desk in the Classifi- 
cation and Assignment Section. During a period of orientation to the organ- 
48 Freedman, H. L.: The services of the military mental hygiene unit. Am. J. Psychiat. 100 : 34-40, 
Jul 1943. 
J,) See footnote 23, p. 180. 
50 See footnote 27 (1), p. 181. 
5! See footnote 26, p. 181. 
52 Hunt, R. C. : History of the consultation service, Camp Wolters, Texas. HD: 730 Neuro- 
psychiatry. PREVENTIVE PSYCHIATRY 
189 
ization, procedures, and training of the replacement training center, he studied 
the official guide for the setting up of the program: The Adjutant General’s 
letter of 30 October 1942, subject: “Assignment of Neuropsychiatrists to Re- 
placement Training Centers.”53 The psychiatrists who were assigned to 
establish consultation services at North Camp Hood, Texas,54 and Camp 
Abbot, Oregon,55 also reported lack of clarity as to responsibilities and 
relationships. The psychiatrist at the latter camp thought some advantage 
resulted from this in that it allowed for local development according to the 
requirements and response of the group being served. However, he thought 
acceptance of the services may have been delayed by the absence of definite 
regulations. 
A difficulty frequently encountered was a lack of sufficient personnel to 
accomplish more than a modest amount of the program prescribed. At several 
camps, little or no stenographic help was available for a time. At North 
Camp Hood social histories were taken by line officers except during a brief 
period in 1943 when an American Red Cross social worker was assigned. These 
line officers were individuals of varying skills who were unassigned for one 
reason or another. Since they were rotated every 1 to 3 months, this resulted 
in unreliable case histories and demanded continuous effort in training new 
officers by the psychiatrist. In the 31 months of performance no enlisted 
social worker or clinical psychologist was available.56 Psychiatrists at other 
posts fared better. The psychiatrist at Camp Abbot, and later Fort Lewis, 
was able to meet the problem of finding qualified enlisted men for interviewers 
by accepting “near-qualified” personnel with good educational backgrounds and 
interest in the work. He then put them through a concentrated and personalized 
training program supervised by the staff. A comprehensive manual of pro- 
cedures was devised for reference.57 
This kind of success depended upon factors not always amenable to the 
psychiatrist’s efforts at solving his own personnel problem. As it was expressed 
by one psychiatrist who had experienced considerable difficulty in this matter: 
“Those consultation services which have been able to build up to a satisfactory 
size have done so due to the special help and understanding on the part of the 
local commands by taking personnel away from other sections in the camp.” 58 
Confirmation of this observation came from another source: “Throughout its 
operation the MHCS [Mental Hygiene Consultation Service] has had to con- 
53 Houloose, J.: History and statistical summary—psychiatric service, Field Artillery Replace- 
ment Training Center, Camp Roberts, California, 1943-1944. HD ; 730 Neuropsychiatry. 
54 Kraines, S. H. : A brief history of psychiatry at the Tank Destroyer Replacement Training 
Center, Camp Hood, Texas, December 1942 to July 1945. HD: 730 Neuropsychiatry. 
55 Eisendorfer, A., and Fowler, D. D. : History of the Fort Lewis consultation service—an out- 
patient psychiatric clinic. HD : 730 Neuropsychiatry. 
58 See footnote 54. 
r>7 See footnote 55. 
58 Ltr, Maj G. S. Goldman, MC, Consultation Serv IRTC, Camp Wheeler, Ga., to Maj M. S. Gutt- 
macher, MC, SGO, 19 Oct 44. HD : 730 Neuropsychiatry. 190 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
sistently borrow men from other units because insufficient personnel is allowed 
under the present table of distribution.” 59 
Lack of space to establish a clinic was a handicap which some were able 
to convert to an advantage. Maj. James Houloose, MC, while at the Field 
Artillery Replacement Training Center, Camp Roberts, never formally estab- 
lished a separate clinic, but maintained a desk in the classification section. He 
utilized willingly the various orderly rooms for his examinations and interviews. 
This allowed him to keep in continuous contact with battery headquarters and 
to develop a working acquaintance with commanders, noncommissioned officers, 
and trainees of the units. While he gathered information of use in his function 
as psychiatrist, he explained his role and taught psychiatric concepts. This 
was a practical and effective manner of continuously orienting battery cadre.60 
Maj. Robert C. Hunt, MC, at the Infantry Replacement Training Center, Camp 
Wolters, Texas, was similarly assigned desk space in the classification office, 
but “conducted a traveling clinic; interviewing soldiers in six area dispensaries.” 
He saw the noncommissioned officers and officers in their orderly rooms to discuss 
individual problems with a mutually valuable exchange of information and 
resultant education. He had appreciated at the beginning of his assignment that 
he “had much to learn about the Army and that the Army had much to learn 
about psychiatry.”61 This was an effective approach in the conciliation of 
varying views on problems of common interest to command and psychiatry. 
Of the functions outlined by the authorizing directive, the most familiar 
one to most psychiatrists from civilian experience was that of consultation. It 
wTas also the function that was inevitably first in demand. Being both most in 
demand and most familiar to the psychiatrist from his clinical practice in 
civil life, it was often the first function to receive attention. The accomplish- 
ment of the consultation function entailed various operations: 
1. Referrals: These came from the unit commander, dispensary surgeon, 
personnel officer, classification and assignment officer, school director, chaplain, 
judge advocate, provost marshal, information and education officer, special 
services officer, and American Red Cross representative. 
2. Evaluation: This was the process of utilizing the professional techniques 
appropriate to the presenting problem and the individual referred. 
3. Reports and recommendations: These were made either to the individual 
liimself or to the interested staff officer after psychiatric evaluation had indi- 
cated the advisability or desirability for certain action to be considered or taken. 
4. Followup: This was the establishment and maintenance of an effective 
program to appraise the effectiveness of the recommendations and the progress 
being made by the soldier after return to duty. 
58 Brewer, F. W. : History of mental hygiene consultation service, Infantry Advanced Replace- 
ment Training Center, Camp Livingston, Louisiana, 29 Aug 45. HD : 730 Neuropsychiatry. 
• 80 See footnote 53, p. 189. 
81 See footnote 52, p. 188. PREVENTIVE PSYCHIATRY 
191 
The last was frequently undeveloped during the early period because of a 
lack of personnel commensurate with the magnitude of the consultation require- 
ment. In response to this need, the principal function in the replacement 
training centers immediately after establishment of a consultation service was 
that of consultation or of screening. 
The variable manifestations of failure in the adjustment process were used 
as a basis for referral for psychiatric evaluation. Some of these were: com- 
plaints for which no physical basis could be found on medical examination, 
difficulty in concentration and learning, undue anxiety on the rifle range or 
infiltration course, unusual awkwardness, insubordination, unfriendliness to 
fellow trainees, depression, tremulousness, insomnia, and frequent petty mili- 
tary offenses. The principal purpose in obtaining an evaluation was selectively 
to eliminate the potentially maladjusted individuals—hence the frequent use 
of the term screening when consultation wTas described. 
One of the difficulties in the screening at basic training centers which psy- 
chiatrists soon experienced was expressed as follows by an officer at Camp Croft, 
South Carolina:62 
.... The greatest hazard in the psychiatric screening of soldiers in the army is that, 
once given an awareness of the omnipresence of maladjustment, the inexpert observer, 
in his endeavor to find a case, may make a case. Too often a man will be referred to 
this service in the early weeks of his cycle when he is displaying a moderate and under- 
standable anxiety which is indicative of nothing more or less than his difficulty in 
orienting himself away from the hbme to the army. For the military authorities to 
show undue concern over this serves only to crystallize a neurotic reaction pattern in 
men who might otherwise attain an adequate adjustment. 
Experience demonstrated that those who appeared hopelessly inadequate on 
arrival often were able to complete training and were never seen in the con- 
sultation service. Major Hunt at Camp Wolters described this type of 
trainee:63 
.... The typical example is an eighteen year old, group IV on AGCT. He tells 
the Classification interviewer that he has always been weak and sickly, that he can’t 
stand crowds or excitement and is afraid of guns. On filling out the questionnaire he 
indicates that there is a family history of nervous or mental illness, his health is gen- 
erally poor, he has had to quit jobs because of his health, he is nervous much of the 
time, does not like to mix with people, cannot work well when watched, is bothered by 
headaches, dizzy spells, and back trouble, has worrisome problems at home, thinks his 
induction into the army was a mistake and does not think he can become a good soldier. 
This is all prognostically bad, of course, yet many of this sort do finish training. 
It came to be considered that most personal adjustment problems could be 
and should be dealt with by the platoon or company commander. Such officers 
02 Frankfurth, V. L. : A brief history of the development and functions of the consultation service, 
IKTC, Camp Croft, S. C„ 9 Dec 44. HD ; 730 Neuropsychiatry. 
03 Ltr, Maj R. C. Hunt, MC, Hq IRTC, Camp Wolters, Tex., to Maj J. W. Appel, MC, SGO, 9 Nov 
45. HD : 730 Neuropsychiatry. 192 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
were assisted by conferences with the psychiatrist on problem cases. Often such 
a conference between the company officer and a member of the clinic staff re- 
sulted in the desired improvement without the need for the soldier to be 
formally referred to the clinic for evaluation. However, if initial efforts failed 
to provide the necessary solution, the soldier was referred to the mental hygiene 
consultation service. 
Among the soldiers referred were individuals who lacked the intellectual, 
cultural, or emotional requirements for prompt adjustment to military service. 
In addition to the slow learners, there were individuals who gave the appear- 
ance of being mentally deficient, but who responded to appropriate training 
with a performance which indicated that the basic problem was not one of low 
innate intelligence, but rather one of insufficient previous opportunity. Another 
group of soldiers referred were men who had not mastered the English lan- 
guage. All of these individuals wTere placed in the special training units at 
various training centers. Where such units were in operation, the mental 
hygiene consultation service was presented with a problem predominantly 
related to the maladjustment of trainees with defective intelligence. 
For some time following its establishment at Camp Croft, the consultation 
service functioned mainly as a psychological screening service for the special 
training unit. During this period, the emphasis in function was on psycho- 
metric evaluation and recommendations for discharge under appropriate 
administrative regulations. So long as the special training unit was active, 
the main body of referrals came from it and defective intelligence was seen as a 
frequent basis for the maladjustment. The experience of the psychiatrist at 
the Fort Bragg Field Artillery Replacement Training Center was similar:64 
As in any new medical setup where the most pressing and striking cases take prece- 
dence initially, the severe mental defectives were the first to claim attention and most of 
the psychiatrist’s time was taken up in the organization of a psychometric program and 
the actual giving of intelligence tests. Since it was keenly felt that casual estimation of 
mental age was futile and misleading, the Replacement Training Center provided test 
materials for the Stanford-Binet Scale, Form L, 1937, and the psychiatrist proceeded to 
weed out most of the severe intellectual defect problems and bring them to the attention 
of the Center Reclassification-Disposition Board for discharge. The value of psychome- 
try in the weeding-out process soon proved so great that the test-battery was expanded 
to include the 1937 Stanford-Binet, Form M, the Kent Emergency and the Porteus Mazes. 
An attempt to have laymen (platoon officers and noncommissioned officers of the Special 
Training Battery) learn and administer the E-G-Y was unsatisfactory, and the intro- 
duction of an enlisted psychologist finally solved the psychometry problem and enabled 
the psychiatrist to devote more of his time to strict neuropsychiatry. 
With his full-time assignment to the replacement training center, the 
psychiatrist at Fort Bragg was able to extend his resources beyond diagnosis 
and disposition. This led him into activities of a preventive nature:85 
61 Abrams, A. L.; Structure and functions of a neuropsychiatric service in a replacement train- 
ing center, Jul 1943. HD: 730 Neuropsychiatry (Fort Bragg). 
86 Ibid. PREVENTIVE PSYCHIATRY 
193 
.... We felt ourselves responsible for a “preventive psychiatry” which would prevent 
those unfit from getting to theaters of operations. 
Accepting as its primary purpose the elimination of the mentally unfit from the 
Replacement Training Center situation so that they are never given a chance to burden 
and endanger the overseas combat units. . . . Our secondary purpose has been to salvage 
as many cases as possible. 
The prevention was still one of screening, however. 
Various methods were devised to screen the new arrivals. The screening 
process at the Fort Bragg Field Artillery Replacement Training Center utilized 
officer and enlisted cadres who had been educated to the problem of the emo- 
tionally unstable by a series of lectures. This indoctrination worked satisfac- 
torily and helped the cadres to deal at first hand with many problems in which 
the psychiatrist participated as an adviser only. Referral was accomplished 
by telephone; forms and questionnaires having been discarded as unnecessary. 
At Camp Croft the basic trainee was seen soon after arrival on the post by 
personnel of the classification section. This was primarily to conduct a voca- 
tional interview, but the interview was utilized additionally for the screening 
of men with mental disorders. The interviewers, who were enlisted men, had 
been instructed to refer any trainee about whom there were doubts concerning 
his ability to adjust. Trainees so referred were then evaluated by the senior 
psychiatric caseworker wffio scheduled appointments at the consultation service 
for those who were most in need of further evaluation. Generally, these were 
men who were depressed, acted eccentrically, admitted enuresis or other unde- 
sirable habits, appeared extremely effeminate, or who claimed to be conscientious 
objectors. 
An interesting observation was made at Camp Wolters, Texas, when a 
system of spotting potential casualties was begun at a later time: 
.... Early in our work with the method we were able to demonstrate statistically 
that one third of the interviewers were doing most of the spotting, and some were doing 
practically none. These data were given to the section chief, and I never asked just how 
he handled it, but from then on the interviewers all spotted approximately the same 
numbers, and the coverage was more complete.90 
During the training cycle, any member of the training command staff could 
refer cases to the clinic for examination. At Camp Croft the referral method 
found to be most satisfactory included the following points:67 
1. Responsibility for referral rested with line officers. 
2. The telephone was used to make the referral because it was considered 
a most ready and convenient means of communication and was conducive to a 
more lucid statement of the problem than the written method of referral, 
3. Recording of the problem, as it was received, was accomplished on a 3 
by 5 card and entered upon a daily schedule sheet. 
m See footnote 52, p. 188. 
1)7 See footnote 62, p. 191. 194 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
The company commander of the trainee was notified in every instance 
when a referral had not originated with him. In some instances, a soldier came 
to the clinic as a self-referral. However, the primary sources for referrals were 
company commanders, dispensary surgeons, staff judge advocates, chaplains, 
and the Red Cross. Cases referred from the dispensaries were to have had a 
recent physical examination prior to referral. If a report of such an examina- 
tion was not available, the psychiatrist was responsible for the determination 
of physical status. 
Sometimes an elaborate operating procedure was prescribed for the referral 
procedure. An example of this is the first memorandum at the Replacement 
Training Center at Camp CrowTder, Missouri. This publication announced 
that a neuropsychiatric consultation service for the replacement training center 
had been established on 10 June 1943. It was stated that full advantage of the 
service had not been taken. This memorandum established procedure as 
follows:68 
1. Platoon officers were to interview each trainee prior to completion of 
the first 2 weeks in the replacement training center (both basic and specialist 
trainees). 
2. Trainees having difficulty adjusting were to be reported to the company 
commander and a checklist was provided as a guide for determining those who 
required referral to the neuropsychiatric consultation service. 
3. The company commander was to interview the men considered malad- 
justed or of dubious value to the military service and submit a report to the 
director of personnel. 
4. The report to the director of personnel was to state that all men assigned 
within the past 21 days had been interviewed and none required referral, or a 
list of those requiring referral was to be appended. 
5. In the latter instance, a memo wTas to be appended for each soldier 
requiring referral stating (a) the problem, (b) a specific example of the 
difficulties, and (c) an estimate of his potential value. If the report were made 
on a soldier in specialist training, information wras also to be included con- 
cerning the progress he was making in the specialist course. 
Problems which were considered a matter of misassignment were handled 
by the classification branch, but those which had some degree of personal 
maladjustment as wTell wTere referred to the neuropsychiatric consultation 
service. This memorandum specified the channels through which consultations 
were to be sent, requiring an indorsement, with pertinent information, including 
recommendations as to possible disposition, and provided that when “neuro- 
psychiatric examination reveals that reclassification or reassignment will enable 
the enlisted man to make a more satisfactory adjustment, this will be done.” 
88 Hq ASFTC, Camp Crowder, Mo, Personnel Memo 23, 7 Oct 43. HD : 730 Neuropsychiatry. PREVENTIVE PSYCHIATRY 
195 
The cumbersome referral system was changed approximately a year later 
by a directive which provided for referral directly to the Chief, Neuro- 
psychiatric Consultation Service, Personnel Division.69 The referring organ- 
ization was made responsible for the soldier’s appearing, with all his medical 
records, from post installations. 
Intake procedure varied between consultation services, depending upon 
the available staff. At Camp Roberts, California, in the Field Artillery Re- 
placement Training Center, the procedure in accomplishing consultations was 
geared to the psychiatrist as the only member of the staff. Requests for con- 
sultation came through the post personnel office from the battery commander 
or other individuals. The trainee was initially interviewed at the orderly room 
of his organization, where care was exercised to make the situation as private 
as possible. Then the progress record of the trainee was reviewed and con- 
sultation was held with the trainee’s noncommissioned officer and platoon 
leader. Other sources utilized for information which might be an aid in mak- 
ing a diagnosis or in planning for the adjustment of the trainee were: unit 
dispensary, station hospital, and civilian social agency educational or employ- 
ment records.70 
By way of contrast, the intake procedure at Camp Wolters was more 
elaborate. The clerk first entered information from the enlisted man’s per- 
sonnel records (Form 20) on the consultation service face sheet; the chief social 
worker then scheduled an appointment. At the time of the appointment the 
social worker saw the patient first for a history; then the psychiatrist saw the 
patient. If the personnel records disclosed an Army General Classification Test 
of under 75, the enlisted man was routinely sent to the personnel consultant 
for a psychological evaluation before being scheduled in the mental hygiene 
consultation service.71 
At Camp Croft, the soldier was scheduled for an hour and was seen initially 
by the psychiatric social worker who prepared a history. Depending upon the 
nature of the problem and the amount of time available, the personality develop- 
ment was carefully traced, exploring the most pertinent areas thoroughly. 
These workers used the Wechsler Individual Mental Abilities Scale if mental 
deficiency was to be evaluated. A questionnaire with 20 neurotic trends was 
used as a key to further history taking. The psychiatrist reviewed the history 
before seeing the patient and was able to get to the problem with minimum 
time spent in investigation. The problem had been pointed up by this process 
and it left further development of the case to him. His wTas the responsibility 
for diagnosis, treatment, or recommendations for disposition. In cases which 
required supplemental information, the American Red Cross was requested to 
89 Hq ASFTC, Camp Crowder, Mo., Personnel Memo 3, 22 Aug 44. HD : 730 Neuropsychiatry. 
70 See footnote 53, p. 189. 
71 See footnote 52, p. 188. 
346336 0—55 14 196 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
provide social histories. Followups in the individual units were conducted by 
the enlisted psychiatric social worker.72 
At North Camp Hood, Texas, all emergency cases were seen immediately 
by the psychiatrist. The procedure with routine cases was spread over a 3-day 
period, incorporating one feature of the adviser system. On the first day the 
social worker took an essential background history and returned the soldier 
to his unit with three request forms. One was for a report on his medical status; 
another was to obtain a report from his commanding officer; and the third was 
a request for the adviser or platoon sergeant to report to the clinic on the second 
day. On the second day the adviser furnished the social worker or the psy- 
chiatrist with a complete social case study of the soldier’s activities in camp. 
This information was most valuable since it was the result of a day-to-day 
observation of the patient’s activities, attitudes, and abilities. On the third 
day the referred soldier was examined by the psychiatrist with social history, 
medical report, commanding officer’s report, and the adviser’s observations.73 
Yet, in spite of the familiarity of the psychiatrist with the clinical pro- 
cedures involved in consultation and with well-planned screening, referral, 
and intake procedures, he still found that military psychiatry required a some- 
what different evaluation than his previous civilian experience permitted him 
to anticipate. The symptom complexes presented by the soldiers seemed to be 
familiar insofar as diagnosis was concerned. The difficulty was in translating 
diagnosis into an evaluation of the man's fitness to perform, in the military 
service so that proper recommendations could he made. The advantages of 
illness—secondary gains—were comparatively greater than had been present 
in ordinary civilian practice. Therefore, although the presenting symbols 
were familiar, the setting was not, and it took a while for the psychiatrist 
to appraise the problems in terms of the new situation. Maj. S. H. Kraines, 
MC,74 refers to this as the “military orientation of the psychiatrist” and Maj. 
(later Lt. Col.) George S. Goldman, MC,75 writes of the emotional adjustment 
required before an effective consultation function could be accomplished. As 
the psychiatrist shifted his sights to new aims, these of necessity were con- 
cerned with what would be best for the group being served. He became 
familiar with matters of motivation, incentive, morale, factors of stresses and 
supports in groups as well as individuals. As he did so he became better 
equipped to recommend consistently and meaningfully to staff officers in indi- 
vidual cases and for groups. 
However, formulation of recommendations was difficult because policy 
with regard to many matters in the utilization of manpower fluctuated con- 
7- See footnote 62, p. 191. 
73 See footnote 54, p. 189. 
74 Kraines, S. H.: Psychiatric orientation of military nonmedical personnel. In Manual of 
Military Neuropsychiatry. Philadelphia, W. B. Saunders, 1944, pp. 481-505. 
75 Goldman, G. S. : The psychiatrist’s job in war and peace. Psychiatry 9 : 263-276, Aug 1946. PREVENTIVE PSYCHIATRY 
197 
siderably. This had its unsettling effects upon the training center psychi- 
atrists whose recommendations were required to reflect the perspective of each 
new directive. Recommendations were not always easily effected as a result 
of changes in policy. When emphasis was placed upon the training of indi- 
vidual combat replacements, transfers to a specialist training unit or to other 
branches of the service were nearly impossible. There was continuous uncer- 
tainty about which individuals would be considered as unfit. Early in the war 
conservation by utilization of reclassification procedures was directed:76 
During the emergency, it is essential that manpower be conserved. Therefore, 
releases from active service will be granted only when in the interest of the Government 
or when the necessity therefor is extreme. ... No man will he separated from active 
service because of disability, inaptness or undesirable habits or traits of character, 
unless the Government can obtain no useful service from him. Full use will be made of 
reclassification procedure and additional training in special training battalions. 
This policy was to undergo many changes during this period when psy- 
chiatrists’ services were being extended to all training centers. The Surgeon 
General summarized this evolution for the Assistant Chief of Staff, G-l, as 
follows:77 
.... In the early days of the war there was no classification limited service. Men 
with psychoneuroses were marked full duty or were discharged. Limited service was 
authorized in the summer of 1942, permitting the retention of men with borderline or 
mild psychoneurosis. In March 1943 (Memorandum No. W600-30-43, Adjutant General’s 
Office, March 25, 1943), attention was called to the need for preventing men with neuro- 
psychiatric disorders from being sent overseas, and increasing numbers were retained 
on duty in this country. In April 1943 (Memorandum No. W600-39-43, Adjutant 
General’s Office, April 26,1943), it was directed that individuals with any neuropsychiatric 
disorder who could not be expected to render full military duty were to be discharged. 
In July 1943 (W. D. Circular No. 161, 14 July 1943, as amended by W. D. Radiogram, 
29 July 1943), the classification limited service was discontinued and anyone who did 
not meet the minimum standards for induction was discharged except when his com- 
manding officer specifically requested his retention for a specific assignment. Large 
numbers of men with mild psychoneuroses were discharged from the service by ODD 
[Certificate of Disability for Discharge], since anyone with a psychoneurosis of any 
degree was automatically below minimum standards for induction. In November 1943 
(W. D. Circular 293, 11 November 1943), it was directed that no individual would be 
discharged from the service regardless of diagnosis if he was capable of performing 
effective duty. This resulted in the retention of many men with psychoneuroses in the 
service, but only those with mild transitory psychoneuroses could be sent overseas. As 
an amplification of this policy, S. G. O. Circular Letter No. 194, 3 December 1943, directed 
that separations from the service would not be recommended merely because a man has, 
or has had, a psychoneurosis or similar disorder. 
One of the effects of changing policy on disposition may have assisted the 
psychiatrist to seek better means than disposition to satisfy his own require- 
7» WD Cir 270, 27 Dec 41. 
77 Memo, Maj Gen N. T. Kirk for ACofS, G—1, 7 Dec 44, sub: Psychoneuroses. HD: 730 Neuro- 
psychiatry. 198 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
merits as a physician to individual soldiers. As Major Goldman at Camp 
Wheeler, Georgia, stated:78 
.... We have not, of course, been able to maintain a constant policy as regards 
dispositions such as discharge, or as concerns therapy. We were better able to orient 
ourselves toward therapy during the time when discharge was extremely difficult to 
effect, although at the same time we saw a great deal of unnecessary and useless suffer- 
ing. While our attempts at individual therapy have necessarily been somewhat limited, 
we have from the beginning tried to do as much as possible by educating the officers 
and cadre. 
Particularly important to the effectiveness of the consultation service was 
its relationship to the reclassification-disposition board. This was facilitated 
at Camp Croft by the personnel consultant of the consultation service acting as 
classification officer of the board. The personnel consultant also served as 
recorder of the boards convened under provisions of section VIII, AR 615-360. 
At Camp Wolters a cumbersome board procedure was modified for increased 
effectiveness. For example, as much as a half day might be used to take detailed 
testimony from six witnesses to dispose of a single case of enuresis. This was 
shortened by having only one witness testify who usually was a noncommis- 
sioned officer knowing the man well. Additional documentary evidence such 
as certificates by psychiatrist, psychologist, and commanding officer were intro- 
duced. The psychiatrist was a member of the Section VIII board at this camp 
after June 1943, This practice was subsequently discouraged because, in effect, 
the psychiatrist might act as both witness and judge in some cases. The 
psychiatrist frequently had to familiarize board members with the intent of the 
provisions of the regulation under which the board was convened. When the 
turnover of officers detailed to such duty was rapid, there were delays and 
misunderstandings until interpretations could be made. 
Although most of the psychiatrist’s time at the outset was spent with the 
consultation and screening activities, circumstances were combining in 1943 to 
favor an increasing attention to the function of treatment. At Camp Wolters, 
Texas, after running a “discharge mill” for the first few months, the backlog 
of inapt soldiers had been processed by March; special training units were 
opened at reception centers in July 1943, materially reducing the large numbers 
of mental defectives which formerly had composed 75 percent of the problem 
cases. The staff was enlarged by the addition of a full-time stenographer and 
a social worker. Doubtless, similar circumstances were in process elsewhere. 
As a clinically oriented physician, it was inevitable that the psychiatrist 
should select for treatment cases which he believed were likely to result in 
improved adjustment following treatment. Thus, one of the functions of the 
mental hygiene consultation service came to be the careful selection of candi- 
dates for treatment in an outpatient capacity. This was an important adjunct 
78 Sec footnote 58, p. 189. PREVENTIVE PSYCHIATRY 
199 
in assisting the adjustment of the individual soldier who, because of lack of 
motivation, defective attitudes, mental, emotional, or personality factors, had 
encountered problems in adjusting to military service. 
Major Kraines79 believed that not only was diagnosis more effective while 
the man was still in his organization than after he was admitted to the hospital, 
but also psychotherapy was more effective in the training setting. He had 
observed the frequency with which symptoms recurred following the return of 
the soldier from the hospital to the stress of military life. On the other hand, 
adjustment during training by means of social and psychiatric measures re- 
sulted in more effective performance and fewer exacerbations of symptoms. 
As one psychiatrist stated it, psychotherapy was “. . . aimed at retaining the 
soldier in duty status, in the environment of his unit. It prevented many men 
from being hospitalized and removed from an ostensibly threatening environ- 
ment to which they had not become acclimated.” 80 This was analogous to the 
method of treating combat casualties as soon as possible in the setting of the 
breakdown. 
Treatment took many forms in application. Measures which the psy- 
chiatrist in civilian practice perhaps would not have rated high were success- 
fully utilized. Intensive, or deep, therapeutic techniques were eliminated by 
press of circumstance prohibiting long-term relationships. Used as psycho- 
therapy at North Camp Hood were explanation, reassurance, persuasion, and 
occasionally, authoritarian measures. When emotional disturbances secondary 
to environmental pressures were present, advice was given, help procured 
through the American Eed Cross, and emergency furloughs obtained. Indi- 
rect therapy was provided through the company commander or adviser by 
acquainting them with the understanding of the soldier necessary to his good 
management. Reclassification and reassignment were considered therapeutics 
and for some, separation from the service was “treatment.” 
Therapy, at Camp Roberts Field Artillery Replacement Training Center, 
consisted of the establishment of rapport, explanation of the soldier’s problems 
in terms of reality principles, and reassuring him of his ability to overcome 
the difficulty. 
The training center psychiatrist was called upon to advise many individuals 
who manifested symptoms during the transitional period of adjustment to 
military service. Some of these individuals, abruptly severed from the sup- 
ports and security upon which they had depended in civilian life, developed 
depression, anxiety, and in severe cases, panic. Maj. Arnold Eisendorfer, 
MC, in the training center at Camp Abbot and later at Fort Lewis, studied a 
group of these individuals and described them as the “passive personality 
79 Ltr, Maj S. H. Kraines to Maj M. S. Guttmacher, SGO, 2 Oct 44. HD ; 730 Neuropsychiatry 
(Camp Hood). 
80 See footnote 55, p. 189. 200 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
reaction type.”81 These individuals were characterized as being intensely 
dependent upon a parent or parent-substitute with what had appeared to be 
an adequate social adjustment in civil life. The loss of the source of his 
security and satisfaction (job, sweetheart, family, avocation) was produced by 
entry upon military service. This was followed by the development of a syn- 
drome, which Major Eisendorfer referred to as “acute nostalgic state.” The 
importance of early treatment in these cases was emphasized and the results 
were gratifying. Treatment was based upon an understanding by the psy- 
chiatrist of the psychodynamics of dependence. The individual was given 
support by the psychiatrist until such time as his characteristic pattern of 
dependence could be transferred to the unit of which he gradually came to 
consider himself a part. While no claim was made that this type of therapy 
effected a cure, it was considered that one of the possible outcomes of success- 
ful management might bring the man to the threshold of newly found self- 
esteem and emancipation. This method of supportive treatment has been 
summarized by Major Eisendorfer as follows:62 
.... When he comes to the neuropsychiatric service, he finds the psychiatrist 
receptive; immediately he unconsciously attempts to reestablish that emotional pattern 
he had had with his previous parental figure. This is called the transference situation. 
It is a rapport made with an individual in the immediate environment based on emo- 
tional ties which had been stimulated by a previous object of security. After a few 
interviews a considerable amount of the intense anxiety is eliminated. Once the initial 
panic is diminished, the practical part of the therapy is begun. The vital reasons for 
his being here are discussed in a language the patient can understand. The enormity 
of his disadvantage in this conflict because of his nervousness and dependency is con- 
stantly brought to his attention. Meanwhile, the soldier is beginning to make progress 
in training. The sense of accomplishment which accompanies such progress also helps 
to alleviate the initial anxiety ; as he continues to make progress in training, he identifies 
himself more and more with the healthy soldiers about him, and the basic dependence 
on the ever-protecting parent is shifted to the powerful organization of which he now 
feels himself a more integral part. It is interesting to watch these men, as they gain 
confidence in themselves and their leaders, develop into soldiers who take pride in the 
role they have to play in the Army. The powerful Army and the cause for which it is 
fighting become a substitute for the benevolent protector, which was so necessary for 
their stability in civilian life. By this therapy we are not so naive as to believe that 
we bring about a cure. We simply attempt to substitute one type of dependency for 
another; we initiate a process of emotional conditioning which if continued leads to a 
satisfactory adjustment in the Army. 
The aims and objectives of the treatment program at Camp Lee Army Serv- 
ice Forces Training Center were reported by Lt. Col. Samuel A. Sandler, MC. 
Out of the therapeutic relationship some interesting studies were made at this 
81 Eisenddrfer, A. : Some salient dynamic factors of the passive personality reaction type. 
Ment. Hyg. 30: 226-234, Apr 1946. 
82 Eisendorfer, A. ; Clinical significance of extramural psychiatry in the Army. War Med. 5 : 
146-149, Mar 1944. PREVENTIVE PSYCHIATRY 
201 
mental hygiene consultation service on camptocormia and somnambulism con- 
cerning the psychodynamics of these two symptoms.83 
An interesting development during 1943 was the adviser system which 
was initiated in February at North Camp Hood, Texas, in the Tank Destroyer 
Replacement Training Center by Major Kraines.84 The object of this system 
was to assist trainees with personal problems by providing specially qualified 
and psychiatrically oriented noncommissioned officers in each company to whom 
trainees would turn for advice. It was considered that morale would be en- 
hanced by bringing good counsel to the unit level in a form readily available 
and easily acceptable. These advisers were to be selected by the company com- 
mander and to be responsible to him and work through him, calling to his 
attention morale problems of which he should be made aware. Advisers were 
initially planned to be the platoon sergeants; however, they were found to be 
too often engaged in punitive measures or too busy with administration to effect 
the desired relationship. Failing in this, the company commanders were then 
asked to select two qualified men for these duties. They were to be responsible 
to the company commander. Meetings with the advisers of each battalion were 
held by the psychiatrist every 2 weeks. General instructions were given them 
on the importance of understanding men, with specific instructions relative to 
cases referred from their units. To assist in the indoctrination of the advisers, 
a weekly publication called the Advisor Bulletin was produced. The specific 
duties of the advisers were:85 
1. To be available to answer questions concerning problems of the trainees. 
2. To seek out maladjusted men and endeavor to assist them. 
8. To provide social case histories on men referred to the mental hygiene 
consultation services. 
4. To assist in adjusting men seen by the psychiatrist, especially in the 
field of social contacts. 
5. To conduct group meetings with trainees in their barracks, discuss 
trainee problems, answer their questions, explain the reasons for Army 
procedures. 
Later another function spontaneously developed; to inform the psychiatrist 
of serious morale problems which had been relayed to the commanding officer, 
but upon which no action had been taken. The purpose of this effort wTas an 
attempt to find a method of supplying psychiatric understanding to many more 
individuals than the psychiatrist could himself reach. 
83 (1) Sandler, S. A. : The Army and the maladjusted soldier. Mil. Surgeon 96 : 89-93, Jan 1945. 
(2) Sandler, S. A., and Rotman, S. R. : Adjusting the emotionally unstable soldier. Bull. U. S. Army 
M. Dept. No. 85, Feb 1945, pp. 103-107. (3) Sandler, S. A. : Camptocormia : a functional condition of 
the back in neurotic soldiers. War Med. 8 : 36-45, Jul 1945. (4) Sandler, S. A. : Somnambulism 
in the Armed Forces. Ment. Hyg. 29 : 236-247, Apr 1945. 
84 Kraines, S. H. : The advisor system—prophylactic psychiatry on a mass scale. Ment. Hyg. 27 : 
592-607, Oct 1943. 
83 Kraines, S. H. : Managing Men : Preventive Psychiatry. Denver, Hirschfeld Press, 1946. 202 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Another type of applied psychiatry to groups commanded the attention of 
the Neuropsychiatry Branch, Office of The Surgeon General. There was active 
interest in Major Cohen’s project in mental conditioning of new troops at the 
Ordnance Replacement Training Center, Aberdeen Proving Ground, Maryland. 
Members of the Surgeon General’s Office worked in an advisory capacity and 
in close cooperation with the experiment being conducted to deliver talks 
on mental hygiene to new troops. Results seemed to be encouraging. The 
Training Division of the Services of Supply was contacted and was favorably 
impressed by the project. As a result of this, the experiments were enlarged to 
include the Quartermaster Replacement Training Center at Camp Lee, Virginia. 
The activities of the Neuropsychiatry Branch were of such scope during 
the latter half of 1943 that consideration was given to its reorganization into 
a separate division under the Chief of Professional Service. Prior to the 
arrival of Lt. Col. (later Brig. Gen.) William C. Menninger, MC, as successor 
to Colonel Halloran in the capacity of Chief of Neuropsychiatry Branch, Office 
of The Surgeon General, it was proposed that a division of neuropsychiatry be 
organized. It is of interest that in this proposal the psychiatric activities in 
replacement training centers were considered to be a concern of the Psychiatry 
Branch rather than of the proposed preventive psychiatry branch, which would 
be interested in the broad application of educational mental hygiene activities 
by means of publications and other media, maintaining the necessary liaison 
with other staff agencies of the Army Service Forces. It is of further interest 
that the latter branch under the reorganization on 1 January 1944 was desig- 
nated Mental Hygiene Branch. Captain Appel, who had been assigned 24 
March 1943 as liaison officer between the Neuropsychiatry Branch and Special 
Services Division of the Army, became Chief of the Mental Hygiene Branch. 
In summarizing the efforts in 1943, to encourage a truly preventive appli- 
cation of psychiatry in training centers, Captain Appel observed:86 
An attempt to emphasize the preventive aspect of the training center psychiatrist’s 
duties was made in the Summer of 1943 when a letter was [sent] out over the Surgeon 
General’s signature to each of [the] training center psychiatrists, drawing their attention 
to the existence of the Information and Education Division—then known as the Special 
Services Division, informing them of the liaison with this Division which had been made 
by the Neuropsychiatric Branch of the Surgeon General’s Office and instructing the 
psychiatrists to effect a similar liaison with the Information and Education organization 
in their own training centers. Then in the Fall of 1943 eight of the training center 
psychiatrists who had been most active in pursuing preventive measures were called 
into Washington by the Chief of the Mental Hygiene Branch for conference. Ways and 
means of pursuing preventive psychiatry were discussed . . . and representatives of 
the Information and Education Division were brought in to describe their facilities and 
activities concerning morale and motivation through their orientation and information 
program. Although this conference stimulated interest and clarified methods to some 
extent it was evident that the training center psychiatrists were so overburdened with 
88 See footnote 42, p. 186. PREVENTIVE PSYCHIATRY 
203 
the load of screening and disposal that not a great deal of headway in prevention could 
be expected. 
Notwithstanding the high priority given the screening and consultation 
functions, with necessary concentration on matters of referral, intake, evalua- 
tion, and recommendation procedures, the need for methods directed at larger 
groups had continued to find expression. Major Kraines’ adviser system was 
one of these manifestations. The effort in the various experiments in attitude 
conditioning at the replacement training centers near Washington was another. 
At Camp Abbot, late in 1943, still another was started. Weekly meetings were 
held by each squad leader with his squad. Current events provided the themes, 
but free discussion was the principal objective. This was considered to be an 
effective method of bolstering morale because “ ... in the mind of the newly 
inducted trainee who had suddenly, as it seems to him, had all his freedom 
restricted, there occurs an unconscious inhibition of thinking and expression 
which results in the harboring of intense resentment which is directed against 
the authorities. This program provided a means of ventilating this resentment 
and prevented dissension or impaired morale.”87 
Psychiatric experience during this period had resulted in the emergence 
of a new orientation. Although he was still concerned with the individual 
patient, the psychiatrist had found that he was unable to fulfill the larger mis- 
sion if he confined himself to working with soldiers as individual problems of 
diagnosis and treatment. There was a pressing need for the application of 
his knowledge to the problems which faced the individual, but the major effort 
would have to be directed toward groups. This function could not be per- 
formed except in terms of the requirements of the group, with the understand- 
ing and support of its key members. To obtain that support and understanding 
wmuld be a major task during the following months. 
On 3 February 1944, official cognizance was given to the importance of 
attitude conditioning activities which had been initiated independently at the 
replacement training centers at Aberdeen Proving Ground, Camp Callan, and 
North Camp Hood. In a publication88 issued to stress the importance of 
informing both enlisted men and officers on matters of sanitation, personal 
adjustment, and first aid, it was asserted that prevention and control of 
neuropsychiatric cases was of equal importance to the maintenance of physical 
health. Training courses were to insure that individuals would have . . a 
knowledge of personal adjustment problems in the Army; relation between 
emotions, feelings, and body functions; and a healthy viewpoint toward being 
a soldier.” Toward this end the subject and scope of a series of lectures on 
personal adjustment for enlisted men, and for officers and noncommissioned 
officers, were outlined. The 1-hour lectures, of 3 and 6 total hours, respectively, 
87 See footnote 55, p. 189. 
88 WD Cir 48, 3 Feb 44. 204 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
were to be based upon technical medical bulletins which were then in prepara- 
tion and were to be given by medical officers, preferably psychiatrists. The 
complete outlines appeared subsequently as War Department technical bulletins, 
TB MED 12, 22 February 1944, and TB MED 21, 15 March 1944. 
Mental Hygiene Phase 
The first of the lecture outlines, published as TB MED 12, included six 
subjects that were considered to be of importance to noncommissioned and 
commissioned officers. The subj ects were: 
Principles: modern conception of personnel adjustment and its importance 
to the Army officer 
Personalities and the adjustment process 
Motivation 
Specific factors of stress in the Army affecting adjustment 
Signs and symptoms, types of breakdowns, and 
Measures to maintain mental health of command. 
At about the same time, the other series of lecture outlines were subjected to 
field tests at Army Service Forces Training Centers, Aberdeen Proving 
Ground, and Fort Bel voir. These lectures were approved early in March for 
publication and appeared as TB MED 21, with subjects listed as: 
Personal adjustment problems in the Army 
Emotions and feelings and how to handle them, and 
A healthy viewpoint toward being in the service. 
Early in the phase of development now under consideration, a meeting 
was held at North Camp Hood, Texas, by the training center psychiatrists of 
Army Ground Forces replacement training centers. The purpose of this 
meeting was for the evaluation of the adviser system which Major Kraines 
had put into effect a year earlier. The consensus of opinion of the visiting 
psychiatrists was reached on 17 March 1944 and expressed by one recorder as 
follows:89 
As practiced at TD RTC, North Camp Hood, and as demonstrated and described 
by Major S. H. Kraines and his staff, the Advisor System delegates mental hygiene and 
psychiatric responsibilities to selected cadre-men in each company. In actual practice, 
these men are called on to meet psychiatric situations beyond their capacity and experi- 
ence. The advisors are essentially untrained individuals who can presumably decide 
when and what kind of specialized medical care should be made available to the malad- 
justed trainee. The trainee is encouraged to bring all his problems, psychiatric, social, 
personal, physical, to his advisor. There is real danger in delegating such serious 
responsibilities to men of such limited experience and training. Dangerous possibilities 
lie below the surface of many cases of maladjustment; suicide or other unpredictable 
complications may arise. Only the psychiatrically minded or trained physician, or a 
trained allied professional under his supervision, should be burdened with such responsi- 
8B Rpt, Maj O. B. Markey, MC, sub : Conference on advisor system, as observed and studied at 
North Camp Hood, TDRTC, March 15-18, 1944. SG : 337 (Camp Hood) C. PREVENTIVE PSYCHIATRY 
205 
bility. The proper supervision of a large number of advisors is professionally impossible 
for a psychiatrist charged with the mental health of a large command, ranging from 
7,000 to 50,000 trainees, aside from cadre. 
The system highlights and emphasizes facilities for the care of early maladjustments. 
There is the reasonable possibility that an aggressive method of seeking out the individual 
who may need help tends to weaken, rather than strengthen him. On the other hand, 
the soldier who must be resourceful enough to seek and find available psychiatric help, 
more readily develops self-dependence in the military situation. In that sense, psychiatry 
should be accessible and available, but not predominant in a training camp. 
The system threatens to set up a separate channel of authority in the military 
family. The advisors are appointed by the company commander, but they are profes- 
sionally responsible to the psychiatrist. Their reports necessarily bring in problems 
involving disciplinary relationships with the normal chain of command, from corporal 
to company commander. The latter, whose interest in the total health and adjustment 
of every member of his company is a command function, may be displaced by the psychia- 
trist, though this may not be the intention. 
The aims of such a system are the same as those followed in the mental hygiene 
services offered in other RTC’s. The method is different. Advantages accruing to the 
Advisor System, such as increasing attention to the help that trainees can be given; 
lectures to officer, cadre and trainees on military mental hygiene; cooperation with allied 
agencies (ARC, Orientation Officer, Hospital and Infirmary Surgeons) are indigenous 
to every adequate program of prophylactic psychiatry. No one “system” is necessary, 
for every local system has localized needs and every properly trained psychiatrist should 
be encouraged to use his own methods. In that case, he will be able to favorably exploit 
many of the sound practices offered by the Advisor System in operation at North Camp 
Hood, TD RTC. 
Of the comments made, there were two which were considered of most 
serious character: the effect of placing too much professional responsibility in 
the hands of individuals ill-prepared to assume it, and the setting up of a 
hierarchy of a professional-type functionally separate from the traditional 
command structure of the Army. The valuable features of the program were 
recognized to be: the improved dissemination of information to cadre which 
would be of assistance in the exercise of leadership and training functions, the 
generalized awareness of the wisdom and usefulness of early attention to adjust- 
ment problems, and effective cooperative effort with other staff agencies of 
command. 
Major Kraines later attempted, unsuccessfully, to modify his system at 
North Camp Hood to conform to the usual command channels by using the 
platoon sergeants as advisers. However, at other camps modifications of the 
adviser systems were adopted with success. 
Although the conference at North Camp Hood had failed to win complete 
acceptance of the entire adviser system, it had stimulated interest in the 
problem of prevention. The value of the psychiatrist’s advisory function to 
command was more clearly seen in this perspective. Major Hunt reported 
increased interest:90 “Previous to this time reports had been prepared at in- 
1,0 See footnote 52, p. 188. 206 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
tervals of several months when there was a slack period. In May, this was 
changed to regular monthly reports ... to bring to the attention of the 
commanding general situations which are affecting the morale and mental health 
of the command and which can sometimes be corrected.” 
Recognition of the mental hygiene consultation service as an important 
source of information was extended when training center psychiatrists were 
requested during April 1944 to formulate opinions regarding the factors con- 
tributing to the incidence of psychiatric disorders in basic training camps. 
Colonel Menninger directed letters of inquiry to psychiatrists in 14 Army 
Ground Forces and 7 Army Service Forces training camps. The replies were 
extracted and consolidated in a report to Mr. Harvey H. Bundy, Special Assist- 
ant to the Secretary of War, in June 1944.91 Comments were made summar- 
izing the psychiatrists’ views in matters pertaining to: leadership, psychiatric 
understanding required by officers and cadre, instructors, comments on train- 
ing methods, infiltration courses and rifle training, relation of training to the 
development of psychoneurosis, classification and assignment, orientation prob- 
lems of labor battalions, adviser system, and miscellaneous suggestions. 
In this report the matter of leadership as it affected morale and the im- 
portance of a well-informed company commander were emphasized. To the 
psychiatrist the company structure resembled the family unit in the manner 
perceived by soldiers:92 
There is frequent reference to the importance of the commissioned officer as he is 
related to morale and to the successful training of the soldier, with a direct relationship 
between these and the neuropsychiatric casualties. There is wide recognition by the 
psychiatrists of the similarity of the company, and a family and the soldier’s response 
depends on the father-substitute: the unit commander. . . . 
One of the psychiatrists strongly recommended the preparation of a training bul- 
letin on the subject of leadership, to be issued and placed in the hands of all officers. 
He summarized the contents as follows: 
“A concise bulletin describing the psychiatric aspects of group leadership should 
be prepared. A few important concepts, such as the following, should be considered (in 
a language understandable to everyone) : 
“a. The officer-soldier relationship as a duplication of the parent-child relationship, 
“ft. The affectional interest of the parent person must be balanced against the 
authoritative and disciplinary aspect. 
“c. The magical power of the leader in affording protection and inspiring a feeling 
of confidence. 
“d. The need for inspiring troops with enthusiasm and motivation in getting the 
job done.” 
The newly authorized mental hygiene lectures might have been expected 
to begin to correct some of the deficiencies in the area of leadership. However, 
there was considerable variation between commands in the utilization of the 
91 Memo, Col W. C. Menninger to Mr. Harvey H. Bundy, 7 Jun 44, sub : Comments and sugges- 
tions regarding psychiatric problems occurring in basic training camps. HD: 730 Neuropsychiatry. 
02 Ibid. PREVENTIVE PSYCHIATRY 
207 
lectures. In some instances, both series were being given; in others, no lecture 
was given. It was the consensus that too many officers failed to realize their 
importance—the necessity for stressing their personal and paternal relation- 
ship to their men. 
In addition to the factors inherent in the exercise of leadership in training 
(amount of the commander’s understanding of the individual soldier; degree 
of emphasis on the use of fear of being killed, fear of punishment, or competi- 
tiveness as motivating forces), there were other factors which were considered 
to produce psychoneurotic symptoms: 
1. Difference in the mental capacities of the trainees who are all subjected to 
the same course at the same speed; 
2. Difference in the physical condition among trainees of different ages; 
3. Insufficient consideration that training is the trainee’s first military 
experience, requiring much readjustment, all to be accomplished in a unit of 
temporary structure; and 
4. A lack of flexibility in arranging special opportunities for training and 
disposition. 
Colonel Menninger went on to comment that:93 
.... In addition, although not mentioned by the reports, an important psychological 
hurdle in training is inherent in the program; to learn to kill and avoid being killed. 
This ideology must be closely linked with motivation and tied into the mental hygiene 
presentations and the orientation lectures. 
It is the consensus of opinion of most of the psychiatrists that it is the total pressure 
of garrison life which acts as the precipitating factor of emotional instability rather 
than any specific feature of basic training, as such. There is the unanimous opinion, or 
nearly so, that “we do increase the already existing psychoneurotic tendencies in certain 
individuals.” That we do produce psychoneurotic responses seems certain, although it is 
probable that the great majority of these occur in predisposed individuals. 
The year 1944 saw articles published by various members of the staff of the 
Neuropsychiatry Division, Office of The Surgeon General, reflecting a strong 
trend toward prevention as the main aim of military psychiatry. Colonel 
Farrell94 in a paper presented before the Iowa State Medical Society in April, 
indicated the importance of the training period as demonstrating the need for 
the development of preventive methods. Observing that the incidence of 
neuroses among trainees in training centers is highest during the third or fourth 
week of training, he pointed to the recent progress in providing for the mental 
hygiene lecture series. In a paper read in May at the Centenary Meeting of 
the American Psychiatric Association in Philadelphia, Col. M. J. Farrell, MC, 
and Major Appel95 indicated that preventive measures were being pursued by 
93 See footnote 91, p. 206. 
64 Farrell, M. J. : Developments In military neuropsychiatry. J. Iowa M. Soc. 34 : 387-391, Sep 
1944. 
95 Farrell, M. J., and Appel, J. W. : Current trends In military neuropsychiatry. Am. J. Psychlat. 
101 : 12-19, Jul 1944. 208 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
psychiatrists in three different areas: education, motivation, and environment 
as an adviser to commanders with regard to environmental factors of signifi- 
cance to mental health. These three areas for preventive activity were defined in 
a subsequent paper by Major Appel and Capt. (later Maj.) D. W. Hilger, MC.06 
As used by these authors, education meant . what is usually thought of as 
mental hygiene and actually amounts to the attempt to teach military personnel 
what has been learned about human nature from the study of mental disease. 
The premise is that this knowledge can be used by individuals for the mainte- 
nance of their own mental health and by commanders in their problems of 
leadership and morale.” 
Although the mental hygiene lectures were the foremost example of the 
educational endeavor, other measures were being used including the informal 
personal orientation of commanders by psychiatrists and the use of various 
printed media in acquainting the military with psychiatric principles. In the 
field of motivation, the psychiatrist collaborated with the information and 
education officer who was charged with responsibility in this operational area. 
It was both as a collaborator and adviser that the psychiatrist was active in 
the modification of environmental factors. Here the psychiatrist’s viewpoint 
was added to that of the personnel officer, training officer, legal officer, chaplain, 
recreation officer, and others who were concerned with the morale of troops. 
Final responsibility for the factors crucial to mental health was inevitably that 
of command. As an adviser, the psychiatrist could influence these factors in- 
directly by contributing toward the commander’s understanding of significant 
environmental stresses. The role and function of the psychiatrist as an officer 
of prevention was becoming clearer and better defined in the training situation. 
There was a new activity of certain replacement training center psychia- 
trists which was briefly referred to by Colonel Menninger in an address before 
the American Psychoanalytic Association in May 1944.97 This was referred to 
as the salvage of psychoneurotic patients, either for further Army service or 
for return to effective civilian life. In the frame of reference that considers a 
complete preventive program to include rehabilitation and disability limitation, 
this salvage of men was patently a comprehensive part of a developing preven- 
tive psychiatry. Colonel Farrell98 reported later in the year that the develop- 
mental training units, as they were termed, had been successful in the rehabili- 
tation of neurotic patients outside of the hospital wdth a substantial number 
performing satisfactory duty after such training. 
On 22 January 1944, Colonel Menninger had accompanied Generals Kirk 
and Hillman to a preliminary meeting concerning the proposed retraining of 
98 Appel, J. W., and Hiller, D. W. : Morale and preventive psychiatry. Bull. Menninger Clin. 8 ; 
150-152, Sep 1944. 
97 Menninger, W. C. : Psychiatry and the Army. Psychiatry 7 : 175-181, May 1944. 
98 Farrell, M. J. : Psychiatry in training centers. Bull. Menninger Clin. 8 : 133-135, Sep 1944. PREVENTIVE PSYCHIATRY 
209 
salvable psychoneurotic soldiers. This meeting was attended by representatives 
of the Military Personnel Division, Office of The Adjutant General; the Train- 
ing Division, Army Service Forces; and the Office of The Surgeon General. 
At successive sessions, plans were formulated for the development of three pilot 
retraining centers at the Engineer Replacement Training Center, Fort Belvoir 
(Va.), the Quartermaster Replacement Training Center, Camp Lee (Ya.), and 
the Ordnance Replacement Training Center, Aberdeen Proving Ground (Md.), 
It was decided that Camp Lee would be the reception center for all incoming 
specially selected salvable troops to be retrained from the Second, Third, 
Fourth, and Fifth Service Commands. It was further decided that the initial 
distribution of these troops would be carried out by a special group of officers 
made up of 1 commanding officer, 2 classification officers, 2 neuropsychiatrists, 
2 personnel consultant officers, and a special cadre of enlisted men to assist 
them in the examination and special assignment of these troops. It was antici- 
pated that this initial classification and allocation would take about 2 weeks. 
The entire retraining program was to be set up within the existing organization 
of the replacement training centers selected, to which additional medical-officer 
and other personnel were added. The initial training program was to extend 
over a period of 2 months. Those soldiers benefiting by this training were 
to be assigned to specified duties within the Army; those failing were to be 
separated from the service. 
In March 1944 it was considered that the experimental program regarding 
the retraining of selected psychoneurotic soldiers was progressing in a very 
satisfactory manner. On 15 February, Maj. (later Lt, Col.) William H. Everts, 
MC, visited the three replacement training centers where the special retraining 
and vocational centers had been established. A battalion of 440 men had been 
set up at each center, under the command of selected personnel. Specially as- 
signed neuropsychiatrists, under the supervision of the replacement training 
center neuropsychiatrist, had been assigned to oversee the neuropsychiatric 
aspects. Men assigned to these training battalions, including officers and en- 
listed men, were enthusiastic and the commanding generals of the replacement 
training centers, being personally interested in the experiment, rendered every 
cooperation. In each instance, the commanding officer of the training battalion 
was directly responsible to the commanding general." 
After the war, General Menninger100 stated that of the entire experimental 
group, TO percent were made available for limited assignment. An account of 
the experiment at Fort Belvoir was reported by Capt. (later Maj.) Stanley L. 
Olinick, MC, and 1st Lt. (later Capt.) Maurice R. Friend, MC, who referred to 
99 Semimonthly Rpts, Neuropsychiatry Consultants Dlv SGO, 1 Jan-31 Jan 1944; 16 Feb-29 
Feb 1944. HD. 
100 See footnote 2, p. 171. 210 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
the entire process as indirect group therapy. Of those who benefited under the 
regimen at Fort Bel voir, Captain Olinick and Lieutenant Friend concluded;101 
The soldiers who benefited in this process need not have developed insight into their 
problems in order to derive that benefit. Nor are they to be considered as literally having 
“toughed it out . . . learned to live with their symptoms.” Rather, what happened was 
that the unresolved emotional drives responsible for the previous maladjustments were 
tested against a firm but tolerant and individualized reality; the drives were then 
reintegrated, sublimated, remobilized on a higher level. 
It must be emphasized also, that this reintegration did not take place spontaneously, 
in response to simple environmental manipulations. Those who have worked with the 
men are confident that suitable work assignments, even in conjunction with placement 
close to their homes would not alone have been sufficient, except in a very few instances. 
What was essential to the reintegrative process was the experience of planned group 
living. 
Colonel Cruvant102 who suggested that this treatment program might well 
be called “milieu therapy,” stated that it appeared in 1941 that such a program 
would be effective with “situationally conditioned, emotionally maladjusted or 
physically sub-standard soldiers” as a result of his own experiences with the 
special training units. The results of the work done in these “Developmental 
Training Units (Experimental)” seemed to confirm such hopeful anticipa- 
tion.103 However, the application of these units was never approved for gen- 
eral use because of the difficulty in making special assignments after training 
and the cost in terms of trainer personnel. 
A brief resume of the administrative efforts to increase the effectiveness 
of military psychiatry up to and including this period was published in 1944 
by Colonel Menninger.104 Efforts were being increased to potentiate the ef- 
fectiveness of psychiatry by the assignment and utilization of clinical psycholo- 
gists and psychiatric social workers. During the latter part of April 1944, 
a directive was submitted for publication outlining the duties of clinical psy- 
chologists.105 At about the same time, Machine Records Division, Office of 
The Adjutant General, was requested to determine the number of psychiatric 
social workers in the Army. A directive pertaining to the use of these profes- 
sional workers, then in preparation, appeared as War Department Circular 
295, 31 July 1944, which outlined the functions of psychiatric social workers 
and designated them as critically needed specialists. 
This amplified the previous authoritative description of the duties of 
psychiatric social workers (Specification Serial Number 263) which had been 
101 Olinick, S. L., and Friend, M. R. : Indirect group therapy of psychoneurotic soldiers. Psychiatry 
8 ; 147-153, May 1945. 
102 Cruvant, B. A. : Pragmatic psychotherapy in military training centers. Am. J. Psychiat. 108 : 
622-629, Mar 1947. 
103 Senerchia, F. F., Jr. : Experimental unit for the retraining of psychoneurotic soldiers. A. 
Research Nerv. & Ment. Dis., Proc. (1944) 25: 87-93, 1946. 
104 Menninger, W. C. : Administrative aspects of neuropsychiatry in the Army. Bull. Menninger 
Clin. 8: 129-132, Sep 1944. 
105 This was published as WD Cir 270, 1 Jul 44. PREVENTIVE PSYCHIATRY 
211 
issued in 1943, It also underlined the importance of these workers to the 
psychiatric program. The rapidity of expansion of psychiatric facilities had 
not allowed for the social worker requirements to be met, notwithstanding the 
efforts which had been made to obtain the necessary numbers by means of 
classification procedures and the recruiting of women for the positions of 
psychiatric social worker and psychiatric assistant. All of these develop- 
ments had been aided by the active interest and advice of Mrs. Elizabeth H. 
Ross, the secretary of the War Office of Psychiatric Social Work, a joint 
undertaking of the American Association of Psychiatric Social Workers and 
the National Committee for Mental Hygiene. 
Increased demands were made upon the profession of psychiatric social 
work by the rehabilitation program for psychiatric patients at Army hospitals 
during the last half of 1944. As a result of a conference between the Chief, 
Neuropsychiatry Division, Office of The Surgeon General, and American Red 
Cross representatives, a large number of Red Cross social work personnel 
were approved for assignment to convalescent hospitals for the needs of psy- 
chiatric patients. 
At a time when social workers from this source were already at a premium, 
a new, heavy request was thus made for such personnel.106 It was plain that 
renewed effort would be necessary to staff psychiatric social workers from 
military resources. To facilitate the development of this program, Mrs. Ross 
was appointed as consultant to the Neuropsychiatry Division on 21 December 
1944. A similar development in clinical psychology had been earlier estab- 
lished on 8 June when Lt. Col. Morton Seidenfeld, MSC, Office of The Adjutant 
General, was appointed as liaison between the Classification Branch, Office of 
The Adjutant General, and the Neuropsychiatry Division, Office of The Sur- 
geon General, for the purpose of selection, appointment, and supervision of 
clinical psychologists.107 
More effort was yet to be expended in bringing the clinical psychologist 
and military social workers to the mental hygiene consultation service. A 
conference to this end was held on 10 November by Colonel Menninger and 
Major Guttmacher with representatives of the Classification Branch, Office of 
The Adjutant General, on the problems relating to utilization of clinical psy- 
chologists in mental hygiene consultation services. The need for clinical 
psychologists and psychiatric social workers was expressed by many psychi- 
atrists at the time of the conference held at Aberdeen Proving Ground early in 
1945. 
The problem of evaluating the effectiveness of the lecture program as 
an instrument of the mental hygiene approach to problems of morale was a 
difficult one and objective means were never satisfactorily developed, A for- 
ice O’Keefe, D. E.: Development of military psychiatric social work. HD ; 700.7. 
107 Semimonthly Rpt, Neuropsychiatry Consultants Div SGO, 14-31 Dec 1944. HD; 024. 
346336 0—55—15 212 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
mal examination following the lecture series was not considered to be an 
appropriate method. It was pointed out that the value of the lectures was 
expected to be reflected in the mental health, morale, and operational effec- 
tiveness of units. However, statistical analysis of certain data might be of 
help in approaching the problem objectively. It was suggested that various 
rates might be reported as was customary with other medical statistics; i. e., 
rates based upon monthly recordings expressed in terms of the annual rate 
per 1,000 strength. It was believed that unit AWOL, sick call, company pun- 
ishment, court-martial, venereal disease, discharges under the provisions of 
section VIII, AR 615-360, neuropsychiatric, and hospital admission rates 
might each provide useful indexes of the mental health of the unit. Interest 
in exploring this possibility further was expressed by the Neuropsychiatry 
Division: “If it seems advisable to adopt a simple workable reporting system 
of these data this office would be very interested in lending any assistance de- 
sired in devising the reporting forms and setting up criteria of evaluation so 
that the data might be correlated with other existing data related to mental 
health.”108 No general reporting system for such data was developed and the 
utilization of these indexes was to be a matter of independent action in the 
field. 
Certain objections to the lecture series were voiced soon after publication 
at staff level in Headquarters, Army Service Forces. It was considered that 
the lectures were in an area believed to be the responsibility of the morale 
services division and the orientation officer. A part of the difficulty, aside from 
the acknowledged overlapping of interest with morale services, was in under- 
standing the ambiguous phrases personal adjustment and personnel adjust- 
ment. These had been selected after objections had been raised to the use of 
mental hygiene. It was agreed that although the subject material was pre- 
sented in layman terms, the objective of mental health made it a technical 
subject which was properly the interest of the psychiatrist. Other objections 
were raised regarding: the inclusion of some “strictly orientation material,” 
“the statement as to the inadvisability of the indoctrination of hate,” and the 
sequence of the lectures as presented.109 
Presenting the lecture series, even where the training program had been 
modified to include them, was not without difficulty. At Camp Roberts, Cali- 
fornia, Field Artillery Replacement Training Center, the personnel adjustment 
lectures were given as 2-hour lectures twice weekly to new groups every 2 weeks, 
although it had been suggested that a minimum of 6 hours be used for the 
lectures. Variations in educational background (6th grade to college gradu- 
ate), in age, and in Army experience and ratings made presentation difficult. 
108 Memo, Lt Col W. C. Menninger, MC, to CG AGF, 29 Feb 44, sub : Index of mental health. SG: 
353.-1. 
109 Memo, Col W. C. Menninger, MC, to Chief Prof Serv SGO, 5 Jul 44, sub: Report of conference 
on consideration of TB Meds 12 and 21. HD : 730 Neuropsychiatry. PREVENTIVE PSYCHIATRY 
213 
The psychiatrist reported: “There was criticism that the instruction was above 
the level of the group; that some 40 words were used that could not be found 
in the average desk dictionary.” Attempts which were made to simplify the 
nomenclature and to keep within the educational mean only served to reduce 
the scope of the material.110 
The psychiatrist at Camp Wolters observed that although it was too early 
to evaluate the effectiveness of the lecture program, the first three battalions 
given the instruction had had comparatively fewer maladjustments. He re- 
ported that lectures to trainees had not been instituted until September, although 
the lectures to the cadre had been started in June. In both instances, the 
amount of time was less than that prescribed: two 1-hour lectures per series.111 
The changing character of the trainee population of some camps from 
inductees to overseas returnees was introducing a new problem: “As you know 
the number of redeployed troops is increasing progressively. I feel that our 
material for personal adjustment lectures in keeping with WD [Cir] 48,1944 is 
inadequate. TB MED 21 of 1944 gives us some help but does not seem to get 
the job done as far as redeployed troops are concerned.”112 
On 15 September 1944, Major Guttmacher reported for duty in the Office 
of The Surgeon General. His projected primary duties were to be the super- 
vision and coordination of the work done by the psychiatrists in the mental 
hygiene consultation services of the training camps, numbering about 40.113 
One of his immediate duties was the assumption of responsibility for the prepa- 
rations which had been under way for a few months for a meeting which would 
bring together all training center psychiatrists for an exchange of experiences 
gained in the nearly 8 years since the initial effort at Fort Monmouth. This 
meeting was considered necessary to take account of the demands being made 
upon psychiatry, the measures instituted to meet the needs of military service, 
the changing perspectives of psychiatric practice in the Army, and the require- 
ments of the training center psychiatrists to accomplish their part of the 
military mission. 
To obtain some advance information on these matters, Major Guttmacher 
addressed a questionnaire to the chiefs of mental hygiene consultation services, 
receiving replies early in December.114 Of 21 camps reported, the largest from 
the standpoint of numbers of trainees served was Camp Blanding, Florida, with 
approximately 44,000, The smallest was at North Camp Hood with less than 
3,000. Eight psychiatrists served training commands with under 10,000 
110 See footnote 52, p. 189. 
111 See footnote 52, p. 188. 
1U Ltr, Capt C. J. Kurth, ASFTC, Camp Crowder, Mo., to Maj M. S. Guttmacher, SGO, 2 Jun 45. 
HD: 730 Neuropsychiatry. 
113 Memo, Col W. C. Mennlnger, MC, to Maj Gen N. T. Kirk, SG, 9 Aug 44, sub: Projects under way 
in the Division of Neuropsychiatry. HD : 730. 
114 The replies from chiefs of mental hygiene consultation services to questionnaire sent by Major 
Guttmacher are filed in HD : 730 Neuropsychiatry. 214 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
trainees; there were 7 replacement training centers with between 10,000 and 
20,000 trainees; and 5 had 20,000 trainees and above; 1 psychiatrist did not 
report the trainee strength at his camp. With regard to anticipated gains or 
losses in the new year, 5 expected the trainee strength to diminish, 5 expected 
an increase, 8 foresaw no change, 1 reported his replacement training center 
would be closed, and 2 camps did not report with respect to this question. 
In reply to a question “Do you do all the outpatient psychiatry for the 
trainees?” 19 replied in the affirmative, 2 of these indicating that emergencies 
were usually seen at the hospital. One shared the work about equally with 
the hospital outpatient clinic (Camp Plauche) and another considered that 20 
percent of the trainee work was done at the hospital outpatient clinic (Camp 
Croft). The training cadre was also served by consultation services except at 
the Camp Plauche installation. The cadre varied proportionately with the 
size of the trainee strength from 600 to 7,250. 
Most mental hygiene consultation services served no units or installations 
other than trainees and cadre, but a few also provided consultation service to 
service schools, separate battalions, hospitals, and units temporarily assigned to 
the post. 
An average monthly caseload varied with the numbers being served from 
between 800 and 900 at Camp Blanding, Florida, to about 60 at Camp Roberts, 
California. All reported seeing old cases except the psychiatrist at Camp 
Plauche, Louisiana, who saw none. The psychiatrists at Fort Leonard Wood, 
Missouri; Camp Lee, Virginia; Mississippi Ordnance Plant, Flora, Mississippi; 
and North Camp Hood, Texas, were the only ones who reported seeing more old 
cases than new. 
Only at Camp Blanding and Fort Lewis had a second psychiatrist been 
assigned; in addition, a psychiatrist was loaned to the consultation service at 
Fort Devens, Massachusetts, by the post Army Service Forces Training Center. 
Seven had no commissioned clinical psychologist or personnel consultant, but 
two such officers were assigned to Fort Devens and Camp Blanding. Red Cross 
workers were assigned to only 7 mental hygiene consultation services. Of those 
which had no Red Cross worker, 6 considered such an addition desirable, but 
8 did not. Some of the latter qualified their answers by stating that the addition 
would be favorably received if the person were a trained psychiatric social 
worker; others did not consider a full-time assignment necessary because of 
adequate liaison provided by the Red Cross workers in the hospital or post; 
and another had a qualified social worker as an enlisted man which met the 
need in his situation. 
Increases in staff were considered immediately desirable by 14 of the 
psychiatrists. Seven of these believed an additional psychiatrist was needed; 
7 thought a commissioned psychologist was required, sometimes in addition to 
the additional psychiatrist and sometimes in lieu of another medical officer. PREVENTIVE PSYCHIATRY 
215 
Six psychiatrists felt the need for enlisted personnel in psychology and social 
work. 
Criteria for staffing the mental hygiene consultation services had not yet 
been established, but in his reply Major August (Camp Blanding, Fla.) 
recommended that there be 1 psychiatrist per 11,000 trainees, 1 commissioned 
psychologist per 15,000 trainees, and 1 enlisted personnel consultant per 3,000 
trainees. He also recommended that an appointment clerk, file clerk, stenog- 
raphers, and clerk typists be provided. 
The mission of the mental hygiene consultation service was formulated in 
December by 1 psychiatrist as follows:115 
The difficulty, and frequently the impossibility, of attaining significant results through 
individual therapy due to the limitations of time and setting is well recognized. If 
important therapy is to be accomplished it must be of the prophylactic variety performed 
on a mass scale. This has been more and more recognized and the psychiatrist has been 
called upon more and more to supply this need through lectures on personal adjustment 
in the army given to all trainees, cadre and officers. 
If a man appreciates well enough why we fight, and why, specifically, he fights, and 
if he believes in the rightness of our cause, he is not likely to become a psychiatric casualty 
at a replacement training center. It is to instill and to develop such an attitude that 
the consultation service has devoted itself. 
Patently, by this time, the mission of the psychiatrist and the mental 
hygiene consultation service included the promotion of mental health. How 
this objective was accomplished was described by a training center commander 
during the same month in the following paragraphs:116 
It would be very presumptuous for me to tell you Training Center Commanders how 
to organize or operate the Consultation Branch of your S-l Section or the duties you 
assign to the neuropsychiatrist in that section. Particularly is this true since my organi- 
zation is based largely on what I learned from observing the operations of these sections 
in other training centers which I visited. I shall confine myself to covering in a few 
words some of the good work accomplished by an exceptionally well qualified psychiatric 
officer. 
First, he is never referred to by his formal designation. Doubtless many men do 
not even know that he is a medical officer. He assumes the role of advisor and helper 
toward both the patients who may come under his observation and the battery com- 
manders whose problem children they are. He has been able to train the classification 
personnel who interview incoming trainees so that they are able to spot men who may 
possibly have personal problems needing the attention of the battery commander and 
the psychiatric officer; that is, he discovers those who may give trouble before trouble 
arises. Battery commanders are given their names in confidence so they may be carefully 
observed from the beginning. A check-up over a period of months shows that probably 
95% of those who are later before the psychiatric officer were spotted at this first inter- 
view by the classification section. 
Second, he has gained the complete confidence of the battery and battalion com- 
manders and they seek his advice and help in handling difficult cases. He has also 
nr’ See footnote 62, p. 191. 
116 Exhibit B to Annual Rpt, Neuropsychiatry Consultants Div SGO, FY 1945. HD. 216 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
interested the first sergeants who are usually good judges of men. Incidentally, he learns 
what noncommissioned officers do not know how to handle men and they are weeded out 
if proper instruction cannot change them. By comparisons between batteries of the 
number of men who have been cured of their fancied ills, he has secured a competitive 
spirit between the battery commanders. In other words, he has built up in these battery 
commanders a very strong interest in salvaging misfit personnel and building up in 
them a healthy spirit and frame of mind so that, instead of being sorry for themselves 
and wishing they were out of the Army, they complete their training with a new pride 
and self-confidence and with a desire to get out and take their part in winning the war. 
Third, he works very closely with the summary court officer and the judge advocate 
to determine the most appropriate action to be taken in cases where offenses have been 
committed. I also use him to advise me as to the appropriateness of sentences adjudged 
by courts. This may take the form of a conference between the JA, psychiatric officer, 
and myself. 
In short, this psychiatric officer has a healthy view toward his duties. He has 
established very friendly relations with all battery commanders. They believe in and 
trust his decisions and work together to solve the personal adjustment problems which 
arise. He had done this with a minimum of overhead or red tape. 
Two factors had led to the selection of Aberdeen Proving Ground for the 
meeting of training center psychiatrists, one of which was its proximity to 
Washington, D. C. The other reason was “because of the fact that its consulta- 
tion service is one of the most outstanding in the Army.”117 The 40 psychia- 
trists which were to be assembled were a small but significant fraction of the 
fifteen hundred then on duty with the Army. The first general meeting of all 
training center psychiatrists was held on 8, 9, and 10 January 1945 at the 
Ordnance Training Center, Aberdeen Proving Ground, Maryland. In addi- 
tion to representatives of the Neuropsychiatry Consultants Division of the 
Surgeon General’s Office, other interested agencies were represented. These 
included representatives of the Information and Education Division, Army 
Service Forces; a representative of the Replacement and School Command, 
Army Ground Forces; representatives of the Adjutant General’s Office; and 
representatives of the Office of the Director of Military Training, Army Service 
Forces. The conference provided the first118 opportunity for all training center 
psychiatrists to meet as a group, exchange experiences, and receive orientation 
from staff officials regarding the reaction at headquarters level to the methods 
being utilized toward solution of problems which were of mutual concern. 
Subjects presented for discussion were: the problem of sick call; motivation 
and orientation; returnees and redeployment; disqualifying neuropsychiatric 
standards for overseas service; military forensic psychiatry and legal respon- 
sibility ; the role of the consultation service in training; the educational func- 
tions of the consultation service; the Negro trainee; the roles of the personnel 
consultant, Red Cross social worker, and psychiatric social worker in the con- 
117 Ltr, SG to CG ASFTC, Aberdeen, Md., 13 Dec 44, sub : Meeting of psychiatrists. HD : 730 
Neuropsychiatry. 
118 Two earlier conferences of training center psychiatrists had been held, but this was the first 
meeting at which all mental hygiene consultation services were intended to be represented. PREVENTIVE PSYCHIATRY 
217 
sultation service; relationship of the consultation service to other medical of- 
ficers; and the use of testing agents. Discussion was freely engaged in and 
conclusions of a diverse character were reached which were important to 
psychiatric applications in the military situation. 
Of the several subjects discussed, some were of particular interest to the 
training center psychiatrists alone; others were of general psychiatric interest. 
Recurrent throughout the discussion was evidence of crystallizing opinion as 
to the role and function of the training center psychiatrist, his relationship to 
command, his liaison with other members of the training command staff, his 
relationship with other medical officers and units, his own contribution to the 
individual soldier and to groups, and the utilization of psychologists and social 
workers in joint effort. The significance of the services performed by the train- 
ing center psychiatrists was expressed by Brig. Gen. Herbert J. Lawes, Com- 
manding General of the Army Service Forces Training Center at Aberdeen 
Proving Ground; Brig. Gen. Arthur Trudeau, Assistant Director of Military 
Training, Army Service Forces; and Colonel Menninger. The importance of 
a focus upon the needs of the group was emphasized at the outset of the meeting. 
In the same vein, in deciding upon a priority among the various functions of 
the mental hygiene consultation service, it was considered that prevention 
should be first and foremost. On these points, Generals Lawes and Trudeau 
and Colonel Menninger were clear. 
In his prepared lecture, Maj. Gen. Ralph M. Pennell, Commanding Gen- 
eral, Field Artillery Replacement Training Center, Fort Sill, Oklahoma, made 
the following pertinent remarks:119 
In the first place, medical and psychological personnel must be ever conscious of the 
fact that in the Army it is as important to think of the morale of the men of the total 
command as it is of the welfare of the particular individual referred because of personal 
difficulty. This should be remembered when making recommendations for individual 
men. Perhaps this is suggesting that medical and psychological personnel apply their 
skills in an unusual way. But as staff officers in the Army, it should be remembered 
that the primary mission of the Army is the building, training, and deployment of our 
Armed Forces in such a way as to defeat the national enemies and safeguard the nation. 
The Army insists that all possible be done for those who stumble or fall by the wayside 
in the dislocations which accompany rapid mobilization—but not at the expense of the 
primary mission. 
In the second place, in dealing with unadjusted personnel, the impression should not 
be conveyed too readily to them that there is an easy way out of the Army by admitting 
to personality difficulties. I have seen certain questionnaires used by Consultation 
Services which make me wonder w'hether we are trying to cure the soldier or give him an 
opportunity to put down in writing all of his troubles—real or imagined—and so get out 
of the Army. The latter is an easy job for him to accomplish if our questionnaires suggest 
a variety of troubles he might report. 
In the third place, Consultation Service officers have an opportunity in their various 
interviews of men to obtain an insight into and an understanding of many general camp 
319 See footnote 116, p. 215. 218 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
situations. I am not suggesting that these officers violate any of their professional obliga- 
tions to specific men by making public, material which is given to them in confidence. 
I am saying, however, that when matters of sufficient general importance are revealed 
that affect the total command, they should be brought to the attention of the responsible 
personnel. In this way, remedial action can be accomplished. 
In the fourth place, Consultation Service personnel should consider the continuous 
education and training of commissioned and noncommissioned training officers as a part 
of their mission. It is sometimes possible through such training to prevent occurrence 
of maladjustment among the men. In a command, where the officers and noncommissioned 
officers are untutored, many more problems may be generated than can be handled by the 
limited number of officers available in the Consultation Service. 
In the discussion following General Pennell’s paper, the gradual shift in 
emphasis from the treatment of the individual toward prevention was recapitu- 
lated. The experiences of combat psychiatrists had contributed an under- 
standing of the importance of motivation, leadership, and proper assignment 
to be nearly equivalent with mental stability in the matter of preserving mental 
health. The psychiatrist had been afforded the opportunity to become effective 
in prevention through his position as adviser to staff officers. In his report of 
the conference, Major Guttmacher gave the chief conclusions reached during 
the conference as follows:120 
Motivation plays a vital role in determining mental health. Insufficient realization 
by the average soldier of the degree to which he and his family were threatened by the 
enemy has been a basic cause for the high incidence of psychiatric disorders among 
military personnel. Attempts to develop healthy attitudes toward the war have been 
relatively ineffective. It is the responsibility of the psychiatrist to point out the medical 
importance of this problem and lend full support to the I. & E. [Information and 
Education] Division and the command in its solution. 
Whereas the treatment and disposition of individuals suffering from psychiatric 
disorders must be continued, it is evident that the chief military value of a training center 
psychiatrist can be in the prevention of psychiatric disorders. The factors which deter- 
mine mental health of military personnel such as motivation, leadership, training, job 
classification and assignment are functions of command. In these matters the psychiatrist 
can function only as an advisor to the command. In order to carry out this mission, it 
would be necessary for him to act as a staff officer. At the present time, limitation of 
assisting personnel barely permits the psychiatrist time to handle his heavy case load 
of treatment and disposition. Assumption of duties in regard to prevention must be 
gradual and depend upon the feasibility of adding further trained personnel to the 
consultation staff. 
These two main points had been expressed by Major Kraines121 shortly 
after the meeting, at which time he stated his belief that half of the training 
center psychiatrists’ time should be spent in the field studying the attitudes of 
officers and men; informally educating officers and noncommissioned officers; 
discussing with officers the development of group spirit and the fostering of an 
120 Rpt, Maj M. S. Guttmacher, sub : Meeting of consultation service psychiatrists held at Aber- 
deen Proving Grounds, January 8-10, 1945. SG : 337 (Aberdeen Pvg Gd)N, 1945. 
121 Ltr, Maj S. H. Kraines, MC, to Maj M. S. Guttmacher, SGO, 16 Jan 45. HD: 730 Neuro- 
psychiatry. PREVENTIVE PSYCHIATRY 
219 
aggressive attitude; advising officers in the handling of incorrigibles in their 
units; and seeing sick call reporters at the unit dispensaries. From this activity, 
then, a basis would be laid for recommending remedial measures. The role of 
the psychiatrist in the prevention of psychiatric disorders was published in 
War Department Circular 81,13 March 1945. The scope of his field of activity 
was stated in a paragraph on utilization and prevention. After clearly stating 
that the responsibility for preventive psychiatry was one for command; and, 
further, that the majority of factors which determine the mental health of 
personnel were responsive to command action, the text of the circular continued: 
.... The psychiatrist acts as adviser to the command. In training centers or in 
Army divisions as a member of the division surgeon’s staff, he is to be regarded as 
having a staff function in advising the command on policies and procedures which 
affect mental health and morale. In certain divisions and in some commands there 
appear to be excellent morale and splendid accomplishment which are in part due to 
an ideal relationship between the psychiatrist, the surgeon, and the responsible officers 
of the commander. It is the responsibility of the psychiatrist to be alert to the situa- 
tional factors which are precipitating psychiatric disorders and to recommend the 
measures necessary to alleviate or remove these factors. He should survey the training 
program from a psychiatric viewpoint, advise concerning schedules, the method of 
conditioning troops to battle situations, and adjustment to extremes in climate. He 
should pay close attention to such matters as the furlough policy and the handling of 
AWOL cases. Through collaboration with the personnel classification officer he should 
be able to prevent many psychiatric disorders by bringing a medical viewpoint to bear 
in the job assignment problems. He should be alert to evidence that troops are ap- 
proaching the limit of their endurance and in need of rest. Equally, he should be alert 
to untoward effect of boredom from excessive idleness. He should advise other agencies 
which are important to the morale and mental health of the troops: the information and 
education officer, the chaplain, the Red Cross, and the special services officer. 
Preventive Psychiatry Phase 
The continuing demands of military circumstances had forced adoption of 
new policies with regard to utilization of manpower. As new policies were 
instituted, new methods were developed; as the new methods were applied, new 
problems were faced and solutions sought; as new solutions were proffered, new 
military roles were defined. Commanders, confronted with the difficult prob- 
lems attendant on the requirements of a tremendous mobilization of military 
manpower, learned how to utilize effectively the skills of these three professions 
in a manner and to a degree never before realized in military psychiatry. As 
commanders found new significance and meaning in their relationship to psy- 
chiatry, psychiatrists also found new responsibility and perspective of con- 
siderable importance as a result of the wartime experience. 
One of the important developments in military psychiatry came about as 
a result of an increased awareness that the needs of the group were of as great 
a concern for the military psychiatrist as were the needs of the individual 
patient. Preventive psychiatry had come to be the designation for that branch 220 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
of military psychiatry which was concerned with the evaluation of the atti- 
tudes of men and the effects of environmental stresses and supports at play 
upon them. It was concerned with providing counsel and advice on measures 
required in the preventive effort, together with the reasons why particular 
measures were indicated. This was military psychiatry on a firm, positive 
basis. It made its contribution to the military community in constructive 
terms. It helped individuals to find a measure of success and satisfaction in an 
occupation that was for many soldiers reluctantly assumed and difficult. 
It helped commanders and staff officers in the appraisal of men, the selection of 
leaders, and the training of individuals of widely differing qualities and ex- 
perience. It assisted in the maintenance of morale and promotion of mental 
health and treated individuals before serious reaction patterns were firmly 
established. It was a social psychiatry far removed from the earlier practice of 
rigidly excluding and eliminating any who might potentially have an emo- 
tional disorder. It was a psychiatry which took serious note of its responsi- 
bilities to the individual patient and to the community of which both the 
military psychiatrist and the individual soldier were members. This was 
a departure from the traditional role of the civilian psychiatrist; it was a 
definite advance from the traditional application of psychiatry in the military 
service. To indicate this broad scope, the term preventive psychiatry seemed 
most appropriate to many of those who were engaged in these activities. 
Publication in June 1945 of the technical bulletin, TB MED 156, on the 
consultation service, provided an official reference to the function, organization, 
and procedure in training center mental hygiene clinics. These units, which 
prior to World War II had no military counterpart, were now firmly estab- 
lished as important resources to command. In internal organization, they 
were similar to civilian community mental hygiene clinics; in external rela- 
tionships they were operated as the local mental hygiene unit for a circum- 
scribed community of military personnel. Thus had been overcome a prin- 
cipal obstacle in the development of preventive psychiatry: the lack of a func- 
tional unit for bringing psychiatrists into intimate relationship with the 
problems of trainees and training cadre. Now psychiatry in World War II 
had produced in the training setting an organization which would facilitate 
the broader application of psychiatric theory and practice. Apropos of this, 
Lemkau 122 has recently stated that improvement of health follows when “theory 
matures into operating procedure, when plans become people at work,” 
These steps had been taken by training center psychiatry. 
The chief aim of the psychiatrist, clinical psychologist, and psychiatric 
social worker as a team was declared to be prevention of mental disorder as a 
contribution toward the ultimate objective of maximum conservation of man- 
122 Lemkau, P. V. : Local mental health services. Ann. Am. Acad. Polit. & Social Sc. 286 : 116-125, 
Mar 1953. PREVENTIVE PSYCHIATRY 
221 
power. The relatively high incidence of psychiatric disorders during training 
had made prevention in this setting a problem of primary importance. In the 
accomplishment of the preventive program, the staff of the mental hygiene 
consultation service utilized psychiatric doctrine and methods to assist in the 
solution of problems which are the responsibility of command: morale, leader- 
ship, and motivation; basic loyalty and group identification; discipline and 
justice; training and satisfying occupational experience. From the foregoing 
list, it is apparent that psychiatrists and the ancillary professional personnel 
were not, and could not be, sole advisers in any of these areas. Actually, to be 
most effective in the prevention of psychiatric disorders, the staff of the mental 
hygiene consultation service had to work as an integral unit of the training 
command and maintain a close working liaison between mental hygiene consul- 
tation service personnel and other concerned officers of the training staff. 
It is clear from the foregoing that the scope of the military psychiatrist’s 
job goes far beyond the usual kind of civilian practice in which one may have 
become expert by long clinical experience. The way in which the psychiatrist 
became proficient in this was outlined by General Menninger:123 
The psychiatrist . . . had to know the Army and its mission; he had to be able to 
identify himself closely with the Array; he had to reorient from his interest in treating 
one person to the prevention of mental ill health in groups; he had to attempt to apply 
the best of his psychiatric knowledge to the social situation in which he worked. . . . 
.... His work specifically required him to know the structure of the Army and the 
methods that were used in the Army. He had to know the point of view of the men in the 
Army, what they were experiencing, what they were expected to do, how they felt about 
it, and the prevalent emotional stresses as well as the available emotional supports. 
Furthermore, he had to identify with the Army to the extent of believing in it, wanting 
to contribute constructively to it, and feeling of sense of pride in being a part of it. 
The forging of effective relationships with other staff officers was essential 
for the psychiatrist’s professional growth in military psychiatry. Therefore, 
perhaps the first important step to be taken was for the psychiatrist to realize 
that other staff officers were also concerned with the same basic problems as 
confronted him. The approaches of other staff officers to problems of motiva- 
tion, utilization, morale, and leadership were from backgrounds which were at 
considerable variance with that of the psychiatrist. For the psychiatrist, then, 
to make a significant contribution he had to be clearly understood, both in 
terms of his evaluation of a given problem and his recommendations toward 
its solution. Because of difficulties in common understanding, resulting from 
varying backgrounds, it was necessary for the psychiatrist to be able to explain 
his concepts in terms which were readily understood by people unfamiliar with 
psychiatric terminology. The education of staff officers was facilitated by use 
of expressions which were readily understood by them. The reserve which was 
encountered in the application of psychiatric principles was often dissipated 
123 See footnote 2, p. 171. 222 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
when it became clear that the problems were mutual ones and that they were 
more profitably approached as joint ventures with the psychiatrists contributing 
a fair share. 
As in civilian life, psychiatrists encountered resistance to psychiatry among 
military personnel because of fear of, aversion for, or misconceptions regarding 
individuals who required psychiatric assistance. Such reactions were best 
dealt with by the continual familiarization of key personnel with the nature of 
emotional illness. The tendency to ostracize the psychiatric patient by means 
of punitive dispositions had to be handled by a consistently interpretative ap- 
proach. In this the psychiatrist who could welcome constructive criticism of 
his own services was more effective than the psychiatrist who could not. For 
if he reacted to criticism with hypersensitivity, he tended to isolate himself 
from the military community, distinctly diminishing his effectiveness as the 
leader of the mental hygiene consultation service. Such isolation failed to 
promote the mutual understanding which was absolutely necessary for the 
military psychiatrist to serve effectively the organization to which he was 
assigned. The ability to provide satisfactory professional services to other 
members of the training staff was commensurate with mutual understanding of 
each other’s role. 
Of all the training cadre, the psychiatrist’s relationship to the company 
commander was of primary importance. His was the direct responsibility for 
the individual soldier. How well he exercised his command was a potent factor 
in maintaining morale and promoting mental health. To assist him with diffi- 
cult individual problems, conferences were held at which psychiatrist and com- 
pany commander could discuss possible solutions. Colonel Cruvant character- 
ized the intelligent line officer as a “bulwark” in the “early recognition, 
prophylaxis, prevention and prompt elimination of the psychiatrically unfit.”124 
In relation to the company commander, it was important that no confusion 
arise between medical function and command responsibility in the disposition 
of the administratively unfit soldier. In his relationship to the company com- 
mander, the psychiatrist was active at the basic level of prevention by promot- 
ing mental health. His advice to the company commander was for general 
application to help prevent a decline in morale and increase in neuropsychiatric 
disability. The lecture program to cadre and trainees was also directed at 
the promotion of mental health. 
In addition to the level of prevention represented by promotion of mental 
health, other functions in prevention at other levels were practiced: specific 
preventive measures based on etiology; early diagnosis and treatment; limita- 
tion of disability; and rehabilitation. 
Specific preventive measures within the strict sense of the term are not 
generally considered to be applicable to most psychiatric disorders—the etiology 
124 See footnote 102, p. 210. PREVENTIVE PSYCHIATRY 
223 
of many conditions being so characteristically multiple factor in type. How- 
ever, in the military service, psychiatric disability had a distinct relationship 
to morale and the latter to leadership. Therefore, when the environment of 
the soldier was affected by policies set forth by command, these became factors 
that were considered as supports or stresses for the mental health of the indi- 
vidual soldier and, in a sense, factors of etiologic significance in the matter of 
psychiatric disability. Policies which were not cognizant of certain needs of 
the individual often acted as stresses which tended to estrange the soldier from 
his group. On the other hand, policies which were important to the preserva- 
tion of mental health and the maintenance of morale were those which provided 
incentive, stimulated motivation, inculcated responsibility, and developed a 
sense of duty. Clearly, the psychiatrist in training centers had to be sensitive 
to policies, procedures, and environmental factors which acted adversely on 
morale and precipitated psychiatric disorders. When warranted, he recom- 
mended measures necessary to alleviate or remove stress factors. To function 
adequately in this capacity, the psychiatrist had to evaluate the total man- 
environment complex in light of the main objective: to make the soldier well- 
trained, properly informed, mission-oriented, and group-identified so that he 
would be more apt to be effective and to take satisfaction in his military life. 
Valuable policies and practices were those which enhanced the individual’s 
self-esteem and considered him as a person when important matters concerning 
him were at issue. Insofar as these policies were modified in response to 
psychiatric evaluation and recommendation, the measures were, indeed, specific 
preventive ones. 
When promotion of mental health and specific preventive measures of the 
order indicated above were insufficient, the trainee experienced symptoms which 
brought him to medical attention. Nearly always when this occurred, some 
degree of psychiatric disability was present. In such cases the aim of the 
preventive program shifted toward early diagnosis and treatment. Here, the 
dispensary surgeon was important in the preventive approach. 
A good working liaison between the psychiatrist and dispensary surgeon 
was essential in the proper management of trainees in whom early symptoms 
of maladjustment were often referrable to various organic systems of the body. 
Apprehension in response to such symptoms often led the trainee to believe 
that he had heart disease, gastrointestinal disease, or other physical disorders. 
The proper management of the trainee required a point of view by the medical 
officer and psychiatrist of considerable importance to process of adjustment 
by the trainee. Every individual who presented a diagnosable symptom com- 
plex or personality disorder was not necessarily to be recommended for separa- 
tion from the service; nor was hospitalization to be recommended for all who 
presented diagnosable conditions. Rather, maximum efforts were to be made 
to help the individual make a satisfactory adjustment in the training situations. 224 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
In accomplishing this, it was important for an appropriate physical examination 
to be made, including, of course, an examination of the organic system referred 
to. A perfunctory or careless examination only exaggerated an already present 
anxiety, making subsequent management more difficult. When a well-conducted 
examination disclosed no physical disease, it was best for the soldier to be 
promptly so informed. If his anxiety persisted, the medical officer would 
interpret the soldier’s symptoms as manifestations of a common response to the 
stress of training. Along with such an interpretation, reassurance was given 
by the medical officer that notwithstanding certain common difficulties encoun- 
tered in training, most men were able to make the adjustment. Sometimes 
trainees were encouraged to discuss their problems and symptoms with friends 
because it was reassuring for some to learn that others had experienced similar 
disturbances or were carrying on effectively in spite of symptoms. Emphasis 
was placed upon exerting maximum effort in spite of defects as contrasted to 
the focusing of attention upon defects. This approach had the salutary effect 
of diminishing the tendency of the trainee to utilize symptoms or defects for 
purposes of primary or secondary gain. It was found that such management 
during the early period of adjustment of training allowed trainees soon to 
become asymptomatic, no longer requiring the medical officer’s reassuring 
support. Cases of maladjustment which did not respond satisfactorily to the 
efforts of the company officer or dispensary surgeon were afforded a first echelon 
type of psychiatric treatment at the mental hygiene consultation service where 
similarly oriented treatment was offered. Thus, the trainee was seen early in 
the development of his symptoms, evaluated with regard to the training situa- 
tion and the individual’s potential, and afforded treatment which was 
appropriate to both. 
Yet another level of preventive effort was practiced in the important matter 
of occupation. When definite disability was present of a type, which by reclassi- 
fication or reassignment would result in productive service rather than total loss 
of the individual to the military service, the result was limitation of disability. 
Efforts at utilizing the mentally retarded and emotionally unstable were clearly 
directed toward this end. In solution of such problems, good liaison with the 
classification and assignment section was of most importance. In this area, 
the psychologist was often of most value as liaison between the mental hygiene 
consultation service and the personnel division. 
Finally, rehabilitation as a measure of a complete preventive program 
was carried out at several training centers on an experimental basis with the 
mental hygiene consultation service staff participating. With this type of 
“milieu therapy” organized effort at all levels of prevention of psychiatric 
disability was engaged in and all the elements of a comprehensive program 
of preventive psychiatry were established in the training center. This develop- 
ment had taken place in units which in almost every instance were a part of 
the training center command. PREVENTIVE PSYCHIATRY 
225 
The mental hygiene consultation service as an integral part of the training 
division had developed as a result of a recognized need for professional services 
at this echelon. The advantages of this close relationship were several. For 
example, it had been found that when similar facilities were provided as part 
of a hospital outpatient service, the effectiveness of the mental hygiene consul- 
tation service in support of the training mission was considerably diminished. 
This was the result of a combination of factors having to do with the reaction 
of the referred enlisted personnel and the reaction of referring staff officers. 
An enlisted man tended to react to being sent to the hospital clinic in such a 
way as to undermine further his already weakened motivation for performing 
duty. He reacted as though it had been indicated to him that he was too sick 
to continue on duty. Furthermore, he lost identification with the mission of 
his organization. At the same time, unit commanders reflected much the 
same point of view in other ways. It was a common belief that the men should 
be sent to such a facility only when the commander was convinced that the 
men were not worth any further effort expended toward making them into 
soldiers. It was also feared that if members of the hospital staff did not fully 
understand the nature of referrals from the training organization, an easy exit 
from the difficulties of the adjustment period might be offered the trainee. 
It was found that when the mental hygiene consultation service was in the 
training area, and outpatient care provided in that setting, the suggestion of 
escape via the hospital was much diminished. Company and battalion com- 
manders as well as other staff officers of the training division came to view 
the activities of the mental hygiene consultation service as being not in oppo- 
sition to, but, rather, in concert with their own efforts. 
Assignment of the mental hygiene consultation service personnel to the 
training command was important to establishing the esprit de corps so im- 
portant to the maximum effectiveness of the team. It provided the mental 
hygiene consultation service personnel with strong incentive to become identi- 
fied with the training command and its objectives. Furthermore, personnel of 
the training command more freely requested the help of the mental hygiene 
consultation service staff when it was part of the same command than when the 
services were supplied as part of the hospital service. 
As a corollary to these observations, the optimum location of the mental 
hygiene consultation service was in a building in close proximity to the head- 
quarters of the training center. The numerous necessary staff associations of 
the mental hygiene consultation service personnel with other staff and command 
agencies required the physical location of the clinic in the headquarters area. 
Because of the community of interests with the classification and assignment 
section in so many of the cases referred to the mental hygiene consultation 
service, it was most conveniently situated near that unit. The training center 
psychiatrist also had to maintain a close working relationship with officers in 226 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
S-l, S-3, unit dispensaries, various companies, office of the post surgeon, office 
of the judge advocate, office of information and education, and the office of the 
chaplain. All of these important associations were best maintained by a central 
location so that frequent visits between staff officers could be conveniently 
arranged for collaborative effort. 
Inversely, the effectiveness of the mental hygiene consultation service was 
considered definitely limited by its location in the hospital area or as part of the 
hospital outpatient service. Thus, at Fort Francis E. Warren, Wyoming, in 
June 1945, of 501 new cases seen, only 9 were referrals from company command- 
ers and the type of service was narrowly restricted:125 
The Consultation Service continues to be burdened with a large dispositional load 
which limits the time available for an adequate treatment program. Preventive psychia- 
try is almost nonexistent, the psychiatrist of the Consultation Service having had an 
opportunity to make only two mental hygiene talks in a period of five months. In dis- 
cussing this matter, the Post Surgeon and . . . Executive Officer of the ASF Training 
Center, explained that the MTP schedule is so crowded that to date it has been impossible 
to find time for such mental hygiene lectures. 
Too close a relationship to the hospital tended to minimize the number of 
valuable contacts made between staff members of the mental hygiene consulta- 
tion service and the other officers of the training command. The mission of the 
mental hygiene consultation service in providing psychiatric services was 
adapted to the training mission of the organization which it served. This frame 
of reference tended to be obscured both to the medical personnel and training 
cadre, when the mental hygiene consultation service was physically placed in 
the hospital or hospital area. When this occurred, the professional services 
became less frequently sought by the training cadre and less appropriately 
given. 
The Chief of the Mental Hygiene Consultation Service at Camp Crowder 
was assigned to the station hospital. The post surgeon, who was also the 
commanding officer of the hospital, believed all medical personnel should be 
directly responsible to him. The commanding general of the training center, 
however, thought it desirable for the training center psychiatrist to be assigned 
to him and this was in accord with the recommendation made from the Surgeon 
General’s Office. 
Still another example of difficulties in relation to the hospital staff associa- 
tion is disclosed by the psychiatrist’s remarks concerning affairs at Camp 
Claiborne where acceptance by the training staff had also lagged:126 
The situation at this camp is rather difficult. I am assigned to the hospital and 
operate under the jurisdiction of the neuropsychiatric ward. The functions of a con- 
125 Ltr, Lt Col J. H. Greist, Consultant in Neuropsychiatry, 7th SvC, to Surg 7th SvC, 7 Aug 45, 
sub ; Report of inspection of consultation service, Fort Francis E. Warren, Wyoming ... 2 and 3 
July 45. HD : 730 Neuropsychiatry. 
12a Ltr, Maj S. H. Kraines, Camp Claiborne, La., to Col W. C. Menninger, 12 Aug 1945. HD : 
730 Neuropsychiatry. PREVENTIVE PSYCHIATRY 
227 
sultation service are new to the hospital and difficult for them to accept. The training 
command also is adverse to activities of such a consultation service. . . . 
In September 1945, the Eighth Service Command neuropsychiatric con- 
sultant visited Camp Claiborne, Louisiana. As a result of his visit, he reported: 
“This Mental Hygiene Clinic is unique in that its psychiatrist is assigned to the 
neuropsychiatric section of the Station Hospital. Heretofore such units have 
been independent of a station hospital. The present arrangement does widen 
the scope of hospital activities but is of no particular advantage to the Mental 
Hygiene Clinic.” 127 The situation, unsatisfactory as it was at Camp Claiborne, 
had, nevertheless, improved over the earlier character of service offered at this 
post. Before establishment of the clinic as subordinate to the hospital service, 
it had been under the direction of a nonmedical officer. This unit was then 
entitled the “Personnel and Separation Branch, Military Personnel Division.” 
The name suggests the strong emphasis placed upon the administrative character 
of the mission assigned by local authority. This is clearly indicated by the post 
regulation describing the Personnel and Separation Branch. Although the 
general scope of a mental hygiene consultation service was included in outlining 
the functions of this unit, far greater emphasis had been placed upon the pro- 
cedures to facilitate the separation from the service of men who wTere to be 
discharged administratively. 
In situations in which the mental hygiene consultation service was not 
overburdened by disposition problems, or too closely identified with the hospi- 
tal mission, the preventive mission was furthered. Of the effective ways to 
approach prevention, the modification of attitudes, a traditional technique of 
mental hygiene, had been best developed in most instances. However, some 
efforts were made toward a statistical basis for preventive measures. Such 
studies were of two types: the continuing type of study of a particular problem 
to establish trends, and the brief studies of special problems when required. 
The former group included studies in which the mental hygiene consultation 
service regularly procured data on unit AWOL rates, unit incidence of venereal 
disease, and unit sick call rates. These rates were believed to indicate the 
presence of problems related to morale and leadership. When AWOL, venereal 
disease, and sick call rates were low, it was interpreted that supporting factors 
were effective or that stress was minimal. When such rates were high, further 
study was deemed necessary to elucidate the significant factors responsible so 
that recommendations could be formulated. 
The psychiatrist at Camp Wolters attempted to evaluate the morale of 
the training company, first by measuring the productivity of each company, 
and later by figuring weekly sick call rates and transfers:128 
127 Ltr, Lt Col P. C. Talklngton, to CO Sta Hosp, Camp Claiborne, La., 24 Sep 45, sub : Report of 
neuropsychiatric consultant's visit to station hospital, Camp Claiborne, Louisiana. HD : 730. 
128 Ltr, Maj R. C. Hunt to CG IRTC, Camp Wolters, Tex., 7 May 45, sub : Report of consultation 
service for the month of April 1945. HD : 730 Neuropsychiatry. 
346336 0—55 16 228 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
An effort was made to work up statistics and charts on production efficiency of the 
company level. No honest statistical basis could be found and the project was abandoned. 
The men eventually lost have usually been in two or more different organizations before 
final failure, so that it is impossible to determine which organization should receive the 
discredit, and the number transferred as training deficients and the numbers pending at 
the end of cycle are much larger than the losses. 
Because this study was a failure, weekly sick call rates and transfers were 
charted. It was suggested that morale level would be reflected by the degree 
that men would strive for hospitalization and emergency furloughs. 
Questions were raised with respect to the reliability of this type of index 
to morale:129 
.... The relationship between morale and sick-call rate is by no means consistent; 
we have all seen occasional units with low morale and low sick-call, perhaps because 
artificial and repressive measures are used to hold down sick-calls. This illustrates the 
necessity of watching all possible morale indicators, including gossip and one’s intuitive 
feelings about a group which shows nothing wrong statistically. 
The use of repressive measures to keep indicators of poor morale from re- 
flecting such circumstances was considered by another observer to warrant 
another index as a validating check against the incorrect morale indices: “It 
is a pity that the number of courts-martial is not published for each ETC and 
the average number of years in the sentences. This would give an opportunity 
for a comparative study on the means with which ETC’s try to maintain 
morale.”130 
Two factors may have adversely affected the development of a statistical- 
epidemiologic approach to preventive psychiatry in the training centers, 
although an interest in this methodology was being manifested with regard to 
combat psychiatry. One of these was the loss of personnel at local installations 
as a result of personnel surveys. The result of such economy measures was to 
place greater burden upon the psychiatrist for detailed administrative matters 
connected with the operation of the consultation service. Another result was 
that such cuts did not allow assignment of additional required professional 
personnel to free the psychiatrist from strictly clinical responsibilities so that 
an effective preventive program could be developed. The effects of such 
measures were being felt shortly after the Aberdeen conference. 
The second major factor in the failure to develop further the epidemiologic 
approach to preventive psychiatry may have been the beginning of demobiliza- 
tion when numerous training centers were scheduled to close beginning late in 
1945 and continuing into 1946. Most training center psychiatrists became con- 
cerned with the problems of demobilization rather than the maximum utiliza- 
tion of manpower or the cause and prevention of psychiatric disabilities in 
130 Ltr, Capt K. R. Eissler, IBTC, Camp Fannin, Tex., to Maj M, S. Guttmacher, SGO, 18 Jul 45. 
HD : 730 Neuropsychiatry. 
12,1 See footnote 63, p. 191. PREVENTIVE PSYCHIATRY 
229 
the training situation. It was an understandable shift in interest which the 
nation at large shared following cessation of hostilities and promise of peace. 
SUMMARY 
One may define preventive psychiatry as that particular branch of medicine 
which studies disorders of intellect, emotions, and behavior in relation to the 
group as well as to the individual. Not merely concerned with individual ill 
health, it is also actively interested in the maintenance of the physical, mental, 
and social well-being of the man-environment complex. In the military serv- 
ice, preventive psychiatry had become concerned with stresses affecting groups 
of soldiers, and the supports which could be provided for the group. To obtain 
the kind of information needed for his counseling role in matters of mental 
health, it had been necessary for the military psychiatrist to utilize methods 
which were applicable to groups. Thus he studied the incidence and prevalence 
of a disorder, employing data related to these factors in the evaluation of 
etiology and construction of a program of prevention. 
The evolution of preventive psychiatry was not a goal envisioned at the 
outset of World War II by most psychiatrists. Indeed, the meaning and use 
of the word “prevention” in military psychiatry had unudergone great change. 
It had generally implied that psychiatric casualties were to be prevented by 
judicious examination at induction stations, applying standards that excluded 
the potential casualty. This had been current opinion among well-informed 
military and civilian psychiatrists alike: prevention and screening were con- 
sidered to be practically synonymous. This view appeared to be consistent 
with the basic mission of the Army Medical Department in preserving and 
maintaining the fighting strength. It was based upon the ideal hope that the 
elimination of potential casualties before exposure to the stresses of military 
service would constitute a valuable contribution to the forging of a dependable 
arm for war. It was also foreseen that fewer pensioners for combat-incurred 
neuropsychiatric disabilities would result during World War II than had been 
the experience in the previous world conflict. 
However hopeful men had been initially of the potential effectiveness of 
this means, the application of screening technique had left much to be desired. 
The psychiatric casualty was not eliminated, in spite of generally high rates 
of rejection at induction stations. Prevention of psychiatric casualties had 
not been achieved by the application of screening devices and classification 
practices; on the contrary, large numbers of men had been excluded or elimi- 
nated from contributing to the military effort. It can be fairly stated that 
these failures opened the way to developments which culminated in the estab- 
lishment of a psychiatric prevention of a vastly different order than foreseen 
at the beginning of the war. With utilization of manpower a vexingly com- 230 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
plicated, as well as supremely important, matter, psychiatry had to develop 
techniques which were distinct modifications of the diagnostic and prognostic 
skills that had been so confidently relied upon. 
Most military psychiatrists in the training centers were trained to, or 
acquainted with, the psychodynamic concept of etiology for psychiatric dis- 
orders. The psychiatrist, acquainted with dynamic factors in etiology, pos- 
sessed an attitude of scientific receptiveness which permitted observations to be 
made regarding the adjustment process among trainees. In this frame of 
reference, a psychiatric disorder was viewed as the symptomatic expression of 
a reaction to stressful inner conflict between the forces of an impulse to gain 
satisfaction and deterring forces against that end. The imposed deterring 
forces could be internal (conscience) or external (social). In the training 
circumstances, the latter tended to overshadow the former. The resulting 
struggle could be completely unconscious, completely conscious, or. perhaps, 
but vaguely perceived, with manifestations as symptoms or as aberrant behavior. 
This conflictual state could be affected by environmental factors acting as indi- 
vidual stresses or supports. The dynamically oriented psychiatrist became 
more and more concerned with environmental factors and found new avenues 
of approach to the evaluation and treatment of these conditions. 
The soldier entered the military service with a whole set of experiences 
which conditioned his adjustive processes. He might enter into immediate and 
overt conflict with the new authority or group. On the other hand, a latent 
conflict might become activated and be expressed symbolically as a behavior 
disorder or a symptomatic emotional reaction. The internal conflict between 
forces thus might be a symbolic representation of an actual conflict in external 
reality. When the internal struggle was severe, symptoms emerged in various 
ways as a manifestation of the conflict between forces. It was at this point that 
the psychiatrist was frequently called upon for his services as a clinician because 
of the effects of these manifestations. Because the first requirement of the 
psychiatrist was for his clinical services, much effort was bent in the direction of 
extending such services to the individual. However, it was soon perceived that 
although individual factors were of significance, the perspective was often 
changed by an understanding of group factors. The entire man-environment 
complex had to be considered so that individual biologic and cultural factors 
could be evaluated in terms of the soldier and his group. Treatment was based 
upon such an evaluation and preventive techniques were directed with focus 
upon the group. 
The clinician’s role in the study of the individual patient is the traditional 
one from which epidemiologic studies have originated and was the foundation 
upon which a design for prevention was based. In his role as the physician to 
the ill individual, questions emerged which had significance for the group to 
which the patient belonged. In the mental hygiene consultation service the PREVENTIVE PSYCHIATRY 
231 
psychiatrist was in the advantageous position of being both psychiatrist to the 
individual soldier and adviser to the commander on matters affecting the mental 
health of the group. In the first instance he was afforded the opportunity of 
studying individual cases, drawing conclusions and formulating plans. In the 
second instance, he in a position to present his observations, formulations, 
and conclusions to the commander directly for consideration and action. 
This dual role forced a clarification of the differences between the preven- 
tive and clinical roles in military psychiatry. The aim of both is to interfere 
with symptom formation; however, one of the principal differences between 
the clinical psychiatrist and the preventive psychiatrist is in the unit of study. 
The former is concerned with the individual who seeks help for himself or has 
been referred for assistance; the latter is concerned with essentially the same 
phenomena as they affect the group. 
Symptoms could be alleviated by methods directed toward modification 
of stress or support factors. If the stress to be diminished was an inner dynamic 
factor, or, if the support to be augmented was an individual resource, the 
methods used were a modified form of psychotherapy. On the other hand, if 
the modifiable stress or support was a quality of the individual’s surroundings, 
the methods were those of environmental manipulation. Preventive psychiatry 
aimed both at the early amelioration of symptoms in the individual by the 
modification of individual etiologic factors, as well as at the prevention of the 
development of the same disorders by group studies and group measures. 
From the foregoing, it will be seen that steps in the historical development 
of mental hygiene were rapidly retraced in the establishment of a preventive 
psychiatry in the military service. This psychiatrist, armed with a holistic 
approach to the patient’s problems, came to see these in terms of disorders 
arising in the unit analogous to the family, and subject to modification by meas- 
ures focused at the group. The use of an individual prophylactic guide for 
each soldier was issued in the form of lectures and pamphlets applied in groups. 
The broad implications for the group, in addition to the individual soldier’s 
adjustment problem, had been acknowledged and was being met by appropriate 
preventive measures. 
The close of the war found training center psychiatrists engaged in a pre- 
ventive program which was largely carried on by means of attitude condition- 
ing and staff advisory functions. The increased utilization of psychiatric 
social workers and clinical psychologists had contributed significantly to this 
program. Preventive psychiatry based upon a statistical epidemiology ap- 
peared to be on the threshold of development. Since psychiatric disorders had 
important sociologic, psychologic, and somatic components, they were poten- 
tially amenable to study by epidemiologic methods. Epidemiologic methods, 
applied to the problems of psychiatry, might have provided a basis for recom- 
mending preventive measures and establishment of a body of preventive psy- 232 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
chiatric principles. Although not trained to be an epidemiologist, the psychia- 
trist was familiar with manifestations of contending dynamic forces within 
the individual; therefore, the epidemiologic concept of mass disease as a mani- 
festation of contending forces between host and environment would not have 
been an unfamiliar frame of reference. Similarly, multiple causation of 
disease as an epidemiologic principle would be familiar to psychiatrists trained 
to consider multiple factors in the determination of symptom formation. As 
modern epidemiology utilizes the contributions of various allied disciplines, so 
also did military psychiatry, in that the psychiatric team studied the soldier in 
relation to his fellows and environment, employing the professional viewpoints 
of the psychologist and the social worker. Although the way appeared to be 
opening for the development of an epidemiologic approach, the efforts in this 
area were preliminary in nature. CHAPTER VII 
Accidental Trauma 
Major Edgar L. Cook, MC, USA 
and 
John E. Gordon, M. D.* 
NONBATTLE INJURY 
The Wartime Problem 
During World War II every 5th notification of the death of a member of 
the United States Army sent to American families was caused by nonbattle 
trauma, and every 20th was due to disease. In the past the problem of disease 
was more important than that of nonbattle trauma, but due to modern advances 
in prevention and treatment of infections there has been a relative change 
in position especially when mortality is used as the index. The effect of epi- 
demics of infectious disease which rendered whole armies ineffective has been 
well documented in history. The relative importance of mortality from disease 
and nonbattle trauma in wars in which the United States has participated, and 
for which data are available, is presented in Chart 1. 
In the Mexican War, 1846 to 1848, there were 28 deaths due to disease for 
each death due to nonbattle trauma. In the Civil War (Union Troops), the 
ratio was 9 to 1; Spanish-American War, 16 to 1; World War I, 12 to 1, In 
World War II the ratio was reversed for the first time with nonbattle injury 
deaths exceeding disease deaths. During this war there were 4 deaths from 
nonbattle injury to every death from disease. There were 61,640 deaths due 
to nonbattle injury, a rate of 2.40 per thousand per annum for the period 
December 1941 through 1945. For the same period, there were 15,779 deaths 
due to disease, a rate of 0.61 per thousand per annum. Thus, with death as 
the measure, one of the important mass health problems of a modern army is 
nonbattle injury. 
The Peacetime Situation 
Nonbattle injury, as wTell as disease, is present during periods of peace as 
well as war, and therefore is not a problem peculiar to war, although many 
times modified by operations in the field. Battle trauma, on the other hand, is 
•Professor of Preventive Medicine and Epidemiology, Harvard University School of Public 
Health, Boston, Massachusetts. Formerly Colonel, MC, AUS. 234 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
DISEASE 
NONBATTLE INJURY 
BATTLE 
Chart 1. United States Army death rates in various tears. (Death rate per 1,000 per 
annum.) Considerable uncertainty surrounds the exact number of deaths from broad- 
cause groups during some of the early wars. This chart does not purport to be official 
as to the precise values, but does represent the general lev>el of relative magnitudes of 
these values. ACCIDENTAL TRAUMA 
235 
like a point or common source epidemic, being limited by definition to the 
period of conflict. A comparison of death rates for the years 1900 through 
1945 is presented in Table 10. For many years, deaths from disease exceeded 
those for injury: after World War I the differences were never great. In 
1922 the rates were even, and in 1925,1932, 1936, and 1938 the nonbattle injury 
rates were higher. Beginning in 1940, the trends changed sharply, with non- 
battle injury regularly exceeding deaths from disease, and by a considerable 
margin. 
Table 10. Death Rates Per 1,000 Per Annum, Disease and Nonbattle Injury, 
Total United States Army, 1900-45 
Year 
Disease 
Nonbattle 
injury 
Year 
Disease 
Nonbattle 
injury 
1900 
15. 79 
6. 95 
1923 
2. 01 
1 90 
1901 
9. 58 
4. 36 
1924 
1 94 
1 89 
1902 
12. 78 
2. 71 
1925 
1. 77 
1 99 
1903 
7. 02 
2. 28 
1926 
2. 27 
1. 67 
1904 
4. 05 
3. 73 
1927 
2 35 
1 65 
1905 
3. 73 
2. 86 
1928 
2. 30 
1. 80 
1906 
3. 77 
2. 76 
1929 
2. 29 
2. 05 
1907 
3. 57 
2. 14 
1930 
2. 08 
1. 81 
1908 
3. 63 
2. 59 
1931 
2. 47 
2. 13 
1909 
3. 28 
1. 81 
1932 
2. 11 
2. 15 
1910 
2. 50 
1. 86 
1933 
2. 11 
2. 10 
1911 
2. 70 
2. 05 
1934 
2. 04 
1. 99 
1912 
2. 47 
2. 30 
1935 
2. 09 
1. 75 
1913 
2. 60 
2. 55 
1936 
2. 00 
2. 03 
1914 
2. 35 
2. 05 
1937 
1. 87 
1. 61 
1915 
2. 53 
1. 92 
1938 
1. 54 
1. 71 
1916 
2. 71 
2. 48 
1939 
1. 55 
1. 50 
1917 
4. 91 
1. 22 
1940 
1. 04 
1. 76 
1918 
18. 81 
1. 39 
1941 
. 60 
1. 58 
1919 1 
7. 61 
1. 34 
1942 
. 68 
2. 08 
1920 
4. 67 
2. 24 
1943 
. 58 
2. 26 
1921 
2. 24 
2. 02 
1944 
. 55 
2. 45 
1922 
2. 28 
2. 28 
1945 
. 62 
2. 47 
Source: Annual reports of The Surgeon General and “Army Battle Casualties and Nonbattle Deaths in World War 
II,” Final Report, 7 December 41—31 December 46, AGO. 
Civilian Accidental Trauma 
The problem of accidental trauma has also shown increasing magnitude in 
the civilian population of the United States. In 1910, accidents ranked sixth 
as a cause of death,1 and in 1945, this cause of death was fourth.2 Considering 
1 Mortality Statistics 1910. Washington, Government Printing Office, 1913. 
2 Vital Statistics. Special Reports 26, No. 1, USPHS, FSA, 4 Apr 47. 236 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
age and sex distributions of the two populations, accidental trauma has even 
more significance under civilian conditions than for the Army. In 1945, the 
leading cause of civilian deaths for the age group 1 to 24 years was accidents, 
and accidents ranked second for ages 25 to 45 years. The Metropolitan Life 
Insurance data for insured populations reveal a greater incidence of accidents 
in the male population.3 These facts are important, because the majority of 
the Army population is male and of these age groups. 
Classification of Army Casualties 
ARMY REGULATIONS 
An understanding of the classification of military casualties is essential to 
evaluation of accidental trauma. The definitions of terms that follow are from 
Army Regulations (AR) 40-1080,28 August 1945: 
A battle casualty is a traumatism (wound or injury) which is incurred as a direct 
result of enemy action during combat or otherwise, or is sustained while immediately 
engaged in, going to, or returning from a combat mission. It does not include traumatisms 
occurring on purely training flights or missions. Psychiatric cases occurring in combat 
will not be reported as battle casualties. 
The term “injury” will include traumatisms other than those defined as “battle 
casualty.” (The term “traumatism” refers to morbid conditions due to external causes. 
It includes acute poisoning except food poisoning, the results of exposure to heat, cold, 
and light as well as various types of wounds.) 
All cases other than those due to injury or battle casualty will be classed as “disease.” 
Included among the disease cases will be patients suffering from reactions to medication 
other than acute poisoning, patients admitted for the sequela of an injury incurred prior 
to entering service, and patients readmitted for the results of a traumatism (battle or 
nonbattle) incurred during service. 
The classification in most instances is obvious but in others is arbitrary. 
Trenchfoot, although sustained in battle, is classified as a nonbattle injury. 
Also, when an individual is admitted with both a disease and an injury, the 
classification is according to the more serious condition at time of initial ad- 
mission. When an individual with battle wound and disease or injury is ad- 
mitted, he is classed as a battle casualty. The three major groups are well 
defined by regulations, but the subdivisions of nonbattle injury are not well 
distinguished. 
A CLASSIFICATION OF NONBATTLE INJURY 
Since Army regulations make no provision for the separation of the various 
kinds of trauma included under nonbattle injury, and since this study is pri- 
marily concerned with accidental trauma, an arbitrary division has been made, 
recognizing three broad subgroups. Chart 2 shows this in schematic arrange- 
3 Fatal accidents and the venturesome male. Statist. Bull. Metrop. Life Insur. Co. 30: 6-7, 
Mar 1949. ACCIDENTAL TRAUMA 
237 
ment. Nonbattle injuries are divided into: accidental trauma, intentional 
trauma, and climatic trauma. Climatic trauma includes cold injury of all 
gradations from chilblains to frostbite, trenchfoot, and immersion foot. The 
class also includes trauma due to heat, a result evidenced in heat exhaustion or 
heat stroke. Intentional trauma includes homicide, suicide, and self-inflicted 
wounds. This leaves the group of accidental traumatic conditions resulting 
from automobile and aircraft accidents, burns, drowning, and other sources. 
The purpose of this arrangement is to make possible a specific and separate 
analysis of accidental trauma. In some instances, a particular case is found 
difficult to classify according to this scheme. 
NONBATTLE INJURY 
THERMAL (CLIMATE) ACCIDENTAL 
INTENTIONAL 
• HOT 
• VEHICULAR 
• SUICIDE 
• COLD 
• AIRCRAFT 
• HOMICIDE 
• DROWNING 
• SELF-INFLICTED 
• FIREARMS and 
EXPLOSIVES 
• BURNS 
• ATHLETICS 
• FALLS 
• ETC. 
• ETC. 
Chart 2. Schematic arrangement of classification of nonbattle injury. 
HISTORY OF ACCIDENTS AND ACCIDENT 
PREVENTION IN MILITARY PRACTICE 
American Revolutionary War 
Accidents have been a factor in military operations of the United States 
Army since earliest days. The first Army regulations drafted by Major General 
von Steuben in 1780 stated that surgeons would remain with their regiments on 
the march as well as in camp so that in case of sudden accidents they would 
be at hand to apply the proper remedy. There are no officially recorded statistics 
on nonbattle injury during the Revolutionary War, but James Thacher, a 238 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
surgeon, gives a stimulating account of medical problems in his Military Journal 
during the American Revolutionary War from 1775 to 1783.4 An entry under 
date of September 1776 states that “a soldier had the imprudence to seize a 
rattlesnake by its tail; the reptile threw its head back and struck its fangs into 
the man’s hand.” On 10 March 1782 he added, “A singular incident occurred 
in the Sixth Regiment to-day. Two soldiers were eating soup together, and 
one forbid the other eating any more; as he did not desist, his comrade gave him 
a blow with his fist on the side of his head, on which he fell to the ground and 
instantly expired. On close examination, I could discover no bruise or injury 
which could enable me to account satisfactorily for his death.” This author also 
intermingles pertinent medical observations among his many vivid accounts of 
duels, brawls, and scalpings. 
Nineteenth Century and the 
Twentieth Century to 1930 
During the 19th century, accidental trauma continued to take its toll. It 
was commonly interpreted as being caused by events beyond control, that 
happened despite all foresight and expectation. Since accidents were considered 
inevitable, little attention was given to the question of prevention. The 
strongest efforts were made in attempting to solve the mysteries of unknown 
fevers and consumptive disease. The perfection of the microscope and Pasteur’s 
work at the end of the century brought the infectious diseases into clearer focus. 
During the first part of the 20th century, until World War I, there was 
scarcely mention of accidental trauma in the annual reports of The Surgeon 
General, although during that time a gradual narrowing of the gap between 
the death rates for disease and nonbattle injury was under way, as seen in 
Table 10. There is nothing to indicate that the problem of accidents was given 
much attention in World War I; again in all probability because of the rela- 
tively greater importance of disease control. 
During the years of the 1920’s the recognition of the importance of non- 
battle injury became evident. In the Report of The Surgeon General, IT. S. 
Army, 1932, there is a paragraph on the increase in relative importance of 
injuries as a cause of death, stating: 
It is apparent . . . that external or violent causes were by far the most important 
cause of death in the Army in 1931. Thus they caused 46 percent of all fatalities. . . . 
During the early period [1852-1861], deaths from external causes were only 11 percent 
of the total ones as compared with 50 percent during the last 10 years [1922-1931]. . . . 
Fatalities from automobiles, airplanes, etc., are largely responsible for the greater relative 
increase in deaths from violent causes. 
4 Thacher, James : A Military Journal during the American Revolutionary War from 1775 to 
1783. Boston, 1823. ACCIDENTAL TRAUMA 
239 
Accident Activities of the Medical 
Department, 1930 to World War II 
In the late 1930’s a need for more detailed evaluation of the problems was 
generally appreciated. A reporting system was developed which was designed 
to evaluate death, defect, and disability from accidental injury. It included 
information on disability discharges, days lost, an analysis of the place of the 
accident, and whether it occurred on duty or leave. It also had an analysis of 
fault and of influence of alcohol. The collection of information was started in 
1938. Data for 1939 were tabulated in the next annual report and it was stated 
that the 1938 figures were similar. Death, defect, and disability attributed to 
leading causes of accidental trauma were as presented in Table 11. With the 
onset of mobilization in 1940, the strength of the Army increased materially. 
The special reporting system for accidents was no longer considered feasible. 
The 1941 Annual Report of The Surgeon General did not present the detailed 
figures for the year of 1940. 
Table 11. Accidental Injury* in the Total United States Army, by Causative 
Agent, 1939 
Causative agent 
Admissions 
Deaths 
Disability discharge 
Days lost 
Average 
days per 
admis- 
sion 
Number 
Percent 
of total 
Number 
Percent 
of total 
Number 
Percent 
of total 
Number 
Percent 
of total 
Total 
20, 215 
100. 0 
214 
100. 0 
124 
100. 0 
389, 084 
100. 0 
19 
Motor vehicles 
1, 845 
9. 1 
97 
45. 3 
48 
38. 7 
67, 028 
17. 2 
36 
Aircraft 
138 
. 7 
36 
16. 8 
1 
. 8 
3, 252 
. 8 
24 
Athletics 
4, 621 
22. 9 
5 
2. 3 
14 
11. 3 
82, 250 
21. 1 
18 
Falls _ _ 
2, 596 
12. 8 
8 
3. 7 
14 
11. 3 
60, 560 
15. 6 
23 
Fighting 
1, 091 
5. 4 
0 
3 
2. 4 
20, 368 
5. 2 
19 
Firearms 
240 
1. 2 
6 
2. 8 
7 
5. 6 
7, 512 
1. 9 
31 
Drowning 
22 
. 1 
22 
10. 3 
0 
0 
0 
All others 
9, 662 
47. 8 
40 
18. 8 
37 
29. 9 
148, 114 
38. 2 
15 
•Excludes cases of homicide and suicide. 
Source: Annual Report of The Surgeon General, U. S. Army, 1940. 
The 1940 Annual Report of The Surgeon General, at the end of the analysis 
of data on accidental trauma made the following statement: 
These tables give rather detailed information as to the causative agent, show wherein 
the fault lay in many cases, and serve as sources of data to indicate the most fruitful 
fields of accident prevention. However, it should be remembered that there is no evidence 
here as to the particular combination of circumstances which brought about the causation 
of the injuries. It is emphasized that this information can be obtained only by a 
detailed study of each case, and that such studies by unit commanders and medical 
officers can do much in the prevention of injuries. 240 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Col. Samuel Adams Cohen, MC, made the following statement in an 
article in The Military Surgeon, November 1940:5 “In view of the numerical 
increase of its personnel and the broadening of the Army’s mechanization, the 
problem of accidents therefore promises to assume increasing magnitude.” He 
advocated a safety officer at every large post who would know the existing con- 
ditions at the particular post and be responsible for reducing the incidence of 
accidents. He outlined the role of the medical officer in the accident prevention 
program as follows: 
It cannot be overemphasized, however, that the problem of accidents and accident 
prevention should be the direct concern of the medical officer. Since he is the guardian 
of the health of the personnel, he should be the predominant influence in the prophylaxis 
of accidents. 
The medical officer should explore all factors that may lead to accidents and make 
appropriate recommendations for eliminating them or decreasing their frequency. The 
gratifying experiences of the medical officer’s successful efforts to stamp out many diseases 
and reduce the incidence of other diseases should be an added incentive for him to do 
likewise with accidents. 
Another contribution was made just before the beginning of hostilities, 
by Maj. M. H. Fineberg, MC, who made a survey of the serious accidents 
resulting from the maneuvers by the First United States Army in October and 
November 1941 with the object of suggesting methods for their prevention. On 
the basis of 1,820 cases studied, Major Fineberg made the following recom- 
mendations to lessen the number of accidents occurring during maneuvers:6 
1. Unit commanders and all officers having charge of troops should familiarize 
themselves with the most common causes of accidents and make definite plans for their 
prevention. 
2. Soldiers should be given careful instruction in getting on and off trucks. Greater 
caution should also be exercised to keep men from falling out of moving vehicles. 
3. More careful and more thorough training of drivers should be attempted. Also, 
more frequent changing of drivers who are exhausted or who are on the point of falling 
asleep should be effected. 
4. Soldiers should be instructed to walk on the proper side of the road, and to rest 
and sleep in places where a vehicle is not likely to strike them. 
5. Drivers should not suddenly start vehicles which have been standing for a long 
time without first looking around and underneath the vehicle. 
6. Irregularities of the terrain in the camp site and objects over which they might 
stumble in the dark should be pointed out to the soldiers. 
7. An attempt should be made to guard against branches striking the eyes. 
8. Soldiers should be instructed in the proper method of lighting and caring for 
gasoline stoves and in the proper method of handling gasoline. 
9. Soldiers should be cautioned against letting ammunition, even supposedly blank 
ammunition, get close to the fire. 
6 Cohen, S. A. : Accidents in the Army and their prevention. Mil. Surgeon 87 : 434-443, Nov 1940. 
6 Fineberg, M. H.: A survey of the accidents resulting from Army maneuvers with recommenda- 
tions for their prevention. Mil. Surgeon 91 : 75-81, Jul 1942. ACCIDENTAL TRAUMA 
241 
10. Players participating in sports should be more adequately protected and more 
carefully supervised. 
11. More care should be taken to prevent objects from falling on soldiers. 
12. Fights and brawls might be lessened by better discipline with specific reference to 
drinking and gambling. 
13. Soldiers should be instructed in the proper method of lifting heavy objects. 
14. Inexperienced soldiers should be given pointers on how to use an axe. 
15. Rings should not be worn by soldiers on maneuvers. 
ACCIDENT PREVENTION DURING WORLD WAR II 
General Policy 
Prior to the mobilization for war, safety activities were carried on with 
varying emphasis by several of the supply services as a part of plant protection. 
The Ordnance Department had a special safety section for problems related 
to explosives, and cooperation was maintained with the Corps of Engineers in 
building new powder and loading plants. This was an important move in 
the direction of prevention. The major emphasis in plant protection was 
devoted to fire, espionage, and sabotage. However, after 7 December 1941 
accident prevention was stressed more strongly and considerable attention was 
given to the conservation of manpower. At that time the problem of concen- 
tration of effort was considered. Procurement of war material was considered 
of prime importance and safety efforts were turned in that direction rather than 
on troop activities. 
In March 1942, the Plant Protection Division, Office of Under Secretary of 
War, was transferred to the Provost Marshal General’s Office, and combined 
with the Emergency Operations Division to form the Internal Security Divi- 
sion. This placed the policy making responsibilities in the hands of The 
Provost Marshal General. 
Reorganization of the Army (War Department General Orders 85, 1942), 
resulted in changing corps areas to service commands and transferred adminis- 
trative functions from the procurement services to the service commands. In- 
ternal security and accident prevention were included in this transfer, and 
technical services were given certain responsibilities. The Chemical Warfare 
Service and Ordnance Department were given the responsibilities for con- 
tinuing protection of field installations and facilities and manufacturing, stor- 
ing, and processing explosives and allied substances. Since the Chief Signal 
Officer, Quartermaster General, and Surgeon General procured only inert items, 
they were assigned no responsibility for continuing protection. 
Army Service Forces Safety Program 
The Services of Supply Safety Program (later the Army Service Forces 
Safety Program) was established on 31 August 1942.7 The policies and pro- 
7 SOS Cir 55, 31 Aug 42. 242 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
cedures which had governed accident prevention in the Internal Security Pro- 
gram were greatly expanded. The loss of valuable manpower, and the result- 
ing costly delays in war production, were cogent reasons for a comprehensive 
and aggressive accident prevention program in all plants and facilities vital to 
the war effort. Coordination between numerous governmental and private 
agencies engaged in various phases of accident prevention was stressed. Pri- 
mary responsibility was given to the commanding officer of a Government- 
operated plant or facility and to the owner and operator of a privately operated 
plant or facility. The Provost Marshal General was charged with the prepara- 
tion of general policies; supervision over accident prevention activities within 
the Services of Supply; and coordination in Washington with the Department 
of Labor, Bureau of Mines, War Production Board, Office of Civilian Defense, 
War Manpower Commission, the Navy Department, and numerous voluntary 
organizations including the National Safety Council, National Conservation 
Bureau, and National Bureau for Industrial Protection. The responsibilities 
of the Chief of Ordnance, Chief of Chemical Warfare Service, Chief of Trans- 
portation, and Chief of Engineers were outlined, but no mention of The Sur- 
geon General was made. 
In December 1942, the War Department Safety Council was organized.8 
It consisted of representatives of the technical services and staff divisions of 
the Army Service Forces, the Army Air Forces, and the Navy. The officer in 
charge of occupational medicine matters in the Preventive Medicine Service, 
Office of The Surgeon General, United States Army, was designated to represent 
the Medical Department on that council. This council met once a month for 
discussion of War Department safety problems. In addition, annual meetings 
were held and were attended by representatives of civilian safety organizations. 
Because of high admission rates for nonbattle injury in the United States, 
the scope of the safety program turned from production workers to military 
personnel. The first accident frequency reports had been tabulated in January 
1943 and covered private plants. Reporting injuries of military personnel was 
established late in 1944 by adapting the morbidity reports program of The 
Surgeon General.9 The accident rate of soldiers on furlough, leave, or pass 
was considered high, and in June 1944 War Department Pamphlet 21-10 
“Private Droop has Missed the War” was published for distribution. In the 
fall of 1944 a War Department general safety manual, TM 2-350, was pub- 
lished. There is no mention that the Medical Department had any part in the 
preparation of this manual. Also in the fall of 1944, a bimonthly publication, 
“Safety Information,” was started. Five issues were published before it was 
discontinued. 
8 Memo, Chief of Staff, US Army, for PMG, 5 Dec 42, sub: War Department Safety Council, 
HD: 322. 
8 WD Cir 438, 14 Nov 44. ACCIDENTAL TRAUMA 
243 
In February 1944, an advisory board on fire and accident prevention was 
established in the Office of the Under Secretary of War.10 Membership in- 
cluded the Assistant Provost Marshal General as chairman; the Director, Con- 
trol Division, Army Service Forces; and the Air Provost Marshal. There 
were 2 additional members to serve in matters concerning fire prevention and 2 
additional members on matters concerning safety measures. The Director of 
the Occupational Health Division, Preventive Medicine Service, Office of The 
Surgeon General, was 1 of the members representing safety. One of the func- 
tions of the board was to report quarterly to the Under Secretary of War 
providing factual data as to important trends of fire and accidents, both in 
actual number and as related to exposure, making necessary recommendations 
where other agencies of the War Department had previously refused or neglected 
to take action. 
In September 1945, a revision of the accident reporting system and a 
restatement of policy was published.11 The Provost Marshal General was given 
the responsibility for the collection and analysis of accident statistics for Army 
Service and Ground Forces, the coordinated safety activities with appropriate 
governmental and private agencies, and with The Surgeon General, Director 
of Military Training, and Director of Personnel. The Surgeon General was 
given the responsibility of: (1) assisting The Provost Marshal General and 
Director of Military Training in determination of doctrine and in preparation 
of texts, manuals, and other aids for safety training of military personnel, and 
(2) coordinating with the Army Safety Program, his program for control and 
reduction of occupational diseases. 
The new reporting system went into effect 1 November 1945 so that direct 
responsibility for collecting information on accidents now rested with The 
Provost Marshal General. One new “Report of Injury” form for use in record- 
ing accidental injuries to all types of personnel, and three new forms for sum- 
marizing accident frequency, causal data at posts and service commands, and 
technical services were provided. All accident data were to be routed through 
safety personnel of each echelon to The Provost Marshal General. In October 
1945, the War Department Safety Council was abolished, as was the Fire and 
Accident Advisory Board.12 The Army Safety Program participated in 
National Safety Congresses of 1942, 1943, and 1944. Among the speakers at 
these conferences was The Surgeon General of the Army. 
Occupational Health Division, 
Preventive Medicine Service 
The Occupational Health Division of the Preventive Medicine Service of 
the Surgeon General’s Office developed the occupational health program which 
10 WD Memo W850-44, 8 Feb 44. 
« ASF Cir 360, 25 Sep 45. 
I2 WD Cir 305, 5 Oct 45. 
346336 O—55 17 244 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
was carried throughout the war. In January 1944, the director of the Occu- 
pational Health Division recommended that a program of accident prevention 
be established for military personnel because of the high admission rate in 
Army hospitals for nonbattle injuries. He cited the value of such a program 
in industry and suggested to the Chief, Preventive Medicine Service, that an 
accident prevention division be established. This was not approved by The 
Surgeon General because accident prevention was not considered as a primary 
function of the Surgeon General’s Office although its importance was recog- 
nized, and cooperation with other agencies continued. The Occupational 
Health Division assisted in the preparation of War Department Circular 252, 
20 June 1944, sponsored by the Office of The Surgeon General. This circular 
gave directions by which medical officers in the field would prepare reports in all 
cases of accidental injury to military personnel, to be used by accident preven- 
tion officers. 
The activities of the Occupational Health Division, Preventive Medicine 
Service, Office of The Surgeon General, endeavored to promote high standards 
of industrial medicine. The replacement examinations contributed to the 
accident prevention program by listing the number of individuals being placed 
on jobs beyond their physical capacities. A worker with defective vision, if 
placed on a job requiring perfect vision, would be likely to have accidents. The 
control of environmental factors such as toxic dusts, noise, and illumination 
may also be contributing factors in accidents. A worker may be partially 
overcome by some toxic fumes and perform his activities in such an abnormal 
manner as to receive an accidental injury. Such contributions are difficult to 
evaluate from statistics because of the many variables involved, but should be 
considered as an essential part of the overall program of accident prevention. 
Activities Overseas 
IMPORTANCE OF THE PROBLEM 
A comparison of nonbattle injury death rates and admission rates for 
troops stationed overseas and in continental United States reveals that both 
the admission rates and the death rates were much higher overseas (Charts 
3 and 4). In many theaters active accident prevention campaigns were devel- 
oped and in most instances the surgeon provided an analysis of the situation 
from medical records, as reporting of accidents overseas through the Army 
Safety Program was not instituted until after the war. There were also many 
special studies on automobile accidents, poisoning, and burns. Additional 
studies were made on cold and heat trauma, suicides, and self-inflicted wounds, 
but under the scheme of Chart 2 these conditions have been separated from 
accidental trauma and will be covered in other portions of the history. ACCIDENTAL TRAUMA 
245 
OVERSEAS 
CONTINENTAL U.S. 
Chart 3. United States nonbattle injury death rates, per 1,000 per annum, continental 
United States and overseas, These are preliminary data based on statistical 
health reports. 
In the European theater the theater surgeon had the responsibility of 
collecting statistical information on nonbattle injuries and presenting it to 
the provost marshal of the theater.13 The Preventive Medicine Division, Office 
of The Chief Surgeon, European Theater of Operations, prepared extensive 
analyses of nonbattle injuries for 1942, 1943, and the first half of 1944, the 
period immediately preceding continental operations. Because the major prob- 
lems of trenchfoot and typhus control required the maximum utilization of 
the staff on the Continent, detailed analyses for the continental period were not 
made; but general features of accidents and injuries were abstracted and de- 
tailed studies made of specific problems. In 1943 a special study of automobile 
accidents was made. 
13 Gordon, J. E. : A history of preventive medicine in the European Theater of Operations, U. S. 
Army, 1941-1945. HD: 314.7-1. 246 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
OVERSEAS 
CONTINENTAL U.S. 
Chart 4- United States Army nonbattle injury admissions to hospital and quarters, 
per 1,000 per annum, by month, continental United States and overseas. These are pre- 
liminary data based on sample tabulations of individual medical records. 
Because of the importance of nonbattle injuries as a source of noneffective- 
ness in the Southwest Pacific in 1944, an investigation was made under the 
direction of a specially trained Sanitary Corps officer.14 The Surgeon, Head- 
quarters, Mediterranean Theater of Operations, brought to the attention of the 
theater staff in 1944 the extent of the manpower loss resulting from injuries, 
and a safety committee was formed which developed a safety program.15 The 
Army Service Forces Monthly Progress Report, Section 7, “Health,” dated 
31 July 1944 stated: 
Because of the importance of nonbattle injury as a source of non effectiveness, there 
has long been evident a need for an adequate and effective control program, both in the 
Continental U. S. and overseas. During 1943 nonbattle injuries overseas caused a loss of 
almost four million man-days and battle injuries a loss of perhaps half this amount. The 
loss of time from nonbattle injuries is in large part preventable by means of a suitable 
control program. 
H ETMD, SWPA, Jim 1944. HD : 350. 
16 Final Rpt, Prev Med Off, Off of Surg NATOUSA, 2 Nov 45. HD. ACCIDENTAL TRAUMA 
247 
DEATHS 
Nonbattle injuries were responsible for 32,914 deaths overseas, a rate of 
3.06 per thousand per annum, compared with 27,140 deaths in the United States, 
a rate of 1.84 per 1,000 per annum for the period 1942-45 (Table 12). 
An analysis of deaths in the South Pacific area 1 September 1942 to 31 
August 1944 revealed deaths from battle causes as 2,588, nonbattle casualties 
765, disease 166, suicides 51, and cause undetermined 12.16 The survey in the 
Southwest Pacific revealed during the year of 1943:17 
Killed in action 930 
Nonbattle casualty 574 
Disease 152 
Died of wounds 94 
During the period October 1944 to June 1945, inclusive, there were more deaths 
in the European theater due to a single agent, alcohol poisoning (178), than 
to acute communicable disease (162).18 
18 ETMD, SOPAC Base Comd, 16 Nov 44. HD : 350.05 
17 See footnote 14, p. 246. 
18 See footnote 13, p. 245. 
Table 12. Deaths Due to Nonbattle Injuries in the United States Army, by 
Theater of Admission and Year of Death, 1942-45 
Preliminary Data Based on Tabulations of Individual Medical Records 
Theater 
Total 
1942-45 
1942 
1943 
1944 
1945 
Number 
Total Army 
60, 054 
6, 751 
15, 561 
19, 053 
18, 689 
United States 
27, 140 
4, 850 
9, 764 
8, 211 
4, 315 
Overseas 1 
32, 914 
1, 901 
5, 797 
10, 842 
14, 374 
North America 2_ 
1, 493 
359 
622 
297 
215 
Latin America 
1, 587 
385 
509 
487 
206 
Europe 
12, 484 
199 
779 
4, 058 
7, 448 
Mediterranean 3 
6, 644 
149 
1, 915 
2, 277 
1, 303 
Middle East _ 
538 
22 
174 
256 
86 
China, Burma, India 
Pacific Ocean Areas 4 
2, 525 
J 8, 557 
73 
f 348 
285 
866 
1, 021 
} 2, 431 
1, 146 
3, 943 
Southwest Pacific 4 
1 340 
629 
See footnotes at end of table. 248 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Table 12. Deaths Due to Nonbattle Injuries in the United States Army, by 
Theater of Admission and Year of Death, 1942-45—Continued 
Theater 
Total 
1942-45 
1942 
1943 
1944 
1945 
Annual rate per 100,000 mean strength 8 
Total Army 
235. 70 
208. 19 
226. 49 
244. 55 
246. 
72 
United States 
184. 09 
182. 54 
188. 40 
206. 73 
147. 
19 
Overseas 1 
306. 57 
324. 53 
343. 44 
283. 88 
309. 
56 
North America 2 _ 
303. 21 
356. 80 
319. 83 
229. 81 
315. 
85 
Latin America 
416. 10 
377. 74 
421. 24 
567. 61 
282. 
81 
Europe. 
283. 78 
239. 74 
291. 97 
241. 96 
313. 
96 
Mediterranean 3 
380. 57 
649. 92 
419. 30 
350. 54 
368. 
24 
Middle East 
368. 00 
363. 88 
328. 03 
553. 91 
210. 
32 
China, Burma, India 
575. 85 
834. 67 
719. 37 
605. 19 
517. 
60 
Pacific Ocean Areas 4 
J276. 62 
|230. 53 
297. 02 
J248. 58 
279. 
28 
Southwest Pacific 4 
1477. 37 
331. 21 
1 Includes admissions on transports. 
2 Includes Alaska and Iceland. 
3 Includes North Africa. 
4 Not available separately in 1944 and 1945. 
5 The strengths on which these rates were based are mean strengths and will vary therefore from the official strength 
reports of The Adjutant General. 
ADMISSIONS 
The admission rates to hospital and quarters for nonbattle trauma in over- 
seas theaters were variable. In some areas, mainly the European theater, Medi- 
terranean theater, and Alaska, the cold injury which is a component of nonbattle 
trauma was a large factor during the seasons of cold weather. In the Southwest 
Pacific area, a survey of 16,486 completed cases tabulated from the April 1944 
admissions showed that 2,676 or 16 percent were admitted for nonbattle injury.19 
NONEFFECTIVENESS 
Much of the military significance of the admission rate derives from the 
length of time the patients remain noneffective. A study was made of the 
average days lost per admission for troops overseas to hospital or quarters for 
the year ending 30 June 1944.20 The average number of days lost per admission 
was 48 for wounded, 13 for disease, and 19 for nonbattle injury. This excludes 
time lost subsequent to evacuation to the United States. There is a presumption, 
therefore, that these data are somewhat understated in terms of the true non- 
effective time. The report of this study further states, “The fact that the aver- 
19 ASF Monthly Progress Rpt, Sec. 7, Health, 31 Jul 44. 
20 ASF Monthly Progress Rpt, Sec. 7, Health, 31 Jan 45. ACCIDENTAL TRAUMA 
249 
age patient suffering from an accidental injury loses 40 percent more time than 
the average disease patient helps to explain the tremendous drain on manpower 
which accidents cause overseas as well as at home.” 
A study of surgical dispositions was made for March through June 1944 
in the South Pacific.21 Of 14,738 dispositions there were 3,877 injury patients 
with an average stay of 28 days; 3,604 were returned to duty; 243 were evacuated 
to the Zone of Interior; and 30 died. A detailed distribution of events is given 
in Table 13. The type of injury and days lost wTere tabulated. Accidental dis- 
charge of guns and ammunition caused 11 percent of the days lost, had the 
highest average of days lost, and the lowest percentage of return to duty 
(Table 14). The dispositions were also divided into specialty fields, with 47.5 
percent orthopedic and 44.9 percent general (Table 15). During the 4 months, 
accidental injuries cost 92,869 man-days lost, or an equivalent of an entire 
division for a week. 
DISABILITY 
Disability in an overseas theater cannot be measured by discharges from 
service, but can be by evacuations to the Zone of Interior, as these represent a loss 
to the theater. This varied in different theaters depending on the individual 
evacuation policy. An analysis was made of the cause of evacuation of nonbattle 
injuries to the Zone of Interior from the European theater of command for 
1943. Of the 24,919 men admitted to hospital for nonbattle injury, 1,1 percent 
were evacuated to the Zone of Interior (3.2 percent died).22 In the Southwest 
Pacific during 1943 there were 751 nonbattle injuries evacuated to the United 
States, compared with 551 battle casualties.23 The South Pacific Base Command 
Table 13. Surgical Dispositions, South Pacific Base Command, United States 
Army, March-June 1944 
To duty 
To Zone of Interior 
Deaths 
Total 
Type of cases 
Patients 
Average 
hospital 
days 
Patients 
Average 
hospital 
days 
Patients 
Average 
hospital 
days 
Patients 
Average 
hospital 
days 
Surgical disease 
8, 639 
21 
564 
57 
9 
8 
9, 212 
23 
Injury 
3, 604 
25 
243 
72 
30 
4 
3, 877 
28 
Battle casualty 
873 
29 
286 
55 
23 
9 
1, 182 
35 
No disease 
466 
12 
1 
62 
0 
0 
467 
12 
Total 
13, 582 
22 
1, 094 
60 
62 
6 
14, 738 
25 
Source: ASF Monthly Progress Rpt., Sec. 7, Health, 31 Jan 45. 
21 See footnote 20. p. 248. 
£S> See footnote 13, p. 245. 
23 See footnote 14, p. 246. 250 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Table 14. Causes of Nonbattle Injury, United States Army, South Pacific Base 
Command, March-June 1944 
Cause of injury 
Number of 
Hospital days 
Percent 
returned 
to duty 
patients 
Total 
Average 
Falls and jumps, _ 
706 
21, 420 
11, 149 
8, 650 
10, 775 
9, 377 
10, 018 
3, 659 
2, 393 
30 
96. 9 
Moving objects _________ 
474 
24 
95. 4 
Organized athletics 
385 
22 
96. 6 
Moving vehicles 
368 
29 
88. 9 
Burns 
354 
26 
95. 5 
Accidental discharge of guns and ammunition 
235 
43 
78. 7 
Sharp objects.. _ 
171 
22 
96. 5 
Lifting. 
135 
18 
99. 3 
Assault 
135 
3, 090 
23 
95. 6 
Unspecified 
467 
12’ 438 
27 
93. 4 
Total* 
3, 430 
92, 869 
27 
93. 9 
‘These represent cases among the 3,877 shown in Table 13 which were considered to be acute. 
Source: ASF Monthly Progress Rpt., Sec. 7, Health, 31 Jan 45. 
Table 15. Classification of Injury Dispositions by Surgical Special Fields, United 
States Army, South Pacific Base Command, March-June 1944 
Special field 
Percent of 
patients 
Percent of 
hospital days 
Average stay 
in days 
Percent re- 
turned to duty 
Orthopedic 
47. 5 
56. 3 
33 
92. 9 
General 
44. 9 
37. 1 
23 
94. 9 
Neurosurgery 
3. 4 
4. 1 
33 
71. 5 
Eye _ - -------- -- - -- 
2. 5 
1. 6 
17 
85. 7 
Ear, nose, throat 
1. 2 
. 6 
14 
95. 8 
Urology _ 
. 5 
. 4 
21 
95. 0 
Total 
100. 0 
100. 0 
28 
93. 0 
Source: ASF Monthly Progress Rpt, Sec. 7, Health, 31 Jan 45. 
evacuated 243 out of 3,877 injury dispositions, or 6.3 percent during the 4-month 
period from March through June 1944.24 
OVERSEAS ACCIDENTS AS AN ECOLOGIC PROBLEM 
In the study of mass disease the causes of origin ana course are multiple. 
They reside in influences sometimes associated with an agent of disease, a 
24 See footnote 20, p. 248. ACCIDENTAL TRAUMA 
251 
particular inciting cause; sometimes in innate or acquired characteristics of the 
host or population that suffers the disease or injury; and almost invariably in 
the many features of the environment in which both agent and host find them- 
selves. An ecologic approach to causality is helpful in formulating a control 
program, for intelligent action depends upon a direct attempt to eliminate or 
modify identified causes. In any specific situation, causative factors are ex- 
pected from all three general sources. Commonly one may exert dominant 
action, but rarely to the exclusion of all others. The complex of causation is 
an association of multiple factors. 
Agents Acting in Accidents 
In current considerations of accidental trauma, much variability exists 
in the use of the several terms of agent, agency, mechanism, and action. Many 
reports follow a common classification. Others employ an entirely different 
arrangement, sometimes unique and sometimes a mixture of many different 
classifications. This makes comparison difficult, and in some instances 
impossible. 
One feature becomes strongly evident, namely an appreciable difference in 
death and admission rates for accidents, when these are arranged according to 
the various agents involved. This is clearly visible in the 1939 figures in Table 
11. Aircraft injuries have a high mortality, but a low admission rate. During 
the first year of World War II, 1942, for which preliminary tabulations of indi- 
vidual medical records have been made, deaths due to aircraft accidents account 
for 44 percent of the total deaths from nonbattle injury in the Army, but only 
1.8 percent of admissions for this class. The numbers of aircraft used in various 
areas influenced the death rates from accidental injury in that area. In Table 16 
a comparison of death rates from nonbattle injury in continental United States 
and overseas for the year 1942 reveals a much higher death rate overseas for 
aircraft, firearms and ammunition, and for athletics and sports, while death 
rates from injury due to motor vehicles, fire, and heat were about equal. In 
three specific studies overseas, aircraft, automotive, drowning, and firearms- 
explosive accidents accounted for 72.5 to 85.2 percent of the total deaths from 
nonbattle injury in those areas (Table 17). 
In the Southwest Pacific area in 1943, 54.5 percent of accidental deaths 
were associated with air transportation. Since that group was judged to con- 
stitute a special problem of control, accidental deaths related to aircraft, along 
with suicides and homicides, were excluded from nonbattle injury deaths by 
cause. Under that modification, automobiles were then responsible for 24,8 
percent of all accidental deaths, firearms for 23.5 percent, and drowning 19 
percent.25 
26 ASF Monthly Progress Rpt, Sec. 7, Health, 31 Jul 44. 252 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Table 16. Deaths Due to Nonbattle Injuries in the United States Army, by 
Area of Admission and Causative Agent, 1942. 
Preliminary Data Based on Tabulations of Individual Medical Records 
Causative agent 
Total Army 
Continental 
United States 
Overseas 
Number 
Total- _ 
6, 751 
2, 986 
1, 489 
963 
4, 850 
2, 122 
1, 222 
555 
1, 901 
864 
Aircraft accidents _ 
Vehicle accidents _ _ __ 
267 
Firearms and ammunition _ 
408 
Falls, jumps. 
106 
77 
29 
Athletics and sports 
124 
88 
36 
Ill-fitting clothing 
Fire or heat 
60 
49 
11 
Tools, instruments 
64 
57 
7 
Chemicals 
128 
98 
30 
Excessive heat 
29 
26 
3 
Excessive cold 
3 
1 
2 
Other agents 
799 
555 
244 
Annual rate per 100,000 mean strength 
Total 
208. 19 
182. 54 
324. 53 
Aircraft accidents. 
92. 09 
79. 86 
147. 50 
Vehicle accidents 
45. 92 
45. 99 
45. 58 
Firearms and ammunition 
29. 70 
20. 89 
69. 65 
Falls, jumps 
3. 27 
2. 90 
4. 95 
Athletics and sports 
3. 82 
3. 31 
6. 15 
Ill-fitting clothing 
0 
0 
0 
Fire or heat_. 
1. 85 
1. 84 
1. 88 
Tools, instruments . 
1. 97 
2. 15 
1. 20 
Chemicals 
3. 95 
3. 69 
5. 12 
Excessive heat 
. 89 
. 98 
. 51 
Excessive cold 
. 09 
. 04 
. 34 
Other agents 
24. 64 
20. 89 
41. 65 
Other variations in agent pattern included snakes and other reptiles as a 
biologic contribution to the more common physical agents of disease. In no 
theater did they play a prominent role in accidental trauma. 
Among chemical agents in accidental injury, methyl alcohol was a con- 
siderable factor during the continental phase of operations in the European 
theater. An interesting variable of agents active overseas was the cited in- 
stance during 1 month in a Pacific island area when 50 percent of the nonbattle 
injury deaths were due to falling trees, weakened by preinvasion naval gunfire.26 
28 ETMD, SPA, 2 Dec 43. HD : 350.05. ACCIDENTAL TRAUMA 
253 
Table 17. Principal Causes of Accidental Death, Selected Theaters of Operation, 
World War II, United States Army, by Percent of All Accidental Deaths 
Theater and year 
Aircraft 
Motor ve- 
hicle 
Drowning 
Firearms, 
explosives 
European: 1943 1 
54. 5 
13. 0 
2. 5 
8. 5 
Southwest Pacific: 1943 2 __ 
54. 5 
11. 3 
8. 7 
10. 7 
North African: January-May 1944 3_ 
30. 3 
21. 8 
5. 1 
18. 5 
South Pacific: September 1942-August 1944 4 
30. 6 
12. 0 
21. 7 
20. 2 
1 Gordon, J. E.: History of preventive medicine in European Theater of Operations, 1941-1945. HD: 314.7-2. 
2 ETMD, SWPA, Jun 1944. HD; 350.05. 
3 ASF Monthly Progress Rpt, Health, 30 Sep 44. 
4 ETMD, SOPAC Base Comd, Nov 1944. HD: 350.05. 
Host or Population Factors in Causation 
Many factors, such as anatomic structure, physiologic state, psychical con- 
stitution, and intrinsic characters contribute to accidents just as to disease. 
The initial physical examination upon entrance into the service eliminates 
many physically handicapped individuals. However, there are special assign- 
ments in various branches of the services which make greater demands on 
physical qualification than are called for by entrance requirements to service. 
Complicated mechanized army equipment should be designed with considera- 
tion of the physical limitations of individuals operating the equipment. Con- 
siderable research initiated by the Preventive Medicine Service, Office of The 
Surgeon General, was conducted at the Armored Medical Research Laboratory 
at Fort Knox, Kentucky, on anthropometric measurements especially in relation 
to the design of tanks. Studies were also made on the physiologic and. psycho- 
logic requirements of tank crews. This material was turned over to the Ord- 
nance Department for use in the design of tanks. 
Fatigue. Fatigue is another important factor. A fatigued individual 
often reacts sluggishly to stimuli at a time when precision and accuracy are 
essential and thus the liability to accidents is increased. In an overseas theater 
this factor is of no small consequence, because of the many circumstances calling 
for extreme effort. 
Alcohol. Increased blood alcohol levels are capable of altering the re- 
action of individuals and may be a factor in the production of accidents. In 
the 1939 Army survey,27 in 636 out of 19,707 injuries, or 3,2 percent, alcohol 
was considered a contributing factor. In one Australian mainland base, sur- 
veyed over a 3-month period in 1943, in patients with nonbattle injuries entering 
general hospitals of the base, the influence of alcohol was assessed as follows:28 
27 Annual Report of The Surgeon General, U. S. Army, 1940. Washington, Government Printing 
Office, 1941. 
38 See footnote 25, p. 251. 254 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
.... Sixty percent of the days lost were attributable to traffic accidents, in 6 percent 
of which alcohol was a contributing factor. Twenty-seven percent of the days lost were 
allocated to burns, and 13 percent to personal assaults and injuries. In 49 percent of 
the latter group alcohol was a contributing factor. 
In overseas areas during active operations, the availability of alcohol varies 
greatly. When beer and whiskey are not available, substitutes in the form of 
methyl alcohol, canned heat, and antifreeze have been used, all with serious 
toxic hazards. 
Accident Proneness. Another inherent factor on causalty of accidents is 
the concept of accident proneness. The characteristic is otherwise referred to 
as that of accident repeaters or the accident habit. Such a concept raises the 
question of possible differences among individuals in liability to accidents, and 
if such differences exist, how they can be detected. A considerable amount of 
literature on accident proneness had been published before the onset of World 
War II but these studies had brought no definite tests for identification of such 
individuals. Flanders Dunbar 29 reported the results of psychosomatic studies 
among industrial workers and members of the Armed Forces. In a psychoso- 
matic study of cardiovascular and diabetic patients a control group had been 
selected, composed of patients with fractures admitted to the same hospital. 
On the basis of observations on these patients with fractures the author felt 
that the accident-prone person belonged to a personality type which could be 
described with fair accuracy. Such individuals give a history of a large number 
of previous accidents, and a lack of colds, indigestion, or other “vegetative dis- 
turbances.” They did not finish educational courses which they undertook, 
whether grammar school, high school, or college. They had an unstable work 
record and changed jobs frequently. There was a tendency to focus on imme- 
diate values rather than on long-range goals, to appear casual about feelings 
and personal problems, and to avoid responsibility—to live from day to day. 
Dunbar concluded by stating: 
I would suggest that those persons in charge of selective service or industrial activity 
be on the lookout for persons of the types here delineated and that such persons be given 
special attention in placement and treatment. It has been suggested, for example, that 
a person who is accident prone would probably do better in a commando or a paratroop 
unit or in some other more or less individualized and adventurous assignment, just as 
persons who are potential sufferers from cardiovascular disease, if they follow the 
coronary or anginal pattern, will do better and maintain health longer if given recognition 
and authority. 
Whether better suggestions than these could be made will remain for those in charge 
of Army personnel to discover. The aim in this article was merely to call attention to 
the possibility of excluding from service persons with a well confirmed accident habit 
who may prove to be a liability to themselves and others or of placing them in such 
a way that their liabilities may prove if not an asset at least a minimal danger. 
29 Dunbar, F.: Medical aspects of accidents and mistakes in the industrial army and in the 
Armed Forces. War Med. 4: 161-175, Aug 1943. ACCIDENTAL TRAUMA 
255 
In considering whether such persons should be rejected, carefully placed or treated, 
the material given here may be useful. Because of the limited time and personnel avail- 
able for medical and psychiatric examination, it seems obvious that the greatest possible 
use should be made of social workers and public welfare agencies in supplying the 
specific details of past history here indicated as having a bearing on the problem. 
The fact cannot be too much emphasized that persons whose histories suggest 
accident proneness are of most vital interest. Such persons can make the kind of 
mistake that sinks a ship, loses a battle or explodes a munitions plant. And apart from 
its consequences, the mistake will appear to be just the kind of unfortunate mistake that 
any one might make. But, nevertheless, there is evidence that only certain types of 
people make such mistakes. 
Personality Changes. Menninger,30 after the war, brought attention to 
the personality factor in accidents by stating, “A small minority of combat 
soldiers were unable immediately to rechannel their aggressive behavior into 
socially approved activity. Following YE and VJ days in the various theaters, 
although no figures are available, it was apparent that automotive and traffic 
accidents increased.” 
Brigadier General Bliss 31 in a letter to the Army Assistant Chief of Staff 
G-4, 23 August 1945, stated: “Early termination of hostilities in the Pacific will 
result in an immediate increase in anticipated evacuations from that area rather 
than the reverse. However, most of these evacuees will represent disease and 
non-battle injury patients rather than battle casualties.” 
The intrinsic characteristics of age, sex, and race were not analyzed in 
respect to accidents during the war experience of 1941-45. Alterations in age 
composition for the Army as a whole were recognized, primarily as a reflection 
of changes in the draft policy bringing a lower age at induction. A correlation 
with frequency of accidents is not known. 
Environment 
Physical aspects of the environment of man, such as weather, climate, 
season, soil, and terrain, were factors exerting a measurable influence on the 
incidence of accidents in different areas. In the United States a definite 
seasonal variation in incidence of admissions was observed for nonbattle injury. 
(See Chart 4.) Speculation could be offered as to the precise influence arising 
from these physical factors of environment as such, but data are insufficient 
for true evaluation. 
The consideration of population pressures, crowding, density, and extent 
of movement are given considerable attention in evaluating causal factors in 
mass disease. An excellent illustration that these social factors of the environ- 
ment contribute to accidents, along with others relating to host and to agents, 
30 Mennlnger, William C.: Psychiatry in a Troubled World. New York, Macmillan, 1948, see 
p. 150. 
31 Ltr, Brig Gen R. W. Bliss, Asst SG, to ACofS G-4, thru CG ASF, 23 Aug 45, sub: Zone of 
Interior hospitalization. SG : 322 Hospitals. 256 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
is seen in the 1945 annual report of the 8th Evacuation Hospital in the Medi- 
terranean Theater of Operations. The report states:32 
The surrender of the German Army created the problem of handling thousands of 
German troops. . . . The overturning of one 10-ton trailer killed several and put the 
remainder of the 50 Germans in the hospital. During May, the roads were filled with a 
great variety of German vehicles, many of them in rather bad repair, manned by German 
drivers and transporting Germans to P. O. W. stockades at Modena, Florence and points 
south, . . . 
With the end of the war, a great deal of confusion arose. Added to the stream of 
German Prisoners of War were thousands of Italian civilians who suddenly decided to 
go somewhere other than where they were located. Roads were crowded with civilians, 
men, women, children and infants in arms, on foot, bicycles, carts, wagons, old cars and 
dilapidated trucks. Displaced persons and repatriated individuals trying to get home 
added to the confusion. 
Military personnel seemed also affected by the rush and confusion and continued 
to operate vehicles at high speed and in a reckless fashion. Accidents were frequent 
and tragic. A truck load of Russians, formerly German prisoners and labor troops, 
returning to Russia, overturned, killing one woman and sending 15 other individuals to 
the hospital. Italian civilians scrambling into an abandoned German ammunition dump 
for wooden boxes, precipitated an explosion that killed many and put 18 civilians in the 
hospital. 
A regiment of Czechoslovakian troops sent numerous patients to the hospital. Ger- 
man Prisoners of War continued to be admitted for illness and injury until the Prisoner 
of War hospital at Mantova began to function. During May, 592 patients out of a total 
of 2,183 admissions were due to accidents of various kinds, including accidental gunshot 
injuries. With the break-up and surrender of the German Army, unfamiliar weapons 
fell into the hands of the Allies as captured material and souvenirs. During the month 
of May, 42 soldiers shot themselves, and 31 more were shot by their buddies, while 
handling enemy guns, usually pistols. 
In the European theater following V-E Day, the Commanding General, 
Third United States Army, undertook special measures, such as intensifying 
the activities of Military Police patrols on main highways, in order to curb 
motor accidents involving military personnel and resulting from speeding and 
reckless driving. It is an ironical fact that several months thereafter he 
himself died as the result of a motor accident. 
A separation of accidents by rank and service was made in the Southwest 
Pacific theater in April 1944 (Table 18) representing in all some 2,676 cases. 
Although personnel of the Corps of Engineers suffered 17 percent of the 
injuries, no statement of strengths was provided by which to determine rates.33 
The Fifth United States Army conducted a study of battle casualties and 
nonbattle casualties from the standpoint of military occupational specifications 
(Table 19).34 The observations were based on the experience of the 3d, 84th, 
36th and 45th Infantry Divisions while in combat between 9 September 1943 
32 Annual Rpt, 8th Bvac Hosp MTO, 1945. HD. 
33 See footnote 14, p. 246. 
34 Monthly Progress Rpt, Sec. 7, Health, Sep 1944. ACCIDENTAL. TRAUMA 
257 
and 4 April 1944. The experience was thus heavily weighted by winter opera- 
tions. During this period the rates were 8.7 for battle casualties and 4.7 for 
nonbattle casualties. For the Fifth United States Army during the period 
December through March the average rates were 1.2 for battle casualties and 
3.3 for nonbattle casualties. For the Mediterranean theater as a whole, from 
1 October 1943 to 1 April 1944, the rates were 0.4 for battle casualties and 3.0 
for nonbattle casualties. By a wide margin the occupation of rifleman was 
the most dangerous. Both battle and nonbattle casualty rates were about twice 
as high as those for artillerymen (gunners), the next highest group. Before 
reasonable conclusions can be made about accidents, the material must be con- 
sidered in terms of Chart 2. In the analysis under consideration, nonbattle 
casualty included both disease and cold injury. Cold injury has a high inci- 
dence among riflemen. The analysis states:35 “Combat may be said to increase 
exposure to a wide variety of diseases and injuries, to hinder the precautionary 
measures usual under non-combat conditions and to impair physical and psycho- 
logical reserves to a degree which renders the individual more susceptible to 
disease and injury.” 
A study of parachute injuries was made for the first and second years of 
parachute training at Fort Benning, Georgia.36 From a total of 89,551 train- 
ing jumps 1,386 injuries were noted, of which 272 were fractures and 2 died. 
During the first year of operations the total injury rate was 2.69 percent and 
the fracture rate 0.55 percent. During the second year the total rate was 1.48 
percent and the fracture rate 0.29 percent. The injury rate was considered low 
in view of recognized hazards of parachute jumping. The possibility of effect- 
ing further reduction in accident losses through preventive measures was an 
outgrowth of this study. 
SPECIAL STUDIES OVERSEAS 
The following special studies are included because they represent impor- 
tant contributions to the prevention of accidental trauma overseas. They 
also represent examples of what can be done with a specific problem. 
Low Back Injury 
A survey of low back injury in the Persian Gulf Command 37 was made for 
the 20 months between 1 March 1943 and 31 October 1944. The command was 
composed of supply troops of all branches. A review of case records revealed 
that 466 individuals were hospitalized for one or another type of low back 
33 See footnote 34, p. 256. 
36 Tobin, W. J. ; Ciccone, R. ; Yandover, J. T., and Wohl, C. S.: Parachute injuries. Army M 
Bull. 66 : 202-221, Apr 1943. 
37 ETMD, Persian Gulf Comd, Oct 1944. HD: 350.05. 258 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Table 18. Southwest Pacific Area, United States Army Nonbattle Injuries, April 1944, by Type and Arm or Branch 
of Service (2,676 Completed Cases) 
Arm or branch of service 
Total non- 
battle 
injuries 
Lacera- 
tions 
Abrasions 
and con- 
tusions 
Other 
wounds 
Strains 
and 
sprains 
Frac- 
tures 
Burns 
Old in- 
juries 
Disloca- 
tions 
Eye in- 
juries 
All 
others 
Gasoline 
Chemical 
Others 
Total Southwest Pacific Area 
2, 676 
441 
385 
129 
777 
421 
176 
19 
102 
89 
33 
29 
75 
Officers 
22 
20 
4 
34 
18 
2 
1 
5 
6 
5 
1 
Enlisted men 
419 
365 
125 
743 
403 
174 
18 
97 
83 
28 
28 
75 
Engineers. 
442 
81 
73 
25 
108 
79 
23 
1 
16 
15 
3 
4 
14 
10 
3 
1 
3 
2 
1 
Enlisted men 
432 
81 
70 
24 
105 
77 
23 
1 
15 
15 
3 
4 
14 
Air Corps 
423 
58 
51 
26 
142 
60 
32 
1 
20 
13 
2 
9 
9 
Officers 
46 
12 
4 
2 
12 
6 
2 
3 
3 
1 
1 
Enlisted men 
377 
46 
47 
24 
130 
54 
30 
1 
17 
10 
1 
8 
9 
Infantry. 
335 
55 
48 
9 
110 
53 
20 
1 
8 
17 
3 
1 
10 
6 
1 
2 
1 
1 
1 
Enlisted men 
329 
55 
47 
9 
108 
52 
20 
8 
16 
3 
1 
10 
Quartermaster 
253 
45 
40 
4 
84 
38 
15 
10 
6 
4 
7 
5 
1 
1 
2 
1 
248 
44 
39 
4 
82 
37 
15 
10 
6 
4 
7 
Medical Corps 
179 
31 
27 
5 
48 
30 
11 
2 
8 
6 
2 
2 
7 
8 
2 
4 
1 
1 
Enlisted men 
171 
31 
25 
5 
44 
29 
11 
2 
8 
6 
1 
2 
7 
Ordnance 
168 
29 
25 
9 
43 
20 
18 
1 
10 
4 
4 
5 
5 
3 
1 
1 
163 
26 
25 
9 
42 
19 
18 
1 
10 
4 
4 
5 
Field Artillery 
119 
24 
14 
8 
31 
18 
5 
5 
4 
5 
1 
2 
2 
3 
1 
1 
1 
Enlisted men 
116 
24 
13 
7 
30 
18 
5 
5 
4 
5 
1 
2 
2 
Coast Artillery 
115 
18 
7 
9 
28 
23 
10 
5 
2 
6 
1 
6 ACCIDENTAL TRAUMA 
259 
1 
1 
114 
18 
7 
9 
28 
23 
10 
5 
2 
5 
1 
6 
Signal Corps 
112 
17 
7 
3 
30 
19 
13 
1 
8 
6 
1 
2 
5 
2 
1 
1 
Enlisted men 
no 
16 
7 
3 
30 
18 
13 
1 
8 
6 
1 
2 
5 
Cavalry 
70 
18 
5 
6 
19 
7 
10 
1 
1 
1 
1 
1 
Enlisted men 
70 
18 
5 
6 
19 
7 
10 
1 
1 
1 
1 
1 
15 
2 
4 
5 
2 
1 
1 
Others _ 
445 
63 
84 
25 
129 
72 
19 
7 
12 
13 
9 
3 
9 
17 
3 
4 
4 
3 
1 
1 
1 
Enlisted men.. 
428 
60 
80 
25 
125 
69 
19 
7 
11 
12 
8 
3 
9 
Source; ETMD, SWPA, Jun 1944. HD: 350.05. 
346336 0—55 18 260 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Table 19. Battle and Nonbattle Casualties by Military Occupation Specialty, 
Four Infantry Divisions, Fifth United States Army, October 1943 Through 
March 1944 
Military occupational specialty 
Percent of division 
casualties 
Casualties per 1,000 table 
of organization strength 
per division combat day 
Number 
Title 
Battle 
Non- 
battle 
Total 
Battle 
Non- 
battle 
Total 
745 
Rifleman 
38 1 
25 5 
30 4 
10 7 
22, 9 
603 
Gunner. _ 
8 0 
5 5 
6 4 
fi ?, 
5 5 
11 7 
663 
Squad leader 
8 1 
7 5 
7 8 
5 2 
6 9 
11 1 
761 
Scout 
1 1 
1 0 
1 0 
4 9 
5 5 
in a 
667 
Litter bearer 
1. 2 
1 7 
1 6 
3 4 
6 8 
9 2 
746 
Automatic rifleman 
3 9 
2 9 
3 4 
4 8 
4 3 
9 1 
652 
Section leader . 
1. 4 
1 7 
1 6 
3 7 
5 4 
9 1 
661 
Platoon sergeant 
1 8 
1 8 
1 9 
3 9 
4 7 
8 6 
504 
Ammunition handler. 
8. 3 
9 0 
8 7 
3 6 
4 8 
8 4 
238 
Lineman telegraph and tele- 
1. 4 
2. 0 
1. 8 
2. 7 
4. 7 
7. 4 
phone. 
675 
Messenger 
2. 6 
2 5 
2 6 
2 8 
3 3 
6 1 
610 
Antitank gunner 
1. 0 
1. 0 
1 0 
2 4 
3 3 
5 8 
060 
Cook 
. 7 
1 9 
1 4 
1 2 
4 5 
5 7 
531 
Cannoneer 
1. 2 
2 7 
2 1 
1 4 
4 2 
5 6 
246, 345 
Truck driver 
2. 6 
7. 0 
5. 3 
1. 0 
3. 5 
4. 5 
014 
Auto mechanic 
. 4 
1 0 
7 
1 0 
3 3 
4 4 
539 
Section chief.. 
. 2 
5 
4 
1 0 
3 3 
4 3 
225 
Surgical technician 
. 5 
7 
6 
1 6 
2 5 
4 0 
177 
Radio operator. 
. 5 
9 
7 
1 i 
2 4 
3 6 
521 
Basic 
4. 0 
4 1 
4 0 
1 4 
1 9 
3 3 
821 
Supply NCO 
. 2 
. 5 
3 
8 
2 6 
3 3 
695 
Orderly _ . _ 
. 2 
. 4 
3 
9 
2 1 
3 0 
405 
Clerk typist 
. 2 
. 6 
4 
5 
2 0 
2 5 
Other enlisted men 
7. 0 
13. 1 
10. 9 
1. 8 
3. 7 
5. 5 
Total enlisted men 
94. 6 
95. 5 
95. 2 
3. 7 
4. 7 
8. 4 
Officers 
5. 4 
4. 5 
4. 8 
4. 0 
4. 2 
8. 2 
Total division 
100. 0 
100. 0 
100. 0 
3. 7 
4. 7 
8. 4 
Source: ASF Monthly Progress Rpt, Sec. 7, Health, 30 Sep 44. ACCIDENTAL TRAUMA 
261 
condition, some having as many as 6 admissions. Distribution according to 
branch is shown in the following tabulation: 
Quartermaster 
Engineer 
Port personnel 
Branch 
Cases 
104 
_ _ 91 
72 
Ordnn nr>p 
71 
"Railway 
51 
Medical personnel _ 
2fi 
Military pnlire 
12 
Others 
38 
Total 466 
Of the 466 patients, 138 were truck drivers who were either actually injured 
while driving or complained of aggravated symptoms while so engaged. Of 
the 138 patients, 94 were Quartermaster Corps truck drivers, accounting for 
all but 10 of the total low back injuries sustained by Quartermaster personnel. 
Many reasons in explanation of the undue incidence were considered such as 
(1) rough roads, particularly in the early months of the command when 8 to 
12 hours were required to negotiate an average run of 150 miles; (2) hard, un- 
comfortable seats, particularly in the Studebaker 6 by 4 and 6 by 6 trucks, 
causing every bump to vibrate through the driver’s body; (3) lack of drivers’ 
belts as supports (not included in the tables of equipment) ; (4) long hours of 
driving with insufficient rest periods during peak tonnage months; (5) con- 
tinued use of army cots which develop “sags” and do not afford relaxation to 
tired back muscles; and (6) failure of the drivers to seek proper massage and 
heat for tired back muscles after a run, and failure to report the conditions 
until the symptoms were severe. Accidents were more frequent during the 
early months in the theater and, therefore, more of these injuries were incurred. 
One hundred patients, approximately 21 percent, were transferred from a 
station or field hospital to the general hospital serving the command; and 20 
were evacuated to the Zone of Interior for further observation and treatment. 
Specific preventive recommendations were made and are considered in greater 
detail under Control Measures. 
A survey of eye injuries was made at the 21st General Hospital, Eye Center, 
North African Theater of Operations, for the period 10 May 1944 to 1 August 
1944 as types of cases were distributed as follows: 
Accidental Eye Injuries 
Battle casualties 135 (49.4 percent) 
Eye disease 101 (37.0 percent) 
Accidental injury 37 (13.6 percent) 
38 ETMD, NATO, Sep 1944. HD: 350.05. • PERSONAL HEALTH MEASURES AND IMMUNIZATION 
The dispositions made of 212 of these cases are shown in Table 20, Twelve 
accidents happened near the frontlines, while 25 occurred in rear areas. The 
causes were extremely varied. Seven mechanics, struck by flying particles 
while at work, constituted the largest group from a single cause. 
Table 20. Eventual Disposition of 212 Patients With Eye Injuries, North 
African Theater of Operations, United States Army, 1944 
Type of casualty 
Num- 
ber 
Evacuated to 
Zone of Interior 
Returned to 
duty class B 
permanent 
Returned to 
duty A-l 
Type of disposi- 
tion unknown 
Num- 
ber 
Percent 
Num- 
ber 
Percent 
Num- 
ber 
Percent 
Num- 
ber 
Percent 
Total 
212 
68 
32. 0 
26 
12. 2 
no 
51. 8 
8 
4. 0 
Battle casualties 
88 
53 
60. 3 
8 
9. 1 
25 
28. 4 
2 
2. 2 
Accidental injury 
37 
6 
16. 2 
8 
21. 6 
22 
59. 4 
1 
2. 8 
Disease, 
87 
9 
10. 3 
10 
11. 4 
63 
72. 4 
5 
5. 9 
Source: ETMD, NATO, Sep 1944. 
HD: 350.05. 
In the North African Theater of Operations it was stated that:39 
The great majority of burns in the theater occur in the Lines of Communications, 
from accidents and unauthorized use of gasoline. During the month of August, the 73rd 
Station Hospital, sited in Constantine, records 222 admissions to the surgical service, 
94.3% of which were non-battle casualties; 10.35% of admissions were for burns. It is 
stated that 65% of the burns were caused by accidents wdth the fire units of field ranges. 
The 54th Station Hospital in Tunis reports 53 burns, many severe, among 998 surgical 
admissions, 108 of which were battle casualties. 
Gasoline burns often involve large areas of body surfaces, but tend to be negligible 
in depth. Only rarely is skin grafting required. This impression is gained from examina- 
tion of large numbers of these burns and from reports of the surgeons in the Mateur- 
Bizerte area during the summer months. It is contrary to the impressions received at 
the 12th General Hospital, where large numbers of burns are treated in Mediterranean 
Base Section. This, however, was during the cold and damp spring months. It is 
suggested that, in the hot (95°-110°) dry summer climate of Tunisia, gasoline tends to 
vaporize more readily and produces a true flash explosion of short duration. Full thick- 
ness burn areas are produced by contact with the flaming liquid as it is thrown into the 
air by the explosion, or spilled from the burning container. It is quite possible, therefore, 
that during the approaching cool rainy season, the gasoline burns may be more severe. 
Such variables, always modifying the pattern of trauma, constantly must be kept in 
mind in judging the relative merits of therapeutic procedures. 
Later from this theater the 12th General Hospital made a survey of burns 
during the first 8 months of its operation, from 26 January to 26 September 
Burns 
36 ETMD, NATO, Sep 1943. HD : 350.05. ACCIDENTAL TRAUMA 
263 
1943.40 The causes of burns were related to battle casualties in 49 instances 
(32.5 percent), and to accidental injuries in 102 (67.5 percent), a total of 151. 
The specific circumstances associated with accidental burns were gasoline fire in 
77 cases, and burning plane, car, or motorcycle in 9 cases, to account for 84.3 
percent of the total. Seven other cases were related to electricity; 5 to boiling 
water or steam; 1 each to mustard gas and shell explosion; and 2 were due to 
acid burns. A startling fact is that 85 percent of the accidental burns were the 
result of the use of gasoline in the bivouac area. When analyzed further, it 
was noted that the cause was the abuse of the use of gasoline. Americans in 
civilian life seldom use gasoline for heating and cooking but overseas it was 
common practice, with the result that unnecessary accidents were bound to 
occur unless instructions were given on the precautions to take. Some accidents 
were the result of explosion while lighting or filling various types of stoves; 
others were the result of pouring gasoline on an open flame; and still others were 
from cleaning clothes or equipment in the presence of an open fire. Some few 
were the result of using gasoline for burning garbage or insects. The final 
disposition of 102 cases of accidental burns was that 51 (50.0 percent) were 
sent to the Zone of Interior; 6 (5.9 percent) were classified limited service 
and 43 (42.1 percent) returned to combat duty. There were 2 (2.0 percent) 
deaths. 
The most important group were the 86 cases of preventable burn resulting 
from the use or abuse of gasoline. Of this group more than half (44) had to be 
returned to the Zone of Interior. Many of these gasoline bums were serious, 
since 53 required skin grafting and the 2 deaths of the total burn cases were 
included. Deeply burned areas were frequent, because of clothing catching on 
fire. 
Poison Liquor 
Accidental poisoning by alcohol or substances thought to be alcoholic is to 
be expected in areas where the supply of ordinary alcoholic beverages is short. 
In the European theater 178 deaths were attributed to alcohol poisoning or a 
rate of 0.12 per 1,000 strength per annum for the period October 1944 to June 
1945.41 During the same period acute communicable disease accounted for 162 
deaths, a rate of 0.11. 
Prior to the invasion of the Continent, in the United Kingdom, there were 
few difficulties. Beer was available, and although hard liquor was scarce, it 
could be obtained in recognized bars. 
On the Continent the situation was very different. Beer was limited and 
wine did not have the potency of whiskey, so that frequent attempts were made 
to fortify wine with alcohol of undetermined quality. Samples of this liquor 
40 ETMD, NATO, Feb 1944. HD : 350.05. 
41 See footnote 13, p. 245. 264 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
were examined by the central laboratory of the theater in Paris. Methyl alco- 
hol was the cause of most deaths, but other substances such as antifreeze and 
buzz bomb fluid were used accidentally or in the belief that they were potable. 
The majority of deaths due to methyl alcohol and other toxic agents were among 
ground combat troops. The Air Corps and troops of the communications zone 
were less involved, chiefly because their source of liquor supply was better 
and substitutes were not necessary. 
Control Measures 
In. making a general evaluation of the accident problem in the years before 
the war, reports of The Surgeon General had stated that effective control meas- 
ures would come through analysis of the individual local post or area. Colonel 
Cohen suggested that the medical officer contribute through an epidemiologic 
analysis of the situation, and that unit safety officers be appointed.42 Major 
Fineberg, who made a detailed analysis of accidents during maneuvers, made 
specific recommendations for control of accidents under such circumstances.43 
In overseas theaters, European, Mediterranean, and Southwest Pacific, reports 
based on medical records were submitted to commanders for formulation of 
programs and evaluation of the problem. Special problems such as low back 
pain, burns, and poison liquor were studied. In the European theater an 
estimate of the amount of preventable accidents was made and given with other 
data to the provost marshal, Table 21. Eight principal causes were shown 
to be responsible for the accidents of about 20 percent of those able to return 
to duty, 50 percent of those evacuated to Zone of Interior, and 80 percent of the 
deaths. The approach to prevention was demonstrated. In the Mediterra- 
nean theater the extent of the manpower loss was brought to the attention of the 
Mediterranean theater staff by the theater surgeon and a safety committee was 
formed and drafted.44 Theater G-l (personnel) was given the staff super- 
vision responsibility and the theater provost marshal the operational 
responsibility. 
In the Southwest Pacific the accident prevention program was delegated 
to the Office of the Assistant Chief of Staff, G-3 (Training) by the command- 
ing general and a suitably trained Sanitary Corps officer was assigned as acci- 
dent officer.45 Commanders of all bases and units under their command were 
instructed to appoint an officer to act as accident prevention officer. Pertinent 
data relative to the causes of nonbattle injuries, together with corrective 
measures for their reduction, were prepared by theater headquarters, and sent 
through channels to all base and unit accident prevention officers. Accidents 
occurring within each unit were recorded and analyzed by base and unit acci- 
42 See footnote 5, p. 240. 
48 See footnote 6, p. 240. 
44 See footnote 15, p. 246. 
46 BTMD, SWPA, Dec 1944. HD : 350.05. ACCIDENTAL TRAUMA 
265 
Table 21. Selected Preventable Causes of Nonbattle Injuries, European Thea- 
ter of Operations, United States Army, February 1942 to March 1944 
Percentage which specified types of accidents constituted of all nonhattle 
injuries where the patient was— 
Cause of accident 
Returned to duty 
Evacuated to the Zone 
of Interior 
Died 
1942 
1943 
1944 Jan- 
uary- 
March 
1942 
1943 
1944 Jan- 
uary- 
March 
1942 
1943 
1944 Jan- 
uary- 
March 
Motor vehicle accidents 
9. 4 
7. 9 
6. 2 
17. 2 
21. 8 
19. 0 
18. 2 
12. 9 
17. 7 
Tank and tractor accidents 
. 5 
. 3 
. 4 
2. 9 
0 
0 
0 
. 4 
. 9 
Bicycle accidents 
2. 9 
5. 1 
2. 9 
2. 3 
7. 6 
6. 0 
1. 6 
1. 2 
. 5 
Other road accidents 
1. 0 
. 8 
. 3 
2. 9 
2. 2 
0 
0 
2. 2 
2. 6 
Air transport accidents 
2. 3 
3. 5 
2. 2 
. 6 
5. 5 
1. 0 
39. 6 
54. 2 
44. 0 
Firearms _ 
2. 9 
2. 2 
1. 3 
17. 8 
15. 3 
13. 0 
13. 0 
8. 5 
21. 7 
Machinery 
1. 0 
1. 6 
. 9 
1. 1 
5. 5 
1. 0 
. 5 
. 6 
0 
Burns 
. 6 
0 
. 9 
0 
0 
0 
0 
0 
0 
Total 
20. 6 
21. 4 
15. 1 
44. 8 
57. 9 
40. 0 
72. 9 
80. 0 
87. 4 
Source: Gordon, J. E.: History of preventive medicine in the European Theater of Operations 
314.7-2. 
1941-1945. HD: 
dent prevention officers and immediate corrective and/or disciplinary action 
was taken. The program was publicized by radio broadcasts, lectures, news 
bulletins, signs, posters, slogan contests, moving pictures, and film strips. 
Particular emphasis was also placed on measures to be taken for reducing the 
destruction and loss of vital equipment and supplies through carelessness and 
accidents. It was also suggested that an instructional and training program, 
devoted to swimming, be instituted through each Base S-3. The aid of the 
special service officer and Red Cross representative was utilized to develop 
such a program for reducing accidents and casualties resulting from swimming 
and diving, and to prevent drowning. It was estimated that 65 percent to 70 
percent of the soldiers were unable to swim and that only 5 percent were 
proficient swimmers. 
In the European theater where the problem of poison liquor was becoming 
evident, efforts were made to provide sources of safe and relatively mild 
drinks.46 A team consisting of a sanitary engineer, a toxicologist, and a bever- 
age expert from Special Services Division, Headquarters, made special surveys 
of facilities for providing beer and soft drinks for the troops. Most of the 
breweries, many of which had closed during the war, were found acceptable 
when operated under American sanitary control. Breweries were reopened, 
processes were modified, facilities were occasionally provided to local operators, 
46 See footnote 13, p. 245. 266 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
and an adequate supply of beer was assured. No instance ever came to the 
attention of Army authorities of an outbreak of intestinal infection traced 
to beer. 
Suggestions for the reduction of burns were made from the North African 
theater in March 1944. That headquarters recommended;47 
To prevent such unnecessary injuries, it would seem possible that the various types 
of stoves used for cooking or heating should be made more “foolproof,” since explosions 
resulting from the use of improper type of fuel or failure to clean the jets are too common. 
The proper method of making, lighting, filling and cleaning the various types of G-I or 
improvised stoves, should be better demonstrated and unless their use is absolutely 
necessary the use of such stoves should be discontinued. 
The average soldier is not acquainted with the potential dangers of improper use of 
gasoline. This is demonstrated by the statements overheard on a “burn” ward where 
other patients see these seriously injured men and are amazed that such injuries can 
and do result from gasoline. 
Gasoline is too vital an item of war to be used for cleaning clothing or burning 
garbage and some conservation could be accomplished by disciplinary measures. 
To summarize, it would seem possible to reduce the incidence of accidental burns by : 
1. Proper instruction in the danger of the indiscriminate use of gasoline. 
2. Proper instruction in the use of the various stoves that require gasoline for fuel. 
3. Disciplinary measures where infractions have occurred after the men have been 
instructed. 
It would seem possible to attain all of these aims by the use of a well prepared color 
movie that could demonstrate to the troops what might be a real cause of disability to 
themselves and the loss of important equipment by the careless use of gasoline. 
In the Persian Gulf Command certain measures for the reduction of low 
back injuries were suggested:48 
1. General Measures for Reducing Back Injuries 
a. Don’t lift loads too heavy to lift or support normally. 
b. Always face swinging loads and cables. 
c. Don’t push heavy loads with body “off balance.” 
d. Learn to lift objects correctly (lift with legs and back, not back alone). 
e. Don’t stand under heavy loads. 
f. Never be in such a hurry as to be careless. 
2. Special Measures for Reducing Truck Driver Low Back Injuries 
a. Have better cushioned seats for drivers (even if it is a supplemental cushion 
and back rest.) 
b. Have sufficient belts provided so that all deserving cases can wear one. 
c. Provide adequate rest periods for drivers between long hauls. 
d. Provide, preferably, a hard surface bed, one that will not sag. 
e. Advocate massage and heat to backs after a long trip (This should be done 
preferably by trained personnel, as it relieves fatigue symptoms early). 
f. Avoid sudden jerking motions while shifting or making a curve. 
g. Avoid accidents. 
47 See footnote 40, p. 263. 
48 See footnote 37, p. 257. ACCIDENTAL TRAUMA 
267 
Conclusion ; Low back injuries appear to be one of the outstanding forms of injury among 
troops, requiring long hospitalization or loss of time from normal duties. As brought out 
in this report, this is particularly true among truck driver personnel in all branches 
of the service. If some, or all, of the suggested measures can be taken to afford relief, 
or prevention of injuries, the noneffective rate among troops can be greatly lowered. 
Troop commanders have a great responsibility in preventing injuries of this nature. If 
they will conduct lectures and safety campaigns for instruction of troops and better under- 
stand these injuries and their treatment themselves, perhaps, more than anything else, 
this would prove to be one of the best forms of prophylaxis. 
Evaluation 
The Medical Department had been pointing out the increasing importance 
of nonbattle trauma before World War II, and during the war, especially in 
overseas theaters where admission and death rates were high. The Medical 
Department tabulated the data which enabled commanders to see the tre- 
mendous loss of manpower and thus establish programs of control. In the 
Mediterranean theater there was a marked drop in the nonbattle injury admis- 
sion rate in 1945 and the theater surgeon felt this was due to the Accident Pre- 
vention Program.49 In the Southwest Pacific, a comparison wTas made of acci- 
dent rates during the 8 months prior to the initiation of the program and the 
5 months after it.50 This analysis revealed the following; 
Hospital and quarters cases of non-battle injuries averaged 18.9 days per patient for 
1943, 16.3 days for 1944. This represents a reduction of 13.7% in average hospitalization 
time per patient admitted to hospitals and quarters for non-battle injuries. 
The average non-effective rate for non-battle injuries was 8.5 per 1,000 per annum 
for 1943, 7.0 per 1,000 per annum for 1944. The reduced rate with a strength of 750,000 
has resulted in saving of 1.125 man days per day in the SWPA. Because of this reduction 
in rate, approximately 1,000 more hospital beds are released every day and approximately 
125 more men are available for duty every day who would be confined to quarters as a re- 
sult of non-battle injuries. 
Twenty-two more men would have been evacuated to the U. S. and 8 more would 
have died from non-battle injuries if the same rate for 1943 had prevailed for the first 
6 months of 1944. 
Admission rates of non-battle injuries to hospitals and quarters for the 6 month 
period previous to the initiation of the Accident Prevention Program was 174 cases per 
1,000 per annum; the 5 months following the initiation of the program shows 146 cases 
per 1,000 per annum, a reduction of 16%. With a strength of 750,000, this reduction 
in rate will result in a decrease of 5,700 admissions to sick reports for non-battle injuries 
per year. 
Such an evaluation (see Chart 5) certainly brings out the importance of 
prevention of nonbattle trauma in the saving of life as well as of medical 
facilities. 
The contributions of the Industrial Hygiene Section, Preventive Medicine 
Division, Office of The Surgeon General, are more difficult to evaluate. Their 
40 See footnote 15, p. 246. 
80 See footnote 45, p. 264. 268 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
effort to promote industrial medicine contributed toward a good working 
environment and aided effort to place the individual in a job within his physical 
capabilities. These factors are important in accident prevention. The work 
on anthropometric, physiologic, and psychologic measurements at the Armored 
Force Medical Research Laboratory provided data for the design of vehicles 
and equipment which could be used more effectively and safely by the soldier. 
The activities of this laboratory are discussed further in the chapter on 
Occupational Health in another volume in this series. 
RATES PER 1,000 PER ANNUM 
RATES PRECEDING PROGRAM 
RATES AFTER PROGRAM 
Chart 5. Nonbattle injury rates. A comparison of hospital admission rates for 8 months 
preceding accident prevention program and for 5 months after institution of program. 
Source: ETMD, USAFFE, Dec 19U- HD: 350.05. 
In future operations the problem of alcoholic beverages and nontoxic beer 
needs serious consideration. The American soldier will find a substitute which 
may be poisonous, if a supply is not available. 
In addition, the lack of knowledge of the use of gasoline was evident 
throughout World War II, and instruction in its use should be given serious 
emphasis early in the training of the soldier. 
As the war progressed, need was demonstrated for better classification 
and reporting of injuries, especially those occurring overseas in theaters of 
operations. The Army Safety Program system had been developed for analysis 
of the agency, act, and action of accidental injury. This should be fused with 
medical records of type of injury, duration of hospitalization, disability, and ACCIDENTAL TRAUMA 
269 
discharges in order to define the problem as to time, place, and person, and as 
to the resulting death, or extent of defect and disability. 
There is need for continued study on basic research on anthropometric, 
physiologic, and psychologic factors which would guide engineers in designing 
new equipment. The concept of accident proneness requires further testing to 
establish its validity and to determine whether objective or subjective physio- 
logic or psychologic tests can be developed to detect such persons. 
As the war closed, the outstanding demonstration was the need for many 
professions to combine and work on the problem of accidental trauma, which 
had become recognized finally as one of the major mass health problems of 
armies; indeed, a problem that develops even greater significance as armies 
become increasingly mechanized. CHAPTER VIII 
The Army Immunization Program 
Colonel Arthur P. Long, MC, USA 
The Army immunization program was a positive, direct, and specific 
approach to disease prevention and control. This program as it developed 
just before and during the war period represented a very considerable expan- 
sion of the application of immunization procedures in the Army. The pattern 
for the extended program was set at an informal meeting of representatives of 
the medical services of the Army, Navy, and the United States Public Health 
Service. At this meeting, called by Lt. Col. James S. Simmons (later brig, 
gen.), MC, in the spring of 1940, a general program considered desirable in 
the event of war was outlined. It was the consensus of the group that tetanus 
immunization in the Armed Forces should be instituted at the earliest possible 
date. 
The Army immunization program, as it was evolved and applied, required 
not only the acquisition and application of the best available professional 
knowledge and techniques but also the rapid development of effective mecha- 
nisms to insure adequate administrative control and technical guidance. The 
general supervision of the Army immunization program was one of the major 
functions of the Epidemiology Division of the Preventive Medicine Service, 
Office of The Surgeon General. Many of the technical problems related to 
this program, as well as the administrative details, were handled by that divi- 
sion. The following is an outline of the activities of the Epidemiology Divi- 
sion in connection with that program: 
1. Collection of the necessary information and establishment of policies 
governing the various immunization procedures. 
2. Compilation and publication of general and specific instructions on 
various administrative and technical matters. 
3. Investigation and evaluation of the development and improvement of 
materials and procedures. 
4. Investigation and study of problems arising in connection with the 
immunization program such as the indications for special immunizations, occur- 
rence of reactions, and efficacy and practicability of various procedures and 
methods. 
5. Provision of technical advice and assistance to the Supply Service, Office 
of The Surgeon General, with respect to estimates of requirements, procure- 
ment, distribution, and storage of prophylactic biologicals. 272 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
6. Conduct of miscellaneous correspondence with both civilian and military 
personnel and agencies and with various governmental and civilian groups con- 
cerning the immunization program. 
It is the purpose of this chapter to present a review of the entire program, 
to trace as accurately as possible the important steps in the development, adop- 
tion, and use of each of the various immunizing procedures authorized by the 
Army during the war, and to summarize and evaluate the experiences gained. 
In the interest of uniformity of presentation and to facilitate reference, discus- 
sion of the individual procedures will be presented under the general headings of 
development and adoption of the immunizing agent, methods and requirements 
for immunization, and experience with the procedure. While emphasis is 
given to the developments arising from the demand of mobilization and conduct 
of the war, those procedures already practiced before the mobilization period 
are also discussed from the viewpoint of their application during the emer- 
gency. In addition to the discussion of the various immunizing agents and 
their use, an attempt is made to present the salient features of the general 
administration of the immunization program. 
TYPHOID-PARATYPHOID VACCINATION 
Development and Adoption 
The full history of typhoid vaccination in the Army is a long one1 and 
need not be recounted here. It is sufficient to state that the regular administra- 
tion of typhoid vaccine to all Army personnel had been routine since 1911 so 
that at the beginning of World War II, this practice was almost an Army 
tradition. 
The Immunizing Agent 
For many years, including the period of World War I, the typhoid or 
typhoid-paratyphoid vaccine used in the Army had been that prepared at the 
Army Medical School. This was continued throughout World War II. These 
vaccines had undergone changes as to content from time to time, and intensive 
research and investigation had been continuous. As a result, the production 
of typhoid vaccine for the expanding Army and such changes as were required 
to meet the new situation were not new projects, but represented rather expan- 
sion and intensification of previous efforts and existing facilities. In 1928 the 
paratyphoid B fraction contained in the vaccine during World War I was 
eliminated; the paratyphoid A fraction was discontinued in 1934. From that 
time until the World War II emergency period, a monovalent vaccine containing 
Salmonella typhosa organisms only was used.2 
1 Siler, Joseph F., and others: Immunization to Typhoid Fever. Baltimore, Johns Hopkins Press, 
1941. 
2 Ibid. IMMUNIZATION 
273 
In view of the anticipated increase in field service of troops and likelihood 
of exposure to enteric organisms, in early 1940 it was considered advisable to 
readopt a triple or typhoid-paratyphoid vaccine. This decision was reached 
after careful consideration by a committee representing the Army, Navy, and 
United States Public Health Service. Acting on the advice of this committee, 
The Surgeon General on 9 July 1940 instructed the Commandant of the Army 
Medical School to prepare a typhoid-paratyphoid vaccine for distribution to 
the Army.3 The triple vaccine was manufactured in September 1940 at which 
time official announcement of its readoption was made by Circular Letter 67, 
Office of The Surgeon General, 3 September 1940. 
The vaccine contained in each cubic centimeter 1,000 million typhoid bacilli 
and 250 million each of the paratyphoid A and B components. The JS. typhosa 
strain used was the Panama carrier strain 58 (Army Medical School culture 
collection No. 42-A-58); the Para B {S. schottmuelleri) organism (Army Med- 
ical School culture strain 41-H-6); and the Para A {S. paratyphi), originally 
Army Medical School strain 41-N-8, but replaced in 1942 by an English strain 
HA-6 (Army Medical School strain 41-N-22). Since the criteria for the 
selection of these strains is discussed at length elsewhere,4 as are their character- 
istics, these will not be presented here. It is enough to state that they repre- 
sented the most highly immunogenic strains obtainable and were selected on 
the basis of their virulence, their biochemic behavior and productivity of agglu- 
tinins and protective substances, and their production of cross-immunity against 
other strains of homologous species. These strains were continued in the manu- 
facture of the triple vaccine throughout the war. 
On some occasions questions were raised as to the specificity of this vaccine 
for protection against infection with strains encountered in overseas areas. For 
example in 1942 the occurrence of three cases of typhoid fever among American 
troops in India occasioned the recommendation by the surgeon of that theater 
that typhoid vaccine produced locally be used there in place of the Army 
Medical School product.5 After study of strains isolated from cases in India 
and of the Indian-produced vaccine, it was determined that the United States 
Army vaccine was at least equal to the Indian vaccine in protection against the 
local strain of typhoid bacillus. 
Methods and Requirements 
At the beginning of the emergency, the vaccine was given in 3 subcutaneous 
doses administered at intervals of 7 to 10 days, the 1940 regulation reading 
“. . . intervals of not less than 5 nor more than 14 days between consecutive 
3 Ltr, SG to Commandant Army Med School, 9 Jul 40, sub : Change in the composition of typhoid 
vaccine manufactured for use in the U. S. Army. SG : 444.2-1 (AMS)GG. 
4 Longfellow, D., and Lulppold, G. F.: Immunization to typhoid and paratyphoid fevers. Am. J. 
Hygiene 38 : 139-151, Sep 1943. Also see footnote 1, p. 272. 
5 Ltr, Surg CBI Theater to SG, 12 Dec 42, sub ; Typhoid fever. HD: 720.3. 274 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
doses; ordinarily the doses will be spaced at intervals ranging from 7 to 10 
days. . . The dosage was 0.5 cc. for the first dose and 1 cc. each for the 2 
subsequent doses. The interval between series was stipulated as 3 years, with 
only 2 such series being required under ordinary circumstances. A complete 
series of 3 injections was required within 1 year of departure for theaters of 
operations, and provisions were made for revaccination in face of a threatened 
outbreak (individuals over 45 years of age were exempted from typhoid vac- 
cination except under these circumstances). The method for the accomplish- 
ment of the first series of typhoid vaccine injections (the basic immunization) 
remained unchanged throughout the war except for the required time interval 
between individual injections. It was soon learned that the requirement of an 
interval “not to exceed 14 days between doses” was undesirable and impractical 
when applied to large numbers of troops in a rapidly expanding Army. Fre- 
quently, when for one reason or another this interval was extended, literal- 
minded officers (medical and nonmedical, commissioned and noncommissioned) 
would require the repetition of the entire series. To correct this undesirable 
practice, Army regulations governing immunization were revised in 19426 
and the circular letter implementing these regulations7 did not state a maximum 
allowable interval between individual doses, but indicated that the desired 
interval was 7 to 10 days. If this time were exceeded, the next dose was to 
be administered as early as possible and the entire series was not to be repeated. 
The recommendation concerning the interval between individual injections 
was again changed in 1944.8 At that time the recommended interval was stated 
to be from 7 to 28 days. This policy was adopted largely for administrative 
reasons, chief among which was the desirability of simplifying the immuniza- 
tion schedules for individuals receiving the basic immunizations of typhoid and 
tetanus at the same time. Under the old system, with typhoid vaccination ac- 
complished at weekly intervals and tetanus toxoid injections spaced every 3 
weeks, at least 5 visits to the dispensary or other agency were required. By 
giving typhoid-paratyphoid vaccine and tetanus toxoid at the same time, a 
saving of 2 visits could be accomplished. This saving when translated into 
terms of hundreds of thousands of individuals was an extremely significant one. 
There was little hesitancy to accept this change of policy, from a technical point 
of view, since the 1-week interval was originally based on administrative 
grounds only and it is an accepted principle that in general and within reason- 
able limits the immunity response tends to increase rather than decrease with 
longer periods between the administration of individual doses of antigen in 
series. This hypothesis was borne out in part at least by the result of experi- 
mentation at the Army Medical School where it was determined that 3 doses 
8 AR 40-210, 15 Sep 42. 
7 S6 Cir Ltr 162, 28 Nov 42, sub : Immunization. 
8 TB Med 114, 9 Nov 44. IMMUNIZATION 
275 
of typhoid-paratyphoid vaccine when administered to rabbits at intervals of 
3 weeks were just as effective in the production of protective antibodies as were 
similar amounts of the antigen administered at intervals of 1 week.8 
The only other changes effected in the typhoid-paratyphoid immunization 
practices were those in connection with revaccination methods and require- 
ments. Following the demonstration by workers at the Army Medical School 
and elsewhere 10 of the efficacy of 0.1 cc. of vaccine administered intradermally 
or of 0.5 cc. given subcutaneously as stimulating doses, serious consideration was 
given to the adoption of one or the other of these methods as routine practice 
in the Army. It was considered, however, that such a change in practice dur- 
ing the early phases of mobilization was not justified. This decision was based 
principally on the fact that prior to September 1940 the vaccine used by the 
Army for some years had been monovalent in type. Hence those who had 
received it rather than the triple vaccine had no basic protection against Para 
A or B, without which the effect of single small stimulating doses was question- 
able. Accordingly revaccination with the complete series of three injections 
of the triple vaccine was continued until 30 August 1943, at which time the 
practice of annual administration of 0.5 cc. of triple vaccine was adopted for 
reimmunization to the typhoid and paratyphoid fevers.11 The subcutaneous 
route rather than the intracutaneous one was chosen since the response was 
known to be at least as good with the former as with the latter, and it was 
considered that the intracutaneous technique when applied to large numbers 
of troops was considerably less certain of proper accomplishment than was the 
subcutaneous method of injection and would inevitably be more time consuming. 
At the time of the adoption of this method of reimmunization, the exemption 
from revaccination of those over 45 years of age was removed, the only exemp- 
tion remaining being that of the presence of a medical contraindication to the 
procedure. 
To recapitulate, the final policy for the administration of typhoid-para- 
typhoid vaccine was briefly as follows:12 
1. Initial immunization: 3 doses of typhoid-paratyphoid vaccine, 0.5 cc., 
1 cc., and 1.0 cc. respectively, administered subcutaneously at 7- to 28-day 
intervals without unnecessary delay after entry into the Federal service. 
2. Revaccination: 0.5 cc. typhoid-paratyphoid vaccine administered sub- 
cutaneously annually or in the presence of danger from an outbreak of typhoid 
fever or the paratyphoid fevers, this revaccination procedure to be followed 
if an initial series as above had been received at any time in the military service. 
B Army Med School, “Comparative effectiveness of 1-week and 3-week intervals between doses of 
T. A. B. vaccine,” 16 Oct 44. HD : 720.3 Typhoid and Paratyphoid. 
10 See footnote 1, p. 272. 
11 AR 40-210, C 6, 30 Aug 43. 
i- (1) AR 40-210, 25 Apr 45. (2) See footnote 9. 
346336 0—55 19 276 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
3. Initial vaccination or revaccination required within the 12-month period 
prior to embarkation for overseas duty. 
Experience 
Effectiveness. The effectiveness of typhoid vaccination as employed in 
the Army over a period of approximately 35 years has been generally accepted 
and requires little exposition here. In the historical review, previously referred 
to, were presented the results obtained from the inception of the procedure in 
1909 through the year 1939.13 These will not be repeated other than to recall 
that the incidence rates for typhoid and the paratyphoid fevers during World 
War I in a vaccinated Army were approximately one three-hundredths of those 
experiences in the Spanish-American War when no immunization was prac- 
ticed, this difference being stated to be . . a result of the routine use of 
typhoid vaccine as a protective measure and improvement in methods of 
environmental sanitation.” 
A continuation of these excellent results is indicated by the fact that the 
combined average annual rates for these diseases during World War II was 
approximately 0.05 per thousand which is about one-eighth of the combined 
rate for World War I which was 0.42. Table 22 shows the cases and rates per 
thousand per annum for typhoid fever, paratyphoid fever, and the diarrheal 
diseases as they occurred in the Army during World War II, and Table 23 
provides the same type of data as nearly comparable as possible for World 
War I. 
15 See footnote 1, p. 272. 
Table 22. Typhoid, Paratyphoid, and Dysentery, Diarrhea, and Enteritis, United 
States Army, 1942-45 
Rates Per 1,000 Troops Per Year 
Typhoid 
Paratyphoid 
Dysentery, diarrhea, 
and enteritis* 
Cases 
Rates 
Cases 
Rates 
Admissions 
Rates 
Total Army _ _ 
505 
0. 02 
839 
0. 03 
785, 164 
30. 82 
United States _ 
91 
. 01 
125 
. 01 
294, 346 
19. 97 
Overseas. 
414 
. 04 
714 
. 07 
490, 818 
45. 72 
Europe only 
64 
. 01 
84 
. 02 
92, 304 
20. 98 
•Relates to all dysenteries, enteritis, gastroenteritis, colitis, enterocolitis, and diarrhea (not elsewhere classified). 
No vaccination is applicable to these groups of diseases. IMMUNIZATION 
277 
Table 23. Typhoid, Paratyphoid, and Dysentery, Diarrhea, and Enteritis, United 
States Army, World War I 
Rates Per 1,000 Troops Per Year 
Typhoid 
Paratyphoid 
Dysentery, diarrhea, and 
enteritis* 
Cases 
Rates 
Cases 
Rates 
Admissions 
Rates 
Total Army __ _ _____ 
United States. _ 
Overseas (Europe only) _____ 
1, 529 
546 
885 
0. 37 
. 24 
. 53 
212 
32 
151 
0. 05 
. 01 
. 09 
92, 512 
39, 854 
48, 202 
22. 4 
17. 8 
28. 9 
•Relates to all dysenteries, enteritis, gastroenteritis, colitis, enterocolitis, and diarrhea (not elsewhere classified). 
No vaccination is applicable to these groups of diseases. 
It will be seen that the rates for typhoid alone in the Army during the last 
war were only about one-twentieth of those experienced in the former conflict, 
while that for the paratyphoid fevers was about three-fifths that encountered 
in the earlier experience. This difference seems to be particularly striking 
when considered in the light of the rates for the diarrheal diseases which were 
essentially the same for both periods. This single observation might suggest 
that the chances of acquiring an enteric infection were approximately the same 
in both wars, that the nonspecific protective measures were equally effective 
during the two periods, but that the protection from specific vaccination par- 
ticularly that against typhoid fever was considerably improved over that 
afforded in World War I. If such were the case, however, it would be reason- 
able to have expected the rates for the diarrheal diseases to have increased at 
least as much as did typhoid under the unfavorable conditions met in overseas 
theaters of operations. This did not occur since typhoid fever among troops 
stationed overseas was approximately 4 times higher than for those in this 
country while the diarrheal disease rates showed an increase of about 2 times. 
A ratio approximating this held for all the major theaters despite wide varia- 
tions in the actual incidence of the diseases in question. For example, the 
European Theater of Operations reported the lowest typhoid and diarrheal 
disease rates for any major theater and the China-Burma-India theater, the 
highest. The European theater typhoid rate was essentially twice that in the 
United States and the diarrheal disease rate about the same. The typhoid rate 
in the China-Burma-India theater was 30 times greater than that in this country 
and the diarrheal disease rate showed an increase of about fl fold. 
This situation also obtained in World War I when the rate in Europe for 
typhoid fever was just over twice as high as in this country and the diarrheal 
disease rate was slightly over iy2 times that experienced here. The experience 
with the paratyphoid fevers essentially paralleled that with typhoid in this 278 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
regard, the former showing a slightly greater increase in incidence in overseas 
theaters than did typhoid fever. 
This view of the occurrence of typhoid and paratyphoid fevers does not 
bring forth evidence against the efficacy of vaccination for the prevention of 
these diseases nor does it gainsay the probability of a considerably improved 
typhoid vaccine. These observations do, however, emphasize again that the 
incidence of typhoid fever and the paratyphoid fevers, as well as of the other 
enteric infections, tends to be in proportion to the opportunities for infection 
existing in the environment and that specific protection through vaccination 
does not eliminate the necessity for proper application of sanitary measures 
for the control of these infections. 
Histories were received by the Epidemiology Division, Office of The Sur- 
geon General, of most of the cases of typhoid and paratyphoid fevers reported 
in the United States during the war. In a number of instances it was apparent 
from these histories that the diagnosis had been made on insufficient evidence. 
There were a few individuals in whom the clinical course and laboratory find- 
ings were such that a diagnosis of typhoid or paratyphoid fever could be made 
with reasonable assurance in spite of failure to obtain positive cultures of the 
organisms from stool, blood, or urine. These cases, however, were not included 
in the data presented in Table 24. There were 42 cases of typhoid fever in the 
4-year period from whom the organism was recovered and on whom clinical 
and epidemiologic information was received. Eleven cases occurred in each of 
the years 1942 and 1943, and 10 in the years 1944 and 1945. Twelve cases had 
had not only a basic series of typhoid vaccine injections but 1 or more stimu- 
lating doses in addition. Eighteen had had the basic series but no stimulating 
doses. In 9, the basic series had been begun but not completed at the time of 
onset of typhoid, and in 3, no vaccination had been done, the individuals having 
just been inducted. Among the 12 who had had a basic series and 1 or more 
stimulating doses, there were 8 who had had 1 stimulating dose, 3 who had had 2, 
and 1 who had had 4. This last case was a result of a laboratory infection as 
was 1 other in the series. The intervals which had elapsed between the last dose 
of vaccine and the onset of typhoid were studied for those individuals who had 
completed a basic series with or without additional stimulating doses. The 
interval was less than a week in 2 cases, between 1 week and 1 month in 3, 1 
month to 6 months in 9, from 6 months to 1 year in 9, and in excess of a year in 6. 
It is of interest that in 1942, when men were being inducted at a rapid rate, 
the majority of cases of typhoid occurred in those who had not received a com- 
plete basic series of typhoid vaccine whereas in subsequent years, particularly 
in 1945, most of the cases had had not only a complete basic series, but 1 or 
more stimulating doses. In summary, it may be stated that except for the year 
1942, most cases of typhoid fever in the United States occurred in fully vac- 
cinated personnel and that such cases as did occur during the war in unvac- IMMUNIZATION 
279 
cinated individuals were not due to failure to carry out immunization. It is 
also apparent that most of the typhoid occurred through failure of immuniza- 
tion to protect against the dosage of the infecting organism received. Whether 
the important factor here was the strain of the infecting organism, against 
which standard Army vaccine might not have been adequate to protect, whether 
it was the number of organisms ingested or whether it was some deficiency in 
the individual’s ability to develop immunity after vaccination cannot be 
determined. 
Table 24. Immunization Status of 42 Cases of Typhoid Fever Among Army 
Personnel in the United States, 1942^45 
Oases Proven by Positive Cultures, on Whom Histories Were Received by 
Epidemiology Division, Office of The Surgeon General 
Received 
Immunization Record 
1942 
1943 
1944 
1945 
Total 
Typhoid Vaccine Received 
Basic series completed, stimulating dose(s) given 
1 
5 
6 
12 
Basic series completed, no stimulating doses,. 
4 
9 
3 
2 
18 
Basic series not completed 
6 
1 
1 
1 
9 
No vaccination _ 
1 
1 
1 
3 
Total . _ _ 
11 
11 
10 
10 
42 
Number of stimulating doses given 
1 dose. _ _ _ _ 
1 
5 
2 
8 
2 doses. ... __ _ 
3 
3 
3 doses 
4 doses _ _ _____ 
1 
1 
Interval From Last Dose to Onset of Disease 
{For Cases Who Had Completed Basic Series) 
Less than 7 days 
1 
1 
2 
1 week to 1 month _ _ 
1 
1 
1 
3 
1 to 6 months 
2 
4 
2 
1 
9 
6 months to 1 year 
1 
5 
1 
2 
9 
More than 1 year* . _ _ _ __ _ 
3 
3 
6 
Not stated _ _ ___ 
1 
1 
Total _ 
4 
10 
8 
8 
30 
•Of the 6 cases in this group, the interval was 12 to 15 months in 3. 
Reactions. As pointed out previously, typhoid-paratyphoid vaccination 
has for many years been an accepted, almost traditional procedure in the Army. 
That this procedure is attended by local and systematic reactions has also become 
more or less generally accepted. Accordingly, the proportion of such reactions 280 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
in those receiving the vaccine is not definitely known nor has it been considered 
to be of enough importance to initiate a study of sufficient magnitude to allow 
such definition. 
During only one brief period of the war were reports received indicating 
an unusually high occurrence of untoward reactions following the administra- 
tion of this vaccine. This was during the first half of the year 1942 and the 
reports indicated reactions to typhoid-paratyphoid vaccine unusual both in 
number and degree when the vaccine was administered within 5 to 10 days 
following yellow fever immunization.14 The occurrence of such reactions, how- 
ever, was not sufficiently frequent nor were the reactions themselves of such 
severity as to warrant concern and the matter was automatically rectified with 
the discontinuance of routine vaccination against yellow fever. The matter 
was given considerable study, howTever, and it was considered that the apparent 
increase in reactions to typhoid-paratyphoid vaccine when this material was 
administered a short time after the yellow fever antigen were in the nature of 
a summation of reaction to the two agents (the febrile reaction to yellow fever 
vaccine having a usual incubation period of 5 to 7 days) rather than a true 
augmentation of the reaction from typhoid vaccine itself. This formed the 
basis for the recommendation that administration of typhoid-paratyphoid 
vaccine within a week following yellow fever immunization should be avoided 
whenever possible.15 
Other than that just referred to, the experience with reactions from triple 
typhoid vaccine during World War II apparently differed little from that of 
previous years. A fairly high proportion of individuals receiving such vaccine 
will exhibit reactions, local or systemic or both. As previously indicated, the 
exact proportion of such reactors is not known. Previously published figures 
of 10 to 20 percent16 are probably safely conservative. The most common 
reaction is that of local redness, heat, and tenderness at the site of injection. 
The systemic reactions encountered are characterized by general malaise, head- 
ache, and elevation of temperature. The second injection of the basic series 
is the dose most likely to cause reaction but untoward effects from stimulating 
doses are not uncommon particularly in individuals who have received several 
“basic series” or stimulating doses in the past. 
SMALLPOX VACCINATION 
Development and Adoption 
Smallpox vaccination may well be classified as one of the most important 
measures for disease prevention that has been applied in military as well as 
in civilian populations. It has long been recognized that vaccination is, for 
14 Report of Conference on Yellow Fever, Typhoid Vaccine Reactions, SGO, 14 Mar 42. HD : 720.3. 
15 See footnote 8, p. 274. 
18 See footnote 1, p. 272. IMMUNIZATION 
281 
all practical purposes, the only practicable effective procedure for the prevention 
of variola. The story of the recognition by Jenner of the effectiveness of 
cowpox inoculation for the prevention of smallpox and the subsequent develop- 
ment, refinement, and general application of this principle is one of the classics 
of medicine and has been recounted so often that its review here is not 
warranted. 
Smallpox vaccination in the Army antedates the application of any other 
immunization procedure. The exact date of the adoption of this procedure 
for routine use in all Army personnel does not appear to be a matter of record. 
However, its first use is said to have been early in the last century. Its applica- 
tion was expanded somewhat during the Civil War period and its adoption as 
a routine measure was presumably at or near the turn of the century.17 Vacci- 
nation against smallpox has, of course, been continued since that time as a 
routine procedure and is applied on entry into the service and at intervals 
thereafter. 
The Immunizing Agent 
Glycerinated calf dermovaccine is the agent used in the Army. Army 
Medical Department specifications applicable to the purchase of this vaccine 
are quoted in part as follows: 
Smallpox Vaccine, U. S. P. 
General description.—Vaccine shall conform to the requirements of the National 
Institutes of Health. 
Quantity.—Vaccine shall be supplied in capillary tubes, each tube sufficient for one 
vaccination. Ten such tubes shall be the unit of quantity, furnished with 10 sterile 
needles and one rubber bulb. 
Packaging and Packing.—The unit of quantity shall be furnished in suitably sized 
and constructed individual containers. Shipment shall be made in a waterproof bag or 
envelope, in an insulated container, having enough dry ice to keep the vaccine at the 
proper temperature until it reaches destination. 
Expiration date.—Shall not be less than 2y2 months after delivery date. 
It will be noted that these specifications in stipulating refrigeration during 
shipping take cognizance of the fact that this vaccine, containing a living virus, 
loses its potency rapidly unless kept cold (preferably at freezing temperatures) 
at all times. This extreme lability and the short expiration date resulting there- 
from were obvious obstacles to the maintenance of stocks of fully potent ma- 
terial in Army installations in the various theaters of operations and in this 
country as well. Continued emphasis was given to the necessity for proper 
shipment, storage, and care of this agent. In order that proper instructions in 
this regard might be disseminated to supply depots and other agencies concerned, 
17 The Medical Department of the United States Army In the World War. Washington, Govern- 
ment Printing Office, 1928, vol. IX, pp. 357-386. 282 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
a memorandum outlining the proper procedure was forwarded to the Finance 
and Supply Division, Office of The Surgeon General, from the Epidemiology 
Branch, on 2 December 1941.18 In brief, this memorandum presented the fol- 
lowing procedures as requirements: 
1. Shipment to be made by the most rapid and direct method and route 
2. Ordinary shipment by express, etc., or long distanced shipping by air, to 
be made by packing vaccine in dry ice and insulating the package properly 
3. For extended shipment such as by boat, the vaccine to be held at freezing 
temperatures 
4. Upon arrival at destination and thereafter until use, the vaccine to be 
kept at all times below 5° C., preferably below 0° C. 
Essentially this same information was disseminated to all medical installa- 
tions and medical officers in Circular Letter 162, Office of The Surgeon General, 
28 November 1942, and again in November 1944 in War Department technical 
bulletin, TB MED 114. In addition, it was recommended in both of these 
publications that because of its perishable nature and the brevity of the period 
of expected potency, the amount requisitioned should not be in excess of the 
anticipated need for approximately 2 months. It was also recommended that 
for use overseas smallpox vaccine of acceptable quality be purchased locally 
whenever possible. This procedure was followed quite extensively in the United 
Kingdom for troops stationed there. Local procurement was also accomplished 
in India for a time but was discontinued upon the development of a more 
satisfactory system of air shipment with adequate dry ice refrigeration. Local 
procurement was also practiced in other areas but as a rule only to meet unusual 
needs. 
The question of specificity of the action of American-made vaccine when 
used for the prevention of the virulent smallpox of the Far East and other areas 
was brought up from time to time. In view of the basic nonspecificity of the 
procedure (vaccinia virus being used for protection against variola virus) and 
the lack of evidence of noneffectiveness of American-made vaccines in these 
situations, this matter was not considered to present a problem. It was con- 
sidered that vaccination properly performed and interpreted, using potent 
vaccine, would afford adequate protection. 
Methods and Requirements 
The method recommended for the performance of vaccination was the so- 
called “multiple pressure” method now generally accepted in this country to be 
the one of choice.19 The instructions issued with respect to this procedure em- 
18 Memo, Chief Epidemiology Branch SGO for Dir Finance and Supply Dlv SGO, 2 Dec 41, sub: 
Shipping and storage of smallpox vaccine. HD : 720.3. 
19 See footnotes 1, p. 272 and 11, p. 275. IMMUNIZATION 
283 
phasized adequate care of the vaccine to insure its potency, careful attention 
to the vaccination procedure itself, and proper interpretation of the results 
obtained. It was stipulated that the procedure be repeated until a satisfactory 
result (vaccinia, vaccinoid, or immune reaction) was demonstrated. 
Early in 1943 when large numbers of men were passing very rapidly 
through induction and reception centers, it became apparent that vaccinations 
performed at these centers could not always be properly interpreted, and hence 
it was thought that considerable value from the procedure was lost. Accord- 
ingly, a memorandum was published by The Adjutant General directing that 
smallpox vaccination should not be performed unless the personnel concerned 
were to remain at the center at least 1 week.20 It was thought that the results 
incurred by the postponement of this procedure for a short time were more than 
compensated for by the advantage which would accrue with the opportunity 
for observation and interpretation of the vaccination result. 
Because of the occurrence of a certain number of cases of smallpox in 
overseas installations, it was found necessary in 1944 to emphasize once more 
to medical officers in the field the necessity for careful attention to the per- 
formance and interpretation of this simple procedure. To this end there was 
published in the Army Medical Bulletin, August 1944, a special article on 
smallpox vaccination.21 Unfortunately in some instances a lack of knowledge 
or failure to appreciate the importance of the development and maintenance of 
satisfactory immunity to smallpox resulted in failures to vaccinate troops prop- 
erly. As will be seen, these failures led to a certain number of cases of small- 
pox, some of which were fatal. 
The stated requirements for smallpox vaccination were such that had the 
vaccination been performed properly in each case the Army should have been 
essentially 100 percent immune to this disease. It was required that all per- 
sonnel be vaccinated without unnecessary delay after entry on active duty and 
once every 3 years thereafter. In addition, provision was made for the vaccina- 
tion or revaccination of all personnel ordered to duty beyond the continental 
limits of the United States unless such vaccination has been accomplished dur- 
ing the 12-month period prior to departure. Provision was also made for the 
revaccination of all personnel on the occurrence of the disease in a command or 
in the presence of a threat of such an outbreak.22 In other words, smallpox 
vaccination at least once every 3 years was required for all personnel and more 
frequent vaccinations were authorized and recommended in the event of possible 
exposure to the disease. 
20 WD AG Memo S40-6-43, 12 Apr 43, sub: Smallpox vaccination at Induction and reception 
centers. AG: 720.3. 
21 Smallpox vaccination. Bull. U. S. Army M. Dept.. No. 79, Aug 1944, p. 2. 
22 See footnote 6, p. 274. 284 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Experience 
Effectiveness. The Army experience with smallpox during the war years 
is further testimony to the effectiveness of vaccination in the prevention of 
this disease. There occurred during this period a total of 115 cases of which 
10 were reported from the United States and 105 from overseas. This is in 
rather sharp contrast to the experience of the last war during which a total 
of 853 cases were reported, 780 from the United States and 78 from overseas 
stations.23 While the current record is an excellent one and shows a marked 
improvement over that of World War I, it appears profitable to inquire briefly 
into the reasons for the occurrence of even a few cases in a 100-percent vaccin- 
ated group. The review of the incidence figures reveals that almost half the 
cases reported occurred in the India-Burma theater and the Persian Gulf 
Command, the cases reported from these areas being 83 and 15 respectively. 
(See chapter on smallpox in another volume in this series.) Investigations 
conducted by the surgeons of these theaters led to the conclusions that failure 
to vaccinate properly was responsible.24 These conclusions were based on the 
fact that, with very few exceptions, the individuals who developed smallpox 
either presented no indication of a previous satisfactory vaccination as evi- 
denced by a scar, or the scar present was the result of vaccination in infancy 
or childhood. The records of such individuals, however, almost invariably 
indicated immune reactions to vaccinations performed while in the military 
service. The fact that they then developed smallpox is clear indication of 
unsatisfactory performance of the vaccination procedure and failure to read 
and interpret the result properly. These findings were confirmed by study of 
the few cases which occurred in this country.25 
Additional evidence pointing to unsatisfactory routine vaccination prac- 
tice was found in the unusually high proportion of individuals presenting vac- 
cinia or vaccinoid reactions when vaccinations were carefully performed in 
special situations and the results critically observed and analyzed. Two such 
instances are cited as examples. 
In the Persian Gulf Command in 1944, 16,515 individuals were revac- 
cinated with a fresh potent vaccine because of the occurrence of cases in the 
area and among military personnel. The result in reactions were as follows: 
vaccinia, 9.1 percent; vaccinoid, 35.5 percent; immune reactions, 55.4 percent.26 
In the face of an outbreak of smallpox among civilians employed in the 
1155th Army Air Force Base Unit (Fortaleza, Brazil), all military personnel 
23 See footnote 17, p. 281. 
24 (l)ETMD, CBI, 30 Apr 44. HD. (2) ETMD, Persian-Gulf Comd, 21 May 44. HD. (3) 
BTMD, Indla-Burma Theater, 1 .Tun 45. HD. 
25 File : Smallpox, Incidence, Treatment, and Control, ZI. HD : 710. 
28 ETMD, Persian Gulf Comd, 17 Aug 44. HD. IMMUNIZATION 
285 
subject to exposure were revaccinated in August 1944.27 Of the 155 individuals 
concerned, reactions of vaccinia resulted in 95, vaccinoid in 9, immune reactions 
in 39. Twelve were interpreted as being failures and repetition of the pro- 
cedure was required. 
In both instances the individuals concerned had all been vaccinated within 
3 years and many within a considerably shorter period, obviously unsuccessfully 
in many cases. It was the consensus of the various observers that these fail- 
ures were traceable to the use of outdated or improperly refrigerated vaccine 
or faulty technique. The basic fault, however, lay in the failure to observe and 
assign the proper interpretation to the reactions following vaccination. There 
was apparently a certain tendency to consider that all individuals not respond- 
ing with a vaccinia or vaccinoid reaction were immune. This, of course, was 
fallacious and such individuals in many instances were in fact not immune at the 
time of vaccination, nor did they profit by the procedure if in fact it was an 
undetermined failure. As a result such individuals were unprotected. 
Thus while the record with respect to the occurrence of smallpox among 
troops during the war period was probably the best ever achieved under kindred 
circumstances, the fact remains that failure of proper vaccination in individual 
cases did result in cases and death from this disease. 
Reactions. Reactions, in the sense of untoward effects and complications 
following smallpox vaccination, were of little moment. A certain number of 
those vaccinated did require medical care because of fever, infection at the site 
of vaccination, et cetera. These incidents are not worthy of detailed study 
but an approximation of the extent of their occurrence is of some interest. For 
this purpose, the experience in the United States for the year 1943 may be taken 
as a representative sample. During that year there were admitted to Army 
hospitals in the continental United States, 5,260 individuals with admission 
diagnoses of reaction to smallpox vaccination. While there is no accurate 
method of determining the portion of total vaccinations thus represented, a 
figure for such reactions of approximately 1.7 per thousand vaccinations may 
be arrived at by considering that one vaccination was performed on each in- 
dividual entering active service with the Army during the period. Since the 
total number of vaccinations performed was unquestionably greater than this, 
this ratio is undoubtedly high, but, even so, represents a small price to pay for 
the protection afforded. Of some interest is the fact that untoward reactions 
to vaccination tended to increase somewhat during the summer months. Apply- 
ing the same method of calculation referred to above, it is estimated that the 
rates for such reactions were approximately 0.7 per thousand in January, and 
3.3 per thousand during August. The only immediately available explanation 
27 Ltr, Chief Surg USAF South Atlantic to SG, 8 Sep 44, sub : Epidemiological report on smallpox 
at Fortaleza, Brazil. HD : 710. 286 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
for this is that during the summer months there is a greater tendency toward 
maceration of the vaccinated area through increased skin warmth and perspira- 
tion, and thus a more favorable site for secondary infection is afforded. Also, 
in some areas the opportunity for contamination from outside sources, such as 
dust, is greater in summer than in winter. 
The only other type of untoward reaction to smallpox vaccination reported 
was postvaccinal encephalitis. (See Table 25.) This condition was reported in 
Table 25. Postvaccinal Encephalitis 
Case 
Date 
Time between vaccination 
and onset of symptoms 
Outcome 
Remarks 
19^2 
1 
March 
10 days 
Fatal _ _ _ _ 
Pathological diagnosis; 
meningo-encephalitis, 
cause undetermined. 
Symptoms and signs 
more closely simulated 
those of peripheral 
neuritis than of en- 
cephalitis. 
2 
May _ _ 
31 days (?) _ 
Recovery complete _ _ 
Recovery partial. 
Fatal 
3 
November, 
7 days, __ __ _ 
4 
November 
(?) Onset nervous 
symptoms 17 days 
after induction. 
Pathological diagnosis: 
infective polyneuro- 
nitis. 
1943 
5 
February 
August 
3 days. 
Fatal _ 
No specimens submitted 
to Army Medical Mu- 
seum. 
6 
17 days 
Recovered. 
1945 
7 
February 
March 
10 days 
Recovered with some 
8 
2 days 
loss of vision. 
Recovery complete. 
8 individual instances, 4 such cases being reported in 1942, 2 in 1943, none in 
1944, and 2 in 1945. Such study of these cases as it has been possible to make in- 
dicates that, while in fact they all ocurred following smallpox vaccination, there 
is reason to doubt that some of them, at least, were in fact true postvaccinal 
encephalitis. The onset of central nervous system symptoms varied from 2 to 31 
days following vaccination. Only 3 occurred after an interval of 7 to 10 days. 
Of the entire group of 8 cases, 3 were fatal. Post mortem specimens from 2 of IMMUNIZATION 
287 
these were studied at the Army Medical Musemum and the pathologic diagnoses 
arrived at were meningo-encephalitis, cause undetermined, in one case, and in- 
fective polyneuronitis in the other. Unfortunately, no specimens were available 
in the case of the third fatality. Of the remaining 5 cases, there were 3 who were 
reported to have recovered completely, and 2 with minor neurologic residuals. 
While the proof or disproof of true postvaccinal encephalitis in these reported 
cases cannot be made, it is considered that in at least half of them the only 
relationship between the presenting condition and vaccination was one of time 
and not of cause and result. The other 4 may have been encephalitis resulting 
from smallpox vaccination. Table 25 presents a resume of these cases. 
It is of some interest to note that no postvaccinal tetanus was reported 
among the many millions of vaccinations performed. Inasmuch as tetanus 
immunization was commonly not completed until some weeks after the smallpox 
vaccination in Army inductees, and hence could have afforded no protection for 
the majority of such individuals, freedom from this complication must be 
attributed to the high quality of vaccine used, the technique of application, 
and the avoidance of dressings over the site of vaccination. 
TETANUS IMMUNIZATION 
Development and Adoption 
Administration of tetanus toxoid was the first new, generally applied im- 
munization procedure to be adopted for the Army during the World War II 
emergency and this, added to typhoid and smallpox vaccination, became the 
third of the group of procedures referred to for administrative purposes as 
routine immunizations. Of all new procedures adopted during the war period, 
tetanus immunization was probably the most successful. 
The use of the toxoid prepared from the toxin of Clostridium tetani for the 
production of active immunity to tetanus was not new at the time of its adop- 
tion by the Army. This prophylactic procedure was first applied in France 
prior to 1930.28 Following this pioneer work, extensive investigation of the 
usefulness of the procedure was carried on and numerous reports attesting to its 
efficacy were published both in this country and abroad. 
Tetanus immunization using toxoid was adopted by the British, Canadian, 
and French Armies some time before its application in United States Forces.29 
28 (1) Ramon, G., and Zoeller, C. : L’anatoxine tfitanique et 1’immunisation active de 1’homme 
vis-a-vis du t6tanos. Ann. de 1’Inst. Pasteur 41 : 803-838, Aug 1927. (2) Ramon, G., and Zoeller, C.: 
Sur la valeur et la dur6e de l’immunit6 conf6r6e par 1’anatoxine dans la vaccination de 
1'homme centre le t6tanos. Compt. rend. Soc. de biol. 112 ; 347-350, 3 Feb 33. 
29 (1) Rpt, Intelligence Div, Off of Chief Naval Opns, Navy Dept, 25 Sep 40, sub: Great Britain, 
immunization against tetanus and gas gangrene. (2) Ltr, Dr. R. D. Defries, Actg Dir Connaught 
Laboratories, to Dr. W. T. Harrison, Dir Div of Biological Control, Natl Inst of Health, 16 May 40. 
HD : 720.3 Tetanus Toxoid. (3) Ltr, Gaston Ramon, Institute Pasteur, Prance, to Dr. W. T. Harrison, 
Natl Inst of Health, 17 May 40. HD : 720.3 Tetanus Toxoid. 288 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Toxoid was universally administered to personnel of the French Army as early 
as 1936. Information received from France in 1940 indicated that no cases 
of tetanus had occurred in immunized individuals up to that time. It was esti- 
mated that some 80 percent of the British Expeditionary Force in Flanders in 
the early phase of the war were protected from tetanus by toxoid. During this 
harrowing experience, the incidence of tetanus among British wounded was re- 
ported to have been but 0.45 per thousand, none occurring in any one previously 
immunized with toxoid. (Immunization to tetanus as well as other immuniza- 
tions is on a voluntary basis in the British Army, and it was the policy to 
administer prophylactic antitoxin to all wounded including those known to 
have received toxoid previously.) 
The first step toward the adoption of active immunization to tetanus in the 
United States Army was taken in the spring of 1940. At an informal meeting, 
representatives of the Army, Navy, and the Public Health Service agreed 
unanimously that such a procedure was desirable and should be adopted at 
once.30 A formal recommendation that all military personnel on active duty 
be actively immunized against tetanus was made by The Surgeon General on 
28 May 1940 in a letter to The Adjutant General31 In this letter it was pointed 
out that tetanus is one of the most serious complications of traumatic surgery 
and one that requires consideration in any skin perforating wound. The ad- 
vantages of active immunization with toxoid over the administration of tetanus 
antitoxin for passive protection were emphasized and the necessity for early 
action as a means of preparedness was stressed. In addition an outline of the 
proposed method for the administration of the toxoid was presented. The War 
Department, while receptive to the proposal in general, was unwilling to adopt 
immediately this new immunization procedure. Accordingly, the correspond- 
ence between The Surgeon General and the War Department, initiated by the 
letter of 28 May 1940, was continued by 10 indorsements until 27 January 1941. 
Throughout this correspondence, The Surgeon General urged repeatedly that 
definite action be taken for the adoption of the procedure pointing out that, 
for effectiveness, early basic immunization of all military personnel was required 
and that this could not be accomplished on the eve of combat. He further indi- 
cated that the procurement of sufficient quantities of toxoid would require long- 
range definite commitments with the manufacturers. In support of his posi- 
tion, The Surgeon General referred in his indorsement of 3 December 1940 to 
the minutes of the meetings of three National Research Council committees in 
which each recommended strongly the adoption of this method for the preven- 
tion of tetanus in the Armed Forces. Reference was also made to a letter 
from the Surgeon General, United States Public Health Service (30 October 
30 Memo, Lt Col J. S. Simmons, SGO, for Chief Prof Serv Dlv, SGO, 16 May 40. HD : 720.3 
Tetanus Toxoid. 
31 Ltr, SG to TAG, 28 May 40, sub : Active Immunization military personnel against tetanus, with 
10 inds, 7 incls. SG : 720.3-1. IMMUNIZATION 
289 
1940), in which the procedure was strongly indorsed, and which pointed out the 
difficulties with respect to the procurement of adequate supplies of toxoid or 
of antitoxin, if toxoid were not to be used, unless definite and specific assurances 
could be given at an early date to the various manufacturers of biologies. At 
the termination of this series of indorsements, the proposal still lacked complete 
acceptance by the War Department. It had, however, been “approved in 
principle” and The Surgeon General had been instructed to “adopt a procedure 
wdiich will provide for required immunizations with tetanus toxoid in event 
the War Department determines that the prospect of combat is imminent.” 
Authority had also been given (8 January 1941) for the procurement and storage 
of sufficient toxoid to immunize the total armed force planned to be mobilized 
on 1 June 1941. 
Before the administration of tetanus toxoid to all troops was directed, 
limited applications of this protective measure were made. In March 1941, 
the Commander of the Philippine Department requested advice by radio as to 
the advisability of the routine use of toxoid for all troops in that Department.32 
Upon the recommendation of The Surgeon General, he was directed by the War 
Department to initiate the procedure immediately,33 and instructions for the 
method of administration of the toxoid were dispatched to him. Following 
this, it was recommended to the Assistant Chief of Staff, G-l, that a similar 
policy be adopted for the Panama Department, Atlantic bases, and the Hawaiian 
Department.34 On 11 April 1941, The Surgeon General was advised by The 
Adjutant General that the commanders of these departments and bases had 
been directed by radio to proceed with tetanus immunization of all military 
personnel under their command.35 A schedule for the accomplishment of this 
immunization was indicated, the Panama Canal Department being directed to 
accomplish the measure at once, the Atlantic bases to comply between 1 May and 
1 July, and the Hawaiian Department between 1 June and 1 August 1941. In 
the light of subsequent events, these actions, particularly as they affected the 
Philippine and Hawaiian Departments, were most timely. As will be seen, 
this immunization afforded complete protection against tetanus, and undoubt- 
edly through its application many lives were saved during the early phases of 
war in the Pacific. 
In May 1941, the matter of the routine active immunization to tetanus of 
all military personnel was reopened by The Surgeon General.36 In a letter to 
The Adjutant General, the previous recommendations were reviewed, actions 
33 Radio, Conidr Philippine Dept to SG, 13 Mar 41. AG: 720.3 (3-13-41 )M-A. 
33 1st ind, SG to TAG, 13 Mar 41, and 2d ind, TAG to SG, 25 Mar 44, on basic radio cited in foot- 
note 32. 
34 Memo, SG for WD ACofS G-l, 27 Mar 41, sub : Immunization with tetanus toxoid. HD : 720.3. 
35 Ltr, TAG to SG, 11 Apr 41, sub : Immunization of military personnel in overseas garrisons. 
AG : 720.3. 
36 Ltr, SG to TAG, 27 May 41, sub: Active immunization of military personnel with tetanus 
toxoid. HD: 720.3. 290 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
taken with respect to the immunization of part of the Forces summarized, and 
the desirability for uniform policy for the entire Army stressed. On 11 June 
1941, such a policy was adopted and it was directed by War Department Adju- 
tant General’s letter, that date, that all military personnel on active duty with 
the Army of the United States, regardless of location, be actively immunized 
against tetanus immediately.37 
The Immunizing Agent 
The agent chosen for administration to military personnel for the produc- 
tion of active immunity to tetanus was fluid or plain tetanus toxoid. The 
decision to adopt this form of toxoid rather than the alum precipitated product 
was made only after careful consideration of the known characteristics of each 
of these materials and study of the experiences accrued from their use and 
that of related agents.38 The satisfactory experience with the fluid preparation 
in the British and French Armies 39 weighed heavily in the choice of a like 
preparation for administration to American troops. Relatively little experi- 
ence had been had at that time with the administration of an alum precipitated 
agent to large numbers of adults. There seemed little choice between the 
materials from the point of viewT of satisfactory antigenic qualities. Both were 
known to be effective from the point of view of antitoxin production.40 In fact, 
if the experience with diphtheria toxoid in children could be taken as a criterion, 
two doses of the alum precipitated toxoid administered at intervals of several 
weeks might have been expected to accomplish the same end result as that 
derived from three doses of the fluid agent. It was appreciated, however, that 
alum precipitation of an antigen tends to increase its sensitizing powers thus 
leading to possible complications at the time of repeat doses. The choice 
between the two materials was a fine one, but the factors in favor of fluid toxoid 
were considered to outweigh those for the precipitated product and the former 
was decided upon. As will be seen, subsequent experience demonstrated that 
this agent was entirely satisfactory. Its effectiveness was complete and the 
only difficulty encountered following its administration was the occurrence of 
a limited number of reactions of sensitivity to certain peptone components of 
37 Ltr, TAG to CGs all Armies, Army Corps, etc., 11 Jun 41, sub : Active immunization of military 
personnel with tetanus toxoid. AG : 720.3. 
88 Memo, Drs. McCoy, Harrison, and Leake, USPHS, 17 May 40, sub: Concerning suggested pro- 
gram for the immunization of Army and Navy personnel. HD : 720.3 Tetanus Toxoid. 
30 See footnote 29 (1) and (2), p. 287. 
40 (1) Lincoln, B. M., and Greenwald, C. K. : Active immunization of human beings with tetanus 
toxoid. Proc. Soc. Exper. Biol. & Med. 30: 1241-1243, 1933. (2) Sneath, P. A. T. ; Development of 
tetanus antitoxin following administration of tetanus toxoid. J. A. M. A. 102 ; 1288-1289, 21 Apr 34. 
(3) Bergey, D. H., and Etris, S. : Immunization of humans with alum precipitated tetanus toxoid. 
Am. J. Pub. Health 24: 582-586, Jun 1934. (4) Jones, F. G., and Moss, J. M. ; Studies on tetanus 
toxoid. I. The antitoxic titer of human subjects following Immunization with tetanus toxoid and 
tetanus alum precipitated toxoid. J. Immunol. 30: 115-125, Feb 1936. (5) Cowles, P. B.: Tetanus 
Immunization. Yale J. Biol, and Med. 9: 409-416, May 1937. (6) See also footnote 29 (1), p. 287. IMMUNIZATION 
291 
some of the material used. There is reason to believe that similar reactions 
might well have occurred with an alum precipitated agent containing the same 
peptones. 
The toxoids used by the Army were procured from commercial biologic 
laboratories licensed by the Public Health Service for the production and sale 
of this material, and were required to conform in all respects to the requirements 
of the Biologies Control Division, National Institute (later Institutes) of 
Health.41 Because of the nature of tetanus toxoid, particular precautions were 
taken to insure the safety of the material distributed for use. Thus, in addition 
to special care on the part of the manufacturers to prevent contamination or 
adulteration which might render the product unfit for use and the routine checks 
made by the National Institute of Health, all such material used by the Army 
was required to pass satisfactorily an extra test to insure freedom from toxicity. 
This test was made on samples taken from toxoid lots delivered to Army depots 
and its completion was required before distribution was effected. 
The only change in the toxoid used by the Army during the war period was 
that required when it was determined that certain reactions following the 
administration of some of the material were in all likelihood due to sensitivity 
to specific peptones. The wmrst offenders appeared to be those toxoids con- 
taining Witte’s and Berna’s peptone. Accordingly, it was necessary to dis- 
continue procurement of toxoids of this type,42 and to recall from distribution 
certain lots of toxoid known to contain the reaction producing materials.48 
When it was determined with reasonable surety that the peptone components 
of some of the toxoids were responsible for the reactions, it was suggested that 
toxoids produced on a peptone-free hydrolysate medium such as that devised 
by Mueller and Miller44 wmuld be highly desirable. To this end, the Director, 
Biologies Control Division, National Institute of Health, forwarded to all 
tetanus toxoid manufacturers Mueller’s formula for the hydrolysate medium 
and instructions for its use. He also recommended that it be given full trial 
in the production of tetanus toxoid.45 While it was shown that it was possible, 
in the experimental laboratory at least, to produce satisfactory toxoid from 
toxins made in this medium, these results were not consistently reproducible 
and were not achieved by the commercial manufacturers to the extent necessary 
41 (1) Natl Inst of Health, “Minimum Requirements, Tetanus Toxoid,” 17 Jun 38 and subsequent 
modifications. HD; 720.3. (2) Ltr, Chief Prev Med Serv SGO to Bureau Licensing of Biological 
Products, Natl Inst of Health, 3 Apr 41. HD : 720.3 Tetanus Toxoid. 
42 Memos, Prev Med Dlv SGO for Chief Finance and Supply Div SGO, 17 Oct 41 and 15 Dec 41, 
sub : Purchase of tetanus toxoid. HD : 720.3. 
43 Memo, Prev Med Div SGO for Chief Finance and Supply Div SGO, 19 Feb 42, sub : Recall of 
certain lots of tetanus toxoid. HD : 720.3. 
44 Mueller, J. H., and Miller, P. A. ; Tetanus toxin production on a simplified medium. Proc. Soc. 
Exper. Biol. & Med. 43 : 389-390, Feb 1940. 
45 Natl Inst of Health, Cir Ltr to Licensed Manufacturers of Tetanus Toxoid, 3 Oct 41. HD : 
720.3. 
346336 O—55 20 292 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
for large-scale production.46 As a result, the toxoids used by the Army con- 
tinued to be those made from toxins produced in media containing various types 
of peptones (other than Witte’s or Berna’s) and meat digests. As noted below, 
the reaction producing qualities of such toxoids were minimal. 
Methods and Requirements 
The basic administrative requirements for tetanus immunization have 
already been referred to; namely, the initial direction for the immunization 
of all troops in the Philippine, Hawaiian, Panama Departments and Atlantic 
bases, and later the adoption of the procedure as routine for the entire Army. 
This requirement was subsequently published as an Army regulation, in Section 
III, AR 40-210, September 1942. This regulation provided that all military 
personnel be actively immunized to tetanus without unnecessary delay after 
entry into Federal service, that they receive a single routine stimulating dose 
at the end of 1 year thereafter and a similar dose prior to embarkation for 
overseas duty if the initial series or the routine stimulating dose had not been 
received within 6 months prior to such embarkation. Further stimulating 
doses were, of course, authorized at the time of injury and the details covering 
such administration were published in technical directives. These basic re- 
quirements remained the same throughout the war except that the requirement 
for a stimulating dose within 6 months prior to embarkation for overseas travel 
was rescinded in September 1944.47 This rescission was based on the knowledge 
gained from experience that this added precaution was unnecessary. 
The first formal technical directions for the administration of tetanus 
toxoid were published as Circular Letter 34, Office of The Surgeon General, 16 
April 1941. These instructions called for a basic series of three subcutaneous 
injections of 1 cc. each of fluid tetanus toxoid to be administered at intervals of 
“not less than three or more than 4 weeks.” Subsequent injections of 1 cc. 
each were prescribed as follows: 
1. Under normal conditions, at the end of the first year only (after basic 
series), regardless of duration of service. 
2. In time of war, during the months previous to departure for theater of 
operations unless such departure was within the 6-month period subsequent to 
the stimulating dose referred to above. 
46(1) Mueller, J. H. ; Schoenbach, E. B.; Jezukawicz, J. J., and Miller, P. A.: Production of 
tetanus toxin on peptone-free media. J. Clin. Investigation 22 : 315-318, Mar 1943. (2) Schoenbach, 
E. B. ; Jezukawicz, J. J., and Mueller, J. H. : Conversion of hydrolysate tetanus toxin to toxoid. 
J. Clin. Investigation 22 ; 319-320, Mar 1943. (3) Mueller, J. H.; Seidman, L. R., and Miller, P. A. : 
A comparison of antigenicities of hydrolysate and peptone tetanus toxoids in the guinea pig. J. Clin. 
Investigation 22 : 321-324, Mar 1943. (4) Mueller, J. H. ; Seidman, L. R., and Miller, P. A. : Antitoxin 
response in man to tetanus toxoids. J. Clin. Investigation 22 : 325-338, Mar 1943. (5) CMR Infec- 
tion Disease Rpt No. 15 (Abstracted), “Tetanus,” by Dr. J. Howard Mueller, 14 Jul 44. HD: 720.3. 
47 Ltr, TAG to CGs POEs, COs POEs, CofTrans, 28 Sep 44, sub : Stimulating doses of tetanus 
toxoid. AG: 720.3. IMMUNIZATION 
293 
3. As an emergency stimulating dose, to individuals incurring wounds or 
severe burns on the battle field, to patients undergoing secondary operations 
and manipulation of old wounds and to others with injuries which might be 
complicated by the introduction of Cl. tetani into the tissues. 
Instructions were also given as to the proper recording of completed teta- 
nus immunization. These included: 
1. Recording on the immunization register (WD MD Form 81). 
2. Stamping of the identification tag at the completion of the initial series 
with the letter “T” followed by figures indicating the year, and additional date 
to be stamped on the tag after the routine stimulating dose. “T 41-42” would 
indicate the completion of the basic series in 1941 and the routine stimulating 
dose in 1942. 
The use of antitoxin for passive immunization was reserved for those with 
clinical tetanus, and for individuals with wounds or other conditions requiring 
protection against tetanus who presented no evidence of the previous adminis- 
tration of toxoid. 
These instructions were supplemented on 10 November 1941 by the publi- 
cation of additional information concerning the administration of tetanus 
toxoid in Circular Letter 110, Office of The Surgeon General, These additional 
instructions did not alter the basic procedures as outlined above but clarified 
certain points concerning which questions or misunderstanding had arisen. 
The most important among these were: 
1. In order to avoid unnecessary repetition of injections, it was directed 
that if the prescribed intervals between doses were exceeded the missed dose 
or doses should be administered as soon as possible, but a new series should 
not be started. 
2. It was stated that the stimulating dose to be administered prior to em- 
barkation for a theater of operations should be given unless departure was to 
be within the 6-month period subsequent to the routine stimulating dose (1 
year after the basic series) or within the same period after the basic series itself. 
3. To avoid the undesirable use of prophylactic antitoxin it was pointed 
out that a satisfactory immunity producing mechanism is established at the time 
of completion of the basic three injections of toxoid and hence, toxoid and not 
antitoxin should be administered for emergency protection at any time after 
the completion of the basic series of injections. (This fact was not definitely 
known at the time of the publication of the original instructions but was estab- 
lished in October by a study carried on jointly at the Army Medical School and 
National Institute of Health,48 the details of which are summarized in the 
subsequent discussion of effectiveness of toxoid.) 
48 Ltr, Dr. M. V. Veldee, Chief Dlv of Biologies Control, Natl Inst of Health, to Maj A. R. 
Driesbach, Army Med Center, 27 Oct 41. HD : 720.3 Tetanus-Toxoid, Experimental. 294 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
4. In view of the occurrence of some reactions of sensitivity, specific instruc- 
tions were given with respect to the precautions to be taken in connection with 
such reactions. These included: 
a. Have adrenalin at hand during immunization procedure. 
b. Perform intradermal sensitivity tests using 0.1 cc. of 1 to 100 dilution 
of toxoid on those with a history of previous allergic manifestations, those who 
have exhibited untoward reactions to a previous dose of tetanus toxoid, and 
those who are to receive a dose of toxoid in the initial series after an interval 
of more than 4 weeks has elapsed. 
5, If, in the opinion of the surgeon, previous reactions or positive sensitivity 
tests constituted definite contraindication to further immunization, the pro- 
cedure was to be abandoned, care being taken to avoid stamping the identifica- 
tion tag to indicate completion of this procedure. If further immunization was 
not considered to be definitely contraindicated in such individuals, the 1 cc. dose 
was to be divided and 0.1 cc. administered cautiously. If an anaphylactic type 
reaction occurred, the immunization was to be discontinued. If not, the re- 
mainder of the cubic centimeter was to be administered in 3 or 4 portions at 
daily intervals. 
Though the incidence of known sensitivity to tetanus toxoid was relatively 
low, the problem did arise of possible disqualification for overseas duty on the 
grounds of inability to complete immunization because of such sensitivity. The 
policy with respect to this matter was that sensitivity to tetanus toxoid should 
not be considered to be disqualifying for overseas duty. In such cases it was 
indicated that notation should be made on the service record of the individual 
concerned signifying the sensitivity and that the immunization to tetanus was 
not completed. In addition, the identification tag should not show complete 
immunization to tetanus.49 
The instructions presented in these two circular letters (34 and 110) were 
subsequently combined with only minor changes and published in Circular 
Letter 162, November 1942, which represented a compilation of technical instruc- 
tions covering all the immunization procedures authorized at that time. This 
circular letter was later replaced by TB MED 114, “Immunization,” November 
1944. Instructions in this bulletin concerning tetanus immunization were 
essentially unchanged from those reviewed above with the notable exception 
that, in conformance with the administrative change previously referred to,50 
the stimulating dose of toxoid within 6 months of departure for a theater of 
operations was no longer required. 
Despite these rather specific instructions, toxoid was not administered in a 
completely uniform manner. Perhaps the most outstanding deviation from 
49 Ltr, CO Camp Crowder, Mo., to CG 7th SvC, 11 Aug 43, sub ; Tetanus toxoid immunization 
of officers and enlisted men assigned to foreign service, with inds. HD : 720.3. 
r,n See footnote 47, p. 292. IMMUNIZATION 
295 
the prescribed policy was the use of an annual stimulating dose in the European 
Theater of Operations. There was no clear indication for such a practice at 
the time and the evidence accumulated since indicates clearly that stimulating 
doses at such frequent intervals are not required and, hence, are undesirable. 
Experience 
Effectiveness. The administration of tetanus toxoid for the production of 
immunity to' tetanus proved to be a completely successful procedure. A total 
of 12 cases of tetanus occurred among Army personnel between 7 December 1941 
and 1 January 1946. There were 3 cases in 1942, 5 in 1943, 3 in 1944, and 1 in 
1945. Four of the 12 occurred overseas but only 1 as a result of a battle wound. 
The immunization status of the individuals who developed the disease is shown 
in the tabulation below. 
Fatal 
Total 
cases 
cases 
No active immunization 
2 
6 
Basic immunization (3 injections) accomplished but no booster injection given 
following injury 
1 
2 
Basic immunization and booster injection following injury received 
2 
4 
Total _ ___________ 
5 
12 
Of the 6 cases occurring in unimmunized persons, 4 resulted from injuries 
incurred prior to entry on active duty, 1 was in a soldier with 4 months of 
service, and 1 case occurred in a soldier who, though in the service for a year 
prior to the onset of the illness (January 1941 to February 1942), had received 
only 1 dose of toxoid. One of the 2 patients who had received the basic toxoid 
injections, but no booster dose at the time of injury, was first treated in a French 
hospital in North Africa and later transferred to an American installation. 
The other, who was injured while on furlough, was treated by a civilian physi- 
cian.51 In the latter case, toxoid was administered after the onset of tetanus 
symptoms, some 48 hours after the injury. This injection is not considered to 
be a true emergency stimulating dose of toxoid. 
Four patients in the series had received at least 1 booster dose of toxoid 
in addition to the basic series. One had had 3 such stimulating doses at yearly 
intervals. One of these did not receive a stimulating dose at the time of injury. 
All recovered. The other 2 individuals who had received the basic series of 
injections had been in the service less than 1 year thereafter at the time of 
injury. 
The periods between the injury and the onset of symptoms of tetanus 
varied from 2 to 40 days. The median incubation period of the 6 immunized 
cases was 7.5 days, and of the 6 unimmunized, 13.5 days. The nature of the 
51 Goehrlng, W. O. : Tetanus occurring in immunized individual. Am. J. Surg. 66 : 123-125, 
Oct 1944. 296 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
injury resulting in tetanus with the number of cases in each category were: 
gunshot wound, 5; burn, 1; secondary to operation for osteomyelitis, 1; com- 
pound fracture, 2; miscellaneous injuries, 3. These injuries involved the foot 
in 5 instances, other extremities in 6, and the abdominal cavity in 1 case. 
In summary, there were but 12 cases of tetanus in the Army during the 
war period. Six of these were in unimmunized individuals, including 4 result- 
ing from injuries received prior to entry on active duty, and only 4 cases oc- 
curred in soldiers whose records indicated that they had received toxoid in 
complete accordance with Army requirements including the stimulating dose 
after injury. Tetanus occurred in only 1 battle casualty. There were 5 deaths 
from the disease, 2 in individuals who had received no toxoid and 1 in a person 
who though having had the basic immunization, did not receive a stimulating 
dose at the time of injury. Thus only 2 deaths from tetanus occurred in 
individuals immunized in complete accordance with requirements. 
The contrast between this occurrence of tetanus and that experienced dur- 
ing World War I is not as striking as might be expected since but 70 cases were 
reported among Army personnel during the earlier conflict. It is likely, how- 
ever, that this figure is low due to the incomplete reporting of the time. At 
that time specific protection was afforded by the administration of prophy- 
lactic tetanus antitoxin. There is no satisfactory estimate available as to the 
occurrence of serum sickness, anaphylaxis, et cetera, caused by this antitoxin, 
but it appears safe to assume that such reactions occurred to a significant extent. 
A total of 14 admissions for tetanus among Army personnel were reported to 
The Surgeon General during the period between the wTars (1922-41), 2 more 
than the total number reported during World War II. 
It is manifestly impossible to estimate the number of cases of tetanus ac- 
tually prevented through immunization. There is, however, evidence to indicate 
the presence of potential hazards from this disease in areas where Army troops 
were in operation. In Hawaii, where no cases occurred among Pearl Harbor 
casualties, the annual incidence among the civilian population in peacetime is 
said to be about 5.7 per 100,000.52 No comprehensive data are available con- 
cerning the occurrence of tetanus among Japanese troops and natives in the 
various Pacific operations but sufficient information is at hand to indicate a 
relatively high incidence of the disease among this inadequately protected group. 
(Routine active immunization was not practiced in the Japanese ArmjL 
Selected personnel may have been immunized.) One Navy report indicated 
the occurrence of 14 cases of tetanus in a group of 284 Japanese wounded,53 
Similarly, a report from Headquarters, Kwajalein, the Marshall Islands, re- 
ported 12 cases of tetanus among 266 wmunded Japanese prisoners of wTar.54 
52 Halford, F. J. : Gas gangrene and tetanus; their prevention and management in war wounds. 
Hawaii M. J. 1 : 169-170, 13 Jan 42. 
53 Navy Dept HOMED News Letter, vol. 4, No. 6, 15 Sep 44. 
54 Monthly Sanitary Rpt, Surg APO 241 (Kwajalein Island), Jul 1944. SG : 721.5. IMMUNIZATION 
297 
1 etanus among civilian casualties during the Manila operation was not uncom- 
mon, a total of at least 473 cases with 389 deaths having been reported.55 Also, 
at least 20 cases of tetanus are known to have occurred among civilians on 
Saipan.56 Probably the actual number was considerably greater than this. 
Of this known number, there were 14 fatalities. 
Accurate data are likewise not available concerning tetanus among German 
troops. However, one report indicated that during the Normandy invasion, 
German ground troops (not immunized) suffered over 80 cases of tetanus but 
that there were no cases reported from the protected Luftwaffe.57 That this 
figure may be minimal is suggested by the fact that there were 53 cases of tetanus 
among American-held German prisoners of war in the United Kingdom during 
the period 7 September to 2 October 1944.58 
The British have reported a total of 103 cases of tetanus from 1939 and 
1940 to the end of the war.59 This total, however, included 34 German, 7 
Italian, and 3 French cases. The remainder were in British, Dominion, or 
Colonial troops. Twenty-seven of the 103 were said to have been previously 
protected with 2 or more doses of toxoid. 
From these rather fragmentary data concerning the occurrence of tetanus 
in other than American personnel, it is evident that without the benefit of 
toxoid appreciable numbers of cases of tetanus would have occurred in our 
troops. In addition, through the avoidance of the use of prophylactic anti- 
toxin in the more than one-half million battle casualties an indefinite number 
of serious serum reactions and doubtless some fatalities were prevented. 
In addition to the evidence of the actual protection reviewed above, certain 
experimental evidence was obtained in connection with various factors of the 
immunization processes. Early in the program, it became evident that there 
was at hand no factual evidence as to the rapidity with which a satisfactory 
immunity producing mechanism would be produced following the basic series 
of three injections of toxoid. This information was required for the basis for 
instructions regarding the administration of the emergency stimulating dose 
of toxoid after injury. Accordingly, serum specimens were obtained from each 
of nine individuals a week after the last injection of the initial series.60 At the 
same time, a fourth or stimulating dose of toxoid was administered in the same 
manner as if required by a potentially infected wound. A week after this 
fourth injection, blood specimens were obtained. 
56 ETMD, USAFFE, 2 Jan 45. HD. 
56 ETMD, PDA, Nov 1944. HD. 
57 OSS Rpt (Abstract), 27 Jul 45, sub: Medical installations in Munich area; new medical pro- 
cedures. HD : 720.3 Tetanus Toxoid. 
58 Ltr, Col .T. H. McNlnch, Off of Chief Surg ETO to Lt Col A. P. Long, SGO, 13 Dec 44. HD : 
710 Tetanus. 
59 Cope, Zachary, ed. ; Medicine and Pathology. In Medical History of the Second World 
War. London, Her Majesty’s Stationery Office, 1952, p. 446. 
80 (1) Long, A. P. : Tetanus toxoid, its use in the United States Army. Am. J. Pub. Health 33: 
53—57, Jan 1943. (2) See also footnote 48, p. 293. 298 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
All of the first specimens taken (1 week after the third dose) contained 
at least 0.1 unit of antitoxin per cubic centimeter of serum, and 3 contained 1 
unit or more per cubic centimeter. Of the sera taken 1 week after the fourth 
or stimulating dose, two contained more than 0.1 unit but less than 0.5 unit; 
3 contained more than 0.5 unit but less than 1 unit and the remainder contained 
at least 2 units of antitoxin per cubic centimeter. Since the amounts of circu- 
lating antitoxin necessary for protection had been stated by various workers 
to be 0.01 unit to 0.2 unit per cubic centimeter of serum, it was considered reason- 
able to assume that there was adequate protection based on active immunity 
after the completion of the initial series of three injections of tetanus toxoid, 
and that there was no indication for the use of prophylactic antitoxin after 
this immunity had been established.61 
Late in 1942, in an effort to determine the antitoxin response to the stimulat- 
ing dose of tetanus toxoid administered approximately 1 year after the initial 
series, serums for antitoxin titration were collected from 32 individuals. Stim- 
ulating doses of toxoid were then administered and a second serum specimen 
obtained 1 week later. Fifteen of these persons were stimulated with a regular 
commercial toxoid, while 17 were given a special peptone-free material, hydrol- 
ysate toxoid. Table 26 shows the results of these tests.62 It will be noted that 
while relatively small quantities of circulating antitoxin were present before 
the stimulating dose, 1 week thereafter adequate protective levels were reached 
in all but 1 individual who did not appear to respond well. These results 
compare favorably wdth those obtained by Mueller and his associates with a 
considerably larger sample.63 In their series of 103 individuals to whom stim- 
ulating doses were given 1 year after the basic series, titers from approximately 
1 unit per cubic centimeter of serum to more than 50 w7ere encountered. Ap- 
proximately half of this group were given hydrolysate toxoids and the others, 
regular commercial products. No significant difference was noted between the 
responses from the two types of materials. 
To extend further the knowledge on the immune response to stimulating 
doses of toxoid, a study was initiated early in 1945 to determine this response 
at least 2 years after the administration of the routine stimulating dose of 
toxoid. For this purpose, 22 volunteers were secured who had received their 
basic series of tetanus toxoid at least 3 years previously and the routine stimu- 
lating dose approximately 1 year thereafter with no subsequent doses of toxoid. 
Blood specimens for antitoxin titration were obtained from each of these men 
and a stimulating dose of toxoid was administered to 13. Blood specimens 
were obtained from the latter group on the third and seventh days following 
the injection of toxoid. Thus it was possible to determine the amount of 
61 Ibid. 
62 File : Tetanus Toxold-Experlmental. HD : 720.3. 
M See footnote 46 (4). p. 292. IMMUNIZATION 
299 
Table 26. Results of 1 Cubic Centimeter of Stimulating Dose of Tetanus Toxoid 
Approximately 1 Year After Basic Series 
Before stimulation 
After stimulation 
Num- 
ber 
Units antitoxin per cc. serum i 
Commercial toxoid 
Experimental peptone-free toxoid 
Num- 
ber 
Units antitoxin per ec. serum 
Num- 
ber 
21 
<0.1 
<0.01 __ __ _ __ ___ 
1 
6 
0.1 
>0.01 <.l 
1 
3 
>0.1 <.3 
>0.1 <.3 
2 
1 
>0.1 <1 
>0.3 <.6 . _ 
3 
1 
Sample destroyed 
0.3 or more 2 
4 
15 
0.6 or more 3 
6 
32 
15 
17 
1 The antitoxin determinations were made at the National Institutes of Health and the Army Medical School. 
1 Tested for not more than 0.3 unit, actual value not known. 
3 Tested for not more than 0.6 unit, actual value not known. 
circulating antitoxin present in all 22, and in 13, the increase in circulating 
antitoxin at the end of 3 and 7 days after the injection of 1 cc. of toxoid. The 
results of these determinations are shown in Table 27. It will be seen that only 
2 of this group had less than 0.1 unit of antitoxin per cubic centimeter of serum 
before stimulation, and that 16 had 0.3 unit or more at that time. Thus, with 
the possible exception of the first 2, all were probably completely protected 
against tetanus in the event of an injury even though they were not to receive a 
booster dose. There was little increase in antitoxin level demonstrated at the 
end of 3 days following the booster dose but there was at least some indication 
of effect from the stimulus. At the end of 7 days, however, the rise was quite 
pronounced with only 1 of the 13 demonstrating less than 3 units, and 4 rising 
to a level of more than 10 units of antitoxin per cubic centimeter of serum. 
In addition to the positive evidence of the practical efficiency of tetanus 
toxoid for the prevention of tetanus, there has been experimental evidence to 
indicate a protective response to a booster dose of tetanus toxoid administered 
as late as 3 to 4 years after the initial series, and 2 to 3 years after the routine 
stimulating dose as applied in the standard Army tetanus immunization re- 
gime. Continued investigation will be required to determine the full extent 
of this period of efficacy of the basic tetanus immunization as applied to adults 
in the Army. 
Reactions. The administration of tetanus toxoid was attended by some 
reactions, a great majority of which occurred early in the program. At no 
time wrere these reactions of sufficient import to hamper seriously the practice 300 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Table 27. Sebum Antitoxin Levels 2 Years or More After Routine Stimulating 
Dose of Toxoid and Effect of Booster Dose Administered at That Time 1 
Case number 
Prestimulation anti- 
toxin units per cc. 
serum 3 
Interval since 
previous dose 
of toxoid 
Poststimulation antitoxin units per cc. 
serum 3 
1 
>0. 01 
<0. 1 
months 
34 
3 days 
>0.03 <0.1 
7 days 
>3 <10 
2 
> . 
01 
< . 1 
26 
> . 
03 
< . 1 
> 1 
< 3 
3_ 
> . 
1 
< . 3 
28 
3 
>30 
4 
> . 
1 
< . 3 
28 
> . 
1 
A 
00 
>10 
<30 
5. 
> . 
1 
< . 3 
27 
1 
> 3 
<10 
6 
> . 
1 
< .3 
26 
7- 
3 
33 
3 
> 3 
<10 
8- 
3 
26 
> . 
3 
<1 
> 3 
<10 
9. 
> . 
3 
<1 
33 
> . 
3 
<1 
> 3 
<10 
10 
> . 
3 
<1 
27 
> . 
3 
<1 
> 3 
<10 
11 _ 
> . 
3 
<1 
27 
> . 
3 
<1 
> 3 
<10 
12 
> . 
3 
<1 
26 
> . 
3 
<1 
>10 
<30 
13 
14 
> . 
> . 
3 
3 
<1 
<1 
26 
25 
15 
> . 
3 
<1 
<1 
27 
16 
> . 
3 
27 
17 
> . 
3 
<1 
27 
18 
> . 
3 
<1 
23 
19 ... 
> . 
3 
<1 
26 
20 
>1 
<3 
27 
21 
>1 
<3 
26 
>1 
<3 
> 3 
<10 
22 
>1 
<3 
26 
>1 
<3 
>10 
<30 
1 Antitoxin determinations performed in the laboratories of the Department of Bacteriology, Harvard Medical School. 
3 Arrangements made and specimens obtained by Lt. Col. Francis Cook, Medical Inspector, First Service Command. 
of active immunization. Reactions encountered were classifiable to two main 
categories. Those in the first category caused no concern and were manifested 
by such symptoms as headache, weakness, general malaise, local soreness, and 
occasionally chills and fever. Such reactions were not unlike those experienced 
after typhoid vaccination but occurred much less frequently after tetanus toxoid 
than following the administration of triple typhoid vaccine. 
The reactions of the second category occurred in a majority of instances 
within 80 minutes after the injection and were characterized in general by hush- 
ing and itching of the skin, local and generalized urticarial eruptions, and 
edema of the lips and eyelids. In some instances, edema of the glottis and 
dyspnea were observed. The nature of these reactions more than their fre- 
quency led to considerable study for the determination of their cause. It soon 
became apparent that they were manifestations of sensitivity to some constit- 
uent of the toxoid used. An early opportunity for the investigation of the 
occurrence of these reactions was afforded by their relatively high incidence in IMMUNIZATION 
301 
the Newfoundland Base Command.64 During this investigation, it was deter- 
mined that among 1,722 completed immunizations in that command in August 
1941, there were 22 reactions of sensitivity among 18 individuals, 1 percent of 
those immunized presenting symptoms of sensitivity. All reactions followed 
the second or third dose. Skin sensitivity tests done on a limited number of 
those reacting, using a 1: 100 dilution of the same type of toxoid used for the 
immunization, demonstrated definite local sensitivity of high degree, while 
the same type of test recorded on individuals who had experienced a reaction 
nonsensitive in nature were entirely negative. It suggested by the investi- 
gator that these reactions were the result of sensitization by the first or second 
dose of toxoid, and that a study be made of the various culture media used in 
preparation of toxoid to determine the presence of a protein likely to cause 
such sensitization. 
In view of these findings and the observations of Whittingham,65 Parish 
and Oakley,66 and Cooke and his associates,67 the reports of reactions received 
in the Surgeon General’s Office were carefully scrutinized in an effort to deter- 
mine the relationship between their occurrence and the use of particular lots or 
makes of toxoid. By early October 1941, sufficient evidence had been accumu- 
lated to indicate very strongly that those toxoids containing Witte’s or Berna’s 
peptone were responsible for a great majority of the reactions68 (toxoids con- 
taining Witte’s or Berna’s peptone had been used in about 75 percent of the 
injections reported and had been responsible for at least 90 percent of the 
reactions reported at that time). As a result, the action previously referred to 
was taken to discontinue the use of toxoids of this nature. This was followed 
by a significant decrease in the occurrence of these reactions. 
An accurate figure as to the exact numbers of reactions of sensitivity which 
occurred and the proportion of injections resulting in such reactions was never 
obtained, the problem not having been considered worthy of the detailed inves- 
tigation throughout the Army which would have been required for this pur- 
pose. However, a reasonably good sampling was achieved. Table 28 presents 
an estimate of the proportion of reactions of sensitivity to the number of injec- 
tions given for various periods during the first 3 years of the tetanus immuniza- 
tion program. 
64 Memo, Dir Prev Med Div SGO for SG, 27 Aug 41, sub: Report by Capt. Long of tetanus toxoid 
reactions at Newfoundland Base Command. HD : 720.3. 
“ Whlttingham, H. B. : Anaphylaxis following administration of tetanus toxoid. Brit. M. J. 1 : 
292-293, 24 Feb 40. 
“ Parish, H. J., and Oakley, C. L. : Anaphylaxis after injection of tetanus toxoid. Brit. M. J. 1 : 
294-295, 24 Feb 40. 
67 Cooke, R. A.; Hampton, S. ; Sherman, W. B., and Stull, A.: Allergy induced by immunization 
with tetanus toxoid. J. A. M. A. 114 : 1854-1858, 11 May 40. 
68 Memo, Dir Prev Med Div SGO for SG, 7 Oct 41, sub: Reactions to tetanus toxoid, report of 
conference, Surgeon General’s Office, 2 October 1941. HD : 720.3. 302 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
The highest proportion of reactions experienced, according to this esti- 
mate, was approximatey 63 per 100,000 injections, and by the end of the year 
following discontinuation of the procurement of toxoids containing the offend- 
ing peptones this had dropped to about 2 per 100,000. At tins time, and cer- 
tainly during subsequent periods, the actual proportion was in all likelihood 
considerably lower since negative reports were seldom received; that is, there 
was a tendency to report actual numbers of injections accomplished only when 
one or more reactions occurred. Following 15 July 1943, despite the steadily 
growing Army, the reports were so scattered and few as to make further 
computations entirely unsatisfactory. 
Table 28. Reactions of Sensitivity to Toxoid* 
Injections 
Reactions 
Reactions per 
100,000 injections 
To 1 October 1941 
445, 299 
284 
63 
1 October 1941 to 1 March 1942 _ 
1, 559’ 286 
361, 133 
199, 652 
163, 692 
493 
32 
1 March 1942 to 15 October 1942 
22 
6 
15 October 1942 to 31 December 1942 
4 
2 
31 December 1942 to 15 Julv 1943 _ 
3 
2 
•These figures do not represent the total number of reactions during this period nor the total number of injections. 
As the early experience indicates, the majority of reactions occurred after 
the second and third injections. Of these reactions reported in relation to the 
number of the injection causing the reaction, it was found that 16 percent 
followed the first injection and the remainder of the reactions were about equally 
divided between the second and third doses of the toxoid. 
Earlier estimates of the proportion of reactions caused by the toxoids 
containing Witte’s and Berna’s peptone were also essentially borne out by the 
continued studies. By June 1942, just under one million injections of toxoid 
had been reported with indications of the name of the manufacturer and lot 
number of material used. From this information, it was possible to determine 
the type of peptone or other protein material contained in the product in 
question. This revealed that in this series, toxoids made with Witte’s peptone 
had resulted in reactions of sensitivity in about 43 out of every 100,000 injec- 
tions. Those containing Berna’s peptone had caused similar reactions in 79 
injections per 100,000, and other toxoids caused 16 such reactions in a similar 
number of injections. 
Viewed in another way, toxoids with Witte’s peptone tended to produce 
these reactions 3.3 times and those with Berna’s peptone 5 times more 
frequently than did other toxoids. IMMUNIZATION 
303 
These figures indicate that toxoids other than Witte’s or Berna’s peptone 
toxoid were at that time producing a higher proportion of reactions than was 
subsequently experienced. This may be explained in part on the basis of obser- 
vations made in another study, described below, that individuals sensitized by 
one of the toxoids most commonly producing reactions may react in a sensitive 
manner to toxoids containing meat digests or similar substances, but no peptone. 
Thus, in late 1941 and early 1942, it wras entirely likely that second or third 
injections of digest toxoid might have been administered to individuals already 
sensitized by a first injection of a peptone-containing material. Under such a 
circumstance, the toxoids other than Witte’s and Berna’s peptone toxoid might 
have precipitated a reaction based on earlier sensitization by a toxoid of another 
type. 
In an effort to learn something of the duration of the state of sensitivity 
in individuals who had demonstrated such reactions and to observe the effect 
of nonpeptone toxoids on such persons, a study was conducted with 40 volun- 
teers who had previously demonstrated reactions as subjects.69 Results of this 
study are summarized in Table 29. Of the total of 40 individuals studied, 33 
were still positive to a material causing original reactions, 31 were positive to 
pig stomach digest toxoid, 27 were positive to the other digest toxoid used, and 
none gave positive reactions to hydrolysate toxoid (toxoid produced on Mueller’s 
hydrolysate media). Of 16 people tested who had received peptone toxoid 
(Witte’s or Berna’s) but who had not responded with reactions of sensitivity, 
5 were found to be positive to the material originally received, 3 to pig stomach 
digest, 6 to the other digest toxoid, and none reacted positively to the hydroly- 
sate toxoid. These findings indicated that those individuals who had originally 
reacted in a sensitive manner to the peptone type of toxoids (approximately 1 
year previously) were still sensitive to those materials. Since such toxoids were 
no longer available for use, this caused no concern. However, the fact that such 
individuals might react in a sensitive manner to digest toxoids on subsequent 
injections was viewed with some misgiving. Some effect from this conditioning 
probably was felt as indicated above. However, the fact that practically no 
reactions were reported following stimulating or booster doses during the later 
months or years indicated that this cross sensitivity was apparently of no great 
significance. 
The entire experience with the reactions of sensitivity following tetanus 
toxoid served to emphasize the importance of great care in the selection of 
antigens for such widespread use as is practiced with immunizing agents in the 
Army. There can be no doubt but that in the production of materials of this 
type the greatest possible care should be taken to prepare materials with the 
least possible danger of the production of sensitivity consistent with a potent 
and stable product. 
69 Office memo, A. P. Long, 6 Aug 42, sub : Preliminary report of field study on reactions to sensi- 
tivity to tetanus toxoid. HD: 720.3. 304 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Type of test toxoid 
Hydrolysate 
Digest2 
Digest (Pig stomach) 
Witte peptone 
Reaction.- 
Indefi- 
nite 
Posi- 
tive 
Nega- 
tive 
Indefi- 
nite 
Posi- 
tive 
Nega- 
tive 
Indefi- 
nite 
Posi- 
tive 
Nega- 
tive 
Indefi- 
nite 
Posi- 
tive 
Nega- 
tive 
Number 
4 
0 
13 
0 
13 
2 
1 
15 
1 
0 
17 
0 
II. Skin Tests on Individuals Previously Sensitive to Berna Peptone Toxoid 
Type of test toxoid 
Hydrolysate 
Digest2 
Digest (Pig stomach) 
Berna peptone 
Reaction. ... ... ... 
Indefi- 
nite 
Posi- 
tive 
Nega- 
tive 
Indefi- 
nite 
Posi- 
tive 
Nega- 
tive 
Indefi- 
nite 
Posi- 
tive 
Nega- 
tive 
Indefi- 
nite 
Posi- 
tive 
Nega- 
tive 
Number 
1 
0 
22 
4 
14 
5 
4 
16 
3 
3 
16 
4 
Type of toxoid 
Hydrolysate 
Digest2 
Digest (Pig stomach) 
Witte and Berna peptone 
Reaction 
Indefi- 
nite 
Posi- 
tive 
Nega- 
tive 
Indefi- 
nite 
Posi- 
tive 
Nega- 
tive 
Indefi- 
nite 
Posi- 
tive 
Nega- 
tive 
Indefi- 
nite 
Posi- 
tive 
Nega- 
tive 
Number 
5 
0 
35 
4 
27 
7 
5 
31 
4 
3 
33 
4 
Table 29. Results of Skin Sensitivity Tests on Individuals Known to be Sensitive to Certain Toxoids 1 
I. Skin Tests on Individuals Previously Sensitive to Witte Peptone Toxoid 
III. Summary 
Table A Tests IMMUNIZATION 
305 
Type of toxoid 
Hydrolysate 
Digest2 
Digest (Pig stomach) 
Witte and Berna peptone 
Reaction - 
Indefi- 
nite 
Posi- 
tive 
Nega- 
tive 
Indefi- 
nite 
Posi- 
tive 
Nega- 
tive 
Indefi- 
nite 
Posi- 
tive 
Nega- 
tive 
Indefi- 
nite 
Posi- 
tive 
Nega- 
tive 
Number 
2 
0 
14 
5 
6 
5 
6 
3 
7 
5 
5 
6 
1 Intradermal injections of 0.1 cc. of a 1:100 dilution of the toxoids were used for the tests. 
2 Two individuals not tested with this material. 
T. Skin Tests on Individuals Previously Receiving Peptone Toxoid but Exhibiting no Reactions 
Controls 
Table B 306 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
VACCINATION AGAINST YELLOW FEVER 
Development and Adoption 
The development of a vaccine effective against yellow fever was begun in 
1928 with the demonstration of the virus etiology of the disease.70 The various 
stages in this development have previously been traced and recorded and re- 
quire no further review.71 
Early in 1940 Lt. Col. James S. Simmons foresaw the need to determine 
Army policy on vaccination of troops against yellow fever. He referred the 
problem to the Advisory Committee on Tropical Diseases of the National Re- 
search Council, and on the basis of his suggestions the committee recommended, 
in June 1940, that military personnel going into areas where yellow fever was 
suspected to exist be immunized against that disease.72 In order that a supply 
of the vaccine might be available, this group requested the International Health 
Division of the Rockefeller Foundation to produce a supply of this vaccine for 
possible use by the Armed Forces. At a subsequent meeting held in October 
1940, this committee made further specific recommendations that all military or 
civilian personnel dispersed to the American tropics or other areas where yellow 
fever was likely to be encountered should be immunized. It was recommended 
that the vaccination be done preferably before departure for such areas and 
that those individuals already in the areas should be vaccinated as early as 
possible.73 
In January 1941, The Surgeon General recommended to The Adjutant 
General that all military personnel stationed in tropical regions of the Western 
Hemisphere, including Panama and Puerto Rico, be vaccinated against yellow 
fever.74 In this recommendation, it was pointed out that in the defense of the 
Western Hemisphere, it was anticipated that troops would be sent to certain 
South American countries where exposure to yellow fever was a likelihood. In 
addition, the possibility of the introduction of this disease into areas where it 
did not exist at the time was stressed. It was stated that the introduction of 
the disease into new areas might be accomplished through the increase in travel 
and exchange of troops between endemic and nonendemic areas or by the willful 
introduction by enemy action of the causative virus into areas where the vector 
was already established. Following this recommendation, the War Depart- 
70 Stokes, A.; Bauer, J. H., and Hudson, N. P. : The transmission of yellow fever to Macacus 
rhesus. J. A. M. A. 90 : 253-254, 28 Jan 28. 
71 (1) Smith, H. H.; Penna, H. A., and Paoliello, A.: Yellow fever vaccination with cultured 
virus (17D) without immune serum. Am. J. Trop. Med. 18: 437-468, Sep 1938. (2) Gordon, J. E. ; 
The preparation and use of yellow fever vaccine. In Virus and Rickettsial Diseases. Cambridge, 
Harvard University Press, 1940, p. 767-788. (3) Sawyer, W. A. : Yellow fever and its control. In 
Problems and Trends in Virus Research. Philadelphia, University of Pennsylvania Press, 1941, p. 
27-39. 
72 Minutes of meeting, NRC Advisory Committee on Tropical Diseases, 19 Jun 40. SG : 040.9-10. 
73 Minutes of meeting, NRC Subcommittee on Tropical Diseases, 24 Oct 40. SG : 040.9-10. 
74 Ltr, SG to TAG, 19 Jan 41, sub : Vaccination of troops against yellow fever. HD : 720.3. IMMUNIZATION 
307 
ment, on 30 January 1941, directed vaccination against yellow fever of all mili- 
tary personnel stationed in the tropical regions of the Western Hemisphere, 
including Panama and Puerto Rico, and the preembarkation vaccination of 
personnel ordered to these areas.75 The requirements for vaccination as pre- 
sented in the original directive were changed a number of times throughout 
the war period. These requirements will be reviewed below. 
The Immunizing Agent 
At the time of the adoption of yellow fever vaccination by the Army, the 
only producer of this vaccine in the United States was the laboratory of the 
International Health Division of the Rockefeller Foundation. Accordingly, 
arrangements were made for the procurement of vaccine from this laboratory 
in accordance with the recommendations of the National Research Council 
previously cited. This vaccine was a suspension of viable virus prepared from 
chick embryo cultures of the 17-D strain of yellow fever virus.76 This material 
was the Seitz or Berkefeldt filtrate of a 10-percent infected chick embryo 
emulsion in undiluted, inactivated human serum. The emulsion was placed 
in ampules and desiccated from the frozen state under vacuum. An immuniz- 
ing dose was 0.5 cc, of a 1:10 dilution of this material. Each lot was tested for 
sterility, virus content, and for evidence that the neurotropic virulence was low. 
Shortly after the arrangements had been made for the procurement of 
vaccine from the Rockefeller Foundation, discussions were held with representa- 
tives of the Public Health Service in connection with the possibility of that 
agency also undertaking the manufacture of this agent with a view toward 
ultimately providing all necessary yellow fever vaccine to the Armed Forces. 
The initiation of this second source of supply was considered desirable inas- 
much as the Rockefeller Foundation, wdiile in a position to furnish the vaccine 
as an emergency measure, had recommended that its manufacture be assumed 
by some Governmental agency as soon as it was practicable to do so.77 Accord- 
ingly, the Surgeon General of the Public Health Service took the necessary 
action to establish facilities for yellow fever vaccine production. These facili- 
ties were established and, in September 1941, the Administrator of the Federal 
Security Agency notified the Secretary of War that the Rocky Mountain Labo- 
ratory of the Public Health Service was in a position to furnish yellow fever 
vaccine to the Army.78 During the intervening period, the Rockefeller labora- 
tories had furnished large quantities of vaccine and the director of that organi- 
75 Ltr, TAG to CGs Armies, CAs, etc., 80 Jan 41, sub: Vaccination of troops against yellow fever. 
AG ; 720.3. 
76 (1) Memo, Dr. W. A. Sawyer, International Health Div Rockefeller Foundation, to SG, 9 .Tul 
40, sub: Manufacture of yellow fever vaccine. HD: 720.3. (3) Memo, Dir Prev Med Div SGO for 
SG, 31 Jul 40, sub : Conference with Director, Rockefeller International Health Board concerning 
yellow fever vaccine. HD : 720.3. 
77 Ltr, SG to Surg Gen USPHS, 17 Aug 40, and reply, 3 Sep 40. HD : 720.3. Yellow Fever. 
78 Ltr, Admin Fed Sec Agency to SecWar, 26 Sep 41. HD : 720.3 Yellow Fever. 
346(336 O—55 21 308 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
zation stated his willingness to continue to furnish this material to the Army 
for the duration of the emergency. It was then mutually agreed by representa- 
tives of the Army, Navy, Public Health Service, and Rockefeller Foundation 
that the latter organization continue to furnish vaccine to the Armed Forces, 
the Public Health Service to manufacture such material as was considered 
necessary to meet any anticipated demands of the civilian population and thus 
also provide an emergency reserve of the agent to be available to the services 
if for any reason it should become impracticable to continue with the Rocke- 
feller supply.79 
This arrangement was continued until April 1942 when it became apparent 
that the outbreak of jaundice in the Army at that time was associated with 
yellow fever vaccination,80 While the role of yellow fever vaccine in the pro- 
duction of jaundice was not clearly understood at that time, it was considered 
advisable to discontinue, temporarily at least, the vaccine currently in use and 
to substitute an agent from another source. Accordingly, arrangements were 
made to obtain vaccine from the Public Health Service at least until the true 
nature of the vaccine-jaundice relationship could be established. In addition, 
stocks of the original material in this country were called in and supplies in 
installations outside the country were destroyed.81 
The first vaccine received by the Army from the Public Health Service 
was prepared in much the same manner as that obtained from the Rockefeller 
Foundation and, like that material, contained as a stabilizing agent normal 
human serum.82 However, consideration was being given to the production of 
a vaccine containing no serum and in fact a small quantity of material of this 
type had been prepared previously and was furnished to the Army late in 
May 1942.83 Later in the same month, the decision was made that as soon as 
feasible all of the yellow fever vaccine used by the Army be made without human 
serum.84 In accordance with this decision the vaccine prepared for Army 
use by both producing laboratories, the Public Health Service and Rockefeller 
Foundation, was subsequently of the aqueous base, serum-free type. All of 
the yellow fever vaccine received by the Army after 1 June 1942 had been pre- 
pared in this manner. 
79 (1) Memo, Dir Prev Med Div SGO for SG, 21 Oct 41, sub: Yellow fever vaccine. HD: 720.3. 
(2) Ltr, TAG to Admin Fed Sec Agency, 29 Sep 41. HD: 720.3 Yellow Fever. 
80 Memo, Dir Prev Med Div SGO for SG, 15 Apr 42, sub : Report on jaundice and yellow fever 
vaccination. HD : 720.3 Yellow Fever. 
81 (1) Memo for file, Maj A. P. Long, Prev Med Serv SGO, 15 Apr 42, sub; Change of supply 
of yellow fever vaccine. HD : 720.3. (2) Memos, Asst Prev Med Serv SGO for Chief Prev Med Serv 
SGO, 10 and 18 Apr 42, sub : Recall of yellow fever vaccine. HD : 720.3. 
82 Memo, Dir Rocky Mountain Lab USPHS for Chief Prev Med Serv SGO, 5 May 42, sub; Prep- 
aration, et al., of yellow fever vaccine at the Rocky Mountain Laboratory. HD ; 720.3. 
83 Ltr, Dir Rocky Mountain Lab USPHS to CO Army Med Supply Depot, Brooklyn, N. Y., 20 May 
42. HD : 720.3 Yellow Fever. 
84 Memo, Prev Med Serv SGO for SG, 26 May 42, sub : Supply of yellow fever vaccine. HD : 720.3. IMMUNIZATION 
309 
From this time, there were two sources of fever vaccine. This 
allowed both for adequate amounts of the material for current use and for the 
maintenance of reserve stock piles both in this country and in overseas bases. 
The bulk of the vaccine used by the Army throughout the remainder of the 
wTar was that produced by the Public Health Service, while the Rockefeller 
Foundation also contributed large quantities of this immunizing agent and 
maintained large reserve stocks. 
Methods and Requirements 
The method of administration of yellow fever vaccine remained essentially 
unchanged throughout the war period. This procedure involved the subcuta- 
neous administration of 0.5 cc. of a 1: 10 dilution of the desiccated material. 
Sterile saline solution was furnished in bottles containing the proper amounts 
for making the desired dilutions. Thus wuth the 1 cc. vaccine ampule was 
furnished a bottle containing 10 cc. of saline, and with the 5 cc. ampule, a bottle 
containing 50 cc. of saline. Ten-fold dilutions yielded 10 cc. and 50 cc. of 
vaccine respectively, or 20 and 100 doses of 0.5 cc. each. 
Detailed instructions for handling, storage, dilution, and administration 
of the vaccine were furnished in Circular Letter 9, Office of The Surgeon 
General, February 1941, and later in Circular Letter 162, Office of The Surgeon 
General, November 1942, and TB MED 114, November 1944. In addition, in- 
structions for the dilution and administration of the vaccine were distributed 
with the material itself. The lability of this agent was stressed in all the 
instructions issued, and directions were given that it be shipped and stored at 
freezing temperatures and that diluted vaccine exposed to room temperatures 
for longer than 1 hour should not be used. 
Possible contraindications to the administration of yellow fever vaccine 
at the same time as other antigens were considered. It was believed that since 
smallpox vaccine and yellow fever vaccine both contained living viruses, it was 
not desirable to administer them simultaneously. It was recommended that 
if both were to be administered, the yellow fever vaccine be given first and 
smallpox vaccination done at least 5 days later. Because of the apparent 
exaggerated reaction to typhoid vaccine when it was administered to individuals 
experiencing a febrile reaction from yellow fever vaccine, it was recommended 
that the administration of typhoid vaccine within a T-day period following 
yellow fever vaccination be avoided whenever possible. 
As previously indicated, the requirements for yellow fever vaccination were 
changed from time to time throughout the war period. These requirements and 
the various changes which were made were based on a number of considerations. 
The basic consideration was the provision for adequate protection against 
yellow fever of personnel stationed in or traveling through areas where the 
disease was known or reasonably suspected to exist. A second consideration was 310 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
the possibility of the introduction of yellow fever to areas where, while cur- 
rently absent, the disease might spread rapidly due to the presence of the mos- 
quito vector. Still a third consideration was the necessity for compliance with 
the quarantine regulations of certain foreign governments. Of all of these fac- 
tors, the last-named was perhaps the most troublesome, since, unless these regula- 
tions were complied with, detention of individuals traveling by air resulted, thus 
interfering with military travel and the smooth operation of transportation 
systems, particularly air transport. 
The various administrative requirements for yellow fever immunization 
which were in effect during the years 1941 through 1945 are shown in Appendix 
A. These requirements varied from that of selective vaccination of individuals 
stationed in the tropics, Avhich was in effect early in the program, through the 
vaccination of all military personnel effected during the first half of 1942, to 
the final policy of the immunization of those individuals whose route of travel 
or place of station was considered to require this special protection. The areas 
where hazards from yellow fever were considered to exist were redefined from 
time to time. This was done for two principal reasons. One was consideration 
of possible infection in areas where it had hitherto not been considered. This, 
for example, was the basis for extending the requirement for yellow fever 
vaccination for those individuals stationed in or traveling to Panama and the 
Canal Zone. Changes in definition of the areas requiring yellow fever immuni- 
zation which are found in War Department Circular 254,1943, and Circular 187, 
1944 (see Appendix A) are based on the definition of certain foreign govern- 
ments, particularly India and Egypt. It was not until May 1944 that the 
accepted period of immunity following yellow fever vaccination was increased 
from 2 to 4 years. As will be seen later, it had been considered for some time 
prior to this that immunity produced by yellow fever vaccine was retained for 
longer than 2 years, but there was reluctance on the part of both Indian and 
Egyptian officials to consider individuals vaccinated longer than 2 years pre- 
viously as immune, and hence incapable of introducing the infection into their 
respective countries. The solution of this problem, that is the reconciliation of 
what was considered in this country to be safe practice with the quarantine 
requirements and regulations of India, particularly, was a long slow process 
and involved voluminous correspondence and interchange of communications 
through State Department as well as military channels.85 The later phases of 
these negotiations are discussed in the chapter on Foreign Quarantine in Volume 
II of this series. 
In addition to the War Department requirements for yellow fever vaccina- 
tion as summarized and discussed above, there was a theater requirement for 
this vaccination for troops stationed in Hawaii and the Central Pacific Area 
s5 “R6sum6 of the Controversy Regarding Yellow Fever Vaccination and Quarantine. India and 
the United States.” HD: 720.3. IMMUNIZATION 
311 
from September 1943 until June 1945.86 Hawaii was not considered to be a 
yellow fever endemic area and vaccination was not accomplished for individuals 
prior to their departure from the United States. Instead the vaccine was 
shipped to Hawaii and administered to troops after their arrival. The basis 
for the requirement for yellow fever vaccination in Hawaii and the Central 
Pacific was the concern in the War Department over the potential dangers of 
the introduction of yellow fever into Hawaii which, because of the presence 
of Aedes mosquitoes, was considered to be a fertile area for the rapid develop- 
ment of an epidemic. Such a situation did not develop and yellow fever was 
not identified in the area at any time during the war. Vaccination there was, 
therefore, entirely a precautionary measure taken against this potential hazard. 
Experience 
Effectiveness. The effectiveness of yellow fever vaccine for the preven- 
tion of yellow fever had been well demonstrated prior to its adoption by the 
Army.87 It was generally accepted in this country that satisfactory immunity 
developed within a week to 10 days following vaccination and lasted for an 
indefinite period beyond 2 years. In 1943, however, additional evidence be- 
came available which indicated clearly that the immunity following vaccina- 
tion persisted for a period of at least 4 years.88 It was this evidence which, 
added to previous experiences, made it possible to adopt the 10-day, 4-year 
policy which was then accepted as meeting the quarantine requirements for 
unrestricted entry into Egypt and India from yellow fever endemic areas. 
As far as the effectiveness of yellow fever vaccine in American troops is 
concerned, there is little that can be said. No cases of yellow fever occurred. 
Neither was there appreciable exposure to the disease. Yellow fever did occur 
sporadically in the general areas in which some troops were stationed both in 
South America and in Africa. However, it is not known that the disease actu- 
ally occurred in sufficiently close proximity to Army installations so that expo- 
sure actually took place. 
Laboratory evidence of the efficacy of the vaccination was, however, ob- 
tained. This was done in order to check on the potency of the vaccine as it was 
used in the field. It was accomplished by the procurement of blood specimens 
from representative groups vaccinated at various places throughout the country. 
The presence of protective antibodies in these serum specimens showed defi- 
88 (1) Ltr, Mr. J. W. McCloy, Asst SecWar, to CG Hawaiian Dept, 8 Jul 43, and reply, 20 Jul 43. 
AG: 720 Hawaii. (2) Memo, Chief Prev Med Serv SGO for Mr. J. W. McCloy, Asst SecWar, 13 
Aug 43. AG: 720 Hawaii. (3) Ltr, CG Hawaiian Dept to Mr. J. W. McCloy, Asst SecWar, 6 Sep 43. 
AG: 720 Hawaii. (4) Ltr, CG USAFPOA to TAG, 5 Mar 45, sub: Immunization of personnel pro- 
ceeding to this theater, with 5 inds. HD : 720.3 PDA Reqmts. 
87 See footnote 71 (1) and (2), p. 30(5. 
88 Fox, J. P., and Cabral, A. S.: The duration of immunity following vaccination with the 17D 
strain of yellow fever virus. Am. J. Hyg. 37 : 93-119, Jan 1943. 312 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
nitely that the vaccines used were active and that the desired results were being 
obtained.89 
Reactions. The relationship between apparently augmented reactions to 
typhoid vaccine in individuals recently vaccinated against yellow fever has been 
discussed. It is believed that this reaction occurred in those individuals ex- 
pressing a febrile response to the yellow fever vaccine. Such a response had 
been anticipated, and in the first circular letter prescribing the use of yellow 
fever vaccine, it was pointed out that approximately 5 percent of vaccinated 
individuals could be expected to exhibit a slight general and febrile reaction 
between the fifth and the seventh day following vaccination. These reactions 
did occur but apparently not to the extent of 5 percent of the individuals vac- 
cinated, Accurate figures of incidence are not available since complete report- 
ing of reactions of this type was not required. In one series of approximately 
125,000 vaccinations reported early in the program, febrile reactions were 
reported in just under 300 individuals; an incidence of approximately 0.2 per- 
cent.90 Essentially no reports of reactions were received subsequently but this 
figure is considered to be representative of the total experience. Reactions of 
this type were characterized in the main by variable degrees of malaise, eleva- 
tion of temperature occasionally as high as 101° F. or higher, and occasional 
axillary adenitis. There was no indication that these reactions bore any rela- 
tionship to the postvaccinal jaundice which made its appearance early in 1942. 
In March of 1942 it became apparent that the jaundice then occurring 
among troops was likely to develop into an incidence of epidemic proportions. 
This in fact did occur and the peak of the epidemic among troops in the con- 
tinental United States was reached in late June and in overseas contingents 
about 1 month later. A total of over 50,000 cases of jaundice believed to have 
occurred in relationship to yellow fever vaccination were reported.91 
Exhaustive studies and investigations were instituted as soon as it was 
evident that an epidemic was imminent. Early results obtained from these 
studies indicated that a causal relationship existed between the occurrence of 
jaundice and the administration of at least certain lots of yellow fever vaccine 
2 to 3 months previously. This relationship seemed to be in connection with 
the human serum used for the stabilization of the vaccine. Acting on this evi- 
dence The Surgeon General in April 1942 discontinued the vaccine in current 
use. Soon after this, a serum-free vaccine was introduced and no cases of 
89 File : Yellow Fever Vaccine—Tests. HD : 720.3. 
90 File : Yellow Fever Vaccine—Reactions. HD : 720.3. 
91 (1) The outbreak of jaundice in the Army. Mil. Surgeon 94: 386-393, Oct 1942. (2) Sawyer, 
W. A. ; Meyer, K. F.: Eaton, M. D.; Bauer, J. H. ; Putnam, P., and Schwentker, F. F.: Jaundice In 
Army personnel in the western region of the United States and its relation to vaccination against 
yellow fever. Am. J. Hyg. 39 : 337-430, May 1944 ; idem 40 : 35-107, Jul 1944. (3) Walker, D. W. : 
Some epidemiological aspects of Infectious hepatitis in the U. S. Army. Am. J. Trop. Med. 25 : 75-82, 
Mar 1945. IMMUNIZATION 
313 
jaundice wrere reported traceable to yellow fever vaccination with the new type 
of agent. 
It was subsequently shown without question that jaundice could be trans- 
mitted to humans by the subcutaneous injection of very small amounts of 
human serum obtained from individuals developing the disease after yellow 
fever vaccination and that this jaundice resulted from infectious hepatitis.92 
This and other evidence obtained from the jaundice epidemic experience 
demonstrated clearly that the jaundice after yellow fever vaccination was not 
associated directly wdth the yellow fever virus itself but that it wTas due to an 
extraneous or contaminating virus introduced into the vaccine with the human 
serum component. 
Subsequent to this experience, many thousands of individuals were vacci- 
nated successfully with a yellow fever vaccine not containing human serum. 
Thus the cause of an unanticipated complication of immunization was dis- 
covered and effective steps were taken for the prevention of its future 
occurrence.93 
CHOLERA, PLAGUE, AND 
TYPHUS VACCINATIONS 
Vaccinations against cholera, plague, and epidemic typhus fever were 
“special immunization procedures.” That is, they wTere not applied routinely 
but only for the protection of troops stationed in or departing for areas where 
danger from the specific disease was considered to be a real or potential hazard 
and for troops traveling through such areas. Since these vaccinations were 
considered as a group in the adoption of policies and procedures for their use 
by the Army, they will be treated in a similar fashion here. 
Action looking toward the specific protection of American troops against 
cholera, plague, and typhus, should such protection be indicated, was taken in 
the early autumn of 1941. At that time, no American troops were under actual 
threat of any of these diseases. However, the possibility of future assignment 
to or even action in areas where these diseases wyere present was becoming more 
and more likely. This first action was taken in preparation for the future 
rather than to meet an existing situation. 
The first step taken was the presentation of a memorandum requesting 
recommendations concerning these immunization procedures to the Chairman 
of the Division of Medical Sciences, National Research Council.94 In this 
92 Oliphant, J. W. ; Gillian, A. G., and Darson, C. L. : Jaundice following administration of human 
serum. Pub. Health Rep. 58 : 1233-1242, 13 Aug 43. 
93 Jaundice following vaccination against yellow fever. J. A. M. A. 125 ; 1190-1191, 26 Aug 44, 
94 Memo, Col J. S. Simmons, SGO, for Dr. L. H. Weed, Div of Med Sciences NRC, 8 Sep 41, sub : 
Immunization against certain infectious diseases, notably plague, cholera, and typhus. HD : 720.3 
Typhus. 314 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
memorandum, guidance was specifically requested with respect to the indica- 
tions for vaccination and in connection with a definition of the agents to be 
employed and the methods for their use. In response to this request, a meet- 
ing of specialists in the various fields involved was arranged by the National 
Research Council and pertinent recommendations were made.95 In essence, 
these were to the effect that all individuals stationed in or about to enter areas 
where danger of exposure to typhus fever or cholera existed should be vaccinated 
with an appropriate vaccine. For typhus, the vaccine recommended was the 
Cox type, yolk-sac vaccine; and for cholera, a vaccine containing 8 billion 
killed vibrios per cubic centimeter. It was also recommended that all personnel 
under serious threat of exposure to bubonic plague be vaccinated with “killed 
plague bacilli of an approved strain.” 
Acting on these recommendations, after investigating the source of the 
supply of the agents involved, The Surgeon General, on 13 November 1941, 
recommended to The Adjutant General that these procedures be adopted for 
selective use in the Army.96 This recommendation was approved and these 
procedures were adopted on 6 January 1942 with the publication of War De- 
partment Circular 4 of that date. This circular stated that military personnel 
stationed in or traveling to certain areas should be vaccinated against typhus 
and/or cholera as prescribed by The Surgeon General, and that military per- 
sonnel under serious threat of exposure to epidemics of plague should be im- 
munized with plague vaccine as prescribed by The Surgeon General. This 
administrative directive was implemented on 14 January 1942 by technical 
instructions published in Circular Letter 3, Office of The Surgeon General, 
subject: Vaccination against typhus fever, cholera, and plague. In subsequent 
discussion of these procedures, each will be considered separately. 
Cholera Vaccination 
The Immunizing Agent. The cholera vaccine procured for use in military 
personnel was prepared by commercial manufacturers in accordance with the 
recommendations and requirements of the National Institutes of Health, United 
States Public Health Service.97 The organism strains chosen for the vaccine 
were Inaba and Ogawa strains which were agglutinable, smooth, motile, pre- 
sented characteristic biochemical activities, and were apparently fully virulent 
and antigenic. A large number of freshly isolated strains obtained from India 
were studied both at the Army Medical School and at the National Institutes of 
Health and those chosen for inclusion in the vaccine were considered to be the 
95 Minutes of conference on immunization against typhus fever, cholera, and plague called by 
NRC Subcommittee on Tropical Diseases, 22 Oct 41. HD : 720.3 Typhus. 
®" Ltr, SG to TAG, 13 Nov 41, sub : Immunization against typhus, cholera, and plague. HD : 
720.3 Plague. 
97 (1) Memo for file, 20 Peb 42, sub : Conference regarding cholera vaccine held at the Army 
Medical School. HD: 720.3. (2) Ltr, Dr. M. V. Veldee, Natl Inst of Health, to Lt Col A. P. Long, 
SGO, 4 Apr 44. HD : 720.3 Cholera. IMMUNIZATION 
315 
best obtainable for vaccine production. The finished vaccine consisted of a 
suspension of phenol-killed cholera vibrios containing 8 billion organisms per 
cubic centimeter of the vaccine. 
Methods and Requirements. The method prescribed for the administra- 
tion of cholera vaccine was first presented in Circular Letter 3, Office of The 
Surgeon General, 1942, previously referred to, and was republished subsequently 
in Circular Letter 162, Office of The Surgeon General, 1942, and TB MED 114, 
1944. The initial vaccination consisted of two subcutaneous injections of 0.5 
cc. and 1 cc. respectively at 7- to 10-day intervals. Stimulating doses of 1 cc. 
each at intervals of 4 to 6 months were recommended in the presence of serious 
danger of infection. This procedure as originally adopted was continued 
without change throughout the war. 
Cholera vaccination was required for troops who were stationed in or 
traveling to areas where danger from cholera was considered to exist. The 
requirements as stated in the original War Department directive of 6 January 
1942 were as follows: “All military personnel stationed in or traveling through 
Asia or other regions where cholera is known to be present in endemic or epi- 
demic form will be immunized with cholera vaccine as prescribed by The Sur- 
geon General.” The vaccine was administered in this country only after re- 
ceipt of orders directing travel to one or another of the areas concerned. It was 
fully realized that such immunity as did accrue from cholera vaccination was 
in all likelihood incomplete and probably of short duration. It was therefore 
emphasized that this procedure should not in any way serve as a substitute for 
sanitary or other measures for prevention and control of the disease. 
The official War Department requirements for this procedure are found in 
Appendix B. During certain periods of the war, cholera vaccination was re- 
quired for travel to areas where in fact no cholera existed. This was made 
necessary on administrative grounds in view of the uncertainty of the actual 
destination of certain troop contingents in some instances, and because of the 
difficulty in accomplishing the vaccination in an active theater as a last minute 
procedure prior to an operational move. In a similar manner and for much 
the same reasons, cholera vaccination was required for all operational Army Air 
Force personnel including those assigned to the Air Transport Command. 
While this policy undoubtedly resulted in the vaccination of individuals for 
whom no danger of exposure ever existed, it was the only practicable method 
of accomplishing the protection of all of those for whom it was considered 
necessary. 
Effectiveness. While there had been little experience in the Army with 
cholera vaccination prior to World War II, this procedure had been practiced 
for many years in those areas where cholera is more or less a constant threat. 
First among these areas were India, China, and the Malay States. The results 
of vaccination, however, were never clear-cut and had not clearly demonstrated 316 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
the value of the procedure. Strong, in reviewing this past experience, states 
that “While prophylactic inoculation in cholera has been very widely employed 
for many years no definite unanimity of opinion exists in regard to its value 
during an epidemic though in general the reports have been favorable regard- 
ing its use.” 98 
An analysis of large scale experience with cholera vaccine was presented 
in a study of a cholera epidemic in the Province of Madras, India, in 1942 and 
1943." In this epidemic, the study of two large groups, one vaccinated, the 
other unvaccinated, revealed that the incidence was 10.6 times more in the 
unvaccinated than in the “protected” group. From this and other supporting 
data, the authors drew the conclusion that “. . . there is definite proof that 
the protected persons are 10 to 14 times less susceptible to getting cholera than 
the uninoculated persons in the community.” It was the feeling of the authors 
of this report that the protection afforded from vaccination persisted from 5 to 
12 months. 
The validity of these conclusions can neither be confirmed nor refuted by 
the experience with cholera among American troops during the war. The 
fact remains, however, that the occurrence of cholera among these troops was 
negligible. The disease was present in epidemic or semiepidemic form in a 
number of areas in which troops were stationed. These included China, India, 
and Burma. The only cases in American military personnel occurred in China 
in the summer of 1945 when 6 cases and 1 death were reported from the Liang- 
shan area, and 7 cases and 1 death from Chihchiang.100 The source of the 
infections in the Liangshan group was considered to have been baked goods 
secured from a local bakery. The cases at Chihchiang were believed to have 
resulted from the drinking of contaminated water. All of those developing 
cholera at Liangshan had been vaccinated in August 1943 wdth American 
vaccine (just over 2 years before the onset of illness). Information concerning 
subsequent or stimulating doses was not complete. However, it was determined 
that 5 of the 6 individuals involved had received a stimulating dose of Chinese 
vaccine in April and May 1944. Five of the group also received stimulating 
doses of Chinese vaccine in October 1944 and the sixth was given a dose of 
American vaccine in September 1944. In April 1945, five of the individuals 
concerned received American vaccine and the remaining person was given a 
booster dose of Chinese vaccine in May of the same year. Two received stimu- 
lating doses as late as July 1945. This group then appeared to have been 
08 Strong, R. P. : Stitt’s Diagnosis, Prevention and Treatment of Tropical Diseases. Philadelphia, 
The Blakiston Company, 1944, p. 634. 
99 Adisehan, R., Dir Pub Health Madras, India ; Statistical evaluation of anti-cholera inoculation 
as a personal prophylactic against cholera and its efficacy in the prevention and control of cholera epi- 
demics. HD: 710. 
100 ETMD, China theater, Aug 1945. HD. IMMUNIZATION 
317 
reasonably well vaccinated although the exact nature of the Chinese vaccine 
used was not known. 
Information on the original immunizations on the patients at Chihchiang 
was not obtained but all seven of the individuals had received a stimulating 
dose of vaccine as late as April and July 1945, the one man vaccinated in April 
having received Indian vaccine. These few cases of cholera in American per- 
sonnel in China occurred at a time when there was a sharp outbreak among 
the Chinese in the Chungking area. Stringent precautionary measures were 
applied to safeguard the troops in that area from contaminated food and water. 
The relative effects of this procedure and of vaccination for the prevention of 
the disease in American personnel could not be determined. It was necessary 
to assume that the result obtained accrued from a summation of all the pro- 
tective measures applied and that under similar circumstances, none of these 
measures may be omitted with safety. 
No cases of cholera occurred in military personnel in the India-Burma 
theater although a sharp epidemic was experienced in the civilian population 
of Calcutta early in 1945.101 Some evidence of the efficacy of vaccination in the 
prevention of the disease in this situation was derived from the fact that 
cholera did occur in approximately 50 British and Indian troops in the area at 
that time.102 It was the practice of the British in this area to vaccinate only 
after the epidemic started, rather than to practice immunization before hand as 
was done for American personnel. The risk to which the British and American 
troops were exposed would appear to have been comparable although American 
sanitation may have been superior. As with experience in China, the only 
conclusion that could be drawn was that troops could be protected from cholera 
by the application of all the available preventive measures including vaccination. 
Reactions. Almost no reports were received of untoward reactions fol- 
lowing cholera vaccination. The vaccine used appeared to have been essentially 
free from reaction producing substances. 
Plague Vaccination 
The Immunizing Agent. The plague vaccine secured for use in the Army 
was commercially prepared in accordance with National Institute of Health 
requirements and standards.103 The first procured (approximately 100,000 cc.) 
was prepared from avirulent stock culture strains. The remainder of the ma- 
terial obtained was made from virulent plague bacilli. The original virulent 
strains used were the Ureka strain isolated from a human case of plague in 
1941 and F8251 isolated from infected fleas in 1941.104 These strains were 
101 ETMD, India-Burma theater, 1 Jun 45. HD. 
102 Med Intel Rpt, U. S. Navy Liaison Off, Calcutta, 28 Jul 45, sub : Cholera. HD : 710. 
103 Natl Inst of Health, Minimum Requirements for Plague Vaccine, 20 Apr 45. 
104 Ltr, Dr. M. V. Veldee, Natl Inst of Health, to Maj A. P. Long, SGO, 8 Apr 42, with incls. 
HD: 720.3 Plague. 318 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
replaced in the latter part of 1942 by a virulent Indian strain (No. 337, Hooper 
Foundation, University of California) .105 The finished vaccine was a suspension 
of formalin-killed plague bacilli containing 2,000 million organisms per cubic 
centimeter. 
Methods and Requirements. Instructions for the use of plague vaccine were 
first published in Circular Letter 3, Office of The Surgeon General, 14 January 
1942, and subsequently in Circular Letter 162, Office of The Surgeon General, 
28 November 1942, and TB MED 114. Initial vaccination wTas accomplished by 
the subcutaneous administration of 2 doses of vaccine, 0.5 cc. and 1 cc. each, at 
intervals of 7 to 10 days. Subsequent doses of 1 cc. each were to be administered 
when stimulation of immunity was considered necessary. Under serious threat 
of exposure to plague infection, it was recommended that such doses be given 
as frequently as every 4 to 6 months. 
Basic War Department policy for plague vaccination requirements con- 
templated administration of the vaccine to troops in areas where and when 
special danger from the disease was found to exist. Thus vaccination was not 
to be accomplished prior to embarkation for overseas but rather supplies of 
the vaccine wrere furnished to the theaters for use as indicated.106 This policy 
was adhered to throughout the war with but two exceptions. 
In view of the endemicity of plague in the Azores and in accordance with 
the recommendation made by the Surgeon of the British Base at Lagens, those 
ordered to permanent duty in the Azores were vaccinated prior to departure. 
The second exception was made in connection with troops departing for 
duty in the western part of the Pacific Ocean Areas. At the request of theater 
officials, personnel ordered to duty in those areas wrere given plague vaccine 
prior to embarkation during part of the year 1945,107 This practice was discon- 
tinued, however, shortly after the termination of hostilities.108 
Effectiveness. The effectiveness of plague vaccination as practiced for 
American troops was not determined. No cases of plague wrere reported but 
neither w7as there indication that actual exposure occurred. The disease was 
present, however, in areas where American forces were stationed. These in- 
cluded the Azores where the disease smoulders in low endemic proportions, New 
Caledonia where two cases were reported in 1942, the Suez Area in Egypt where 
there was a brisk outbreak in late 1943 and early 1944, and the Dakar-Mar- 
rakech area where a moderate epidemic occurred in 1943 and 1944. Plague 
was also present in China and India in areas where American troops were 
105 Minutes of Conference on Plague Prevention and Therapy, Division of Medical Sciences, NRC, 
15 Oct 42. HD; 720.3. 
™ WD Cir 4, 6 Jan 42. 
107 Ltr, TAG to CGs AAF, AGF, ASF, POEs, CofTrans, and SG, 20 Nov 44, sub : Immunization 
of troops moving overseas, and Amendment No. 2, 1 Feb 45. AG : 720.3. 
108 Memo, Troops Mvmts Branch Mobilization Div ASF to Opns Branch AGO, etc., 20 Aug 45, 
sub : Revised clothing and equipment chart for troops moving to all overseas commands (Change # 
11). HD : 720.3 Travel Rqmts, POA. IMMUNIZATION 
319 
stationed. (See chapter on plague and plague control in another volume in 
this series.) 
Vaccination of American troops was practiced in all these areas in addition 
to rodent and flea abatement programs and general protective measures. Credit 
for the protection of American personnel against plague must of necessity be 
given to all of the procedures applied. The true value of plague vaccination 
alone could not be determined from the situations encountered and the experi- 
ences obtained. 
Reactions. Reactions reported in connection with the administration of 
plague vaccine were minimal and no difficulties developed from this aspect of 
the use of plague vaccine of the type applied in the Army during the war. 
Typhus Vaccination 
The Immunizing Agent. The first typhus vaccine recommended for use 
by the Army was the Cox vaccine. This consisted of a 2-percent formalinized 
yolk-sac suspension of louse-borne epidemic typhus rickettsiae, Breinl strain. 
The rickettsiae were cultivated in the yolk sac of fertile hens’ eggs and extracted 
by centrifugation and then washed.109 As with all other biologic agents 
obtained commercially, acceptance for use in the Army was based on conform- 
ance with the minimum requirements of the National Institute of Health. 
When the use of typhus vaccine was first contemplated it was being pro- 
duced by only one commercial manufacturer and some time was required before 
large quantities of the agent could be made available. The supply situation 
was further clouded by the fact that sufficient funds were not available to pur- 
chase the quantities which would be needed soon after the procedure was offi- 
cially adopted.110 During the period between the official adoption of typhus 
vaccination and the time adequate procurement from commercial sources was 
effected, considerable amounts of the vaccine were furnished by the laboratories 
of the United States Public Health Service.111 By March- 1942, however, a 
number of commercial laboratories had accepted contracts for the production 
and supply of typhus vaccine and some 239,000 vials had been placed on order 
for delivery within the subsequent 6 months.112 
The use of typhus vaccine for the protection of military personnel served 
as a stimulus to investigations aimed at improvement in the quality and effec- 
tiveness of this agent. Those most actively engaged in this work were investi- 
109 Cox, H. R. ; Use of yolk sac of developing chick embryo as medium for growing rickettsiae of 
Rocky Mountain spotted fever and typhus groups. Pub. Health Rep. 53 : 2241-2247, 23 Dec 38. 
110 Memo, Dir Finance and Supply Div for Dir Prev Med Div, 24 Nov 41. HD : 720.3 Typhus. 
111 Memo for file, 1 Jan 42, sub : Typhus vaccine. HD : 720.3. 
112 Table, Procurement status of typhus vaccine on order with manufacturers, 5 Mar 42. HD : 
720.3. 320 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
gators at the National Institute of Health, the Connaught Laboratories of 
Toronto, Canada, and the Army Medical School.113 
It was early recognized that the original Cox vaccine was deficient in 
antigen content. In December 1941, the workers at the Connaught Laboratories 
in Toronto demonstrated the ether method of extracting rickettsiae from yolk- 
sac suspensions. The vaccine recommended consisted of an ether extraction 
of the yolk-sac suspension followed by centrifugation and resuspension of the 
rickettsiae. Following this the Army Medical School initiated an experiment 
to compare the various typhus vaccines then available and susceptibility of 
being used by the Army. They consisted of the Cox vaccine described above, 
the ether extracted yolk-sac vaccine of the Connaught Laboratories, the French 
epidemic mouse-lung vaccine and the Mexican murine rat-lung vaccine. The 
results of these experiments showed the Cox vaccine and the Mexican murine 
rat-lung vaccine did not adequately protect guinea pigs against epidemic type 
of rickettsiae. The other two vaccines, however, did appear to afford good 
protection. A soluble antigen obtained from ether extracted yolk-sac suspen- 
sion was demonstrated independently and at approximately the same time by 
two of the research laboratories (Army Medical School114 and National Institute 
of Health).115 A vaccine containing a greater concentration of rickettsiae and 
soluble antigen was prepared and tested in man and guinea pigs. This new 
method of processing eliminated centrifugation which in turn eliminated the 
loss of antigen in the form of minute rickettsiae and in the form of soluble 
antigenic material. On 25 May 1942, at a conference called by the Subcom- 
mittee on Tropical Diseases of the National Research Council, it was agreed 
that “Typhus vaccine should contain both the soluble antigen heretofore dis- 
carded and all of the available rickettsiae bodies,” and that the “ether extraction 
method without centrifugation is at present the best method of preparation of 
vaccine. . . .”116 On 26 August it was recommended that the Army, Navy, 
and Public Health Service use a typhus vaccine made from 10-percent yolk-sac 
suspension including the so-called soluble antigen formalin killed and prepared 
by ether extraction.117 
By September 1942, all manufacturers of typhus vaccine for Army use had 
been instructed by the National Institute of Health to prepare this new type 
agent.118 However, in order to avoid a break in the supply, the new material 
113 (1) Memo, Col J. S. Simmons to SG, 26 Dec 41, sub: Report on conference on typhus vaccine 
attended at Connaught Laboratories, U. of Toronto. HD: 720.3. (2) Memo, Chief Virus Lab, Army 
Med School, for Dir Army Med School, 20 Mar 42, sub : Report on the testing of four different typhus 
vaccines in guinea pigs. HD : 720.3. (3) Natl Inst of Health Bull. No. 183, Studies on Typhus 
Fever, 1945. (4) “Outline of Methods Developed for the Preparation of a Concentrated Typhus 
Vaccine,” Army Medical Center, 20 Nov 42. HD : 720.3 Typhus. (5) Connaught Laboratories Memos 
No. 3 and 4, War Project Med 8 (NRC Canada), 13 Nov 42. HD : 720.3 Typhus. 
114 See footnote 113 (2). 
116 See footnote 113 (3). 
113 Minutes, NRC Conference on Immunization against Typhus Fever, 25 May 42. HD : 720.3. 
117 Minutes, NRC Conference on Typhus, Cholera, and Plague, 26 Aug 42. HD : 720.3 Typhus. 
118 Memo for file, 12 Sep 42, sub : Typhus vaccine. HD ; 720.3. IMMUNIZATION 
321 
was brought in gradually and a number of months passed before all the vaccine 
procured for Army use was being made by the improved methods. By late 
March 1943, however, sufficient supplies of this improved agent had been pro- 
cured to allow the discontinuance of distribution of the “old” or original type 
of material.119 
With the increase in experience in production and testing of the vaccine, 
it was possible to improve its quality still further. Such improvement was 
exemplified in May 1943 when the National Institute of Health increased the 
stringency of the antigenicity requirements which the vaccine was required to 
meet before it could be released for distribution.120 As a result of the efforts 
directed toward the preparation of an effective typhus vaccine and the continued 
supervision and control over its production by the Biologies Control Division, 
National Institute of Health, it was considered that this agent as supplied for 
the use in American troops was the most effective obtainable and certainly su- 
perior to any previously produced. 
Methods and Requirements. The methods of use of typhus vaccine were 
first prescribed in Circular Letter 3, Office of The Surgeon General, 14 January 
1942. The initial vaccination consisted of three 1 cc. doses administered sub- 
cutaneously at intervals of 7 to 10 days between doses. It was recommended 
that stimulating doses of 1 cc. each be administered in a similar fashion at 4 to 
6 months intervals in the presence of serious danger from infection. 
This method of administration of vaccine was followed until September 
1944 when in accordance with the recommendation made by a National Research 
Council conference group, the basic immunization was limited to two 1 cc. in- 
jections of the vaccine.121 Instructions concerning this new method as well as 
the recommendation that stimulating doses be administered on a seasonal basis 
rather than at certain time intervals were published in TB MED 114, November 
1944. No other changes in the methods of administering typhus vaccine were 
effected. 
The administrative requirements for typhus vaccination as they obtained 
at various periods throughout the war are shown in Appendix C. The basic 
policy contemplated the protection of those troops likely to be exposed to 
disease. Vaccination of the entire Army against typhus was not done. At the 
end of the war, typhus vaccination was a requirement for travel to, or station 
in, virtually all overseas theater bases. This was necessary both because of the 
wide distribution of typhus throughout the world and because troops ordered to 
certain typhus-free areas were subject to movement to typhus areas on short 
notice. Since it was considered that the protection afforded from vaccination 
119 Memo, Chief Epidemiology Branch SGO for Dir Supply Serv SGO, 23 Mar 43, sub: Typhus 
vaccine. HD: 720.3. 
120 Natl Inst of Health, Memo for Manufacturers of Typhus Vaccine, 11 May 43. HD: 720.3. 
121 (1) Minutes, NRC Conference on Typhus, 22 Jun 44. HD: 720.3. (2) Ltr, TAG to CGs 
POEs, COs POEs, CofTrans, 8 Sep 44, sub : Inoculation for typhus fever. AG ; 720.3 322 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
was considerably augmented by stimulation some months after the initial vac- 
cination the value to such individuals was actually increased by having received 
the first doses of vaccine some time before actual danger from exposure occurred. 
Effectiveness. As indicated, vaccination was practiced for all troops sub- 
jected to possible exposure to epidemic typhus fever. However, the preven- 
tion of typhus, like that of a number of other infectious diseases, was based 
not on vaccination alone but on the application of other protective procedures as 
well. First among there were the facilities, materials, and instructions pro- 
vided for the prevention of louse infestation of troops and the performance 
of rapid and sure disinfestation should lousiness occur. The degree of louse 
infestation of American personnel was very low. For example in the European 
theater in December 1944, it was determined that only 0.5 percent of 1,800 troop 
units had experienced lousiness among their personnel, there being less than 25 
individuals infested.122 The objective of the typhus prevention and control 
measures applied in the Army was the provision of the greatest degree of pro- 
tection obtainable and not the determination of the comparative efficacy of the 
various procedures used. This objective was realized in the occurrence of less 
than 100 cases of epidemic typhus among Army personnel (see discussion on 
typhus fever in another volume in this series). Twenty-eight cases were re- 
ported from the European Theater of Operations, 19 from Africa and the 
Middle East, and 17 from the Mediterranean theater. In all of these areas, 
typhus fever was prevalent among civilians at one time or another during the 
occupation by American troops and the opportunities for exposure were un- 
doubtedly numerous. 
While the exact role played by vaccination in the prevention of typhus 
among troops could not be clearly defined, it was generally accepted that this 
measure was an effective one. Such cases of typhus as did occur among vacci- 
nated individuals were apparently considerably milder than those experienced 
by unvaccinated individuals in the same area. This fact was first noted in 
North Africa in 1943 where about a dozen cases of the disease, all of which 
were mild, occurred among Americans who were vaccinated. Unvaccinated 
British troops on the other hand experienced about three times as many cases, 
one-third of which ended fatally,123 It was also the experience that when vac- 
cinated laboratory workers contracted typhus the disease was modified con- 
siderably from that experienced under similar situations before specific 
protection was afforded by the type of vaccine used in the United States Army. 
In summarizing the efficacy of typhus vaccine, it was agreed by those present 
at the National Research Council conference on typhus, held in June 1944, that 
“The evidence is all in favor of the opinion that while vaccination against 
122 ETMD, ETO, Jan 1945. HD. 
123 (1) Ltr, Lt Col Y. Kneeland, and others, to Chief Surg ETOUSA, 2 Mar 44, sub: Report of 
mission on typhus, ETO. HD: 710. (2) NATOUSA Cir Ltr 43, 11 Nov 43, sub: Typhus fever 
control. HD. IMMUNIZATION 
323 
epidemic louse-borne typhus fever does not always prevent infection, it causes 
the disease to he mild and appears thus far to prevent death from typhus.” 124 
The experience subsequent to this meeting offered no evidence other than in 
corroboration of this opinion. By the end of the war, no reports of deaths from 
epidemic typhus fever in vaccinated Army personnel had been received in the 
Office of The Surgeon General. 
Reactions. Untoward reactions to typhus vaccine were not significant 
either in number or severity and presented no interference with the vaccination 
program.125 Reports were received early in 1943 of reactions occurring im- 
mediately after injection of the vaccine and characterized by intense pain and 
burning. On investigation, these symptoms were determined to be the result 
of excess residual formalin in certain lots of vaccine. Following the discon- 
tinuation of use of these particular lots, no further reports of reactions of this 
type were received. 
With the extensive use of vaccines produced in eggs, there arose the possi- 
bility of the occurrence of reactions of sensitivity to these agents. Such 
reactions, however, did not materialize in any appreciable number. From the 
few reports of reactions of allergic nature following typhus vaccination, it was 
shown, however, that this vaccine was capable of precipitating such a response. 
This was not entirely unexpected since it was known that approximately 10 
percent of the typhus vaccine protein nitrogen was attributable to ovalbumen.126 
Such allergic reactions as did occur appeared for the most part to have been on a 
basis of the presence of sensitivity to egg protein before the vaccination rather 
than the development of this sensitivity through the administration of vaccine 
containing the allergen. Two fatal anaphylactic reactions following the ad- 
ministration of typhus vaccine were reported. In both instances, investigation 
revealed the preexistence of a sensitivity to egg which was not detected prior 
to the injection of the vaccine. These occurrences led to the adoption of routine 
questioning of personnel who were to receive vaccines produced in eggs. A 
question usually used was “Do you eat eggs or chicken?” A negative answer 
required further study to determine the presence or absence of sensitivity. 
INFLUENZA VACCINATION 
Development and Adoption 
The influenza vaccine adopted by the Army and the methods for its use 
were developed through the activities of the Commission on Influenza, Board 
for the Investigation and Control of Influenza and Other Epidemic Diseases 
124 See footnote 121 (1), p. 321. 
125 pjie • immunization, Reactions, Typhus Vaccine. HD : 720.3. 
126 (1) Memo, Chief Div of Virus and Rickettsial Diseases, Army Med School, for Dir Epidemiology 
Div SGO, 17 Jan 44. HD: 720.3 Typhus Vaccine. (2) Rpt of Joint Investigation, Div of Virus and 
Rickettsial Diseases, Army Med School, “Allergenic and anaphylactogenlc properties of vaccines pre- 
pared from embryonic tissues of developing chicks,” 1944. HD : 720.3 Egg Sensitivity, Reactions. 
346336 0-55- 22 324 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
in the Army 127 (later called Army Epidemiological Board), which was admin- 
istered through the Preventive Medicine Service, Office of The Surgeon 
General. 
Influenza vaccination was first adopted by the Army in the autumn of 
1943.128 At that time the procedure was applied in certain Army Specialized 
Training Program units in the Second, Sixth, Seventh, and Ninth Service 
Commands. This selective vaccination was in accordance with provisions of 
AR 40-210, and was accomplished as a field trial of the procedure. Following 
the successful results of this trial, information was published stating that in- 
fluenza vaccine had been approved for the Army but that it would be recom- 
mended for use only in the face of an outbreak or threatened outbreak of the 
disease.129 It was also pointed out that at that time the supply of vaccine was 
limited and that large quantities would not be available before the latter part 
of 1944. Because of this limitation of supply, the material that was available 
was stockpiled in a central depot in the United States so that the most judicious 
use could be made of it should the need arise.130 
Some relatively small-scale influenza vaccination was accomplished in 
the Army in the late spring of 1945 but it was not until September of that year 
that vaccination of large numbers of military personnel was undertaken. At 
that time, in view of the possibility of an influenza outbreak during the coming 
winter, vaccination of the entire Army was directed.131 Because of the special 
nature of the procedure it was not adopted as routine but only for a one-time 
application to be accomplished, for personnel already in the Army, during the 
months of October and November and for recruits as they entered the service, 
from that time through 15 April 1946.132 
The Immunizing Agent 
The vaccine used was a suspension of killed (formalinized) influenza 
virus types A and B made from the growth of the virus in the allantoic fluid of 
the embryonated chicken egg. The vaccine was prepared commercially in 
accordance with the minimum requirements of the National Institute of Health 
and recommendations issued by the Office of The Surgeon General.133 
127 (1) Bayne-Jones, S.: Board for the Investigation and Control of Influenza and other Epidemic 
Diseases In the Army. Army M. Bull. No. 64, Oct 1942, pp. 1-22, (2) Francis, T. : The development 
of the 1943 vaccination study of the Commission on Influenza. Am. J. Hyg. 42 : 1—11, Jul 1945. 
128 Book message 30-33, SG to CGs 2d, 6th, 7th, and 9th SvCs, 15 Oct 43. HD: 720.3 Influenza. 
128 TB MED 85, 15 Aug 44. 
130 Ltr, SG to CGs AGF, AAF, all theaters, etc., 12 Aug 44, sub: Influenza vaccine. HD: 720.3. 
131 WD Clr 267, 5 Sep 45. 
132 (1) WD Clr 381, 21 Dec 45. (2) Teletype message SPMDR, WD to CGs AAF, AGF, and ASF, 
27 Feb 46. HD : 720.3 Influenza. (3) WD Clr 113, 18 Apr 46. 
133 (1) Natl Inst of Health, Minimum Requirements for Influenza Vaccine, 1 Jun 44 and subse- 
quent revisions. (2) SGO, Recommendations for the Preparation of Influenza Virus Vaccine, Types A 
and B, for the United States Army, 9 May 44 ; 2 Apr 45 ; Feb 1946. HD: 720.3. IMMUNIZATION 
325 
The type A virus component consisted of equal quantities of the PR8 
Strain and the Weiss Strain of influenza virus A. The type B component was 
made up entirely of the Lee Strain of virus B. 
Methods and Requirements 
The vaccine was administered in a single dose of 1 cc. given subcutaneously. 
Because the virus was grown in eggs it was emphasized that the vaccine should 
not be administered to individuals hypersensitive to egg protein.134 
It was required that all Army personnel be vaccinated during the months 
of October and November 1945. Those who did not receive the vaccine during 
those periods were vaccinated as soon thereafter as possible. All military 
personnel embarking for overseas travel between 1 October 1945 and 15 April 
1946 were required to have received influenza vaccine subsequent to 1 October 
1945. No repetition of the vaccination was required although a booster dose of 
1 cc. after an interval of approximately 30 days was contemplated if the situa- 
tion warranted. 
Experience 
Effectiveness. The results of the 1943 trials of influenza vaccine in Army 
Specialized Training Program units were considered to be highly successful and 
have been amply described elsewhere.135 These trials were conducted in nine 
Army Specialized Training Program units in various sections of the country. 
The timing of the actual vaccinations was most fortunate since, in most in- 
stances, it was accomplished approximately 2 weeks before the outbreak of the 
1943-44 epidemic of influenza type A. Over 12,000 individuals were included 
in the studies. This number was almost equally divided into a vaccinated 
group and a control group. The aggregate results showed the occurrence of 
approximately 3.5 cases among the controls for each case in the vaccinated 
group. The evidence gathered also strongly suggested that the protection from 
vaccination developed in about 1 week, thus indicating the probable value of 
the vaccine when given just before or even at the onset of an epidemic. As 
was expected, there was no significant difference between the vaccinated and the 
]VJ See footnote 131, p. 324. 
135 (1) Members of Commission on Influenza, Army Epidemiology Board: A clinical evaluation 
of vaccination against Influenza. Preliminary report. J. A. M. A. 124 : 982-985, 1 Apr 44. (2) 
Rickard, B. R. ; Thigpen, M., and Crowley, J. H.: Vaccination against Influenza at the University of 
Minnesota. Am. J. Hyg. 42: 12-20, Jul 1945. (3) Hale, W. M., and McKee, A. P.: The value of 
Influenza vaccination when done at the beginning of an epidemic. Am. J. Hyg. 42 : 21-27, Jul 1945. 
(4) Eaton, M. D., and Meiklejohn, G.; Vaccination against Influenza: a study in California during the 
epidemic of 1943-44. Am. J. Hyg. 42 : 28-44, Jul 1945. (5) Hirst, G. K.; Plummer, N., and Friedewald, 
W. F. : Human immunity following vaccination with formallnized influenza virus. Am. J. Hyg. 42 : 
45-56, Jul 1945. (6) Salk, J. E. ; Menke, W. J., and Francis, T.; A clinical epidemiological and im- 
munological evaluation of vaccination against epidemic influenza. Am. J. Hyg. 42 : 57-93, Jul 1945. 
(,7) See also footnote 127 (2), p. 324. 326 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
unvaccinated group with respect to the occurrence of the so-called common 
respiratory infections or common cold. 
The vaccination of all military personnel in the autumn of 1945 was also 
timely in that an outbreak of mild influenza type B occurred throughout the 
country during the month of December 1945.136 While this outbreak actually 
touched the Army very lightly, it was extremely difficult to arrive at a quan- 
titative estimation of the part played by immunization in the prevention of the 
disease among troops. Unlike the situation in 1943-44, there were no unvacci- 
nated control groups among military personnel for direct comparison. The 
only comparisons possible, therefore, were with other Service groups who were 
unvaccinated and with the civilian population. These comparisons, based on 
the relative experience of these groups in the 1943-44 influenza A epidemic as 
well as the current epidemic of influenza B, indicated strongly that the vaccina- 
tion of military personnel was responsible for a considerable reduction in 
morbidity from that which could have been expected had this measure not been 
applied.137 The degree of this reduction could not be accurately measured for 
the Army as a whole but in two instances where direct comparison could be 
made between small groups of vaccinated and unvaccinated persons, the total 
incidence of the acute respiratory infections among the vaccinated as compared 
to that in the unvaccinated was 1.15 percent to 9.9 percent, and 1.9 percent to 
16.9 percent respectively. 
From all the evidence available from the 1945 experience it was concluded 
that vaccination played a significant role in the prevention of influenza B among 
military personnel in the United States during the epidemic period. 
Reactions. Experience gathered during the trials of influenza vaccination 
in 1943 indicated the occurrence of systemic reactions following administration 
of the vaccine in 16 to 20 percent of those vaccinated. These reactions were 
characterized by generalized aching, chilliness, malaise, and mild fever. Only 
a small proportion of those experiencing reactions of this type required hospi- 
talization.138 There were no anaphylactic reactions encountered in the groups 
studied at the time although there were reports of two instances of cutaneous 
eruption following vaccination. 
Specific reports of reactions encountered following administration of the 
vaccine in 1945 were not required. However, some reports were forwarded to 
the Office of The Surgeon General in accordance with the general instructions 
regarding the reporting of reactions of unusual severity or number.139 These 
reports showed considerable variation in the occurrence of reactions. Some 
136 ASF Monthly Progress Report, Sec. 7, Health, 31 Dec 45. 
137 ASF Monthly Progress Report, Sec. 7, Health, 31 Mar 46. 
138 Rpt, Dir Influenza Commission, Army Epidemiology Bd, to President Army Epidemiology Bd, 
8 Feb 44, sub : Preliminary report of the clinical evaluation of vaccination against influenza. HD : 
720.3. 
139 File : Immunization Reactions—Influenza Vaccine. HD : 720.3. IMMUNIZATION 
327 
organizations reported as few as 7 percent generalized reactions while others 
indicated that as many as 85 percent of those receiving the vaccine experienced 
generalized reactions of varying degrees of severity. The most common inci- 
dence was considered to be between 25 and 50 percent. These reactions were 
characterized in general by fatigue, aching muscles, headache, chilliness or 
slight actual chills, and fever. The onset was usually within 8 to 10 hours 
after vaccination. Only a small proportion of the reactions were of sufficient 
severity to require hospital care. Local reactions consisting of burning and 
stinging of the arm with some residual soreness and stiffness were not 
uncommon. 
In addition to the local and generalized reactions referred to there were 
reported three reactions of an anaphylactic nature. Two of these were fatal. 
All were considered to have been allergic responses to the egg component of 
the vaccine in individuals previously sensitized to egg protein. 
JAPANESE B ENCEPHALITIS VACCINATION 
Development and Adoption 
Large-scale vaccination of human beings against Japanese B encephalitis was 
first practiced by the Russians, but vaccines prepared in the United States ac- 
cording to their procedures were found to possess little or no immunogenic 
potency on assay in animals. In early 1948, however, a mounse brain vaccine 
with immunogenic potency measurable in animals and in human volunteers was 
developed in this country.140 
Action was initiated in September 1944 to obtain a stock of this vaccine 
and to sponsor and encourage efforts toward the improvement of this agent.141 
Because of the unique nature of the vaccine and the difficulties inherent in its 
preparation only limited supplies were available in the summer of 1945. Its 
use was officially adopted by the War Department in July 1945, however, and 
vaccine was sent to Okinawa as it became available.142 
The Immunizing Agent 
The vaccine adopted consisted of a 10-percent saline suspension of virus- 
infected mouse brain, the virus having been inactivated by formaldehyde. The 
Nakayama strain of Japanese B encephalitis virus was used.143 This material 
was procured from commercial biologic manufacturers and was prepared and 
140 Sabin, A. B., and others ; The St. Louis and Japanese B types of epidemic encephalitis. De- 
velopment of noninfectlve vaccines : report of basic data. J. A. M. A. 122 ; 477-486, 19 Jun 43. 
141 (1) Minutes of Conference on Japanese B Encephalitis Vaccine, SGO, 23 Sep 44. HD; 720.3. 
(2) Memo, Chief Prev Med Serv SGO for SG, 7 Oct 44, sub: Japanese B encephalitis vaccine. HD; 
720.3. 
142 (1) TB MED 181, Jul 1945. (2) Memo, Dir Epidemiology Div SGO for Chief Supply Serv 
SGO, 13 Aug 45, sub: Japanese B encephalitis vaccine. HD ; 720.3. 
143 See footnote 140. 328 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
tested for use in the Armed Forces in accordance with National Institute of 
Health Minimum Requirements for this agent.144 
Subsequently, a vaccine prepared from infected embryonated eggs was 
developed in the Division of Virus and Rickettsial Diseases of the Army Medical 
School.145 This vaccine consisted of a 20-percent suspension of virus infected 
chick embryo tissue inactivated with formaldehyde. None of this material was 
available for use during the war. It was first produced in large quantities by 
the Army Medical School Laboratories in 1946, and used subsequently in Japan, 
Korea, and Okinawa.146 
Methods and Requirements 
The method of use of Japanese B vaccine as prescribed in TB MED 181, 
July 1945, was the “subcutaneous injection of two doses of 2 cc. each with an 
interval of 3 days between doses.” The large individual doses were considered 
necessary in view of the apparent low antigenicity of the material and the short 
interval was considered desirable as a safeguard against reactions due to the 
establishment of a sensitive state following the first dose. In view of the low 
order of neutralizing antibody response among the vaccinated on Okinawa147 
and the corroborating evidence obtained in the Virus and Rickettsial Disease 
Division of the Army Medical School,148 this method was later abandoned and 
the following procedure adopted for use in the preepidemic vaccination program 
on Okinawa and Japan in the summer of 1946. “Two doses of 1 cc. each mouse 
brain vaccine with 7 day intervals constitutes basic preepidemic course to be 
followed 1 month after first injection by one single 1 cc. booster dose of either 
mouse brain or preferably chick embryo vaccine. Booster dose may be given 
earlier in presence of threatened epidemic.” 149 
Administrative requirements for this vaccination wTere limited sharply by 
the geographic distribution and the seasonal occurrence of the disease and in 
the first season of its use (1945) by the limited supply of vaccine. Thus the 
procedure was first limited to “the use of combat troops in areas where adequate 
mosquito control cannot be accomplished and not to be (applied) until cases 
of the disease have occurred.”150 This requirement essentially limited the use 
144 Natl Inst of Health “Minimum Requirements Japanese B Encephalitis Vaccine for Use in 
Armed Forces,” 8 Nov 44. 
145 Warren, J. : A vaccine against Japanese B Encephalitis prepared from chick embryos, 1945. 
HD: 720.3. 
146 Ltr, SG to CG Army Med Ctr, 21 Jan 46, sub : Production of Japanese B encephalitis vaccine. 
HD: 720.3. 
147 Rpt, W. McD Hammon, Consultant to SecWar, SGO, sub : Results of neutralization tests on 
sera of military personnel on Okinawa vaccinated by Japanese B mouse brain vaccine, 1946. HD : 
720.3. 
148 Rpt, Chief Div of Virus and Rickettsial Diseases, Army Med School, Mar 1946, sub ; Japanese 
B encephalitis vaccine. HD : 720.3. 
148 Radio SPMDR, CG ASF to CinC AFPAC, 29 Apr 46. HD : 720.3 Jap B Encephalitis. 
350 See footnote 142 (1), p. 327. IMMUNIZATION 
329 
of this vaccine to certain combat troops on Okinawa in the early summer of 
1945. This policy was modified in August 1945 to the extent that the vaccine 
wTas authorized for all troops in the area where the disease was occurring. How- 
ever, limitation of such general vaccination was necessary because of inadequacy 
of the supply of vaccine.151 This policy was still further modified in the spring 
of 1946 to allow for preepidemic vaccination of those troops considered to be 
at the greatest risk. 
Experience 
Effectiveness. A limited vaccination program was carried on in Okinawa 
in August 1945 in the face of an epidemic of the disease beginning among na- 
tives in July. A total of 53,139 individuals were known to have received the 
full course of vaccine and, in view of the limitations of reporting, it was con- 
sidered that several thousand more may have been vaccinated.152 It was agreed 
by competent observers that the 1945 experience did not yield information from 
which conclusions concerning the efficacy of the vaccine could be drawn. The 
bulk of the vaccinations were accomplished as the epidemic was on the wane. 
Of the 38 reported cases of encephalitis among military personnel, 20 occurred 
before any troops in the area from which the cases originated were vaccinated. 
Twelve cases occurred subsequently in nonvaccinated persons and 6 in those 
who had received the vaccine. The fact that vaccination in Okinawa did not 
result in appreciable response in neutralizing antibody titers was suggestive of 
lack of protection but the state of knowledge concerning the significance of such 
a response precluded the complete acceptance of this finding as evidence of the 
immunogenic failure of the vaccine. As previously indicated, there was suffi- 
cient optimism concerning the value of the procedure to justify its use during 
the 1946 encephalitis season in Japan and the Ryukyu Islands, particularly 
Okinawa. 
Reactions. In the preliminary studies carried out by the members of the 
Neurotropic Virus Commission some 1,000 persons (nonmilitary) were vac- 
cinated with a noninfective mouse brain vaccine.153 Approximately 500 of 
these received Japanese B virus vaccine, the other 500, St. Louis virus vaccine. 
The majority of the subjects developed transitory local reactions at the site 
of the injection consisting of erythema, swelling, itching, and in some, pain 
and tenderness. However, these were not considered to be of consequence. 
Between 8 and 9 percent of the total group experienced what were considered 
to be significant untoward reactions. These were mild in all but one instance. 
151 Radio, WD to CinC AFPAC, 13 Aug 45. HD: 720.3 Jap B Encephalitis Vaccine. 
152 Med Bull 20, H(i Army SvC I (Okinawa), 6 Oct 45, sub : Report on immunization with Japanese 
B encephalitis vaccine. HD : 720.3. 
153 Rpt, Commission on Neurotropic Virus Diseases SGO, 24 Jun 43, sub: Preliminary report on 
the vaccination of man against the St. Louts and Japanese B types of epidemic encephalitis. 
HD ; 720.3. 330 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
The complaints most commonly expressed were those of headache, nausea, weak- 
ness, and drowsiness. Four persons receiving the St. Louis encephalitis vac- 
cine experienced generalized urticaria. The one severe reaction followed ad- 
ministration of the St. Louis vaccine, and its onset was 5 days after the second 
dose. This patient developed unmistakable signs and symptoms of encephali- 
tis, the etiologic diagnosis of which could not be made with certainty. It was 
considered to be either demyelination encephalitis from heterologous brain 
tissue or possibly true St. Louis encephalitis, the latter possibility being quite 
remote. 
The true incidence of untoward reactions following the vaccinations on 
Okinawa could not be determined since the exact number of persons receiving 
the vaccine was not known. There were no stated criteria for the type of 
reactions to be reported, hence considerable variation in reporting was in- 
evitable. The reactions reported appeared to have been those experienced 
among the 53,139 persons known to have been vaccinated with the full course 
and 2,274 who received one injection only.154 Sixty-one local reactions were 
recorded, including those with pain and swelling at the site of injection and 
occasionally axillary lymph node enlargement. Actual abscess formation re- 
quiring drainage was reported in 5 individuals in 2 small units, suggesting the 
possibility of a break in technique and the introduction of a microorganism 
other than the virus of the vaccine. Only 19 systemic reactions characterized 
by malaise, fever, headache, and nausea were reported. Nineteen allergic re- 
actions were recorded. These consisted largely of urticarial manifestations 
and in some instances angioneurotic edema with moderate respiratory 
difficulties. 
Eight instances of neurologic reactions were reported. None of these were 
suggestive of a demyelinizing process. Three were so mild and transitory that 
a diagnosis could not be established. There appeared to be little doubt that 
there was involvement of the nervous system in the remaining 5 cases but asso- 
ciation with the vaccine was not clear in all. In 2 the relationship may have 
been temporal only, in that the symptoms and signs did occur after the vaccine 
was administered (2 days and 4 days respectively). The other 3 cases, poly- 
neuritic in nature, occurred at such periods after vaccination as to make causal 
relationship possible.155 
The allergic reactions and those of nervous system involvement were the 
most important encountered. The absence of symptoms or signs pointing to 
demyelination was reassuring. Nevertheless the development and use of a 
vaccine free from nervous system tissue were considered most desirable and it 
154 See footnote 152, p. 329. 
156 Ltr, Actg Dir Commission on Neurotropic Virus Diseases SGO to Chief Prev Med Serv SGO, 
22 Apr 46, sub: Neurological ’’reactions” in military personnel inoculated with Japanese B encephalitis 
vaccine on Okinawa in 1945. HD : 720.3. IMMUNIZATION 
331 
was planned to substitute such an agent for the original vaccine to the greatest 
extent possible during the 1946 season. 
IMMUNIZATION FOR SPECIAL SITUATIONS 
Immunization procedures other than those referred to in the foregoing 
paragraphs were authorized and applied occasionally to meet special situations. 
These included those for protection against diphtheria, Rocky Mountain spotted 
fever, measles, infectious hepatitis, and scarlet fever. The administration of 
rabies vaccine to persons bitten by animals known or suspected to be rabid was 
also practiced when indicated. 
Diphtheria Immunization 
This procedure was not practiced routinely for United States troops but 
was reserved for those situations wThere such protection was considered to be 
particularly indicated. This policy was based on the following considerations. 
First, it was felt that although the age distribution of diphtheria had been 
shifting somewhat in recent years and the disease was becoming more and more 
one of young adults, its incidence among the age group represented by military 
personnel had not yet become sufficiently high, in this country at least, to cause 
concern. In other words, it was considered that the proportion of troops 
possessing actual or latent active immunity to diphtheria was sufficiently high 
that a significant incidence of the disease among them would be unlikely except 
under unusual conditions. It was considered that at least 55 to 60 percent of 
American troops were immune to diphtheria. This conclusion was derived in 
part from a study involving approximately 3,000 personnel at the end of their 
training period in this country. Of this group 55.6 percent were immune as 
determined by the Schick test. Undoubtedly others possessed some degree of 
latent immunity not measurable by this method.156 A somewhat similar study 
wras conducted in a general hospital in the North African theater where it was 
found that 71.5 percent of a group of 1,283 person were Schick negative.157 
The difference in the results in these two groups was considered to be due to 
the possible stimulation of immunity in the overseas group through actual 
contact with the disease. Also the latter group was made up in part of hospital 
detachment personnel including nurses and medical officers, persons more 
likely to have had contact with the disease and hence, more opportunity for the 
development of immunity than had the group studied in this country. 
The second consideration in the decision not to immunize troops routinely 
against diphtheria was based on the fact that while toxoid was believed to be 
150 Diphtheria susceptibility and immunization. Bull. U. S. Army M. Dept. No. 76, May 1944, 
pp. 104-108. 
151 Karelitz, S., and Moloshok, R. E. : Immunity to diphtheria in Army personnel. War Med. 6 : 
232-235, Oct 1944. 332 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
the immunizing agent of choice it was known that there would be an appreciable 
occurrence of reactions in adults following the use of this agent. 
The first instructions issued concerning diphtheria immunization were 
those published in Circular Letter 162, Office of The Surgeon General, 1942. 
These instructions indicated that the fluid or plain diphtheria toxoid was the 
agent to be used. They also referred to the reactions to be expected and indi- 
cated that only Schick positive persons should be immunized and then only in 
the presence of a definite hazard from the disease. The dosage recommended 
was 0.5 cc., 1 cc., and 1 cc. to be administered subcutaneously at intervals of 
approximately 3 weeks. 
In May 1944, these instructions were simplified somewhat in TB MED 47. 
In this publication, the Schick test was described in some detail and an explana- 
tion of the various reactions to this test was presented. It was recommended 
that in the persons demonstrating “combined” reactions to the test, immuniza- 
tions not be accomplished or if done, that small divided doses be employed. 
In TB MED 114, published in 1944, these instructions were modified and it 
was recommended that the regular course of 3 doses referred to above be pre- 
ceded by 48 hours by a dose of 0.1 cc. given subcutaneously and that the admin- 
istration of the remaining doses be limited to those exhibiting no severe reac- 
tions to this test dose. (A severe reaction was considered to be local edema, 
induration more than 6 cm. in diameter, or a marked constitutional reaction 
with fever in excess of 101° F.) The occurrence of such a reaction after any 
of the subsequent doses was also considered to be a contraindication of further 
injections of the toxoid. This method of immunization was thought to be 
particularly applicable in those situations where the performance of mass 
Schick test surveys prior to immunization were not practicable. It was felt 
that such situations might not be uncommon in view of the time required and 
the difficulties surrounding the satisfactory conduct of such testing. As a 
part of one of the studies previously referred to,158 diphtheria immunizations 
were conducted in this manner without regard to the Schick test status of the 
personnel being immunized. In this study, reactions of considerably less sever- 
ity than those described above were accepted as contraindications to further 
doses. It was determined that almost 60 percent of a group starting such a 
regime would complete the full series. Thus it was felt that the use of 0,1 cc. 
of toxoid subcutaneously as an initial test dose would exclude from subsequent 
treatment the majority of the reactors. No method was seen to eliminate en- 
tirely untoward reactions to diphtheria toxoid in adults, and it was realized 
that the regime described did not allow for the accomplishment of the complete 
immunization of any group of persons. It was believed, however, that such 
a program would raise the general level of immunity sufficiently to prevent a 
serious outbreak. 
138 See footnote 156, p. 331. IMMUNIZATION 
333 
The first and only instance of the application in this country during the 
war of a diphtheria immunization program directed by the War Department 
was in the autumn of 1945. At that time, in view of the increase in diphtheria 
among general hospital personnel in the Zone of Interior, all such persons 
coming into contact with patients were Schick tested and the positives immun- 
ized.159 In April 1946 because of the rise in incidence of diphtheria in the Euro- 
pean and Mediterranean theaters, all military personnel under the age of 35 
and all civilian employees and dependents of similar age were required to be 
immunized or Schick negative before traveling to those theaters.160 At about 
the same time a program was undertaken to immunize personnel in the Euro- 
pean theater most likely to be exposed to the disease.161 A short time later, all 
dependents between the ages of 6 months and 15 years departing for theater's 
other than those referred to were required to be immunized to diphtheria 
before departure. 
Diphtheria immunization was practiced only rarely in overseas installa- 
tions during the war and then usually for units or groups considered to be 
exposed to unusual opportunities for infection. For example, some immuniza- 
tions were done in the North Africa-Mediterranean theater because of the high 
incidence of diphtheria among civilians.162 Also certain organizations in the 
Southwest Pacific area were Schick tested and the toxoid was administered in 
1944.163 In some of these units diphtheria toxoid was administered in two 
doses of 0.3 cc. and 0.4 cc. given 1 month apart. This program resulted in 
generalized reactions in approximately 8 percent of those immunized, local 
reactions in about percent. None of these was considered to be severe in 
nature. Immunization programs were also carried out in selected organiza- 
tions in the Persian Gulf Command 164 and the Alaskan Wing, Air Transport 
Command.165 
Rocky Mountain Spotted Fever 
Vaccination against Rocky Mountain spotted fever was practiced only to a 
limited extent. Early in the war the policy was established that mass vaccina- 
tion of troops against this disease would not be undertaken. This policy was 
adopted in view of the general past experience with the disease which indicated 
a low attack rate even in those areas where it occurs with the greatest frequency. 
Consideration was given to the fact that protection by vaccination did not 
159 ASF Cir 415, 9 Nov 45. 
160 WD Clr 100, 3 Apr 46. 
ici ETMD, ETO, 27 Feb 46. HD. 
162 Monthly Sanitary Rpt, 51st Med Bn MTO, Nov 1943. SG : 721.5. 
163 (1) Ltr, SG to CG US Army Forces In South Pacific, 17 Feb 44, sub: Diphtheria. HD: 720.3. 
(2) Ltr, Surg PDA to SG, 6 Dec 44, sub: Transmittal of report on diphtheria. SG : 710. 
164 Monthly Sanitary Rpt, Persian Gulf Comd, Feb 1944. SG : 721.5. 
105 Monthly Sanitary Rpt, Sta 3 ATC, APO 938, 3 Apr 44. SG : 721.5. 334 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
appear to be absolute and was apparently of short duration. For protection 
against Rocky Mountain spotted fever emphasis was placed on frequent inspec- 
tion of individuals in tick-infested areas with prompt removal of ticks found 
on the body.166 
This policy did not prohibit vaccination entirely but limited it to personnel 
located in regions where danger from the disease was particularly great and 
where prolonged contact with brush was inevitable. Thus vaccination was 
considered applicable to such groups as patrols and guards operating in areas 
highly infested by ticks where Rocky Mountain spotted fever was considered 
to be a definite hazard. 
The vaccine used was furnished by the Rocky Mountain Laboratory of the 
National Institute of Health. Both the “tick vaccine” and that produced in 
embryonated eggs were used.167 During the year 1942 enough vaccine was 
supplied to vaccinate approximately 20,000 individuals. Vaccine was adminis- 
tered in 2 doses of 2 cc. each, with an interval of 5 to 7 days. This was considered 
somewhat excessive in view of the policy expressed above. Accordingly in sub- 
sequent years the National Institute of Health was requested to allot a total 
of 50,000 cc. of vaccine for use in the Army each year.168 From this quantity 
suballotments were made to the various service commands and instructions 
were issued emphasizing the desirability of limiting vaccination to the special 
situations previously described. As a result, the quantity of vaccine distributed 
was just over 40,000 cc. in 1943, and 13,000 cc. in 1944.169 
In 1944 the dosage schedule was changed from a total of 4 cc. given in 2 
doses to 3 doses of 1 cc. each.170 During the 1945 season, the National Institute 
of Health distributed to the Army enough vaccine for approximately 16,000 per- 
sons. The increase over 1944 being due largely to the vaccination of prisoners 
of war employed in areas of high tick infestation. 
Only 81 cases of Rocky Mountain spotted fever were reported among troops 
during the war years. None of these were in vaccinated individuals. This was 
perhaps less of an indication of the efficacy of the vaccine than of the fact 
that the disease did not represent a problem of any magnitude among Army 
personnel. While the Army experience could not be taken as evidence of the 
protection offered by Rocky Mountain spotted fever vaccination, there was 
reason to believe that the protection was considerable. The total experience 
with the procedure over the years has suggested that it is probably comparable 
166 (1) Ltr, SG to Surg 9th CA, 2 Apr 42, sub : Vaccination against Rocky Mountain spotted fever. 
HD : 720.3. (2) Ltr, SG to CGs all SvCs, attn Surgs, 8 Jun 44, sub : Rocky Mountain spotted fever 
vaccine. HD; 720.3. (3) TB MED 114, 1944. 
187 See footnote 166 (2). 
188 Ltr, Actg Dir Epidemiology Div SGO to Natl Inst of Health, 3 May 44. HD ; 720.3 Rocky 
Mountain Spotted Fever. 
169 Ltr, Dir Rocky Mountain Lab, Natl Inst of Health, to Actg Dir Epidemiology Div SGO, 1 Jun 
44, with inch HD : 720.3 Rocky Mountain Spotted E'ever. 
170 See footnote 166 (3). IMMUNIZATION 
335 
to typhus vaccination in effect and that, while prevention may not be complete 
in all cases, those that do occur in vaccinated individuals tend to be mild. 
Reactions to Rocky Mountain spotted fever vaccines were of little conse- 
quence and hence little information is available concerning them. Both local 
and systemic reactions were somewhat more frequent following use of the early 
tick vaccines than after the yolk-sac egg vaccines used later. The latter type 
agents were prepared in the same manner as was epidemic typhus vaccine. As 
might be expected, reactions from these vaccines were very similar both in 
extent and nature. However, no reports were received of true anaphylactic 
reactions following Rocky Mountain spotted fever vaccine administration. 
Measles Prophylaxis 
Because of the problems presented by measles during World War I con- 
sideration was given to the provision of specific protection against this disease 
early in the recent war period. There being no agent available for the produc- 
tion of active immunity, the use of human immune serum globulin for passive 
protection was the only procedure available.171 In view of the short duration 
of this protection, the dose of globulin required, and the technique of its 
administration (10 cc. given intramuscularly), this method for the prevention 
of measles was reserved for debilitated persons and those whose protection 
was necessary for military reasons.172 
Stocks of immune serum globulin were not available until early 1944 and 
at that time the quantity was limited. Accordingly this material was furnished 
routinely only to ports of embarkation for use in the protection of embarking 
troops.173 Arrangements were made to furnish this material to other installa- 
tions on special request as a specific need arose. 
In actual experience, globulin was used for the prevention of measles only 
very rarely, the main reason being that measles failed to become a serious prob- 
lem among troops for whom specific protection was urgently needed. All in- 
stances of its use were not reported and there were only two reports received 
which contained indications of the efficacy of the procedure. One of these 
reported the administration of globulin to 610 enlisted men who were exposed 
to measles just before embarkation. None of the individuals so protected de- 
veloped measles.174 The same procedure was applied to an Air Force unit 
under similar conditions and in this unit no measles developed subsequent to 
171 Cohn, E. J.; Onsley, J. L.; Strong, L. E.; Hughes, W. L., and Armstrong, S. H.: Chemical, 
clinical, and immunological studies on the products of human plasma fractionation. J. Clin. Investiga- 
tion 23 ; 417-432, Jul 1944. 
172 (1) Memo, Chief Epidemiology Branch SGO for Chief Prof Serv SGO, 15 Dec 42. HD; 720.3 
Measles. (2) See also footnote 166 (3), p. 334. 
173 (1) Ltr, SG to CG Boston POE, attn Surg, 10 Mar 44, sub: Use of immune serum globulin, 
item No. 16055, for the prevention of measles. HD: 720.3 Measles. (2) Memo, Prev Med Serv SGO 
for Dir Supply Serv SGO, 25 Jul 44, sub : Item No. 1605500, immune serum globulin. HD : 720.3. 
174 Ltr, Surg Camp Kilmer, N. J., to SG, 10 Jun 44, sub: Immune serum globulin for prevention 
of measles. HD ; 720.3 Measles. PERSONAL HEALTH MEASURES AND IMMUNIZATION 
the administration of the globulin and no reactions were reported in connec- 
tion with the injections.175 
Viral Hepatitis Prophylaxis 
Evidence obtained from studies conducted in the Mediterranean Theater 
of Operations in 1944 and 1945 indicated the probable effectiveness of gamma 
globulin (immune serum globulin) for passive protection against naturally 
occurring viral hepatitis.176 However, the practical value of this procedure was 
somewhat limited due to the short duration of the protection afforded (prob- 
ably not more than 2 or 3 months) and the dose and method of administration 
(10 cc. intramuscularly). These limitations militated against the application 
of the measure on a large scale and though recommended for use w7hen the 
indications arose, passive immunization against hepatitis was practiced only 
rarely.177 
Studies conducted in one of the general hospitals in this country in 1944 
and 1945 indicated the possible value of globulin for the prevention of post- 
transfusion hepatitis (homologous serum hepatitis).178 This and other work 
led to the administration of globulin to general hospital patients in this country 
who had been wounded overseas and had received transfusions of blood or 
plasma.179 The globulin wTas administered intramuscularly to those whose 
wounds had occurred at least 4 weeks and not more than 16 weeks previously. 
It was also given to those who, though not wounded, had been given blood or 
plasma not more than 16 weeks prior to the opportunity for the administration 
of globulin. 
Subsequent investigative work as well as results from the administration 
of globulin to returned casualties as outlined failed to corroborate the earlier 
findings and the practice was discontinued early in 1946.180 
Scarlet Fever Immunization 
It was recognized that the available methods for immunization against 
scarlet fever were of little value, at least for military personnel. However, the 
immunizing agent was supplied (scarlet fever streptococcus toxin) and pro- 
visions were made for its use for the protection of nurses, ward attendants, 
and others in close contact with cases of the disease. The probability of un- 
ns jjq Troop Carrier Comd, Stout Field, Ind., Prev Med Bull 7, 20 Apr 45. HD : 720.3 Immune 
Serum Globulin. 
1,6 (1) Gellls, S. S., and others: The use of human immune serum globulin (gamma globulin) In 
infectious (epidemic) hepatitis In the Mediterranean Theater of Operations. J. A. M. A. 128; 1062- 
1063, 11 Aug 45. (2) ETMD, MTO. Feb 1945. HD. 
177 TB MED 206, 3 Nov 45. 
178 Grossman, B. B. ; Stewart, S. G., and Stokes, J. : Post-transfusion hepatitis in battle casualties 
and a study of its prophylaxis by means of human immune serum globulin. J. A. M. A. 129 ; 991-994, 
8 Dec 45. 
179 ASF Clr 329, 31 Aug 45. 
180 (1) ASF Clr 24, 28 Jan 46. (2) Ltr, Surg 2d SvC to CG ASF, attn SG, 13 Aug 45, sub ; Preven- 
tion of hepatitis. HD : 720.3 Immune Serum Globulin. IMMUNIZATION 
337 
toward reactions following the administration of the toxin and the limitations 
of its value were stressed.181 As was anticipated, the procedure was seldom 
practiced. . 
Gas Gangrene 
Throughout the war period, gas gangrene was a perplexing and to some 
extent an unsolved problem. While principally surgical in nature, this prob- 
lem presented some aspects referable to preventive medicine. Among these 
were those matters relating to the prevention and to some extent treatment of 
the condition by immunological methods. At no time, however, were there 
established policies for the prophylaxis of gas gangrene through the routine 
use of antitoxin or toxoid. It was generally agreed that effective surgery plus 
the proper use of the new antimicrobial agents provided the most effective 
prophylactic and therapeutic procedures available. 
An effective active immunizing agent was considered definitely indicated 
and desirable. Almost from the onset of hostilities, great efforts were made to 
develop such an agent. Numerous reports of the Committee on Medical Re- 
search of the Office of Scientific Research and Development and reports of the 
National Research Council attest to the diligence of these efforts. However, 
at the end of the war while much progress had been made no toxoid or other 
agent had been made available for active immunization to gas gangrene. 
OTHER PROBLEMS OF THE IMMUNIZATION PROGRAM 
Administrative Requirements for 
Immunizations in Overseas Theaters 
The administrative requirements established by the War Department for 
the various immunizations have been presented in the foregoing paragraphs in 
the discussions of the individual procedures. In most of the overseas theaters 
or separate commands, local requirements were published in theater or com- 
mand directives. In a number of instances, these included stipulations for the 
application of certain procedures in a manner particularly adapted to local 
needs. Appendix D shows these various overseas requirements. 
Immunization Records 
The proper preparation, maintenance, and forwarding of records of im- 
munization presented some problems during the war period. 
The designation of the completion of tetanus immunization by embossing 
the identification tag with the numerals of the years of completion of the basic 
series and single stimulating dose was mentioned in a discussion of tetanus 
immunization. This procedure appeared to be satisfactory and with a few 
lhl (1) SG Cjr Ltr 162, 1942. (2) Also see footnote 166 (3), p. 334. PERSONAL HEALTH MEASURES AND IMMUNIZATION 
minor exceptions gave rise to no difficulties. None of the other immunizations 
were recorded in such a special manner. 
It was required that records in duplicate be prepared showing all immuni- 
zations received by each person in the military service. These records were 
made on special forms known as immunization registers. The form employed 
from the beginning of the war until early 1945 was WD MD Form No. 81 
(Immunization Register) and that employed after January 1945 was WD AGO 
Form 8-117 (Immunization Register and other Medical Data). 
The greatest difficulty encountered with respect to these records was in 
connection with their ready availability when required. Early in the mobiliza- 
tion period particularly, appreciable numbers of immunizations were repeated 
unnecessarily because of the failure in forwarding adequate records of the 
immunization status of personnel being transferred to new stations. This 
was corrected in part by administrative action requiring the forwarding of 
information of all incompleted immunizations with such individuals. How- 
ever, the fault was not satisfactorily corrected until early 1945 when the new 
form was adopted and provisions were made for each person to have a copy 
in his possession. Under this system the unnecessary repetition of immuniza- 
tions was reduced to a minimum. The adoption of the new form and the im- 
proved methods for its handling and disposition made readily available infor- 
mation concerning the immunization status of each individual as well as that on 
allergic states, spectacles, dentures, et cetera. This was of considerable value 
to the person concerned as well as to those responsible for his medical care and 
processing. 
Supply Problems 
Although the matter of supply of the various immunizing agents was 
closely related to the immunization program, it will be discussed here only 
briefly since a general discussion of medical supplies is presented elsewhere 
in the history. 
As already indicated, the number of immunization procedures used in the 
Army increased from 2 or 3 at the beginning of the war to a dozen or more which 
were applied at one time or another before its end. The success of these pro- 
cedures was dependent upon the availability of adequate quantities of satisfac- 
tory immunizing agents of the various types required. Almost all of these 
agents were procured from commercial manufacturers of biologic products and 
were purchased for Army use subject to the conformance with the minimum 
requirements and standards of the Biologies Control Division, National Insti- 
tute of Health, United States Public Health Service. The interest, efforts, and 
cooperation of the personnel of that agency in their assistance to the Medical 
Department of the Army were of the highest order. Without their expert IMMUNIZATION 
339 
assistance, advice, and guidance, as well as their official actions, the program 
would have functioned poorly if at all. 
The procurement, storage, and issue of biologicals consisted of two separate 
but closely related main aspects. One of these included the fiscal, contractual, 
business, and mechanical handling of the large quantities of materials required. 
The other aspect was the control over the many technical details connected 
with the supply of the various agents used. For the coordination of these two 
aspects of the problem, it was necessary that there be the closest cooperation 
between the Supply Service, Office of The Surgeon General, and the Preventive 
Medicine Service through which the immunization program was administered. 
By this cooperative effort it was possible to establish, for the purchasing office, 
estimates of requirements for the various biologicals in keeping with the overall 
anticipated needs and to effect judicious distribution of materials so that the 
maximum use could be obtained from the quantities available. Such distribu- 
tion control was of particular importance in the early phases of the war when 
many immunizing agents were in short supply. In turn the establishment of 
immunization policies depended upon knowledge concerning the availability 
of the various agents required, and it was only through cooperative, long-range 
planning that it was possible to accomplish the desired procedures by having 
at hand the necessary materials. 
Other matters requiring technical control were those dealing with physical 
conditions of storage and shipment of biologicals. Requirements for refrigera- 
tion were established as wTell as for methods of shipment for the various 
materials. For example, great emphasis was given to the necessity for main- 
taining smallpox and yellow fever vaccines at freezing temperatures while 
other agents could be shipped and stored under less carefully controlled 
conditions. 
It was found that, in general, it was desirable that all technical matters 
relating to the nature, type, potency, safety, keeping qualities, et cetera, of 
the various prophylactic biologicals be the responsibility of the Preventive 
Medicine Service and that the office function as the liaison on all such matters 
with the manufacturers and with the National Institute of Health. This plan 
was effectively followed with but few exceptions throughout the war. It was 
materially aided by assignment to the Preventive Medicine Service of an officer 
experienced in the production and testing of biologicals. 
Long-range planning for the procurement of biologicals was found to be a 
necessity. Many of the materials in this category required extended periods 
of time for their manufacture even if the equipment was available and the 
techniques perfected. Thus for large supplies it was necessary that contracts 
be let well before the time of anticipated use of the various agents. It was 
also found that because of the limited civilian outlet for many of the biologicals 
required by the Army the manufacturers were loath to expand their production 
346836 0—55 23 PERSONAL HEALTH MEASURES AND IMMUNIZATION 
340 
facilities until assurance would be given for definite quantity purchases by the 
Army. 
In general, the supply of prophylactic biologicals was adequate to meet 
the needs. As indicated, there were shortages from time to time but through 
careful distribution planning the greatest use was made of the quantities avail- 
able so that essentially no serious situation developed because of lack of the 
proper immunizing materials. 
Antivaccination Activities 
Throughout the war period, particularly during the early years, there was 
built up in the Office of The Surgeon General a considerable file of correspond- 
ence initiated by antivaccinationist individuals or groups.182 Many of the 
letters were from sincere but misinformed persons who expressed opposition to 
the principle of compulsory immunization of American soldiers. Other com- 
munications voicing opposition to the use of immunization procedures in the 
Army were from individuals obviously attempting to foster the cause of one 
or another of the groups of unorthodox or nonmedical so-called healing pro- 
fessions. Their efforts in this regard took the form of attacks on regular 
recognized medical practices such as the use of vaccines and other immunizing 
agents. 
Considerable time and attention were given to the answering of these com- 
plaints and protests. Argument was avoided wherever possible and straight- 
forward information was provided, whenever requested, concerning the immu- 
nization procedures followed for Army personnel. It was pointed out that 
Army practices followed the precepts of the best medical and scientific teaching 
in the country and that it was the intent of the War Department to continue to 
follow these teachings. 
These antivaccinationist activities led to no real difficulties in the accom- 
plishment of the immunization program and were reflected only to an extremely 
limited extent in the attitude of militarized personnel. The policy requiring 
certain immunizations for all personnel on active duty with the Army was clear. 
The only exceptions afforded were those based on definite medical contraindi- 
cations. The legality of this policy was upheld by The .Fudge Advocate General 
and enforcement was accomplished in all instances.183 
CONCLUSION 
The World War II Army immunization program was in the main success- 
ful. Certainly, smallpox, typhoid and the paratyphoid fevers, tetanus, and 
typhus which were all real hazards occurred with very low frequencies. It is 
182 File, Antivaccination. HD : 720.3. 
188 Ltr, JAG to TAG, 27 Nov 42, sub: Policy to be pursued in the event a soldier refuses to submit 
to preventive immunization. HD : 720.3 Legal Status. IMMUNIZATION 
341 
fair to attribute at least some of this relative freedom from these infectious 
diseases to the immunizations practiced. There were but a few cases of cholera 
and none of either plague or yellow fever. There is no way to tell whether 
these diseases were, in fact, controlled in whole or in part by immunization since 
the degree and extent of exposure to them cannot be determined. The high 
degree of effectiveness of yellow fever vaccine had, of course, been well demon- 
strated previously. It must be remembered also that yellow fever vaccination 
for certain troops and forces was very necessary both because of potential 
exposure and to expedite their movement through the compliance with quar- 
antine regulations of several countries. 
The immunization program was large, comprehensive, and complicated. 
Some of the complications arose from its selective nature; that is, the require- 
ment for specific immunizations for certain wmrld areas. Though difficult to 
administer, this selective type of program was shown to be effective, and defi- 
nitely to be preferred over the application of all procedures to all personnel. 
This program demonstrated perhaps as well as any other of the Medical 
Service, the necessity for close coordination and cooperation between the profes- 
sional and technical groups and administrative, fiscal, and logistic activities. 
Without this cooperation and coordination during World War II, the Army 
immunization program would undoubtedly have failed. APPENDIX A 
Administrative Requirements For 
Yellow Fever Vaccination 
Date 
Requirements 
Authority 
30 January 1941 
All military personnel stationed in 
WD AG Ltr (1-10-41) MA-M, 
the tropical regions of the West- 
30 Jan 41, sub: Vaccination 
ern Hemisphere, including Pana- 
of troops against yellow fe- 
ma and Puerto Rico. Those 
ordered to these areas to be vac- 
cinated prior to departure. 
ver. AG: 720.3. 
9 May 1941. 
All military and civilian personnel 
WD AG Ltr (4-17-41) M- 
stationed in tropical regions in- 
WPD-M, 9 May 41, sub: 
eluding Bermuda; all personnel 
Vaccination of troops against 
who embark on Army transports 
for station in or travel through 
these regions; all personnel of 
tactical and mobile units of 
GHQ Air Force; all other Air 
Corps personnel on a voluntary 
basis. 
yellow fever. AG: 720.3. 
24 January 1942 
All military personnel to be im- 
WD AG Ltr (12-26-41) MB- 
munized as soon as practicable; 
A-M, 24 Jan 42, sub: Vac- 
those vaccinated in accordance 
cination of troops against 
with previous instructions not to 
be immunized a second time. 
yellow fever. AG: 720.3. 
2 June 1942 
All troops leaving United States 
WD AG Ltr (5-13-42) MB-M, 
by air or water. Vaccine avail- 
2 Jun 42, sub: Vaccination of 
able at ports of embarkation and 
troops against yellow fever. 
for the Air Surgeon only. 
AG: 720.3. 
29 June 1942 
Vaccination limited to military 
WD AG Ltr (6-22-42) MB- 
personnel traveling to or through 
SPGA-PS-M, 29 Jun 42, sub: 
or stationed in areas where yel- 
Vaccination of troops against 
low fever is endemic. These 
areas defined by The Surgeon 
General as: In the Western Hem- 
isphere, the mainland of South 
yellow fever. AG: 720.3. 
America lying between latitudes 
Ltr, SG to CGs AGF, AAF, 
13° N. and 30° S. including the 
SOS, all Armies, CAs, Depts, 
islands immediately adjacent. 
Bases and Ports of Embarka- 
In the Eastern Hemisphere, the 
tion, COs all Exempted Stas, 
portion of Africa lying between 
Chiefs of SvCs, 29 Jun 42, 
latitudes 16° N. and 12° S. in- 
sub: Vaccination against yel- 
eluding the islands immediately 
adjacent. 
low fever. SG: 720.3. 
343 344 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Date 
Requirements 
Authority 
17 November 1942 
Same requirements as 29 June 
1942, with redefinition of en- 
demic areas to include the Re- 
public of Panama and the Canal 
Zone. 
Ltr, SG to CGs AGF, AAF, 
SOS, all Armies, SvCs, 
Depts, Overseas Forces, 
Bases and Ports of Em- 
barkation, COs all Exempted 
Stas, 17 Nov 42, sub: Vac- 
cination against yellow fever. 
SG: 720.3. 
27 November 1942 
All military personnel of the Air 
Transport Command and civil- 
ian personnel detailed to flying 
duty with the Air Transport 
Command to be immunized 
against yellow fever as a routine 
procedure. 
Ltr, CG ATC to CG North 
Atlantic Wing, CO Carib- 
bean Wing, CG South At- 
lantic Wing, CG Africa- 
Middle East Wing, CO Alas- 
kan Wing, CO India-China 
Wing, HQ AFATC, 27 Nov 
42, sub: Immunization. HD: 
720.3. 
28 November 1942 
All Army Air Forces personnel of 
air and ground echelons of oper- 
ational and replacement training 
units. 
Ltr, Air Surg to CG each Air 
Force, 28 Nov 42, sub: Med- 
ical. HD; 720.3. 
11 February 1943 
Same as 29 June and 17 November 
1942, with added provision that 
if travel is by air, vaccination is 
to be accomplished at least 10 
days prior to departure in order 
to avoid delays en route. In- 
dividual certificates of vaccina- 
tion required for those traveling 
to India. 
WD AG Memo 40-7-43, 11 
Feb 43, sub: Summary of 
immunization requirements 
for overseas duty. 
15 October 1943 
Same as 11 February 1943, with 
added requirement that individ- 
uals destined for India and 
passing through endemic areas 
as defined in letter of 29 June 
1942, or any part of Angola, 
French West Africa, French 
Equatorial Africa, or Eritrea be 
vaccinated not more than 2 
years nor less than 14 days be- 
fore entering these areas. 
WD Cir 254, 15 Oct 43. APPENDIX A 
345 
Date 
Requirements 
Authority 
11 May 1944 
All military and civilian personnel 
subject to field service with the 
Army and others authorized to 
travel to or through endemic 
yellow fever areas by Army 
transport or airplane to be vac- 
cinated against yellow fever 
within 4 years and not less than 
10 days prior to entry into an 
endemic yellow fever area. The 
yellow fever endemic areas rede- 
fined as follows: In the Eastern 
Hemisphere, that portion of 
Africa lying between latitude 
18° S. and the northern borders 
of French West Africa, French 
Equatorial Africa, and the An- 
glo-Egyptian Sudan, including 
the islands immediately adja- 
cent thereto. In the Western 
Hemisphere, the mainland of 
South America lying between 
latitudes 13° N. and 30° S., in- 
cluding the islands immediately 
adjacent, and Panama, includ- 
ing the Canal Zone. However, 
transit through the Panama 
Canal with brief sojourns within 
the terminal port cities or Army 
posts within the Canal Zone will 
not be considered as travel 
through an endemic area. 
WD Cir 187, 11 May 44. 
9 November 1944 
Restatement of policy established 
in WD Cir 187, 1944. 
TB MED 114, 9 Nov 44. 
21 June 1945 
Discontinuance of yellow fever 
immunization authorized for 
personnel returning from ETO 
by air to the United States 
through Morocco, Dakar, and 
Brazil. 
Radio WARX 20323, OPD 
WDQS to Supreme Hq 
Allied Expeditionary Forces, 
Frankfort, Germany, 21 Jun 
45. 
6 September 1945 
Routine yellow fever immuniza- 
tion of Army Air Forces per- 
sonnel discontinued. This per- 
sonnel in the future to receive 
yellow fever immunization only 
in the case of individuals 
traveling to or through areas 
where yellow fever is endemic. 
AAF Ltr 25-15C to all Air 
Force Comds, 6 Sep 45, 
sub; Immunization for over- 
seas duty. APPENDIX B 
Administrative Requirements For Cholera 
Vaccination 
Dale 
Requirements 
Authority 
6 January 1942 
All military personnel stationed 
in or traveling through Asia or 
other regions where cholera is 
known to be present in endemic 
or epidemic form. 
WD Cir 4, 6 Jan 42. 
27 February 1942 
All military personnel assigned to 
the Air Transport Command 
and civilian Air Transport Com- 
mand personnel detailed to fly- 
ing duty. 
Ltr, CG ATC to Wing Comdrs 
and Hq AFATC, 27 Feb 42, 
sub: Immunization. HD: 
720.3. 
28 November 1942 
All Army Air Forces personnel of 
air and ground echelons of oper- 
ational and replacement train- 
ing units. 
Ltr, Air Surg to CG each Air 
Force, 28 Nov 42, sub: Med- 
ical. HD: 720.3. 
11 February 1943 
Personnel proceeding to or through 
Asia including the Middle East 
and islands of East Indies. 
WD AG Memo W 40-7-43, 11 
Feb 43, sub: Summary of 
immunization requirements 
for overseas duty. 
22 January 1944 
All personnel moving to the South- 
west Pacific area. 
WD AG Ltr (12 Jan 44) OB- 
S-SPMOT-M, 22 Jan 44, sub: 
Vaccinations of personnel 
moving to SWPA. AG: 
720.3. 
9 November 1944 
Personnel s+ationed in or travel- 
ing to or through Asia, includ- 
ing the area around the Persian 
Gulf and islands of the East 
Indies (this requirement in ad- 
dition to that shown in the 22 
January 1944 letter, which re- 
mained in force). 
TB MED 114, 9 Nov 44. 
20 November 1944 
Military personnel moving to Pa- 
cific Ocean Areas and civilian 
personnel with destination with- 
in the Pacific Ocean Areas, west 
of the Hawaiian Islands. 
WD AG Ltr (17 Nov 44) AB- 
S-E-SPMOT-M, 20 Nov 44, 
sub: Immunization of troops 
moving overseas. AG: 
720.3. 
1 February 1945 
Personnel moving to destination 
within Pacific Ocean Areas, west 
of 150° E. longitude (amend- 
ment to letter of 20 November 
1944). 
WD AG Ltr (29 Jan 45) OB- 
S-E-SPMOT-M, 1 Feb 45, 
sub: Amendment No. 2 to 
letter 20 Nov 44. AG: 
720:3. 
347 348 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Date 
Requirements 
Authority 
19 May 1945 
Military personnel moving to Pa- 
WD AG Ltr (16 May 45) OB- 
cific Ocean Areas and to the 
S-E-SPMOT-M, 19 May 45, 
Southwest Pacific; civilian per- 
sub: Immunizationfortroops 
sonnel moving to these areas 
moving overseas. AG: 
when the destination is west of 
the Hawaiian group and north 
of Australia. 
720.3. APPENDIX C 
Administrative Requirements for Typhus Vaccination 
Date 
Requirements 
Authority 
6 January 1942 . 
All military personnel stationed 
in or traveling through Asia, Af- 
rica, continental Europe, or 
other areas where danger from 
epidemic typhus fever exists. 
WD Cir 4, 6 Jan 42. 
5 April 1942 
All military personnel stationed in 
or traveling through the moun- 
tainous regions of Venezuela, 
Colombia, Equador, Peru, Bo- 
livia, Chile, Mexico, and Central 
America (except Panama). 
This in addition to areas men- 
tioned in WD Cir 4, 1942 above. 
WD AG Ltr (3-28-42) MD- 
M, 5 Apr 42, sub: Vaccina- 
tion against typhus. AG; 
720.3. 
11 July 1942 
All military personnel stationed in 
or traveling through the British 
Isles. This in addition to areas 
cited in directives of 6 January 
and 5 April above. 
WD AG Ltr (6-22-42) MD- 
SPMCE-PS-M, 11 Jul 42, 
sub: Vaccination against ty- 
phus for personnel traveling 
through the British Isles. 
AG: 720.3. 
27 November 1942 
All military personnel assigned to 
the Air Transport Command and 
civilian Air Transport Command 
personnel detailed to flying duty. 
Ltr, CG ATC to Wing Comdrs 
and Hq AFATC, 27 Feb 42, 
sub: Immunization. HD: 
720.3. 
28 November 1942 
All Army Air Forces personnel of 
air and ground echelons of oper- 
ational and replacement training 
units. 
Ltr, Air Surg to CG each Air 
Force, 28 Nov 42, sub: Med- 
ical. HD: 720.3. 
11 February 1943 
Personnel proceeding to or through 
Asia, Africa, Europe (including 
the British Isles) and the moun- 
tainous regions of Central and 
South America (including Mexi- 
co but excepting Panama). 
(Summary of directives of 4 Jan- 
uary, 5 April, and 11 July 1942 
above.) 
WD AG Memo 40-7-43, 11 
Feb 43, sub: Summary of 
immunization requirements 
for overseas duty. 
22 January 1944 
All personnel moving to the South- 
west Pacific area. 
WD AG Ltr (12 Jan 44) OB- 
S-SPMOT-M, 22 Jan 44, 
sub: Vaccination of person- 
nel moving to Southwest 
Pacific area. AG; 720.3. 
349 350 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Date 
Requirements 
Authority 
9 November 1944 
Personnel stationed in or traveling 
through Asia, Europe (including 
the British Isles), mountainous 
regions of Central and South 
America (including Mexico but 
excepting Panama), Alaska, the 
Southwest Pacific, and certain 
islands in the South Pacific. 
TB MED 114, 9 Nov 44. 
20 November 1944 
Military personnel moving to Pa- 
cific Ocean Areas and civilian 
personnel with destination with- 
in the Pacific Ocean Areas, west 
of the Hawaiian Islands. 
WD AG Ltr (14 Nov 44) OB- 
S-E-SPMOT-M, 20 Nov 44, 
sub: Immunization of troops 
moving overseas. AG: 720.3. 
1 February 1946 
Personnel moving to destination 
Pacific Ocean Areas, west of 150° 
E. longitude (amendment to let- 
ter of 20 November 1944 above). 
WD AG Ltr (29 Jan 45) OB- 
S-E-SPMOT-M, 1 Feb 45, 
sub: Amendment No. 2 to 
letter 20 Nov 44. AG: 720.3. 
19 Mav 1945 
Military personnel moving to Pa- 
cific Ocean Areas and to the 
Southwest Pacific; civilian per- 
sonnel moving to these areas 
when the destination is west of 
the Hawaiian group and north of 
Australia. 
WD AG Ltr (16 May 45) OB- 
S-E-SPMOT-M, 19 May 45, 
sub; Immunization for troops 
moving overseas. AG: 720.2 APPENDIX D 
351 
Command 
Initial immunization 
Reimmunization 
Authority 
Chinese Combat Command 
Entry to service 
Every 6 months, on or about 1 
China Theater Cir 13, 4 Apr 
(Prov), USF China theater. 
USF India-Burma theater 
do 
April and 1 October. 
Every year (previously every 6 
months). 
Every 3 years 
45. 
India-Burma Theater Cir 5, 20 
Jan 45. 
USAFIA Cir Ltr 12, 18 Jul 42. 
USAF in Australia 
do 
USAF in South Pacific Area 
do 
Every 3 years. Revaccinate on 
entry to theater if not done 
within preceding 12 months. 
Every 3 years 
USASOS Reg 50-30, 29 Nov 42. 
SPA Memo 87, 12 Jun 1944. 
SOPAC Base Comd Memo 78, 
South Pacific Base Command 
do 
Every 3 years and in presence 
of epidemic. 
Every 3 years and within 1 year 
of return to SWPA. 
Every 3 years if vaccinia or 
USAF in the Far East 
do 
28 Jun 45. 
USAFFE Cir 25, 25 Mar 45. 
USAF in the Middle East 
do 
USAFIME Med Sec Cir 7. 21 
Persian Gulf Service Com- 
Within 1 year prior to departure 
from the United States. 
vaccinoid. Repeat in 1 year 
if immune, 
do 
Prior to leaving the Middle East 
Oct 42. 
USAFIME Memo 3, 7 Apr 43. 
PG SvC Med Branch Cir 3, 12 
mand. 
Within 1 year prior to departure 
from the United States. 
for return to the United 
States. 
Every 3 years if vaccinia or 
vaccinoid. Repeat in 1 year 
if immune. 
Apr 43 (in accordance with 
instructions from theater head- 
quarters) . 
PG SvC Cir 37, 20 Apr 43. 
Administrative Requirements (or Immunization of Overseas Areas by Diseases* 
•Based on data available to author in Preventive Medicine Service and Historical Division, Office of The Surgeon General, on 1 June 1946. 
APPENDIX D 
SMALLPOX PERSONAL HEALTH MEASURES AND IMMUNIZATION 
APPENDIX D 
Command 
Initial immunization 
Reimmuntzation 
Authority 
Every year 
USAFSA Memo 2, 10 Jan 44. 
USAFSA Memo 3, 24 Jan 44. 
ETO Adm Cir 63, 9 Sep 43. 
Ltr, CG ETO to CGs each Army, 
Air Force, Corps, Div, etc., 
7 Feb 44, sub: Immunization. 
HD: 720.3. 
ETO Cir 62, 4 Jun 44. 
ETO Cir 1, 7 Jan 45. 
ETO Cir 68, 25 May 45. 
Every 3 years or in presence of 
epidemic. 
Every year. . - 
Immediate if no record since 1 
July 1943. 
Immediate if no record since 1 
July 1943. 
Every 3 years 
TYPHOID-PARATYPHOID 
Chinese Combat Command 
(Prov), USF China theater. 
Every year 
China Theater Cir 13, 4 Apr 45. 
India-Burma Theater Cir 5, 20 
Jan 45. 
USASOS Cir Ltr 12, 18 Jul 42. 
USASOS Reg 50-30, 29 Nov 42. 
USASOS Reg 50-30, C 1, 21 Sep 
43. 
SPA Memo 87, 12 Jun 44. 
SOPAC Base Comd Memo 78, 
28 Jun 45. 
USAFFE Cir 25, 25 Mar 45. 
Every year (previously every 6 
months). 
Every 3 years and in presence 
of epidemic. 
3 years after initial dose, and in 
presence of epidemic. 
Every year, and in presence of 
epidemic. 
Every year 
do 
Every year and in presence of 
epidemic. 
Every year, in presence of dis- 
ease, and within 1 year prior 
to return to theater. 
USAF in the Far East 
USAF in the Middle East 
Persian Gulf Service Com- 
mand. 
USAF South Atlantic 
European theater 
do 
v ycar 
uoAr iivin, Med Sec Cir 7 21 
Oct 42. 
USAFIME Memo 3, 7 Apr 43.<fe 
PG SvC Supply Cir 37, 20 Apr 
43. 
USAFSA Memo 2, 10 Jan 44. 
ETO Adm Cir 63, 9 Sep 43. 
Ltr, CG ETO to CGs each Army, 
Air Force, Corps, Div, etc., 7 
Feb 44, sub; Immunization 
HD; 720.3. 
ETO Cir 62, 4 Jun 44. 
ETO Cir 1, 7 Jan 45. 
ETO Cir 68, 25 May 45. 
do 
do 
Immediate if no record since 1 
July 43. 
Entry to service 
Immediate if no record since 1 
July 43. 
Every year 
TETANUS ~~ 
Chinese Combat Command 
(Prov), USF China theater. 
USF India-Burma theater 
Entrv to service 
1 year after initial dose, and in 
presence of wound or opera- 
tion. 
1 year after initial dose and as 
necessary thereafter. 
1 year after initial dose, within 
6 months prior to combat, 
and after injury. 
1 year after initial dose and 
within 6 months prior to entry 
to theater (possible second, 
stimulating dose), and after* 
injury. 
1 year after initial dose 
China Theater Cir 13, 4 Apr 45. 
India-Burma Theater Cir 5, 20 
Jan 45. 
USAFIA Cir Ltr 12, 18 Jul 42. 
USASOS Reg 50—30, 29 Nov 42 
SPA Memo 87, 12 Jun 44. 
SOPAC Base Comd Memo 78 
28 Jun 45. 
USAF in - 
USAF in South Pacific Area_ 
South Pacific Base Command. 
do 
1 year after initial dose, and 
when indicated clinically. 
SMALLPOX—Continued PERSONAL HEALTH MEASURES AND IMMUNIZATION 
APPENDIX D 
Command 
Initial Immunization 
| 
Reimmunization 
Authority 
USAF in the Far East 
Entry to service 
1 year after initial, after injury, 
and within 1 year prior to 
return to theater. 
At end of 6 months [after initial] 
providing none given in United 
States, and after injury, 
do 
USAFFE Cir 25, 25 Mar 45. 
USAF in the Middle East 
do 
USAFIME Med Sec Cir 7, 21 
Oct 42. 
USAFIME Memo 3, 7 Apr 43. 
PG SvC Supply Cir 37, 20 Apr 43. 
USAFSA Memo 2, 10 Jan 44. 
ETO Adm Cir 63, 9 Sep 43. 
Ltr, CG ETO to CGs each Army, 
Air Force, Corps, Div, etc., 7 
Feb 44, sub: Immunization. 
HD: 720.3. 
ETO Cir 62, 4 Jun 44. 
ETO Cir 1, 7 Jan 45. 
ETO Cir 68, 25 May 45. 
Persian Gulf Service Com- 
do 
mand. 
USAF South Atlantic 
do 
Every year 
European theater 
do 
Every year 
Immediate if no record since 1 
February 1944. 
Entry to service 
Immediate if no record since 1 
February 1944. 
Every year, after injury and on 
operative procedure on old 
wounds. 
1 year after initial, after injury, 
and on operative procedure on 
old wounds. 
_.do 
TYPHUS 
Chinese Combat Command 
Every 6 months on or about 1 
April and 1 October. 
Every fi months 
China Theater Cir 13, 4 Apr 45. 
India-Burma Theater Cir 5, 20 
(Prov), USF China theater. 
USF India-Burma theater 
Theater requirement 
USAF in Australia 
For task forces operating from 
Northern Australian bases 
and for Air Corps. 
Every 4 to 6 months in danger 
of infection. 
Jan 45. 
USAFIA Cir Ltr 12, 18 Jul 42. 
In threat of epidemic or assign- 
USASOS Reg 50-30, 29 Nov 42. 
SPA Memo 87, 12 Jun 44. 
SOPAC Base Comd Memo 78 
28 Jun 45. 
USAF in South Pacific Area__ 
South Pacific Base Command, 
USAF in the Far East 
ment to Asia, Africa, or con- 
tinental Europe. 
If proceeding to SWP, and not 
previously immunized. 
When stationed in or proceeding 
to west of 130° E. or north of 
30° N. if not previously im- 
munized. 
Theater requirement 
In presence of definite exposure.. 
When stationed in or proceeding 
to west of 130° E. or north of 
30° N., every 6 months on or. 
about 1 February and 1 Nov- 
ember in endemic area and in 
presence of epidemic. 
In presence of disease, and with- 
in 6 months prior to return to 
theater. 
USAF in the Middle East 
USAFFE Cir 25, 25 Mar 45. 
Persian Gulf Service Com- 
do 
USAFIME Med Sec Cir 7 
21 Oct 42. 
USAFIME Memo 3, 7 Apr 43. 
PG SvC Supply Cir 37, 20 Apr 43. 
USAFSA Memo 2, 10 Jan 44. 
mand. 
USAF South Atlantic 
European theater.. 
Immediate if no record since 1 
July 1943. 
Theater requirement 
Immediate if no record since 1 
July 1943. 
Every year, and every 4 to 6 
months in danger of infection. 
Every year about 1 December, 
and every 3 to 6 months in 
danger of infection. 
ETO Adm Cir 63, 9 Sep 43. 
Ltr, CG ETO to CGs each Army, 
Air Force, Corps, Div, etc., 7 
Feb 44. 
ETO Cir 62, 4 Jun 44. 
ETO Cir 1, 7 Jan 45. 
ETO Cir 68, 25 May 45. 
TETANUS—Continued 
346.336 0—55 24 PERSONAL HEALTH MEASURES AND IMMUNIZATION 
APPENDIX D 
Command 
Initial immunization 
Reimmunization 
Authority 
Chinese Combat Command 
(Prov), USF China theater. 
USF India-Burma theater 
Every 6 months, on or about 1 
China Theater Cir 13, 4 Apr 45. 
Theater requirement and be- 
tween 6 months and 6 days 
prior to departure for travel 
by air to or through Egypt. 
For task forces operating in 
April and 1 October. 
Every 6 months and between 
6 months and 6 days prior to 
departure for travel by air 
to or through Egypt. 
Every 4 to 6 months in danger 
India-Burma Theater Cir 5,0 
20 Jan 45. 
USAFIA Cir Ltr 12, 18 Jul 42. 
Northern Australian bases, 
and Air Corps. 
of infection. 
USASOS Reg 50-30, 29 Nov 42. 
USAF in South Pacific Area.. 
South Pacific Base Command- 
111 till COl w 
signment to Asia, Africa, or 
continental Europe. 
When proceeding to SWP theater 
if not previously immunized. 
When stationed in or proceeding 
to west of 130° E. or north of 
30° N. if not previously im- 
munized. 
Theater requirement 
In presence of exposure.. 
When stationed in or proceeding 
to west of 130° E. or north of 
30° N. Every 4 to 6 months 
in endemic area, and in pres- 
ence of epidemic. 
Every 6 months for personnel 
SPA Memo 87, 12 Jun 44. 
SOP AC Base Comd Memo 78, 28 
Jun 45. 
USAFFE Cir 25, 25 Mar 45. 
serving in Philippine Islands, 
and within 6 months of return 
to theater. 
Every 6 months 
USAFIME Med Sec Cir 7, 21 
UOAr 111 me iviiuuic tjoot 
Oct 42. 
USAFIME Memo 3, 7 Apr 43. 
PG SvC Supply Cir 37, 28 Apr 
Persian Gulf Service Com- 
mand. 
43. 
USAFSA Memo 2, 10 Jan 44. 
European theater 
For travel or station in Asia 
(including Middle East) and 
\ East Indies. 
Every 4 to 6 months in the areas 
indicated. 
ETO Adm Cir 63, 9 Sep 43. 
For travel or station in Asia 
(including Middle East), the 
Southwest Pacific area, and 
East Indies, 
do 
Every 4 to 6 months when nec- 
essary [in the areas indicated]. 
Everv 4 to 6 months in nresenee 
ETO Cir 62, 4 Jun 44. 
ETO Cir 1, 7 Jan 45. 
ETO Cir 68, 25 May 45. 
of danger of cholera. 
PLAGUE 
Chinese Combat Command 
In threat of exposure to epi- 
zootics and epidemics of hu- 
man bubonic or pulmonic 
plague. 
In threat of exposure to epi- 
demics of human bubonic or 
pulmonic plague (no vaccine 
in Australia at the time). 
For assignment to Asia, Africa 
or continental Europe, or in 
threat of epidemic. 
In presence of disease. _ 
China Theater Cir 13, 4 Apr 45. 
USAFIA Cir Ltr 12, 18 Jul 42 
(Prov), USF China 
theater. 
USAF in Australia 
When indicated 
USASOS Reg 50-30, 29 Nov 42. 
USAFFE Cir 25, 25 Mar 45. 
ETO Adm Cir 63, 9 Sep 43. 
ETO Cir 62, 4 Jun 44. 
USAF in the Far East 
Euronean theater 
In threat of exnosnre to enidemic 
When indicated 
do 
Every 4 to 6 months when neces- 
sary. 
Everv 6 months; in nresenee of 
do. ... _ _ 
ETO Cir 1, 7 Jan 45. 
danger of plague. 
ETO Cir 68, 25 May 45. 
CHOLERA PERSONAL HEALTH MEASURES AND IMMUNIZATION 
APPENDIX D 
Command 
Initial immunization 
Reimmunization 
Authority 
Chinpsp Combat Command 
Every 4 years 
China Theater Cir 13, 4 Apr 45. 
India-Burma Theater Cir 5, 20 
(Prov), USE China theater. 
USE India-Burma theater 
For travel into yellow fever zone 
Advised but temporarily dis- 
continued until new vaccine 
supplied. 
For personnel in endemic regions 
USAF in Australia 
Jan 45. 
USAFIA Cir Ltr 12, 18 Jul 42. 
USASOS Reg 50-30, 29 Nov 42. 
SPA Memo 87, 12 Jun 44. 
SOPAC Base Comd Memo 228, 
26 Dec 44. 
USAFFE Cir 25, 25 Mar 45. 
USAFIME Med Sec Cir 7, 21 
Oct 42. 
USAFIME Memo 3, 7 Apr 43. 
PG SvC Supply Cir 37, 20 Apr 43. 
PG SvC Cir 64, 26 Jul 43. 
USAF in South Pacific Area 
Initial vaccination will be con- 
South Pacific Base Com- 
Theater requirement if not vac- 
cinated during preceding 4 
years. 
In presence of disease 
sidered to protect for 4 years. 
mand. 
USAF in the Far East 
USAF in the Middle East 
Theater requirement 
Persian Gulf Service Com- 
do 
mand. 
Between 2 years and 10 days 
prior to departure for zone of 
the interior. 
For personnel passing through or 
stationed in Anglo-Egyptian 
Sudan, Eritrea, and any coun- 
try south of 15th Meridian at 
least 9 days prior to entry; 
and personnel returning to 
zone of the interior by un- 
known route, 9 days prior to 
departure [cites Memo 9, 
USAFIME, 14 Aug 43]. 
Every 2 years . 
PG SvC Cir, 8 Sep 43. 
Theater requirement and for 
do 
Ltr, CG PG SvC to COs all 
Districts, Posts, Camps, and 
Stations, 3 Mar 44, sub: Yel- 
low fever vaccine. HD: 720.3. 
USAF South Atlantic 
travel to endemic zone. 
Theater requirement 
Theater requirement and 2 years 
USAFSA Memo 2, 10 Jan 44. 
USAFSA Memo 3, 24 Jan 44. 
European theater 
to 2 weeks prior to entry into 
endemic areas. 
For personnel in yellow fever 
ETO Adm Cir 63, 9 Sep 43. 
ETO Cir 62, 4 Jun 44. 
\ 
zone. 
For entry into or passage 
through yellow fever zone. 
ETO Cir 1, 7 Jan 45. 
ETO Cir 68, 25 May 45. 
DIPHTHERIA 
Persian Gulf Service Com- 
In presence of disease 
PG SvC Chart ‘Tmmunizaton 
Required,” 31 Mar 43. HD- 
720.3. 
mand. 
European theater 
In presence of hazard and 
ETO Adm Cir 63, 9 Sep 43. 
positive Schick test. 
Disease among troops with like- 
lihood of spread. 
A v v>ir oz, 4 Jun 44. 
In accordance with AR 40-210, 
ETO Cir 1, 7 Jan 45. 
ETO Cir 68, 25 May 45. 
USAF in the Far East 
25 Apr 45; TB MED 114, 9 
Nov 44; TB MED 143, Feb 
1945. 
In presence of disease 
A ou, Zo oep 45. 
USAFFE Cir 25, 25 Mar 45. 
YELLOW FEVER 360 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Command 
Initial immunization 
Reimmunization 
Authority 
European theater 
Theater requirement 
ETO Cir 69, 28 Sep 45. 
USAFFE Cir 25, 25 Mar 45. 
USAF in the Far East 
Presence of disease 
INFLUENZA The volumes comprising the history of the Medical Department of the 
United States Army in World War II are divided into two series: (1) The Ad- 
ministrative and Operational series which constitutes a part of the general series 
of the history of the United States Army in World War //, published under the 
direction of the Office of the Chief of Military History, and (2) the Profes- 
sional, or clinical and technical, series published as The Medical Department 
of the United States Army under the direction of the Office of The Surgeon 
General. Both series are being prepared by the Historical Unit, Army Medical 
Service. As part of the clinical series, this is the second of a group of volumes 
to be published concerning preventive medicine. Index 
Abbot, Camp: Accidental injury—Continued 
attitude conditioning program, 208 during maneuvers, 240 
consultation service, 189, 199-200 hospital admission rates, 239, 251 
Aberdeen Proving Ground: in civilian population, 235-236 
consultation service, 216 manpower loss, 248-249 
mental conditioning program, 181, 202, See also Nonbattle injury. 
203, 204 Adjutant General, Office of The: 
retraining program, 209 classification course, 177 
Accident (s) : clothing research, 45 
causative agents, 239, 251-253 consultation service development, 176, 
environment as causative factor, 255-257 215 
host factors in causation, 253-255 neuropsychiatrists, functions outlined, 
injury. See Accidental injury. 183-184, 189 
prevention : preventive psychiatry activities, 208-209, 
advisory board, 243 211 
directive, 244 Adolph, E. F., clothing studies, 55 
ecologic approach, 250-257 Adviser system, in mental hygiene pro- 
historical background, 237-241 gram, 201, 204-205 
importance, 244-247 Aero-Medical Center, clothing research, 47 
overseas: Africa: 
European theater, 245, 264 typhus fever, 322 
Mediterranean theater, 246, 264, 267 yellow fever 311 
North African theater, 266 Age, re<l„lKm’eMs for inductlon, 2, 3 
Persian Gulf Command, 266 . . 
Agriculture, Department of, studies in— 
reporting of accidents, 244, 24o „ 
Southwest Pacific area, 246, 264, 267 USe’ -> _ 
special studies, 245 mite control> ,>6 
policy, 241 nutrient cooking loss, 86 
program in Office of The Surgeon protective clothing, 51 
General, 243-244 Air Corps. See Army Air Forces 
safety program, 241-243 Aircraft accidents, injuries : 
training, 264-265 deaths, 251, 252, 253 
proneness, 254-255 disposition of patients, 265 
reporting system, 243, 244 hospital admissions, 251 
See also Safety program. Air Forces. See Army Air Forces. 
Accidental injury; Air Provost Marshal, on safety advisory 
causes, 264, 265 board, 243 
days lost, 239 Air Surgeon, Office of the: 
deaths, 239, 251 research in- 
causes, 253 clothing, 47 
rates, 251, 252, 253 nutrition, 93 
definition, 236-237 tropical uniform, report, 61 
disability discharge, 239 vitamins for aircrews, request, 136 
363 364 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Air Transport Command : A ration—Continued 
cholera vaccination requirements, 315 United Kingdom, 124-128 
diphtheria immunization, 333 Zone of Interior, 90, 91 
nutrition, India-Burma theater, 145 Arctic area, nutrition report, 166 
Alaska ; Arctic overshoe, 38 
clothing field studies, 50, 64 Armed Forces, manpower requirements 
nonbattle trauma, hospital admissions, and utilization, 3, 7 
248 Armies: 
tests for protection against pest insects, Eighth, nutrition study, 157-158 
65 Fifth: 
Alaskan Wing, Air Transport Command, casualties, battle and nonbattle, 256- 
diphtheria immunization, 333 257, 260 
Alcohol: cold injury, relation to clothing, 67, 68 
factor in accidents, 253 nutrition studies, 117 
poisoning, 247, 263-264 sanitation conference, 25 
Aleutian Islands, clothing, 36 shoepacs used, 68 
Allied Military Government, responsibil- shower and clothing exchange units, 
ity for prisoners of war in European 26 
theater, 140 trenchfoot, incidence, 67, 68 
Amebiasis: First: 
cause of rejection, 5 accidents during maneuvers, 240 
preventive measures, 27 sanitation during maneuvers, 16 
American Association of Psychiatric So- Second, sanitation during maneuvers, 16 
cial Workers, 211 Seventh, clothing report, 69 
American Expeditionary Forces ; Sixth, personal hygiene, 28 
clothing, 38-41 Third: 
laundry facilities, 41-42 accident prevention, 256 
American Red Cross: clothing report, 72 
items for nurses’ uniforms furnished, 41 enemy food captured, 131 
personnel for social work, 211 Armored Division, 2d, bathing facilities, 22 
snack bars provided, 139 Armored Force Medical Research Labora- 
social histories provided, 189, 195 tory. See Armored Medical Research 
World War I activities, 41, 42 Laboratory. 
American Revolution: Armored Medical Research Laboratory, 
accidents, 237-328 studies and tests: 
sanitary rules, 13 anthropometric measurement, 49, 253 
Anemia, nutritional deficiency, 166-167 clothing, 47, 48-49, 52-53 
Anglo-American ration scale, 115 flameproof treatments, 49, 75 
Antiaircraft Replacement Training Cen- physiologic studies, 32, 47, 48, 49, 52-53 
ter, mental hygience service, 180, 188, protective, 75 
203 shoes, 62, 64, 79 
Antivaccination activities, 340 socks, 77 
Anzio beachhead, ration for, 118 winter clothing, 64 
Appel, Lt. Col J. W., mental hygiene ac- design of equipment, 268 
tivities, 186, 202, 207, 208 energy expenditure, 87, 101 
A ration; toxicity of mildew-proofing agents, 77 
components, 91, 104, 124, 128 Army, United States, enlistments, 2, 3 
need for, 132 Army Air Corps. See Army Air Forces, 
use in— Army Air Forces: 
hospitals, 123 accidental injury, 258. See also Aircraft 
troop trains and troopships, 22, 92 accidents, injury. INDEX 
365 
Army Air Force—Continued Army Service Forces ; 
aptitude tests, 9, 176 consultation services, training centers, 
cholera vaccination requirements, 315 187, 215 
diet for flying personnel, 92, 93, 94, 154 Geneva Convention, interpretation, 106 
measles prophylaxis used, 335 jungle combat clothing tests, 54 
physical standards for enlistment, 3 restraining, psychoneurotic soldiers, 
rations, 95, 125, 134, 135, 136 208-209 
research and studies in— safety program, 241-243 
clothing, 47 Army Signal Corps : 
nutrition, 92-93, 118 energy-expenditure tests, 87 
Eighth Air Force, 92 nonbattle injuries, 259 
Fifteenth Air Force, 17 Army Specialized Training Program, in- 
Second Air Force, 92-93 fluenza vaccine trials, 325 
Twentieth Air Force, 93 Ascorbic acid: 
oxygen requirements studied, 86-87 amount— 
safety program, 242 consumed in diet, 103, 157, 158 
tropical uniform, 60, 63 in rations, 126, 133, 144 
volunteers for, 3 deficiency in troops, 161, 162, 163 
women’s branch formed, 2 Asia, cholera vaccination requirement, 315 
Army Epidemiological Board, influenza Assam, bathing facilities, 29 
vaccine development, 323 Atabrine— 
Army General Classification Test, in for suppression of malaria symptoms, 
screening, 8, 179, 191 20, 27 
Army Ground Forces: relation to atypical lichen planus, 86 
classification system, 187 Athletics, nonbattle injury, 251, 252 
clothing field tests, 50, 75 Atterbury, Camp, nutrition study, 86 
consultation services at training centers, Attu : 
187, 215 clothing, 36 
nutrition survey, 96, 97 cold Injury incidence, 66-67 
ration planning, 93, 95 Atypical lichen planus, 86 
Army Group, 12th, bathing facilities, 22 August, Maj. H. E., recommendations on 
Army induction board, seminar, 181 consultation services, 215 
Army Industrial Hygiene Laboratory : Australia ; 
clothing research, 49 laundry facilities, 28 
toxicity of dyes and mildew-proofing nonbattle injury, 253-254 
agents, tests, 77, 78 personal hygiene, 27 
Army Medical Museum, post mortem study procurement of food, 156-157 
of postvaccinal encephalitis, 287 rations, adequacy, 156 
Army Medical School, research: Aviation Medicine, National Research 
cholera vaccine strains, 314 Council Committee on, aviation cloth- 
Japanese B encephalitis vaccine, 328 lag studies, 35, 47 
tetanus toxoid, 293 Avitaminosis, in troops, 150, 154, 156 
typhoid-paratyphoid vaccination, 272, Azores, plague, 318 
273, 275 
typhus vaccine, 320 Babcock, Maj. M. J., nutrition survey, 142, 
woolens tested for bacteria, 43 148 
Army Nurse Corps: Barber(s) : 
field uniforms, 41 in American Revolution, 13 
mosquito boots, 63 kit, use in European theater, 24 
Army Safety Program, 244, 268-269 personal cleanliness rules, 15 366 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Bathing: Board for Investigation, etc.—Continued 
anti-louse measure, 15 in the Army. See Army Epidemiolog- 
facilities overseas: ical Board. 
China-Burma-India theater, 29 Boot(s) : 
European, theater, 20-23 combat, 59, 62, 71 
improvised, 25, 28, 29 for prevention of cold injury, 67 
Middle East theater, 25 for wear in tropics, 62 
North African tehater, 25 mosquito, 62-63 
Southwest Pacific area, 27, 28 rubber, 40 
regulations, 14 Bragg, Fort, mental hygiene service, 192 
Battle casualty : B ration : 
definition, 236 acceptability, 121, 122, 146, 147 
dispositions, comparison with nonbattle, caloric value, 115-116, 118 
249 components, 91, 118, 119, 130, 138, 146, 
rates, comparison with nonbattle, 256, 152 
260 deficiencies, 119-120, 133 
Bazett, H. C., studies in blood volume results of prolonged consumption, 87 
changes, 32-33 stocked overseas, 19, 141 
Beach, E. F., nutrition study, 162 stocked overseas, 129, 141 
Bed nets, for protection against mos- 105. 123 
quitoes, 15, 20, 56 supplementation, 117, 120, 133 
Beers, C., recommendations for mental Brazil, smallpox, 284 
patients, 173 British-American rations, 124 
Belvoir, Fort, mental hygiene service, 180, British Army: 
188, 204, 209-210 cholera, 316, 317 
Benning, Fort, parachute injury study, 257 hospitals in North Africa, 114 
„ , , , nutritional problem, 111 
Benzyl benzoate, miticide, 57 
. protective clothing, joint project, 65 
eri ri' , . , psychiatric problems, 173 
hospital admissions, 160 ,. ...... ..... 
* rations, 111, 124, 141, 142, 153 
incidence, 164 tetanus 297 
Chinese troops, 143, 164 , , ’ ., , „„„ 
, . ’ tetanus toxoid used, 287-288, 290 
recovered prisoners, 154, 168 . , , , .. „„ 
trenchfoot, preventive measures, 68 
Berna’s peptone, in tetanus toxoid, 291, typhus 322 
292, o01, 302, 303, 304, 305 British Composite Pack, use by American 
Berrymax, G. H. nutrition survey, 102, troops 114 
British Fighting Vehicle Physiological 
Biologicals, procurement, storage, and is- Laboratory, studies, 48 
sue, 339 British Medical Research Council, clothing 
Biologies Control Division, National Insti- research, 47 
tutes of Health: British Ministry of Agriculture, foodstuffs 
Army immunization program, corpora- for United States troops, 139 
tion, 338 British Ministry of Food, foodstuffs for 
production of typhus vaccine, supervi- United States troops, 139 
sion, 321 Bureau of Standards, clothing research, 
Blanding, Camp, mental hygiene service, 47 
213, 214, 215 Burma, cholera, 316-317 
Brass, Brig. Gen. R. W., prediction of non- Burns: 
battle injury, 255 casualty from, 262-263 
Board for Investigation and Control of In- disposition of patients, 263, 265 
fluenza and Other Epidemic Diseases preventive measures, 263, 266 INDEX 
367 
Calcium : Camp—Continued 
amount— Roberts, mental hygiene service : 
consumed in diet, 103, 138 administration, 188, 190 
in rations, 126, 140, 144 caseload, 214 
deficiency in dietary, 142, 157, 158 intake procedure, 195 
deficiency in troops, 142, 157 personnel adjustment lectures, 212- 
Callan, Camp, mental' hygiene service, 180, 213 
188, 203 therapy, 199 
Oalorie(s) : Upton, study of shoe sizes, 40 
deficiency in troops, 157, 164, 166, 168 Wheeler, mental hygiene service, 198 
expenditure, 108 Wolters, mental hygiene service: 
... administration, 188, 190 
intake, 97, 100, 104 . , ’ ’ 
_ intake procedure, 195 
requirements, 89, 91, 101, 109, 117 , , 
’ ’ ’ ’ ’ lecture program, 213 
\alue in morale, evaluation, 227-228 
food consumed, 97, 99, 100, 103, 104 reclassification board, 198 
food planned, 99 104 screening, 191, 193 
rahons, !17, 126 Campbell, C. M., value of preventive psy- 
B, 115, 120, 130, 151 . . . 
’ ’ ’ chiatry, 171 
C and K, 116, 129 _ . , . .. 
Camptocormia, studies, 201 
.. „ . _ Canadian Army : 
prisoner of war, 119, 139, 140 , . , 
inn physical profile system, 8 
ten-m-one, 130 ....... . ’ . . 
protective clothing, joint project, 6o 
aAlSot tetanus toxoid adopted, 287 
Canadian Research Committee, research 
attitude conditioning program, 203 in aviatlon clothlng 47 
consultation service, 189, 199-200 Canal Zone, yellow fever vaccination re- 
Atterbury, nutrition study, 86 quirements, 310 
Blanding, mental hygiene service, 213, Carbohydrate, amount- 
214, 215 consumed, 103 
Callan, mental hygiene service, 180, 188, in diet for flight creWs, 93 
203 in diet for patients with hepatitis, 120- 
Carson, ration field trials, 104, 161 121 
Claiborne, mental hygiene service, 226- in rations, 126 
227 Cardiovascular disorders, rejection for, 4 
Croft, mental hygiene service; Carlisle Barracks, clothing research, 44 
intake procedure, 195 Carotene, amount in rations, 126 
mental screening, 191, 192, 193 Carson, Camp, ration field trials, 104, 161 
outpatient psychiatry, 214 0agsino beachhead> rations for> 118 
reclassification board, 198 Casualty, classification, 236-237. See also 
Crowder, mental hygiene service, 194- Battle casualty; Nonbattle casualty 
195, 226 Cavalry, nonbattle injury, 259 
Hood, mental’ hygiene service, 189, 201, Cavalry Reconnaissance Squadron, 44th, 
204-20.) bathing facilities, 22 
Iiee; Central Canada, winter clothing, 64 
clothing field tests, 50, 78 Central Pacific Area : 
mental hygiene service, 200-201, 202, jungle combat uniform tests, 54 
214 yellow fever vaccination requirement, 
ration field tests, 87, 122 310-311 
Plauche, outpatient psychiatry, 214 Chanute Field, selection of students, 176 868 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Cheilosis, symptom of nutritional de- Cholera—Continued 
ficiency, 143 vaccination—Continued 
Chemical Corps, responsibility for impreg- effectiveness, 315-317 
nation of clothing, 74 methods, 315 
Chemical warfare agents, protective cloth- reactions, 317 
ing, 38 vaccine, 314, 316, 317 
Chemical Warfare Service: Cincinnati, University of, rebuilt-shoe 
gas masks, responsibility, 76 sterilization studies, 82 
protective clothing: Civilian Defense, Office of, cooperation in 
studies, 43, 75 safety program, 242 
toxicity testing, 49, 77 Civil War: 
safety program, 241, 242 mental hygiene, 172 
Chemicals, causative agent in nonbattle neurology, 173 
injury, 252 nonbattle trauma, 233 
China : smallpox vaccination, 281 
bathing facilities, 29 Claiborne, Camp, mental hygiene service, 
cholera, 315, 316-317 226-227 
plague, 318 Classification: 
China-Burma-India theater: directives, 178, 197 
bathing facilities, 29 for job assignment, 8 
cholera, 316-317 in preventive psychiatry, 176-186, 187 
vaccination, 315 of registrants, 2 
diarrhea and dysentery, 277 personnel, 176, 188, 191 
preventive measures, 20 policies, 197 
dye in laundry marking, skin sensitivity, testing program, 179 
77 Climate, studies in relation to clothing, 35, 
jungle combat uniform field tests, 54 45-46, 49 
malaria preventive measures, 20 Climatic Research Laboratory, studies 
mosquitoproof fabrics, studies, 55-56 in— 
nonbattle injury, 247, 248 anthropometric measurement, 81 
nutrition, 87, 141-153, 166 clothing, 46 
personal hygiene, 28-30 Clinical psychologists, functions, 175, 176, 
rations for, 112, 141-153 177, 189, 210, 211 
training in personal preventive health Clostridia, found in woolen clothing, 44 
measures, 17, 18 Clostridium tetani, in tetanus toxoid, 287 
typhoid fever, 277 Clothing; 
vitamin supplementation of rations, 143, adaptation to military requirements, 35 
145, 151, 152 adaptation to physiologic needs, 35, 45- 
Chinese troops: 55 
beriberi, 164 arctic, 43, 64, 65 
nutritional deficiency, 87, 141, 143 aviation, 47 
ration, 149 cold weather, 36, 37, 38, 63-73 
Chlorine, fungicidal agent, 81 contaminated with Clostridia, 43-44 
Chloropicrin, for typhus control, 57 decontamination, 48, 57, 58 
Cholera: desert, 55 
epidemic, India, 316 design, 35, 36, 47, 48 
incidence in troops, 316-317 development, 42, 43, 44 
vaccination: directives, 78, 79 
administrative requirements, 315, 347- disinfestation, 42, 57, 58 
348, 356-357 durability, 35 
development and adoption, 313-314 electrically heated, 47, 48 INDEX 
369 
Clothing—Continued Clothing—Continued 
environmental hazards, relation, 36 specialized uniforms, 43 
exchange system, 22, 23, 26 supply, 35, 38, 71 
fabrics, 35, 47, 48, 51, 66 tariffs, 80-81 
allergy to, 77 tests, 43, 44, 46, 50 
for cold weather, 36, 52, 63-73 thermal insulation, 47 
for hot climates, 36 toxicity testing, 49 
for jungle uniform, 51, 52, 53, 54 training in proper use, 69 
fireproofing, 49 tropical, 43, 60-61 
fit, 35, 39, 69, 80 tropic-proofed, 77 
causative agent in accidents, 252 waterproofing, 49 
hospital, 41 weight, 39 
hot weather, 36, 51-63 wind resistant, 43 
impregnation: winter, 44, 71 
against chemical agents and fire, 38, woolen, tested for bacteria, 43 
74, 75 World War I, 38-42 
against insects, 38, 42, 57, 58-59 Clothing, National Research Council Sub- 
effect on uniform, 53, 56 committee on, studies: 
physiologic effects, 74, 75 cold weather clothing, 65 
processes, 38, 76 impregnation of clothing, 74, 75 
toxicity, 49, 57, 74, 75 Jungle clotWng> 51, 54 
Industrial medicine aspects of, 82-83 m„squIt„pr00, fabrics, 56 
jungle, 48, 51, 52 ... . . ... ._ 
materials, 48 physiologic aspects of clothing, 35, 47 
medical* problems associated with, 50-73 Coast Artillery. nonbattle injury, 258 
medical research, 45-50 Coast Guard, United States, women’s 
nurses, 41 branch, 2 
porosity, 53 Cohen, Col. S. A., accident prevention rec- 
properties, 35-38 ommendation, 240, 264 
protective against— Cohen, Lt. Col. R. R., mental conditioning, 
chemical agents, 38, 75 181, 202 
cold, 38, 49 Cold : 
cold injury, 38 42, 72 causative agent in nonbattle injury, 251, 
drowning, 47 252 
fire, 38, 47, 49, 75 physiologic effects, 49, 65 
insects, 15, 42, 49, 83 physiologic mechanisms for adaptation, 
mosquitoes, 55-56 32-33 
schistosomiasis, 59 trauma. See Cold injury. 
solar radiation, 55 Cold injury; 
relation to— incidence, 63, 67, 68, 70, 72 
climate, 46, 65, 71 World War I, 64 
cold injury, xi, 38, 42, 66-73 . , , , . . ,,, 
. ’ ’ , included in nonbattle casualty, 257 
environmental hazards, 35 . „„ _0 
fatigue 45 relation to clothing, xi, 38, 42, 66-73 
heat “regulation, xi, 51-55 8ee als0 T^nchfoot. 
industrial hazards, 38 Combat boot, 62, 67, 71, 72 
skin diseases, 61—62 Combat ration. See 'wtidev Ration, 
research, 47, 51-55 Commission, physical standards for, 1 
salvage, 81-82 Compensation, for disability, 1 
science, 31 Connaught Laboratories, typhus vaccine 
shortages, 27, 60-61, 68-69 studies, 320 370 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Consultation services, replacement training Decubitus ulcers, relation to nutrition, 86 
centers. See under Preventive psy- Defects, disqualifying for military service, 
chiatry. xi, 2, 4 
Cook, G., meaning of mental hygiene, 172 Deferment from military service, 3 
Cook, Maj. E. L., “Accidental Trauma,’’ Deficiency diseases: 
233-269 in recovered prisoners, 167 
Cooke, R. A., study of reactions to tetanus minor symptoms in troops, 92, 98, 102, 
toxoid, 301 114, 117, 118, 119, 161, 162, 163, 164 
Corps : research, 161, 169-170 
II: See also Malnutrition; Nutrition, defi- 
nutritiou inspection, 114 ciences. 
rations for, 116 Dehydrated food. See under Food, 
sanitation conference, 25 Dental requirements for induction, 4 
IV, sanitation conference, 25 Department of Agriculture. See Agricul- 
Cdrps Area: ture, United States Department of. 
First, clothing research, 45. See also Dependents, induction regulations, 2, 3 
Service Command. Dermatitis venenata (Dhobie mark), 77 
C ration: Dermatomycosis, prevention, 16 
components, 129 Dermatophytosis, relation to clothing, 62 
criticism, 114 Dermovaccine, glycerinated calf, 281 
misuse, 132 Desert sores, relation to bathing facilities, 
nutritional adequacy, 117, 133 25 
palatability, 114, 133 Desert Training Center, studies on effects 
recommendations, 91, 123 of dry heat, 49 
results of prolonged consumption, 87, Deutsoh, A., meaning of mental hygiene, 
120 171 
stocked in United Kingdom, 129 Devens, Fort, mental hygiene service, 214 
suitability for hospital use, 96 Dhobie itch, skin lesion, 30 
supplementation, 130, 133 Dhobies, laundry methods, 29-30 
use in— Diarrhea and dysentery: 
European theater, 131 hospital admissions, 17 
India-Burma theater, 145 incidence, 276, 277, 278 
New Guinea, 157 Middle East theater, 26 
Pacific theater, 155 North African theater, 119 
Tunisian campaign, 116 methods of transmission, 23, 25 
use restricted, 129 prevention, 20, 26, 27 
Craft, Camp, mental hygiene service: World War I, 277 
intake procedure, 195 Dibutylphthalate, for mite control, 56 
mental screening, 191, 192, 193 Diet: 
outpatient psychiatry, 214 f°r flight crew, 93 
reclassification board, 198 f°r patients in hospitals, 93-94, 119- 
Crowder, Camp, mental hygiene service, 120, 147, 156 
194-195 226 prisoners of war, 119 
Cbuvant, Lt. Col. B. A.: with hepatitis, 120-121 
psychiatric services 180 222 for recovered Allied military personnel, 
training units reports, 210 1^ 
Cutts, F. B., report on beriberi, 164 from Army rations, 86 
Dietary: 
D chocolate bar, ration supplement, 94, adequacy, 90, 95, 97 
131, 155 allowances, 86 
DDT, for louse control, 42, 58 deficiencies, 142 INDEX 
371 
Dietai'y—Continued Edible waste; 
directives, 89 amounts, 97, 98, 99, 102 
for Chinese troops, 144, 157-158 reasons for, 100 
nutritional balance, 89 Education, requirements for induction, 2 
nutritional content, 96, 101 Bigg, sensitivity to, 323 
standards for Army, 86 Egypt: 
Dill, D. B.: plague, 318 
clothing report, 54 yellow fever vaccination requirements, 
physiologic studies, 45 310, 311 
Dimethylphthalate, for mite control, 56, 57 Eighth Air Force, nutrition study, 92 
Diphtheria: Eighth Army, nutrition study, 158 
immunity to, 331 Eighth Service Command, neuropsy- 
immunizatlon : chiatric consultant, 227 
administrative requirements, 359 Eisendorfer, Maj. A., psychiatric treat- 
contraindications, 332 ment, 199-200 
reactions, 332, 333 Emergency ration. See under Ration, 
incidence, 333 Encephalitis, Japanese B. See Japanese 
toxoid, 331, 332 B encephalitis. 
Discharge for disability, 1, 2, 3, 5 Encephalitis, postvaccinal, 286-287 
Disease: Energy requirement studies, 86, 107, 125 
death rates, 235 Engineer Replacement Training Center, 
included in nonbattle casualty, 257 Fort Belvoir mental hygiene service, 
noneffectiveness from, 248-249 180, 188, 204, 209-210 
Dishwashing, relation to transmission of Engineer Replacement Training Onter, 
diarrhea, 25 Fort Leonard Wood: 
Division: personnel consultant service, 178 
5th, clothing tests, 43 psychiatric caseload, 214 
9th, bathing facilities, 22 Engineers, Corps of: 
35th, bathing facilities, 22 accidental injury, 256, 258 
37th, nutrition survey, 155 low back injury, 261 
85th, shower and clothing exchange unit, safety measures, 241 
26 Engineers, Office of the Chief of, safety 
Draft boards. See Selective Service Sys- program, 242 
tern, local boards. England, nutrition study, 92 
D ration, use, 129, 130, 157 Enlistment(s) in Army: 
Drowning, nonbattle death, 251, 253 number, 2 
Dubbin, for waterproofing shoes, 40, 76 physical standards, 1 
DuBois, E. P., study in aviation medicine, Epidemiology Division, Office of The Sur- 
47 geon General, immunization program, 
Dunbar, F., report on psychosomatic 271, 278 
studies, 254-255 Equipment, tropic-proofed, 77 
DuPont Co., flameproof treatment for Equipment laboratory, Army Air Forces, 
clothing, 75 clothing studies, 47 
Dyes, sensitivity to, 77 European theater: 
Dysentery. See Diarrhea and dysentery. accidental deaths, 253 
accidental injury, 252 
Eastern Defense Command, personal hy- accident prevention program, 256, 264, 
giene training, 16 265 
Edema, in recovered prisoners, 167 aircrew tests, followup study, 9 
Edgewood Arsenal, work on protective alcohol poisoning, deaths, 265, 264 
clothing, 43 barber kit, use, 24 
346336 O—55 25 372 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
European theater—Continued Fat, amount— 
bathing facilities, 20-23 consumed, 103 
civilian food problem, 110 in hepatitis diet, 120-121 
clothing, 69, 71-73, 79-80 in rations, 126 
cold injury, 69, 72, 79, 80 Fatigue: 
diarrhea and dysentery, 277 factor in accidents, 253 
diphtheria, 333 relation of clothing, 45 
food for combat troops, 92 Federal Security Agency, yellow fever 
footgear, survey, 70 vaccine arrangements, 307 
gas mask for patients, 76 Feet, care of, 14-15, 16, 17, 28, 38 
laundry facilities, 22, 23 Field Artillery, nonbattle injury, 258 
louse infestation and control, 83, 322 Field Artillery Replacement Training Cen- 
nonbattle injuries, 245, 248 ter, Camp Roberts, mental hygiene 
nutrition, 92, 122-123 service : 
recovered prisoners, 167, 168 administration, 188, 190 
personal hygiene, 20-24 caseload, 214 
prisoners of war, 139-140 intake procedure, 195 
rations, 123, 124-140 personnel adjustment lectures, 212-213 
sensitivity to dyes and fabrics, 77 therapy, 199 
shoes, fitting of, 78-80 Field Artill*ry Replacement Training 
, , , Center, Fort Bragg, mental hygiene 
tetanus toxoid administration, 295 . 
, , , service at, 192 
training in personal preventive meas- , , .„ 
17 i« Field jacket, development, 43 
111 es’ ’ Fifteenth Air Force, nutrition studies, 117 
trenchfoot, 13, 20, 69, 72, 79, 80 Fifth Army . 
typhoid fever, 277 casualties, battle and nonbattle, 256, 260 
typhus fever, 322 clothing, 37 
Evacuation Hospital, 8th accidental in- cold injury, relation to clothing, 67 
juries, 256 nutrition studies, 117 
Everts, Lt. Col. W. H., retraining centers, sanitation conference, 25 
report, 209 shoepacs, use, 68 
Expeditionary Force Menu No. 1 (B ra- shower and clothing exchange units, 26 
tion), 93, 143, 145 146 trenchfoot, incidence, 67, 68 
Explosives, nonbattle injury, 251, 252, 253 Fifth Service Command, nutrition studies, 
Bye injury, 261-262 86 . . , 
Filanasis, cause for rejection, 5 
Fabrics ■ Finance Department, survey of dietary of 
allergy to, 77 small units, 136 
characteristics, 39, 43, 44, 47 Fineberg, Maj. M. H„ report on accidents, 
for cold weather, 37, 65, 66, 73 240-241, 264 
for hot dry climates, 36, 55 Fire and Accident Advisory Board, 243 
for jungle uniform, 48, 51, 52, 53, 54, 59 Firearms’ accidents, 251, 252, 253, 265 
tt, „„ Fire, nonbattle injury, 251, 252 
Falling trees, nonbattle injury, 252 , „„„ 
_ „ , „ Fire prevention, advisory board, 243 
Falls, nonbattle injury, 250 , . . . , ... 
J ’ Fire-retardant for clothing, 75 
Far East, clothing impregnation tests, 57 First Army • 
Farrell, Col. M. J.: accidents during maneuvers, 240 
preventive psychiatric measures, 185, sanitation during maneuvers, 16 
188, 207 First Corps Area, clothing research, 45 
rehabilitation of psychoneurotics, report, Five-in-one ration, 116, 117 
208 Flight lunch, 92, 94 INDEX 
373 
Florida, jungle clothing field tests, 51 Footgear—Continued 
Fly control, relation to diarrhea, 25 waterproofed, 73, 76 
Food : World War I, 39-41 
caloric value, 97, 99, 100, 103, 104 Forbes, W. H., clothing study, 35, 47 
captured enemy foodstuffs used, 131 Foreign Economics Administration, 155 
classification, 90, 97, 98, 127 Formaldehyde fumigation, for rebuilt shoe 
conservation, 102, 112 sterilization, 82 
consumed, 92, 96, 97, 101 Fort— 
dehydrated, 138, 145, 146, 147, 152, 153 Belvoir, mental hygiene service, 180, 188, 
for civilians in liberated and occupied 204, 209-210 
areas, 109-110 Benning, parachute injuries study, 257 
for combat troops, 91 Bragg, mental hygiene service at, 192 
for prisoners of war, 105-109 Devens, mental hygiene service, 214 
groups, 102, 123 Francis El Warren, mental hygiene serv- 
habits, 89, 110-112, 141, 153 ice, 226 
handlers, 25 Knox, energy expenditure studies, 87, 
handling, 96, 156 101 
leftover, 103 Leonard Wood: 
preparation, 96, 103, 110-112, 122, 149, personnel consultant service, 178 
153, 154 psychiatric caseload, 214 
procurement, 95, 109 Lewis, mental hygiene service, 189, 199, 
from local sources, 131, 139, 155, 156- 214 
157 Meade, food consumption survey, 110- 
quantity consumed, 87, 97, 98, 99, 101- 111 
104 Monmouth: 
spoilage, 155, 156 energy expenditure studies, 87 
supply, 112-113, 154 mental hygiene service, 179-180, 183 
transportation, 149, 151, 154 Riley, clothing field test, 43 
unauthorized, 25, 26, 27 Fourt, L., clothing study, 36 
waste, 98, 100, 102, 111, 121, 122, 127 E’rankfurth, V. L., comment on psychi- 
campaign against, 121, 123 atric screening, 191 
See also Ration(s). Maj. H. L., mental hygiene unit 
Food and Drug Administration, 86 development, 179-180 
Food and Nutrition Board, National Re- French Army: 
search Council, 86, 159 tetanus toxoid; use’ 288- 290 
Food and Nutrition Division, Office of The trenchfoot incidence, 68 
Surgeon General, 87, 95 FbieND’ °apt M' R’ report on indirect 
Food Service Program, Office of The Quar- EOUp 2R| 
~ , __ Frostbite, relation to clothing, 38. See 
termaster General, 92 
also Cold injury. 
, g ' Fumigation gases, for typhus control, 57 
for cold weather, 6o, 66-73 „ . , ,. __ no 00 00 
Fungus infections, 27, 28, 38, 81-82 
for desert, 55 
for tropics, 62-63 Gamma globulin: 
relation to cold injury, 38, 66-73, 79-80 measles prophylaxis, 335 
relation to skin diseases, 62 viral hepatitis prophylaxis, 336 
research, 47, 48, 64, 71 Garrison ration. See under Ration, 
shortage, 68-70 Gas gangrene, prophylaxis for, 337 
sizing and fitting, 77-80 Gas masks, for wounded men, 76-77 
toxicity of dyes and finishing materials, Gastrointestinal disease. See Diarrhea 
77-78 and dysentery. 374 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
General hospital: Hawaii: 
12th, admissions for burns, 262 tetanus in civilian population, 296 
17th, nutrition survey, 121 yellow fever vaccination requirement, 
21st, eye injuries, 261-262 310-311 
Wakeman, nutrition studies, 86 Head nets, for protection against mosqui- 
Walter Reed, hospital diet studies, 86 toes, 56 
General service classification, 3, 4, 8 Health education, personal health prac- 
Geneva Convention, food, for prisoners of tices, xi, xn 
war, 105, 106, 108, 140 Health Education Unit, Office of The Sur- 
German Army: geon General, training aids, 17 
ration, 140 Health, National Institutes of. See Na- 
trenchfoot, incidence, 68 tional Institutes of Health. 
German prisoners of war, 105-109 Heat: 
Germany, survey of civilian food needs, causative agent, nonbattle injury, 251, 
110 252 
Glider Infantry, 326th, complaints on re- physiologic mechanisms for adaptation, 
built shoes, 82 31, 32, 33-35 
Globulin. See Gamma globulin. trauma, xi 
Glossitis, symptom of nutritional defi- Hemoglobin deficiencies in troops, 163 
ciency, 143 Hepatitis: 
Gloves, protective, 47, 56, 64 diet, 120 
Golden, W. R. C., nutrition study, 162 jaundice following, 313 
Goldman, Lt. Ool. G. S., consultation serv- posttransfusion, 336 
ice, effectiveness, 196, 198 Herbertson, Lt. Col. E. R., study of Anglo- 
Gonorrhea, deferment for, 6 American ration scale, 115 
Gordon, J. E., “Accidental Trauma,’’ 233- Herrington, L. P., clothing studies, 47 
269 Hilger, Maj. D. W., importance of psy- 
Gray, J. P., meaning of mental hygiene, chiatric preventive measures, 208 
172 Hillman, Brig. Gen. C. C., proposal for 
Griffith, Lt. Ool. W. H., nutrition report, retraining of psychoneurotic soldiers, 
118, 120, 121 208 
Ground Forces. See Army Ground Forces. Hinde, Brigadier H. M., study of Anglo- 
Guttmacher, Lt. Col. M. S.; American ration scale, 115 
clinical psychologists, utilization, 211 Homologous serum hepatitis, prevention, 
mental hygiene services, supervision, 336 
174, 213 Hood, Camp, mental hygiene service, 189, 
military value of psychiatry, 218 201, 204-205 
Hospital(s) : 
Hair cut, regulations, 13 diets, 93.94 
Halloran, Ool. R. D.: evacuation, 8th, accidental injuries, 256 
consultation service, recommendations, general- 
187, 188 12th, admissions for burns, 262 
psychiatric screening, evaluation, 185 17th, nutrition survey, 121 
Hammond, W. A., Surgeon General, re- 2lst, eye injuries, 261-262 
forms instituted, 173 Wakeman, nutrition studies, 86 
Harris, M., clothing research, 36, 47 Walter Reed, hospital diet studies, 86 
Harvard Fatigue Laboratory, clothing re- laundry facilities, 28 
search, 45, 46, 47 ration: 
Harvard University, School of Public in European theater, 133-134 
Health, study of clothing related to in India-Burma theater, 143, 147, 148, 
cold injury, 63 149, 150, 151 INDEX 
375 
Hospital (s) —Continued Immunization—Continued 
ration—Continued influenza vaccination—Continued 
in North African theater, 119-120 methods, 325 
in Pacific theater, 154, 156 reactions, 326-327 
in United Kingdom, 128-129 Japanese B encephalitis vaccination: 
overseas, 93-95 administrative requirements, 328, 329 
supplement, 94, 131, 151 development and adoption, 327 
Turner’s Lane Hospital, studies of nerv- directive, TB Med 181, 328 
ous disorders, 173 effectiveness, 329 
Houloose, Maj. J., psychiatric orientation, immunization agent, 327-328 
190 methods, 328-329 
Howe, Col. P. E.: reactions, 329-331 
nutrition studies, 102, 104, 117 legality of policy, 340 
rations in India-Burma, recommenda- measles prophylaxis, 335 
tions, 145 plague vaccination: 
Human Nutrition and Home Economics, administrative requirements, 318, 357 
Department of Agriculture Bureau of, development and adoption, 313-314 
8ff directives, 314, 318 
Hunt, Maj. R. C.: effectiveness, 318-319 
adviser system, 205 immunizing agent, 317-318 
psychiatric screening, 190, 191 methods, 318 
Hygiene, John B. Pierce Laboratory of, 46 reactions, 319 
records, 337-338 
Immersion heaters, for bath centers, 22 Rocky Mountain Spotted Fever vacci- 
Immune serum globulin. See gamma glob- nation : 
u^n- iimxnunizing agent, 334 
Immunzation: policy, 333-334 
administrative reqirements in overseas reactions, 335 
theaters, 337 scarlet fever immunzation, 336 
Army program, 271-272 smallpox vaccination: 
cholera vaccination ; administrative requirements, 283, 351- 
administrative requirements, 315, 347- 352 
348, 356-357 development and adoption, 280-281 
development and adoption, 313-314 directives 282 
directives, 314, 315 effectiveness, 284-285 
effectiveness, 315-317 Immunising agent, 281-282 
immunizing agent, 314-315 ,, , 000 oc. 
® methods, 282-284 
methods, 315 . „„„ 
reactions 317 reactions, 285-286 
diphtheria ’immunization: Problems’ 338-340 
administrative requirements, 331, 333, tetanus immunization : 
administrative requirements, 292, 293, 
directives, 332, 359 353-354 
immunizing agent, 331 development and adoption, 271, 287- 
reactions, 332, 333 290 
gas grangrene immunization, 337 directives, 292, 293, 294 
influenza vaccination : effectiveness, 295-299 
administrative requirements, 325, 360 immunizing agent, 290-292 
development and adoption, 323-324 methods, 292-295 
effectiveness, 325-326 reactions, 294, 299-305 
immunizing agent, 324-325 recording, 293 376 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Immunization—Continued Indiana University clothing studies, 53 
typhoid-paratyphoid vaccination: Induction : 
administrative requirements, 274, 275, examiners, 4, 7 
276, 352-353 limited service personnel, 3 
development and adoption, 272 numbers of, 2 
directive, 273, 274 physical and mental standards, 1, 2 
effectiveness, 276-279 screening, 1, 2, 7, 185 
immunizing agent, 272-273 Industrial Hygiene Section, Office of The 
methods, 273-276 Surgeon General, accident prevention 
reactions, 279-280 program, 267 
typhus vaccination: Industrial medicine, accident prevention, 
administrative requirements, 321, 244 
349-350, 354—355 Infantry, nonbattle injury, 258 
development and adoption, 313-314 Infantry Board, clothing field trials, 44 
directives, 314, 321 Infantry divisions: 
effectiveness, 322-323 battle and nonbattle casualty studies, 
immunizing agent, 319-321 256, 260 
methods, 321-322 3d, tests of socks, 68 
reactions, 323 9th, bathing facilities, 22 
viral hepatitis prophylaxis, 336 35th, bathing facilities, 22 
yellow fever vaccination: Infantry Replacement Training Center, 
administrative requirements, 309, 310, mental hygiene service: 
311, 343-345, 358-359 administration, 188, 190 
development and adoption, 306-307 intake procedure, 195 
directives, 309, 310 lecture program, 213 
effectiveness, 311-312 morale, evaluation, 227, 228 
immunizing agent, 307-309 reclassification board, 198 
methods, 309-311 screening, 191, 193 
reactions, 280, 312-313 Infectious disease, cause for rejection, 5 
Impregnation of clothing: Influenza : 
against chemical agents and fire, 38, 74, Commission on (Army Epidemiological 
75 Board), development of vaccine, 323 
against insects, 38, 42, 57, 58-59 incidence, 325, 326 
effect on uniform, 53, 56 vaccination : 
physiologic effects, 74, 75 administrative requirements, 325, 360 
processes, 38, 76 development and adoption, 323-324 
toxicity, 49, 57, 74, 75 effectiveness, 325-326 
Indalone, for mite control, 56 methods, 325 
India : reactions, 326-327 
cholera, 316, 317 vaccine, 324 
vaccination, 315, 316 Injury. See Accidental injury; Nonbat- 
nutritional status of civilian population, tie injury; Cold injury. 
141 Insect control: 
plague, 318 impregnation of clothing for, 38, 56 
smallpox, 284 personal preventive measures, 13, 15 
local procurement of vaccine, 282 proper wearing of clothing for, 51, 55-61 
strains for cholera vaccine, 314 supplies for, 27 
typhoid fever, 273 Institutes of Health. See National Insti- 
yellow fever vaccination requirements, tutes of Health. 
310, 311 Internal Security Division, Office of The 
See also China-Burma-India theater. Provost Marshal General, 241 INDEX 
377 
Intestinal disease. See Diarrhea and dys- Korea, Japanese B encephalitis vaccina- 
entery. tion requirements, 328 
Intestinal parasites, 5, 27 Kraines, Maj. S. H.: 
Iron: adviser system, 201, 203, 204, 205 
amount in rations, 126 military orientation of psychiatricts, 
Chinese ration, 144 196 
consumed in diet, 85, 103 military value of psychiatrists, 218-219 
deficiency, 166 psychotherapy in training setting, 199 
Italian campaign, rations for, 116 K ration: 
Italy: components, 129 
clothing, 36 misuse of, 114, 132 
cold injury casualties, 65, 79 nutritional adequacy, 17, 133 
diarrhea, 25 palatability, 114, 133, 157 
footgear, 79 recommendations, 123 
laundry service, 25 results of prolonged consumption, 87 
120 
Japan, Japanese B encephalitis vaccina- st00ked ln Cnlted Kingdom 129 
tlon requirements, 93, 328, 329 suitability for hospital use, 94 
Japanese B encephalitis: supplementation, 130, 133 
incidence among troops, 329 e 
vaccination: tly Army Air Forces, 118 
administrative requirements, 328, 329 European theater, 1S1 
development and adoption, 827 in mdla-Burma theater, 145 
directive, 828 ln Tunislan campalgn, U6 
effectiveness, 329 restricted. 91, 129 
methods, 328-329 
reactions, 329-331 Laboratory, 2d Medical, sanitation confer- 
vaccine, 327-328 ence 25 
Jaundice, associated with yellow fever Labor, Department of, cooperation in 
vaccine, 308, 312-313 safety program, 242 
John B. Pierce Laboratory of Hygiene, Labor reserve, utilization, 3 
clothing research, 46, 74 Latin America, nonbattle injury, 247, 248 
Johnson, G. G., “Manpower Selection,” Laundering, loss of impregnates, 57 
Laundry facilities: 
Josiah Macy Foundation, nutrition improvised, 25, 28, 30 
studies, 86 in European theater, 22, 23 
Judge Advocate General, upholds legality in North African theater, 25 
of compulsory immunization in Army, in Southwest Pacific Areas, 27, 28 
340 mobile units, 25 
Jungle clothing, 48, 51, 52 World War I, 41-42 
Jungle ration, 157 Lawes, Brig. Gen. H. J., significance of 
training center psychiatrists, 217 
Keen, W. S., nutritional disease studies, Leblond, C. P., study in thyroid response 
to cold, 32 
Keys, A., studies in nutritional disease, 169 Ledo Road, river bathing, 29 
Kirk, Maj. Gen. N. T., proposal for retrain- Lee, Camp: 
ing soldiers, 208 clothing field tests, 50, 78 
Knipung, E. F., research in repellants, 56 mental hygiene service, 200-201, 202, 
Knox, Fort, energy expenditure study, 87 209, 214 
Koehn, Lt. Col. K. J., nutrition consultant, ration tests, 87, 122 
India-Burma theater, 148 Lemkaf, P. V., mental health services, 220 378 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Leonard Wood, Fort: Malay States, cholera vaccination require- 
personnel consultant service, 178 ments, 315 
psychiatric caseload, 214 Malnutrition : 
Lewis. Fort, mental hygiene service, 189, epidemiology, 160 
199, 214 incidence, 160 
Lichen planus, atypical, 86 Chinese troops, 143 
Life raft ration, 94 United States troops, 113 
Limited service personnel, 2, 3, 4, 6, 8 *n In(Ba-Burma theater, 142 
Lindquist, A. W., research in repellents, in Pacific theaters, lo4 
j-g in prisoners of war, 159 
T . . ., , i , „ research studies, 160 
Liquor, poison, accidental trauma from, , ’ 
263-264 ®ee a*S° deficiency diseases. 
Local boards. See Selective Service local Maneuvers. 
, accidents, 240 
boards. ., ,. _ 
sanitation, 16 
Locke, Lt. Col. R. F., study of Anglo- ,, . . . ... „ ... 
Manila, tetanus among civilian casualties, 
American ration scale, 115 297 
Long, Col. A. P., “The Army Immunization Mannower 
Program*’’ 271-360 pool, 2 3 
Long, Lt. Col. P. H.; requirements, Armed Forces, 3, 7 
“Nutrition in North African Theater,” selection xi 1-11 
113-122 shortage, 3, 6, 7 
study of Anglo-American ration scale, utilization xi 177 219 
March hygiene, 14, 15 
Louse Marine diving, physical standards, 9 
control: Marines, United States, women’s branches 
anti-louse powder, 18, 26-27 formed, 2 
anti-louse suit, 83 Master menu, 90, 91, 97, 104. See also 
DDT used, 58 Menu. 
impregnation of clothing for, 42, 58-59 McCulloch, R. N„ miticide tests, 57 
in Middle East, 26-27 Meade, Fort, food consumption survey, 110 
research, 57-59 Meals, hot, morale factor, 91 
training, 15, 17, 18 Measles prophylaxis, 335 
World War I, 42 Medical Advisory Board, seminar for psy- 
infestation, 13, 24, 322 chiatrists, 181 
World War I, 14 Medical Battalion, 5th, clothing tests, 43 
Low back injury, study, 257, 261, 266 Medical Board, clothing field trials, 44 
_ . , . Medical Corps, nonbattle injury, 258 
MacArthur, Gen. D., jungle clothing com- ,, ,. , , , 
’ ’ ° s Medical Department: 
men S’ ° accidents, reporting system, 239 
Madden, A. H., research in repellents, 56 antMouse measures, World War I, 13 
Madigan, Col. P. S., importance of psy- bathing facilities, inspection, 22 
chiatric screening, 181, 183 Civil War activities, 173 
Maladjustment, symptoms, 223, 224 clothing field tests, 50 
Malaria : dietary, approval for changes, 105 
area control, 27 energy expenditure studies, 87 
hospital admissions, 17 field equipment, tests, 44 
in China-India-Burma theater, 20 food preparation, responsibility, 85 
individual protective measures, 27, 28 impregnation of clothing, 43 
in North Africa, 119 menus, review, 90 
prevention, training, 17, 20, 28 nonbattle trauma, data, 267 INDEX 
379 
Medical Department—Continued Menningeb, Brig. Gen. W. C.; 
personal hygiene activities, 14,16 clinical psychologists, utilization, 211 
prisoner of war food, duties, 108 military psychiatry, scope and effective- 
rations, revision, 87 ness, 210, 211 
rebuilt shoes, complaints investigated, 82 Neuropsychiatric Division, chief, 202 
safety program, 242 personality factor in accidents, 255 
smallpox vaccine, specifications, 281 psychiatric disorders, factors, 206, 207 
venereal disease, program for treatment, retraining psychoneurotic soldiers, 208, 
6 209 
Medical examiners, for selection and in- training center psychiatrists, signifi- 
duction, 4 cance, 217 
Medical Field Service School, clothing de- Mental defects, screening for, xi 
velopment, 44 Mental hygiene: 
Medical Nutrition Laboratory, nutrition adviser system, 201, 204-205 
studies, 86, 94 clinics, 173, 220 
Medical Nutrition, National Research ednsulation services: 
Council Subcommittee on, 86 development, 175, 18&-204 
, ,, ... . . effectiveness, 225-229 
Medical Research Committee, American , ’ 
. .. „ i ... established in replacement training 
Red Cross, impregnation of clothing, v & 
centers, 187, 188 
42 ft' 19 
Medical Research, Committee on. research . , , ’ 
intake procedures, 195 
m' objectives, 188, 215, 216 
aviation clothing, 47 personnel problems, 189, 214, 215 
gas gangrene immunization, 337 , , . , 
__ psychological screening performed, 
nutrition studies, 86 
Medical Sciences, Division ot: referrals, 190, 191, 192, 193, 194,195 
cholera, plague, and typhus vaccinations , ,. . , .„ ,. 
’ J * relationship to reclassification-disposi- 
recommendations, 314 ,. , , - 
tion board, 198 
clothing, research, 46 , o-.oo-.zv 
report on overall program, 213-216 
shoe sterilization, recommendations, 83- ,. 
space problems, 190 
, ,, studies on camptocormia and somnam- 
Medicine, Committee on, nutrition studies, ... , 
bulism made, 201 
, types of personnel referred, 195, 199 
Mediterranean theater: , 
. , See also «nder Preventive psychiatry; 
accident prevention, 264 , . , . . 
specific replacement training 
accidental injuries, 256 centers 
battle casualty rate, 257 definition, 172-178 
burns, hospital admissions, 262-263 development of concept, 171-173, 175- 
clothing, 68-69 
cold injury, 66-67 lecture program, 181, 206-207 
diphtheria, 333 directives, 204 
glamma globulin for viral hepatitis, evaluation, 211-212, 213 
studies, 336 for redployed troops, 213 
hepatitis, 120 See also Preventive psychiatry, 
nonbattle injuries, 246, 248, 257, 267 Mental Hygiene, National Committee for, 
personal hygiene, 24-27 171, 173, 211 
plastic insoles, tests, 78 Mental Hygiene Branch, Office of The Sur- 
shoepacs, use, 67-68 geon General, established, 202 
typhus fever, 322 Mental standards for induction, 2 380 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Menu; Mississippi Ordnance Plant, Flora, Miss., 
expeditionary, {>3, 143, 145, 146, 147, 148, mental hygiene report, 214 
151 Mitchell, S. W., specialist in neurology, 
for patients with hepatitis, 121 173 
hospital, 89, 94 Mite control, repellents and impregnates, 
master, 90, 91, 97, 104 50> 73 
monthly, 89 Mobilization Regulations, MR 1-9, 3, 4, 5, 9 
plan, 89, 90, 121, 122 Monmouth, Fort: 
prisoner of war, 106, 108-109 energy expenditure studies, 87 
use „ _ , „„ mental hygiene services, 179, 180, 183 
in India-Burma theater, 148 
• » t ,, . „ . ,M __ Morale: 
in North Africa, 121, 122 . , , 
in United Kingdom, 124, 125, 127 mdeX t0’ 228 
Mess operation and practices, 103, 122, 135 psychoneurotic traits as factor, 7 
Mess personnel, personal hygiene regula- value of hot meal, 92 
tions, 15 Morehouse, C. R., neurologic studies, 173 
Metabolism, relation to wound healing, 86 Mosquito control, individual protective 
Methyl alcohol, nonbattle injury, 252, 254, measures, 15, 27 
264 Mueller, J. H., research in tetanus toxoid, 
Methyl bromide: 291, 298 
for louse control, 42, 57, 81 Multivitamins, as ration supplement, 116, 
Metropolitan Life Insurance Co., accident 439 443 
data, 236 Murlin, J. R., nutrition survey, 97, 104 
Mexican War, nonbattle trauma, 233 
,, . , „ MYL powder for louse control, 42, 58 
Meiyer, A., value of preventive psychiatry, 
171 National Association for the Protection of 
Middle East theater: the Insane and the Prevention of In- 
bathing facilities, 25 sanity, 173 
miliaria, 62 National Bureau for Industrial Protection, 
nonbattle injury, 247, 248 cooperation in safety program, 242 
personal hygiene, 25-27 Natlonal 
Bureau of Standards, research in 
typhus, 322 clothing 47 
Mikesell, Lt. Col. H., surgeon, 37th Divi- 
„ National Committee for Mental Hygiene, 
S1°n’ 155 171, 173, 211 
Miliaria, relation to clothing, 62 . ’ ’ . „ 
„ National Conservation Bureau, coopera- 
Mihtary Police, Corps of: ... 
, , , . . „„„ tion in Army safety program, 242 
low back injury, 261 . 
„ , „ „ tJ „„„ fsational Institutes of Health: 
survey of dietary of small units, 136 
eholpra vaocinp • 
Military psychiatry. See Preventive psy- 
chiatry requirements, 314 
Miller, O. N„ nutrition study, 162 stralns studled’ 814 
Miller, P. A., research, in tetanus toxoid, clothing, research, 47, 74 
294 Japanese B encephalitis vaccine, require- 
Mineral(s) : ments, 328 
in rations 85 89 Rocky Mountain spotted fever vaccine 
requirements, 89 supply, 334 
Mines, Bureau of, cooperation in safety smallpox vaccine requirements, 281 
program, 242 tetanus toxoid: 
Minnesota, University of, experiments in requirements, 291 
vitamin requirements, 105 study, 293 INDEX 
381 
National Institutes of Health—Continued Neuropsychiatry Division—Continued 
typhus vaccine : evaluation of program, 212 
new preparation method, 320, 321 meeting of replacement training center 
requirements, 319 psychiatrists, 216 
studies, 320 mental hygiene lecture program, 202 
National Research Council; organization, 171, 174, 181, 202 
cholera vaccination, recommendations, orientation for replacement center psy- 
314 chiatrists, 188 
clothing, research and investigations, 35, preventive psychiatry, development of 
45, 46, 47, 65, 74 concept, 171, 174, 207 
dietary allowance recommendations, 86 professional supervision of mental hy- 
nutrients in diet, guide for, 104 giene consultation services, 180, 215 
plague vaccination, recommendations, social work personnel approved. 211 
314 Neurotic patients, rehabilitation, 208 
screening standards, recommendations, 5 Neurotropic Virus Commission, study of 
tetanus toxoid, recommendation for Japanese R encephalitis vaccine, 329 
adoption, 288 Newburgh, L. H.; 
typhus vaccination, recommendations, clothing studies, 47, 48, 65 
314, 320, 321 studies in physiologic adaptation to heat 
National safety congresses, Army partic- and cold, 35 
ipation, 243 New Caledonia, plague, 318 
National Safety Council, cooperation in Newfoundland Base Command, investiga- 
Army safety program, 242, 243 tion of tetanus toxoid reactions, 301 
Naval Medical Research Institute, nutri- New Guinea; 
tion studies, 87 combat feeding, 92 
Navy, United States: impregnation of clothing, tests, 57 
clothing, research, 47 laundry facilities, 28 
energy expenditure studies, 87 personal hygiene, 27 
immunization, cooperation in program rations, 157 
for Armed Forces, 271 shorts, use of, prohibited, 61 
physical standards for enlistment, 3 Newport News Port of Embarkation, louse 
ration, emergency, 87, 95 infestation, World War I, 14 
ration, money value, 88 Niacin: 
registrants allotted, 3 amount— 
safety program, 242 consumed in diet, 103 
tetanus immunization, 288 *n rations, 126 
tetanus, report on cases among prisop- Chinese rations, 144 
ers of war 296 deficiency in troops, 161, 162, 165 
typhoid-paratyphoid vaccination, 273 Night blindness, symptom of nutritional 
women’s branches formed, 2 deficiency, 143 
Neurology, specialty, 173 Nonbattle casualty: 
Neuropsychiatric casualties. See Psychi- definition, 236 
atric disorders. rates, comparison with battle, 256-257, 
Neuropsychiatric Screening Adjunct, 7 260 
Neuropsychiatrists, at replacement train- Nonbattle injury: 
ing centers. See under Preventive by branch of service, 258-259 
psychiatry. causes and causative agents, 250, 251, 
Neuropsychiatry, 171, 174. See also Pre- 252, 253 
ventive psychiatry. classification, 236-237 
Neuropsychiatry Division, Office of The deaths from, 247-248, 249, 251, 252, 2a3 
Surgeon General: rates, 235, 244-245 382 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Nonbattle injury—Continued North Camp Hood, mental hygiene service ; 
definition, 236 adviser system, 201, 204, 205 
directive, 236 attitude conditioning program, 203 
disposition of patients, 240, 261, 262 caseload, 219 
hospital admissions, 242, 244, 246, 248, intake procedures, 196 
250 psychotherapy, 199 
ih— Nurses, nonbattle injury, 259 
China-Burma-India theater, 247, 248 Nurses’ uniforms, 41, 68 
European theater, 245, 247, 248, 249 Nutrients, loss in food preparation, 85, 149 
Latin America, 247, 248 Nutrition : 
Mediterranean theater, 267 deficiencies in troops, 117, 118, 142, 164- 
Middle East theater, 247, 248 167 
North America, 247, 248 Chinese troops, 141, 143 
Pacific Ocean ax*ea, 247, 248 in China-Burma-India theater, 141-153 
South Pacific area, 247, 249, 250 in European theater, 122-140 
Southwest Pacific area, 246. 247, 248, in North African theater, 113-122 
267 in overseas theaters, 112-158 
manpower loss from, 246, 248-249 in Pacific theaters, 153-158 
peacetime problem, 233-235 in Persian Gulf Command, 140-141 
rates, 233, 235, 256, 260, 267 in World War I, 85 
seasonal variation, 255 level of, 116 
wartime problem, 233 rehabilitation after inadequate diet, 117 
World War I, 233 rehabilitation of recovered Allied mili- 
See also Accidental injury. tary personnel, 123, 137 
Noneffective, from disease and injury, relation to prevention and cure of dis- 
248-249 ease, 86 
Normandy invasion, briefing on typhus, 18 requirements of troops, 86, 87, 89, 90, 93, 
North African Disciplinary Training Cen- 101-104, 123 
ter, nutritional study, 119 standards, policies for prisoners of war, 
North African theater : 108 
accidental deaths, 253 status of troops, xi, xii, 87, 91, 93, 96,155, 
accidental eye injuries, 261-262 157 
accident prevention program, 266 surveys, 87, 91, 95-105 
bathing facilities, 25 in European theater, 136 
burns, 262-263 prisoners of war, 107-108, 140 
DDT impregnates, field test, 58 in India-Burma theater, 145, 150, 151 
diphtheria immunization, 333 in Pacific theaters, 157-158, 161-163, 
diphtheria, study of immunity to, 331 167 
hepatitis, 120 of prisoners of war, 108, 137 
laundry service, 25 value of rations, 126, 157 
malaria, 119 Chinese ration, 144 
MYL powder, for louse control, 58 Nutritional deficiency disease; 
nurses’ uniforms, shortage, 68-69 in recovered prisoners, 167-169 
nutrition, 113-122 minor disturbances in troops, 114, 117, 
personal hygiene, 24-27 118, 160-164 
rations, 113-122 research, 169-170 
supply lines, 113 See also Malnutrition, 
tetanus, 295 Nutrition and Home Economics, United 
training in anti-louse measures, 18 States Department of Agriculture, 
typhus, 322 Bureau of, method of determining 
North America, nonbattle injury, 247, 248 nutritive values, 101 INDEX 
383 
Nutrition Division, Office of The Surgeon Overshoes, 40, 70 
General, appraisal of dietary, 95, 105, Oxygen consumption studies, 86 
108 
Nutrition Foundation, studies in flight Pacific theaters: 
crew diets, 93 jungle clothing tests, 50 
Nutrition Laboratory, Pentagon Restau- nonbattle injury, 247, 248 
rant Association, studies in nutrient nutrition, 87, 104, 153-158, 161-162, 166 
cooking loss, 86 recovered prisoners, 167, 168, 169 
plague, requirement for vaccination, 318 
Oakley, C. L., study of reactions to te- prickly heat, prevalence, 62 
tanus toxoid, 301 tetanus in civilian populations and Jap- 
Occupational Health Division, Office of anese troops, 296 
The Surgeon General; See a^so Southwest Pacific area, 
accident prevention activities, 243-244 Panama Canal Department: 
clothing, research, 49 jungle clothing, field tests, 45, 50, 51 
Office of Scientific Research and Develop- yellow fever vaccination requirements, 
ment: 
clothing research 47 52 Parachute duty, physical standards for, 9 
gas gangrene immunization, studies, 337 Parachute ™ 
nutrition studies, 85, 86, 96 Parachute ration, 94 
Office of The Surgeon General. See- Sur- Paratyphoid fever, incidence, 276, 277, 278 
geon General, Office of The. 8ee aUo Typhoid-Paratyphoid fever. 
, , , . Parish, H. J., study of reactions to tetanus 
Officer candidate schools, course in per- 
... toxoid, 301 
sonal hygiene, 16 „ , . ., _ 
„ , , , Parkas, for protection against cold, 39 
O Flaherty, F., method of rebuilt shoe „ „ . , 
„ Pellagra, in recovered prisoners, 154, 165, 
sterilization, 82 
loo 
Okinawa, Japanese B encephalitis vaccine Pennell> Maj Gen R H > signiflcanCe of 
used in, 327, 328, 329, 330 training center psychiatrists, 217-218 
Olinick, Maj. S. L., report on indirect Pentagon Restaurant Association Nutri- 
group therapy, 209-210 tion laboratory, nutrient cooking loss 
Oral hygiene, rules for, 16 studies, 86 
Oran, laundry service in, 25 Peptones, in tetanus toxoid, 291-292, 303, 
Ordnance Department: 304, 305 
low back injury, 261 Perkins, M. E., “Preventive Psychiatry,” 
nonbattle injury, 258 171-232 
safety program, 241, 242 Pershing, Gen. J. J., clothing recommen- 
Ordnance Replacement Training Center: dations, 39, 40 
consultation service, 216 Pershing shoe, 40 
mental conditioning program, 181, 202, Persian Gulf Command: 
203, 204 accidental trauma, 257 
retraining program, 209 accident prevention program, 266 
Orlando laboratory, research : diphtheria immunization, 333 
DDT, 58 nutrition, 140-141 
mite control, 56 smallpox, 284 
protective clothing, 51 vitamin supplementation of rations, 140 
OSRD. See Office of Scientific Research Personal hygiene: 
and Development. definition, xi, 13 
Osteomalacia, symptom of nutritional de- directives, 10, 14 
ficiency, 143 in China-Burma-India theater, 28-30 
Overcoat, 39 in combat and field conditions, 16, 25, 28 384 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Personal hygiene—Continued Plastic insoles, 78 
in European theater, 20-24 Plauche, Camp, 214 
in Mediterranean theater, 24, 25, 26 Porter, Col. W. C., practical psychiatry, 
in Middle East theater, 25, 26, 27 182 
in North African theater, 24, 25 Post exchange, supplies for personal hy- 
in Southwest Pacific Area, 27-28 giene, 24 
minimum standards of proficiency, 17 Posttransfusion, hepatitis, 336 
policy, 14-15 Postvaccinal encephalitis, 286-287 
supplies, 24 Postvaccinal jaundice, 312-313 
training, 15-20, 26 Postvaccinal tetanus, 287 
Personality factor in accidents, 253 Preventive Medicine Service, Office of The 
Philippine Islands: Surgeon General: 
bathing facilities, 28 accident prevention program, 243-244, 
tetanus toxoid requirements, 289 267 
training program in disease prevention, biologicals, responsibility, 339 
27 clothing studies, 45 
Phosphorus, consumed in diet, 103 Health Education Unit established, 17 
Physical aptitude, for aircrew training, 9 louse control, research, 58 
Physical defects, disqualifying for mili- physical requirements, research, 253 
tary service, xi, 4, 5, 6 research laboratory initiated, 48 
See also Physical standards. safety program, 242, 243 
Physical examination: sterilization of shoes before reissue 
induction, 2, 253 recommendation, 82 
separation, 5 Preventive psychiatry: 
Physical inspection of troops, 16, 27 adviser system, 201, 204-205 
Physical Profile Serial System, 8-9 classification phase, 176-186 
Physical screening. See Screening. consultation service(s) : 
Physical standards— Aberdeen Proving Ground : 
for induction, 1, 2, 3, 4, 5, 9 consultation service, 216 
for special categories, 9 mental conditioning program, 181, 
Physical Standards Division, Office of The 202, 203, 204 
Surgeon General, 1 retraining program, 209 
Physiologic studies, relation to— Camp Abbot: 
clothing requirements, 31-35, 42, 45-50 altitude conditioning program, 203 
diet requirements, 105 consultation service, 189, 199-200 
Pierce Laboratory of Hygiene, New Haven, Camp Blanding, 213, 214, 215 
Conn., clothing research, 46 Camp Callan, 180,188, 203 
Plague— Camp Claiborne, 226-227 
control measures, 319 Camp Croft; 
incidence, 318 intake procedure, 195 
vaccination: mental screening, 191, 192, 193 
administrative requirements, 318, 357 outpatient psychiatry, 214 
development and adoption, 313-314 reclassification board, 198 
directives, 314, 318 Camp Crowder, 194-195 
effectiveness, 318-319 Camp Lee, 200-201, 202, 209, 214 
methods, 318 Camp Roberts: 
reactions, 319 administration, 188, 190 
vaccine, 317-318 caseload, 214 
r,. . „ , ,. T,. . . intake procedure, 195 
n ro ec i\e ivision, Office of Under personnel adjustment lectures. 212- 
hecretary of War, accident prevention 213 
program, 241 therapy, 199 INDEX 
385 
Preventive psychiatry—Continued Prisoners of war—Continued 
consultation service(s)—Continued Rocky Mountain spotted fever, vaccina- 
Oamp Wheeler, 198 tion, 334 
Camp Welters : tetanus, 297 
administration, 188, 790 Professional Service, Office of The Surgeon 
intake procedure, 195 General, interest in cold injury, 65 
lecture program, 213 Protective clothing. See under Clothing, 
morale, evaluation, 227-228 Protein : 
reclassification board, 198 amount 
screening 191, 193 consumed, 103 
Fort Belvoir, 180, 188, 204, 209-210 in hepatitis diet, 120-121 
Fort Bragg, 192 in rations, 126 
f ort f rancis E. Warren, 226 deficiency, in recovered prisoners, 168 
Fort Leonard Wood. metabolism, relations to wound healing, 
personnel consultant service, 178 gg 
psychiatric caseload, 214 requirements, 89, 93 
Fort Lewis, 189, 199, -14 Provost Marshal General, Office of the; 
functions. accident information collection, 243 
diagnosis in terms of military serv- .... , ,. 
Geneva Convention, interpretation, 106 
ice 196—198 
, prisoner of war feeding, conference, 107 
evaluation of cases, 190 . . „... „ .0 
. „ , . ’ safety program, 241, 242, 243 
followup of patients, 190 _ , . . . 
„ Psychiatric consultation, 180. See also 
ort amp oo . Preventive psychiatry, consultation 
adviser system, 201, 204, 20o 
services 
attitude conditioning program, 203 , . , , ' 
, , „ Psychiatric disorders: 
caseload, 219 
.... , causes, 206 
intake procedures, 196 . ’ 
. .. factors in military service, 8, 223, 224 
psychotherapy, 199 diagnosis 174 223 224 
referrals, 180, 190, 191, 193-194, 195 diagnosis, 174, 223, 224 
, , .. disposition of patients, 1, 174 
reports and recommendations, 190 , . ’ 
, „T hospital admissions, 7 
development in World War II, 175 . ., 001 
1 incidence, 221 
directi'es, 186 preventive measures, 219, 222-224 
historical background, 171-173 rehabilitation of patients, 211 
in training centers, 175-229 symptoms, 223, 224 
mental hygience phase, 204-219 treatment, 224 
needs of group, 219-220 World War I, 1 
neuropsychiatrists, functions, 182, 183- Psychiatric screening— 
184, 189 at induction stations, 1, 2, 7, 8, 187 
psychiatric screening, 186-204 at training centers, 174, 191 
psychiatrists, function, 219 in World War I, 1 
rehabilitation of psychiatric patients, Psychiatric Social Work, War Office of, 211 
224 Psychiatric social workers, utilization of, 
statistical approach, 228 175, 180, 195, 210, 211 
treatment phase, 198 Psychiatrists, utilization 
Prisoners of war : induction centers, 7 
dietary and rations, 105-109, 119, replacement training centers, 171, 173, 
139-140 i75> 181> 186> 187> 188> 189 
directives, 106, 107, 108 World War I, 174 
in Zone of Interior, 105-109 Psychiatry, military. See Preventive psy- 
nutritional disease, 159 ehiatry. 386 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Psychiatry, preventive. See Preventive Quartermaster General—Continued 
psychiatry. menus planned: 
Psychological screening, 189, 192 hospital, 96 
Psychologists, clinical: master, 90, 97 
need for, 189, 211 prisoner of war, 107 
utilization, 175, 176, 177, 211 nutrition surveys, 104 
Psychometric evaluation, 192 prisoner of war— 
Psychoneurotic disorders: f°°d conference, 107 
directives, 7 nutrition survey, 109 
factors producing, 207 research in— 
rejection from military service, 7 climatic conditions, 46 
retraining of patients, 208-210 clothing, 40, 45, 47, 81 
Psychosomatic medicine, 172 laundry methods, 80 
Psychotherapy, in training setting, 199 rations, 95 
Public Health Service, U. S. See United subsistence, procurement, 91, 95, 102,121 
States Public Health Service. tests in 
Puerto Rico, yellow fever vaccination re- combat clothing, 53 
quirements, 306 flameproof treatment for clothing, 75 
PULHEMS, Canadian system of physical Quartermaster Laundry Company, 487th, 
classification, 8 
PULHES, system of physical classifies- Quartermaster Replacement Training 
tion 8 9 Center, mental hygiene service, 200- 
201, 202, 209, 214 
Quartermaster Board : Quartermaster School and Depot, clothing 
clothing tests, 50, 53, 78 de' el°P 35, 44 
energy expenditure studies, 87 Quartermaster Subsistence Research Lab- 
Quartermaster Corps: oratory, 86 
clothing; Quartermaster Technical Committee, de- 
conference 71 velopment of clothing, 35 
development, 35, 44 Subcommittee on Combat Winter Cloth- 
surveys of use, 50, 71 71 
food procurement, 20, 121 Queensland, University of, skin physiology 
fumigation and bath companies, 22, 58 research, 62 
laundry service, 23, 28, 30, 80 Quotas, for enlistments and induction, 3, 
low back injury, 261 4, 6 
nonbattle injury, 258 
shoepac recommendations, 66 Ration(s) : 
shoes, investigation of complaints, 82 ®ee ration. 
shower points operation, 22 acceptability, 91, 113, 138 
subsistence, issue, 20, 87 accessory kits, 24 
Quartermaster fumigation and bath com- adequacy, 88-89, 117 
panics, allocation, 22 aid station pack, 94 
Quartermaster General, Office of The: allowances, 133 
clothing, development, 35. 49, 50, 60, 63, amOUnt consamed’ 87’ 97~10^ 
augmentation, 112, 133, 134—137 
combat boot, changes, 71 ®ee ® ration, 
dietary standards, 86 battle, 91 
food service program, 92 C- See C ration, 
footgear development, 62, 63 caloric content, 89, 127, 145 
Geneva Convention, interpretation, 106 caloric requirements, 91 INDEX 
387 
Ration (s) —Continued Ration (s) —Continued 
canned, 122 use overseas : 
captured, 116 China-Burma-India theater, 141-153 
characteristics needed, 87 European theater, 122-140 
Chinese troop, 144 North African theater, 113-122 
combat, emergency, 96, 129-131 Pacific theater, 153-158 
complaints of troops, 114, 145 Persian Gulf Command, 140-141 
components, 88, 89, 91, 94, 97, 135, 137- Vitamin content, 89, 95 
138 World War I, 87-88 
D. See D ration. Ray, I., definition of mental hygiene, 172 
deficiencies in, 114 Reclassification board, 198 
dehydrated, 94, 138 Recovered Allied military personnel, nutri- 
directives, 89, 101, 105, 127 tional status, 137) i67-169 
emergency, 94-95, 133 Registrants: 
evaluation, 101 classification, 2, 3 
excess permitted, 118 number 2 
field, 89, 90, 140 quotas, 3 
field trials, 123, 129, 161 rejected for physical reasons, 6 
Camp Carson, 87, 104 Rehabilitation feeding, 92 
Camp Lee, 87, 122 Rejection for military service, 4, 5, 7 
flve-in-one. See Five-in-one ration. T x „ 
, . , , __ _ . Remedial defects, deferment, 6 
flight lunch, 92, 94 
for casualties, 130-131 Repellents, for insect control, 20, 27, 56 
for training camps 87-93 Replacement training centers, consultation 
garrison 87-93 97 service at. See under Preventive psy- 
hospital. See under Hospital. chiatry. 
hospital supplement, 94, 131, 151 Research in 
increase in allowances, 148 clothing, 45, 47, 50 
issue 89-90 emergency rations, 95 
jungle ration, 157 energy expenditure, 86-87 
K. See K ration. high altitude feeding, 92-93 
life raft 94 malnutrition, 160 
monetary value, 87, 88 nutrition, 85-87 
number drawn, 96, 103 typhoid-paratyphoid vaccination, 272 
nutritive value 87 117 Respiratory infection, individual preven- 
packaged, 91, 94, 112-113 tive measures, 18 
parachute, 94 Riboflavin. 
amount— 
prisoner of war, 119, 139-140 , 
consumed, 103 
reduction in allowances, 116, 118, 133, in rati 126 151 157 
134-137, 139, 150-151 Chinese ration> 144 
scale, 127 deficiency in troops, 161,162,163,165 
supplements: 757; 153 
D chocolate bar, 94, 131, 155 deficiency in troops, 161, 162, 163, 165 
vitamins, 136-137, 143 Riley, Fort, clothing field test, 43 
India-Burma theater, 145, 151-152 Roberts, Camp, mental hygiene service: 
Persian Gulf Command, 140 administration, 188, 190 
supply, 112-113, 129, 133, 136, 141-153 caseload, 214 
ten-in-one. See Ten-in-one ration. intake procedure, 195 
twelve-in-one, 129 personnel adjustment lectures, 212-213 
types issued, 132 therapy, 199 388 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Robinson, S.: Salmonella typhosa, in vaccine, 272, 273 
clothing research, 47, 54 Sandler, Lt. Col. S. A., aims of psychiatric 
skin infections, report, 61, 62 treatment program, 200-201 
sweating mechanism, studies, 34 Sanitary Corps, utilized in accident preven- 
Boehester Desert Laboratory, clothing re- tion program, 246, 264 
search, 47 Sanitation Division, Office of The Surgeon 
Rockefeller Foundation, 173 General, studies in— 
psychiatric problems, studies, 173 climatic conditions, 46 
yellow fever vaccine production, 306, 307, clothing, 46, 46 
308, 309 cold weather clothing, 64 
Rocky Mountain Laboratory; Saran insoles, 78 
Rocky Mountain spotted fever vaccine Scabies, prevention, 16 
production, 307 Scarlet fever immunization, 336 
yellow fever vaccine production, 307, 30S Schachner, H. E., study in thyroid re- 
Rocky Mountain spotted fever : sp0nse to TOld 32 
incidence, 334 Schbchter, M. S., nutrition study, 162 
preventive measures, 334 gchick for diphtheria, 331, 332, 333 
vaccination; „ , . . . . 
is ooo nos Schistosomiasis: 
policy, 333-334 . . .. 
.. cause for rejection, 5 
reactions, 335 ... „ 
. . incidence, 27 
vaccine, 334 ,. ... ~_ 
_ . prevention, training, 17, 27 
Roentgenogram of chest, for tuberculosis , ... ’ 
protective clothing, 59 
screening, 5 _ * t 
Roer campaign, bathing facilities, 22-23 chreiber, . ... 
Ross, Mrs. E. H., recruiting for psychi- menta yg ene program, 
atric social workers, 211 mental hygiene unit’ report’ 188 
Royal Air Force, clothing research, 47 Schwartz, E. R., clothing studies, 47 
Royal Indian Army Service Corps, procure- Scientific Research and Development, 
ment of food for— Office of: 
Chinese troops, 149 clothing, research, 47, 52 
United States troops, 145 Sas gangrene immunization, studies, 337 
Bush, A., nutrition study, 162 nutrition studies, 85, 86, 96 
Russia, Japanese B encephalitis, vaccina- Screening: 
tion development, 327 against tuberculosis. 1. 5 
Rutgers 612, repellent for mite control, 56 against venereal disease, 6 
Ryukyu Islands, Japanese B encephalitis induction, 1, 2, 7, 185-186 
vaccination requirements, 329 mental, 1, 7 
objectives, 1, 2 
Safety— physical, 1, 2 
program, 241-243 psychiatric, 1, 2, 7, 8, 174, 181, 191 
publications, 242 replacement training centers, 184, 185, 
training, 243 191, 192, 193 
Safety Council, War Department, 242, 243 World War I, 174 
Saipan : Scrub typhus, prevention : 
rations for, 155 area control, 27 
tetanus among civilian casualties, 297 impregnation of clothing, 57 
Salmon, Maj. T. W.: training, 17 
preventive psychiatry, value, 171 Scurvy, hospital admissions, 160 
psychiatric problems, report, 173-174 Second Air Force, nutrition study, 92-93 
Salmonella paratyphi, in vaccine, 273 Second Army, sanitation during maneu- 
Salmonella schottmvelleri, in vaccine, 273 vers, 16 INDEX 
389 
Secretary of War, advisory board on fire Simmons, Brig Gen. J. S., immunization 
and accident prevention, 243 program, 271, 306 
Seidenfeld, Lt. Col. M., selection of clinical Siple, P. A., study of clothing in relation 
psychologists, 211 to climate, 46 
Selectees, screening for physical and men- Sixth Army, personal hygiene, 28 
tal defects, xi, 1, 2, 7 Skin— 
Selection of manpower, xi, 1-11 disease ; 
Selective Service System : prevention, 16 
local boards, 2, 4, 6 relation to clothing, 61-62 
policies and procedures, 2, 3 irritation, from fire retardant, 75 
regulations, 4 lesions, associated with laundry meth- 
seminar for psychiatrists, 181 0(^s’ 
Selective Training and Service Act, 3, 4 Smallpox. 
Selye, H., study in body reaction to stress, incidence, 283, 284 
22 revaccination, 284, 285 
Serum protein, deficiencies noted, 163 vaccination. 
„ . „ .... administrative requirements, 283, 351- 
Service Command, Fifth, nutrition studies, 
86. See also Corps areas. , , , , .. 
development and adoption, 280-281 
Service Forces. See Army Service Forces. directives 282 
Services of Supply: effectiveness, 284-285 
mental hygiene services, 183 immune reactions, 283, 284 
safety program, 241 methods, 282-283 
See also Army Service Forces. reactions 285-286 
Seventh Army, clothing report, 69-70 postvaccinal encephalitis, 286-287 
Shepherd, L. B., report on combat boot, 71 vaccinia, 283, 284 
Shoe(s) : vaccinoid, 283, 284 
design, 49 vaccine: 
dubbin, 76 local procurement, 282 
fitting, 40, 49 not administered with yellow fever 
for arctic wear, 38 vaccine, 309 
for aviators, 47 shipment, storage, and care, 281-282 
reissue, 81-82 specifications, 281 
safety program in industrial plants, 49 specificity of action, 282 
sizing, 79-80 Smoky Hill Airbase, flight crew diet 
sterilization before reissue, 81-82 studies, 92 
tariffs, 40, 70 Social workers, in mental hygiene service, 
waterproofing, 40 173, 189, 211 
Shoepac: Socks: 
development, 65, 66, 67, 68, 70 for cold weather operations, 38, 40-41, 
relation to cold injury : 66, 67, 69, 70, 72, 73 
Attu, 66-67 sizing, 80 
European theater, 69, 70, 71, 72 tests, 68 
Mediterranean theater, 67, 68 World War I, 40-41 
Shorts, 60, 61 Solar radiation, protective clothing, 35 
Sicilian campaign ; South America : 
laundry facilities, 25 yellow fever, 311 
rations for, 115 yellow fever vaccination requirements, 
Signal Corps, Army ; 306 
energy expenditure tests, 87 Southard, E. E., value of preventive 
nonbattle injury, 259 psychiatry, 171 390 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
South Pacific Area, accidental deaths and Surgeon General, Office of The—Continued 
nonbattle injury, 247, 249, 253 cholera vaccination, recommendation, 
See also Pacific theaters; Southwest 314 
Pacific Area. dietary standards, opinion, 86 
Southwest Pacific Area: food preparation, responsibility, 85 
accidental deaths, 251, 253 Geneva Convention, interpretation, 106 
accidental injury, 256, 258-259 immunization program, 271 
accident prevention program, 264 limited and general service classiflca- 
atypical lichen planus, 86 tions, summary of changes, 197 
bathing and laundry facilities, 27 mental hygiene program, 202 
disease control measures, 27 morbidity reports program, 242 
food in combat, 92 neuropsychiatrists, assignment recom- 
fungus infections, 28 mendations, 183 
jungle clothing, tests, 51, 54 nonbattle injury report, 238 
mosquito control, 27 nutritional status of troops, responsibil- 
nonbattle injury, 246, 248, 249, 267 ity, 96 
personal hygiene, 27-28 physical standards, responsibility, 1 
skin diseases, relation to clothing, 61-62 plague vaccination, recommendation, 314 
training in disease prevention, 17, 27 prisoner of war food, conferences, 107 
Spanish-American War : rations, recommendations, 89, 109 
dietary, 86 research and tests in— 
nonbattle trauma, 233 clothing, 35, 44, 45, 47, 65, 81-82 
typhoid fever, 276 emergency rations, 95 
Standards, National Bureau of, research in gas mask for hospital patients, 76 
clothing, 47 heat regulation, 51 
Stannard, Capt. P. F., study of Anglo- mite repellents, 56 
American ration scale, 115 nutrition and nutritional disease, 86, 
State, Department of, negotiations with 109-110, 169 
India re yellow fever vaccination re- tetanus toxoid reaction, 301 
quirements, 310 typhus control, 57 
Station hospital: retraining of psychoneurotic soldiers, 
54th, admissions for burns, 262 meeting, 209 
73d, admissions for nonbattle casualties, safety program, 83, 242, 243 
262 sterilization of shoes, opinion, 81-82 
Stone, Col. W. C., Chief Sanitation Divi- tetanus, reports, 296 
sion, Office of The Surgeon General, 45 tetanus toxoid, recommendation, 288 
Strong, R. P., studies in cholera immuni- typhoid-paratyphoid vaccine, recom- 
zation, 316 mendation, 273 
Submarine Center (Conn.), energy expend- typhus vaccination, recommendation, 
iture studies, 87 314 
Subsistence, supply problems, 141, 148-149 yellow fever vaccination, recommenda- 
See also Food ; Ration (s). tion, 306 
Subsistence Division, Office of The Quar- yellow fever vaccine, lot discontinued, 
termaster General, food procurement, 312 
95, 102 Surgeon General, United States Navy, 
Subsistence Research Laboratory, Quarter- studies in aviation clothing, 47 
master, research, 86 Sweetser, W., meaning of mental hygiene, 
Surgeon General, Office of The: 171, 172 
accidental injury, report, 239 SWPA. See Southwest Pacific Area, 
accident prevention, 243-244, 264, 267 Syphilis, affecting induction, 6 INDEX 
391 
Table waste, amount, 97 Textile, research, 65 
Talbott, Ool. J. H., medical research in Textile Foundation, clothing studies, 47 
clothing, 46 Textile Research Institute, clothing re- 
Tank Destroyer Replacement Training search, 47 
Center, mental hygiene service; Thachee, J., accidental injury report, 237- 
adviser system, 201, 204, 205 238 
attitude conditioning program, 203 Thiamine; 
caseload, 219 amount- 
intake procedures, 196 consumed in diet, 103, 157 
psychotherapy, 199 in rations, 126, 133, 151 
Ten-in-one ration; Chinese ration, 144 
acceptability, 129 deficiency— 
availability, 129 -n dietary, 142, 150, 158 
caloric value, 117, 130 jn recovere<j prisoners, 167, 168, 169 
deficiencies, 133 in tr00pgj 150> 161) 163) 164 
hospital diets from, 94 requirement, 104 
misuse, 132 Thiamine hydrochloride, therapy, 150 
recommendations, 123 , . 
„ , , . Third Army 
results of prolonged consumption, 87, ., ,. nt.n 
accident prevention program, 256 
_ „ capture of enemy beef, 131 
use in Europe, 131 , ,, . , _n 
clothing, report on, 72 
use planned, 91 ,, . . . , . 
_ . , .. Toilet facilities, in North Africa and Italy, 
Tests, as classification aids, 179 
Tetanus: m . . 
antitoxin, 288, 293 raining- 
. aids, for personal hygiene, 15, 17 
immunization: 
directives, 16 
administrative requirements, 292, 293, „ ’ , , . „ . , . . 
Q_ „ for men unable to assimilate basic train- 
oOo—o04 , 
antitoxins produced, 298 . mg’ . , , . , 
, , . , . .. _0_ for personnel for mental hygiene serv- 
development and adoption, 271, 287- . „„„ 
290 lces’ 189 
directives, 292, 293, 294 disMSe ,^eTentl0n- ,18’27, „ „„ 
effectiveness, 295-299 m personal 14-1^ 
methods. 292-295 m pr°per o! 69 
,. own o/v- m safety, 243 
reactions, 299-30o , 
recording 293 337 Training center psychiatrists. See under 
. ,. . ’ , „ ... Preventive psychiatry, 
studies in degree of protection, 297- 
2gg Training Division, Office of The Surgeon 
incidence, 295, 296, 297 General. 
postvaccinal, 287 clothing, tests, 43, 44 
prophylactic antitoxin, 298 training aids provided, 17 
toxoid • Trains, food on, 92 
administration, 287, 292, 293, 294 Transportation, Chief of, responsibility in 
agent chosen, 290-292 safety program, 242 
booster dose, 298, 299 Transportation Corps, survey of dietary of 
for emergency protection, 293 small units, 136 
hydrolysate media, 291, 298, 303, 304, Treesdale Laboratory, manufacture of 
305 flameproof treatment, 75 
peptones, 291-292, 301, 302, 303, 304, Trenchfoot: 
305 classified as nonbattle injury, 236 
procurement authority, 289 disability, 13 392 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Trenchfoot—Continued Typhoid-paratyphoid—Continued 
incidence, 13, 67, 68 specificity, 273 
World War I, 42 strains used, 273 
prevention, 17, 18, 20, 65, 71, 72-73, 79 Typhus fever, epidemic; 
See also Cold injury. incidence, 322 
Trichophytosis, relation to footgear, 62, 82 prevention and control, 17, 27, 57, 322 
Troopships, feeding on, 92 vaccination : 
Tropical Diseases, National Research administrative requirements, 321, 
Council Committee on ; 349-350, 354-355 
typhus vaccine, conference, 320 development and adoption, 313-314 
yellow fever immunization recommen- effectiveness, 322-323 
dation, 306 methods, 321-322 
Trudeau, Brig. Gen. A., significance of reactions, 323 
training center psychiatrists, 217 vaccine, 319-321 
Trypanosomiasis, cause for rejection, 5 dosage, 321 
Tuberculosis- supply, 319 
i uuercuiosis . Typhus, scrub. See Scrub typhus. 
discharge from service, 1 
discovered at separation, 5 Ulcers, decubitus, relation to nutrition, 86 
incidence, 5 Undernutrition, 116, 120. See also Malnu- 
World War I, 1, 5 trition; Nutrition deficiency; De- 
rejection for service, 5 flciency diseases. 
screening process, 1, 6 Uniform. See Clothing. 
screening standards, 5 United Kingdom ; 
Tuberculosis, National Research Council bathing facilities, 20, 22 
Subcommittee on, recommendations, 5 prisoners of war, 139-140 
Tunisian campaign, ration for, 115-116 smallpox vaccine, local procurement, 282 
Turner’s Lane Hosp (Penna.), study of training in personal health measures, 18 
nervous disorders, 173 troop rations, 124-131 
Twelve-in-one ration, 129 United States Department of Agriculture. 
Twentieth Air Force, nutrition study, 93 &ee Agriculture, Department of. 
Typhoid fever : United States Military Academy : 
immunization status patients, 279 course in personal hygiene, 16 
incidence, 273, 276, 277 physical standards for entrance, 9 
investigation of outbreak, 25 United States Public Health Service: 
Typhoid-paratyphoid commercial biologic laboratories li- 
vaccination: censed, 291 
administrative requirements, 274, 275, immunization, cooperation, 271 
276 352-353 tetanus immunization, cooperation, 288 
, , , , „„ tetanus toxoid recommendations, 288 
development and adoption, 272 . ., , ., ... 
, „ typhoid-paratyphoid vaccination, co- 
directives, 273, 274 v . 0_„ 
’ operation in, 273 
effectiveness, 276-279 typhus vaccine supply, 319 
methods, 273-276 yellow fever vaccine production, 307, 
reactions, 279-280 308, 309 
revaccination, 275 Universities: 
vaccine: Cincinnati, rebuilt-shoe sterilization 
changes, 272-273 studies, 82 
dosage, 273, 275 Harvard, study of cold injury and cloth- 
not administered with yellow fever ing, 63 
vaccine, 309 Indiana, clothing studies, 53 INDEX 
393 
Universities—Continued War Department: 
Minnesota, studies in— cholera vaccination requirements, 315 
nutritional disease, 169 clothing, issued for nurses, 41 
vitamin requirements, 105 diphtheria immunization program, 333 
Queensland, research in skin physiology, directives relating to— 
62 clothing, 79 
Upton, Camp, shoe size study, 40 dietary, 89 
induction physical requirements, 3, 4, 
Vaccination. See Immunization. 7 9 
Vaccinia. See under Smallpox. mobilization, 3, 4 
Vehicle accidents, 245, 251, 252, 253, 265 personal hygiene, 14, 17 
Venereal disease, affecting induction, 5, 6 psychoneurosis, 7 
Viral hepatitis, prophylaxis, 336 rations, 89, 100,101, 105 
Visual acuity, induction requirements, 4, 5 immunization requirements, 337 
Visual aids, training in personal hygiene, Japanese B encephalitis vaccination re- 
27 quirements, 327 
Vitamin(s) : master menu, 91 
A. plague vaccination policy, 318 
amount prisoner of war, food policies, 106 
consumed in diet, 103 tetanus toxoid requiremeilts- 288, 289, 
in rations, 126 
Chinese ration, 144 yellow fever’ concern oyer introduction 
deficiency in troops, 86, 161, 162, 165- mto Hawau’ 311 
yellow fever vaccination requirements, 
sources, 126 
g War Department Safety Council, 242, 243 
' _ . . „„„ War Manpower Commission, cooperation 
deficiency in troops, 164 . ,v. 
.... . 1fl, m safety program, 242 
requirements determined, 105 __ . „ , .... 
War Office of Psychiatric Social Work, 211 
War Production Board: 
amount in ration, 89 cooperation in safety program, 242 
deficiency in troops, 142, 162, 165 survey of footgear ln European theater, 
need for, 117 
concentrates issued, 116 Warren, Fort Francis E., mental hygiene 
D, deficiency noted, 166 service 226 
deficiencies: Waste, edible, 97, 98 
in recovered prisoners, 168, 169 Water discipline, 20, 23, 25 
in troops, 155, 161-162, 164, 165, 166 Wechsler Individual Mental Abilities 
in ration, 89, 95 Scale, 195 
loss in preparation of food, 96 Weight loss, 91 
requirements, 85, 89 Western Europe : 
supplementation of ration, 136-137 climate in relation to clothing, 36 
in India-Burma theater, 145-152 incidence of cold injury, 66 
in Persian Gulf Command, 140 Whayne, Col. T. F., “Introduction,” XI, 
Von Steuben, Maj. Gen. F., first Army XII, “Clothing,” 31-83 
regulations, 237 Wheeler, Camp, mental hygiene service, 
198 
Wakeman General Hospital, nutrition White, W. A., value of preventive psychi- 
studies, 86 atry, 171 
Walter Reed General Hospital, hospital Whittinghah, H. E., study of reaction to 
diet studies, 94 tetanus toxoid, 301 394 
PERSONAL HEALTH MEASURES AND IMMUNIZATION 
Wickersham, Maj. F. P., personnel con- Wright Field, studies in oxygen require- 
sultant service, 178 ments of pilots, 86 
Witte’s peptone, in tetanus toxoid, 291, 
292, 301, 302, 303, 304, 305 X-ray, examination for tuberculosis, 5 
Wolters, Camp, mental hygiene service; 
administration, 188, 190 Yageou, O. P., research in clothing, 47 
intake procedure, 195 Yellow fever; 
lecture program, 213 cases, 311 
morale, evaluation, 227-228 exposure of troops to, 311 
reclassification board, 198 vaccination : 
screening, 191, 193 administrative requirements, 309, 310, 
World War 1: 311, 343-345, 358-359 
clothing, 3S--42 associated with jaundice, 308, 312, 313 
cold injury, 64 contraindications for administration 
diarrhea and dysentery, 277 0f 399 
laundry facilities, 41-42 development and adoption, 306-307 
louse infestation, incidence of, 13 effectiveness 311-312 
neuropsychiatric casualties, 1 methods and requirements, 309-311 
nonbattle trauma, 233 period of immunity, 310, 311 
nutrition, 85, 98, 95, 97 reactions, 280, 312-313 
Iiersonal hygiene, rules for, 13 vaccine, 
preventive medicine, xi _ 
directives for handling, 309 
preventive psychiatry, 173-174 
psychiatric screening, 1 dosage, 309 
rations, 87 virus’ 307 
smallpox, 284 Youmans, J. B.: 
tetanus, 296 “Malnutrition,” 159-170 
tuberculosis, 1, 5 “Nutrition,” 85-112 
typhoid and paratyphoid fevers, 276, Young, Col. E., study of Anglo-American 
277 ration scale, 115 
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