;x". ;m *?£?£*■ :n- '*«? :■■w;?vf. .Us., i i i;*'!*'-. ;« PROPERTY OF THE NATIONAL LIBRARY OF MEDICINE LETTER OF TRANSMISSION I have the honor to submit herewith Volume IX of the history of THE MEDICAL DEPARTMENT OF THE UNITED STATES ARMY IN THE WORLD WAR. The volume submitted is entitled "Communicable and other Diseases." M. W. Ireland, Major General, the Surgeon General. The Secretary of War. 3 Lieut. Col. Fraxk W. Weed, M. C, Editor in Chief Loy McAfee, A. M., M. D., Assistant Editor in Chief editorial board a Col. Bailey K. Ashford, M. C. Col. Frank Billings, M. C. Col. Thomas R. Boggs, M. C. Col. George E. Brewer, M. C. Col. W. P. Chamberlain, M. C. Col. C. F. Craig, M. C. Col. Haven Emerson, M. C. Brig. Gen. John M. T. Finney, M. D. Col. Joseph H. Ford, M. C. Lieut. Col. Fielding H. Garrison, M. C. Col. H. L. Gilchrist, M. C. Brig. Gen. Jefferson R. Kean, M. D. Lieut. Col. A. G. Love, M. C. Col. Charles Lynch, M. C. Col. James F. McKerxon, M. C. Col. R. T. Oliver, D. C. Col. Charles R. Reynolds, M. C. Lieut. Col. G. E. de Schweinitz, M. C. Col. J. F. Siler, M. C. Brig. Gen. W. S. Thayer, M. D. Col. A. D. Tuttle, M. C. Col. William H. Welch, M. C. Col. E. P. Wolfe, M. C. Lieut. Col. Casey A. Wood, M. C. Col. Hans Zinsser, M. C. 0 The highest rank held during the World War has been used in the case of each officer. 4 PREFACE ° The subject matter of this volume, which, for the most part, comprises the more important communicable diseases that concerned the Army and particularly the Medical Department during the World War, is arranged so as to consider, first, a statistical analysis and then the usual aspects of each of the diseases (diagnosis, treatment, etc.). In so far as the statistical analysis is concerned, a dichotomous table for each disease, or group of diseases com- prising a chapter, forms a basis for subsidiary tables where these have been thought desirable. The basic tables show, for purposes of analysis, strength, and admissions, deaths, and noneffectiveness, not only in absolute numbers but also in rates per 1,000 strength. In addition, the incidence of the diseases considered is given geographically and by race. Where it is desirable, addi- tional tables show urban and rural distribution; local prevalence, as in a large command or at a particular station; comparative incidence of certain diseases in the United States Army and in foreign armies. As explained in Part Two of Volume XV of this history, the number of admissions does not represent the total case incidence. This is due to the fact that, in finally compiling all data on the sick and wounded cards in the Surgeon General's Office, it did not prove practical to record among the admissions all diseases coexisting at time of admission, or diseases occurring as complications while a case was on sick report. Instead, coexisting and complicating diseases were tabulated separately. Since the basic tables of the chapters of this volume, of necessity, comprise primary admissions only, they must be viewed in the light of the above explanation. In conjunction with them, however, additional tables show the number of cases recorded, among enlisted men in the United States and Europe, as concurrent diseases, complications and sequelae, thus approximating the total number of cases. Every effort was made in the Surgeon General's Office, in compiling vital statistics, to charge to original cases the places and times of occurrence, all discharges for disability, time lost, and deaths. This was done to facilitate computing case fatality, percentage of cases discharged for disability, and the amount of time lost for each character of case. Thus is explained attributing to such a disease as measles, for example, deaths which were in fact due to complicating bronchopneumonia. Chapter XXII, concerning decisions as to the line of duty of disabilities, originally was intended for another volume of this history. Though it does not in any sense consider a disease, or a group of diseases, solely from the pro- fessional viewpoint, nevertheless it concerns diseases principally and thus more appropriately forms a part of this volume. 0 For the purpose of the History of the Medical Department of the United States Army in the World War, the period of war activities extends from April 6, 1917, to December 31, 1919. In the professional volumes, however, in which are recorded the medical and surgical aspects of the conflict as applied to the actual care of the sick and wounded, this period is extended, in some instances, to the time of the completion of the history of the given service. In this way only can the results be followed to their logical conclusion. TShe MEDICAL DEPARTMENT OF THE UNITED STATES ARMY IN THE WORLD WAR VOLUME IX COMMUNICABLE AND OTHER DISEASES PREPARED UNDER THE DIRECTION OF MAJ. GEN. M. W. IRELAND The Surgeon General BY LIEUT. COL. JOSEPH F. SILER, M. C, U. S. ARMY WASHINGTON : U. S. GOVERNMENT PRINTING OFFICE : 1928 >-* u H £15 7 A* 59nW_ I3SI-B9 C2, additional copies of this pubucation may be procured from THE SUPERINTENDENT OF DOCUMENTS U.S.GOVERNMENT PRINTING OFFICE WASHINGTON, D. C. AT $2.00 PER COPY TABLE OF CONTENTS Page Preface________________________________________ 5 Chapter I. Typhoid and the paratyphoid fevers. By Lieut. Col. Joseph F. Siler, M. C, and Maj. John S. Lambie, jr., M. C______________________ 15 II. Inflammatory diseases of the respiratory tract (bronchitis; influenza; bronchopneumonia; lobar pneumonia). By Maj. Milton W. Hall, M. C_ 61 III. Tuberculosis. By Col. George E. Bushnell, M. C__________________ 171 IV. Cerebrospinal meningitis. By Maj. James S. Simmons, M . C, and Maj. Henry C. Michie, M. C________________________________ 203 V. Anthrax. By Maj. Henry C. Michie, M. C_______________________ 223 VI. Diphtheria. By Maj. John W. Meehan, M. C, and Maj. Henry C. Michie, M. C____________________________ _______________ 233 VII. The venereal diseases. By Maj. Henry C. Michie, M. C____________ 263 VIII. The diarrheal group of diseases. By Maj. Milton W. Hall, M. C, and Maj. Henry C. Michie, M. C_________________________________ 311 IX. Smallpox. By Lieut. Col. Joseph F. Siler, M. C, and Maj. Henry C. Michie, M. C_____________________________________________*_ _ _ _ 357 X. Chicken-pox. By Maj. Henry C. Michie, M. C_______________________ 387 XI. Scarlet fever. By Maj. Henry C. Michie, M. C_______________________ 391 XII. Measles. By Maj. Henry C. Michie, M. C, and Maj. George E. Lull, M. C_______________________________________________ 409 XIII. Mumps. By Maj. Henry C. Michie, M. C_____________________ 451 XIV. German measles. By Maj. Henry C. Michie, M. C_______________ 463 XV. Encephalitis lethargica. By Maj. Henry C. Michie, M. C___________ 473 XVI. Infectious jaundice; typhus fever; trench fever. By Maj. Arthur X. Tasker, M. C______________________________________________ 483 XVII. Vincent's disease. By Maj. Henry C. Michie, M. C________________ 493 XVIII. The malarial fevers. By Lieut. Col. Charles F. Craig, M. C_________ 511 XIX. Intestinal parasites. By Maj. Charles A. Kofoid, S. C_________ ____ 529 XX. Diseases of the skin. By Maj. Arthur N. Tasker, M. C_______ ____ 551 XXI. Neurocirculatory asthenia. By Col. Harlow Brooks, M. C___ ____ 559 XXII. Decisions as to whether or not disabilities were in line of duty. By Col. Weston P. Chamberlain, M. C________ _______________ ___ 587 Index_____ _______________________________ ------------ ___ 611 list of tables Table 1. Typhoid fever. United States Army by war periods; also the British Army (South African War), showing admissions and deaths. Absolute numbers, rates per 1,000 per annum, and case mortality rates_______________________ 17 2. Typhoid fever. Deaths by years, 1890 to 1919, white enlisted men, United States Army, and estimated rates for male civilian population, ages 20 to 34. Annual rates per 1,000___________________________________________________________ 20 3. Typhoid fever and typhoid vaccination. Admissions, deaths, discharges for dis- ability, and days lost from duty, officers and enlisted men (white, colored, and native troops) United States Army, April 1, 1917, to December 31, 1919. Absolute numbers and ratios per 1,000------------------------------------- 23 4. Typhoid fever. By country of occurrence, showing percentage relationship to total admissions and deaths from disease, and relative standing among the 30 most common causes of admissions and deaths, April 1, 1917, to December 31, 1919__________________________________________________________________ 25 8 COMMUNICABLE AND OTHER DISEASES Table Page 5. Typhoid fever, Schofield Barracks, Hawaii. Vaccinated and unvaccinatcd groups, population, admissions, and deaths. Absolute numbers with rates per 1,000 and case fatality___________________________________________ 28 6. Typhoid fever. Admissions, enlisted men, by camps, September 1, 1917, to December 31, 1918. Absolute numbers and rates per 1,000_______________ 35 7. Typhoid fever. By years of occurrence, in the armies of seven of the important nations involved in the World War, showing number of cases and deaths with ratios per 1,000 per annum, and case fatality rates, 1914 to 1919_____ 38 8. Typhoid fever. Concurrent with other diseases, enlisted men, United States Army, serving in the United States and Europe, April 1, 1917, to December 31, 1919____________________________________________________________ 52 9. Paratyphoid fevers. Officers and enlisted men, April 1, 1917, to December 31, 1919, by country of occurrence, admissions, and deaths. Absolute numbers and rates per 1,000_________________________________________________________ 58 10. Respiratory diseases. Primary admissions, officers and enlisted men, United States Army, by countries, April 1, 1917, to December 31, 1919. Absolute numbers, and annual ratios per 1,000_________________________________ 66 11. Respiratory diseases. Deaths, officers and enlisted men, United States Army, by countries, April 1, 1917, to December 31, 1919. Absolute numbers and ratios per 1,000____________________________________________________ 69 12. Respiratory diseases. Officers and enlisted men, United States Army, by countries, April 1, 1917, to December 31, 1919. Case fatalities and ratios of broncho- pneumonia to lobar pneumonia_______________________________________ 70 13. Total respiratory diseases (influenza, bronchitis, bronchopneumonia, and lobar pneumonia), white and colored enlisted men, United States Army, in the United States, by months, from April 1, 1917, to December 31, 1919______________ 78 14. Total respiratory diseases (influenza, bronchitis, bronchopneumonia, and lobar pneumonia), white and colored enlisted men, United States Army in Europe, by months, from June, 1917, to December 31, 1919______________________ 78 15. Annual admission rates per 1,000 strength, white enlisted men, in the United States, by months, from April 1, 1917, to December 31, 1919____________________ 79 16. Annual death rates per 1,000 strength, white enlisted men, in the United States, from April 1, 1917, to December 31, 1919_____________________________ 79 17. Annual admission rates per 1,000 strength, colored enlisted men, in the United States, from April 1, 1917, to December 31, 1919_____________________________ 80 IS. Annual death rates per 1,000 strength, colored enlisted men in the United States, from April 1, 1917, to December 31, 1919______________________________ 80 19. Annual admission rates per 1,000 strength, white enlisted men in Europe, from June, 1917, to December 31, 1919___________________________________ SI 20. Annual death rates per 1,000 strength, white enlisted men in Europe, from June, 1917, to December 31, 1919_________________________________________' 8i 21. Annual admission rates per 1,000 strength, colored enlisted men in Europe, from November, 1917, to September 30, 1919_____________________________ 82 22. Annual death rates per 1,000 strength, colored enlisted men in Europe, from Novem- ber 1, 1917, to September 30, 1919____________________________________ 82 23. Incidence of influenza and of influenza-pneumonia by weeks, June 17, 1918, to December 29, 1919. Annual rates per 1,000________________________ ,S4 24. Relative admission and death rates, and case fatalities from the respiratory group of diseases for white enlisted men, United States Army, by State of birth____ 98 25. Relative position of the States in respect of rates of natives for admissions, deaths, and case fatality from the respiratory group of diseases, white enlisted men, United States Army____________________________________ 99 26. Relative admission and death rates and case fatality for the respiratory group of diseases for colored enlisted men by State of birth, April, 1917, to December, 1919------------------------------------------------------------- 107 TABLE OF CONTENTS 9 Table page 27. Influenza and pneumonia. Admissions, deaths, and case fatality rates, for 40 large camps in the United States during the fall epidemic, 1918____________ 138 28. Cerebrospinal meningitis. Primary admissions, and deaths shown by countries of occurrence for officers and enlisted men, United States Army, with ratios per 1,000 strength, April, 1917, to December 31, 1919____________________ 205 29. Cerebrospinal meningitis. Primary admissions, and deaths by months with annual ratios per 1,000 strength; white and colored enlisted men, United States Army in the United States and Europe, April, 1917, to December, 1919___________ 208 30. Cerebrospinal meningitis. By camps of occurrence, showing primary admissions and deaths, with annual ratios per 1,000 strength, white and colored enlisted men, United States Army; also case fatality rates, April, 1917, to December, 1919- 211 31. Anthrax. Admissions and deaths, by countries, officers and enlisted men, United States Army, April 1, 1917, to December 31, 1919_______________________ 223 32. Anthrax. Admissions and deaths, by specified camps of occurrence, enlisted men, United States Army, April 1, 1917, to December 31, 1919_________________ 224 33. Diphtheria. Admissions, deaths, discharges for disability, and days lost, officers and enlisted men, United States Army, April 1, 1917, to December 31, 1919. Absolute numbers and annual ratios per 1,000__________________________ 233 34. Diphtheria. Admissions and deaths by months, white and colored enlisted men, United States Army, United States and Europe, April 1, 1917, to December 31, 1919____________________________________________________________ 235 35. Diphtheria. Admissions and deaths, by camps of occurrence, white and colored enlisted men, United States Army, April 1, 1917, to December 31, 1919. Absolute numbers and annual ratios per 1,000__________________________ 240 36. Diphtheria carriers. Admissions, discharges for disability, and days lost, by countries' of occurrence, officers and enlisted men, United States Army, April 1, 1917, to December 31, 1919. Absolute numbers and annual ratios per 1,000__ 251 37. Diphtheria carriers. Admissions, by months, white and colored enlisted men, United States and Europe, April 1, 1917, to December 31, 1919_____________ 253 38. Results of cultures for the detection of diphtheria bacilli among soldiers arriving at the port of Hoboken on transports, December, 1918, to May, 1919_________ 254 39. Diphtheria carriers and clinical cases of diphtheria, relative occurrence, at De- barkation Hospital No. 3, New York, December, 1918, to May, 1919_______ 254 40. Diphtheria carriers. Duration of carrier state, embarkation and debarkation hospitals, New York, showing absolute numbers and average periods of hospital- ization by 10-day groupings_________________________________________ 258 41. Venereal diseases (all). Primary admissions, deaths, discharges for disability, and noneffectiveness, officers and enlisted men, United States Army, by countries of occurrence, April 1, 1917, to December 31, 1919. Absolute numbers and ratios per 1,000___________________________________________________ 264 42. Defects found in drafted men. Venereal diseases (all)______________________ 265 43. Gonococcus infection. Primary admissions, deaths, discharges for disability, and noneffectiveness, officers and enlisted men, United States Army, by countries of occurrence, April 1, 1917, to December 31, 1919. Absolute numbers and ratios per 1,000___________________________________________________ 272 44. Complications, sequelae and concurrent diseases, among primary admissions for gonococcus infections in the United States Army, April 1, 1917, to December 31, 1919_________________________________________________________ 274 45. Syphilis. Primary admissions, deaths, discharges for disability, and noneffec- tiveness, officers and enlisted men, United States Army, by countries of occur- rence, April 1, 1917, to December 31, 1919. Absolute numbers and ratios per 1,000_____________________________________________^-------------- 293 46. Primary admissions with complications, sequelae and concurrent diseases reported of 12,843 cases of syphilis in the United States Army, April 1, 1917, to Decem- ber 31, 1919______________________________________________________ 299 10 COMMUNICABLE AND OTHER DISEASES Table Page 47. Diarrheal diseases. Primary admissions, white enlisted men in the United States, April, 1917, to December, 1919. Annual rates per 1,000 by months-------- 313 48. The diarrheal diseases (dysentery, acute and chronic, and diarrhea). Admissions and deaths, absolute numbers and ratios per 1,000 per annum, white enlisted men, United States Army, 1819 to 1919________________________________ 315 49. Dysentery (all), diarrhea, and enterocolitis. Officers and enlisted men, United States Army, by countries of occurrence. Primary admissions, deaths, dis- charges for disability, and noneffectiveness, absolute numbers and ratios per 1,000 per annum, April, 1917, to December, 1919________________________ 318 50. Diarrheal group of diseases. Comparative mortality in the United States Army during the World War, and the United States registration area, males, age 20-34, 1917-1919. Annual death rates per 1,000________________________ 323 51. Dysentery. Incidence by types, and annual ratios per 1,000 by months, white enlisted men, United States Army, in the United States, April, 1917, to Decem- ber, 1919_________________________________________________________ 329 52. Dysentery. Incidence by types, and annual ratios per 1,000 by months, white enlisted men, United States Army, in Europe, April, 1917, to December, 1919-_ 330 53. Dysentery (all types). Primary admissions, United States Army, 1917 to 1919, shown by etiological types. Total cases in the United States and Europe. Absolute numbers_________________________________________________ 331 54. Smallpox. Admissions and deaths, white enlisted men, United States Army, 1840to 1919. Ratesper 1,000_______________________________________ 358 55. Smallpox. Admissions and deaths United States Army in the Civil War, Spanish American War and Philippine Insurrection, and the World War. Absolute numbers and ratios per 10,000_______________________________________ 359 56. Smallpox. Admissions and deaths, by countries of occurrence, officers and enlisted men, United States Army, April 1, 1917, to December 31, 1919. Absolute numbers and ratios per 1,000________________________________________ 362 57. Smallpox. Admissions by camps of occurrence, white and colored enlisted men, United States Army, April 1, 1917, to December 31, 1919. Absolute numbers and ratios per 1,000________________________________________________ 364 58. Smallpox. Numbers of admissions and ratios per 1,000 enlisted men (white and colored), United States Army, by States and groups of States, and comparable ratios per 1,000 among the civilian population of these States and groups, April 1, 1917, to December 31, 1919_______________________________________ 366 59. Chicken-pox. Admissions and days lost, officers and enlisted men, United States Army, April 1, 1917, to December 31, 1919____________________________ 387 60. Scarlet fever. Admissions, deaths, discharges for disability, and days lost, by countries, officers and enlisted men, United States Army, April 1, 1917, to December 31, 1919_________________________________________________ 391 61. Scarlet fever. Admissions and deaths, white and colored enlisted men, United States Army, United States and Europe, by months, April 1, 1917, to December 31, 1919_________________________________________________________ 394 62. Scarlet fever. Admissions and deaths, by camps of occurrence, white and colored enlisted men, United States Army, April 1, 1917, to December 31, 1919_____ 397 63. Scarlet fever. Complications, sequelae, and concurrent diseases, April 1, 1917, to December 31, 1919_________________________________________________ 403 64. Admissions and deaths from scarlet fever, concurrent with other diseases, enlisted men, United States Army, United States and Europe, April 1, 1917, to Decem- ber 31, 1919______________________________________________________ 404 65. Measles. Admissions, deaths, discharges for disability, and days lost, by coun- tries of occurrence, officers and enlisted men, United States Army, April 1, 1917, to December 31, 1919__________________________________________ 413 66. Measles. Admissions and deaths, by camps of occurrence, white and colored enlisted men, in the United States, April 1, 1917, to December 31, 1919. Absolute numbers and ratios per 1,000_________________________________ 419 TABLE OF CONTENTS 11 Table Page 67. Measles and population, United States registration area, all ages, by States of occurrence, showing estimated population, July 1, 1918. Admissions, and deaths. Absolute numbers and ratios per 1,000_________________________ 424 68. Measles. Admissions, deaths, discharges for disability, and days lost, by race, enlisted men, United States Army, April 1, 1917, to December 31, 1919. Abso- lute numbers and ratios per 1,000____________________________________ 428 69. Measles. Admissions, deaths, and case fatality rates, white and colored enlisted men, United States Army, by sections of the United States, April 1, 1917, to December 31, 1919________________________________________________ 428 70. Measles. Concurrent diseases and complications, enlisted men in the United States and Europe, April 1, 1917, to December 31, 1919__________________ 431 71. Measles with bronchopneumonia. Admissions, deaths, and discharges for disa- bility, by length of service, white enlisted men in the United States, April 1, 1917, to December 31, 1919_________________________________________ 435 72. Measles with lobar pneumonia. Admissions, deaths, and discharges for disa- bility, by length of service, white enlisted men in the United States, April 1, 1917, to December 31, 1919_________________________________________ 435 73. Mumps. Admissions, discharges for disability, and days lost, by countries of occurrence, officers and enlisted men, United States Army, April 1, 1917, to December 31, 1919________________________________________________ 451 74. Mumps. Admissions, by camps of occurrence, white and colored enlisted men, United States Army, April 1, 1917, to December 31, 1919_________________ 453 75. Mumps. Admissions, by months, white and colored enlisted men, United States Army, United States and Europe, April 1, 1917, to December 31, 1919______ 454 76. German measles. Admissions, deaths, discharges for disability, and days lost, by countries of occurrence, officers and enlisted men, United States Army, April 1, 1917, to December 31, 1919. Absolute numbers and ratios per 1,000_ 463 77. German measles. Admissions and deaths, by camps of occurrence, white and colored enlisted men, United States Army, with ratios per 1,000 strength, and case fatality rates, April, 1917, to December, 1919_______________________ 467 78. German measles. Admissions, by months, white and colored enlisted men, United States Army, United States and Europe, Absolute numbers and ratios per 1,000, April, 1917, to December, 1919________________________ 468 79. Comparative occurrence, measles, German measles, and scarlet fever, in a selected group of camps in the United States, 1917 and 1918. Ratios per 1,000______ 472 80. Vincent's disease. Admissions, deaths, discharges for disability, and days lost, white and colored enlisted men and native troops, United States Army, by countries of occurrence, April 1, 1917, to December 31, 1919. Absolute num- bers _____________________________________________________________ 495 XI. Malarial fevers. Admissions and deaths, enlisted men, United States Army, 1911 to 1920. Ratios per 1,000______________________________________ 511 82. Malarial fevers. Admissions, deaths, and discharges for disability, officers and enlisted men, United States Army, April 1, 1917, to December 31, 1919. Absolute numbers, ratios per 1,000, per cent of total diseases, and relative standings________________________________________________________ 512 83. Malarial fevers. Admissions deaths, discharges for disability and days lost, by race, enlisted men, United States Army, April 1, 1917, to December 31, 1919. Absolute numbers and ratios per 1,000-------------------------- 514 S4. Malarial fevers. Admissions, deaths, discharges for disability, and days lost, by countries of occurrence, white enlisted men, United States Army, April 1, 1917, to December 31, 1919. Absolute numbers and ratios per 1,000------- 515 85. Malarial fevers. Large camps, United States. Admissions, deaths, and dis- charges for disability, white and colored enlisted men, April 1, 1917, to Decem- ber 31, 1919. Absolute numbers and ratios per 1,000-------------------- 516 86. Malarial fevers. Admissions, deaths, discharges for disability, by State of induc- tion, white and colored enlisted men, United States Army, United States and Europe, April 1, 1917, to December 31, 1919___________________________ 517 12 COMMUNICABLE AND OTHER DISEASES Table , . Pa*e 87. Malarial fevers. Admissions by months, white and colored enlisted men, Lnited States, April 1, 1917, to December 31, 1919. Absolute numbers and ratios per 1,000________________________________________ f)2,) 88. Malarial fevers, secondary to other diseases. Enlisted men, United States and Europe, April 1, 1917, to December 31, 1919. Absolute numbers, ratios per 1,000, and percentage rates------------------------------------------ 525 89. Comparative results in detection of ova by direct smear and brine flotation-loop methods_________ --------------------------------------------- 532 90. Hookworm infection in States in the hookworm area----------------------- 541 91. Hookworm infection in the Middle West—Mississippi Valley---------------- 541 92. Hookworm infection in the Northeastern States--------------------------- 542 93. Hookworm infection in the Pacific Slope States---------------------------- 542 94. Summary of infection by intestinal parasites in 2,300 overseas troops and 576 home service troops, United States Army------------------------------ 545 95. Infections by hookworm and Hymenolepis nana in men from Northern States-_ 547 96. Infections by hookworm and Hymenolepis nana in men from Southern States-_ 547 97. Diseases of the skin and cellular tissue. Primary admissions, officers and en- listed man, United States Army, April 1, 1917, to December 31, 1919. Abso- lute numbers______ ___ ------------------------------------------ °51 LIST OF CHARTS Chart I. Typhoid and typhus fevers, white enlisted men, United States Army, admissions and deaths, 1820-1919______________________________ 16 II. Typhoid fever, enlisted men, United States Army, in continental United States, excluding Alaska, admissions and deaths, by years, for the period 1897-1919. Annual rates per 1,000_______________________ 18 III. Deaths, typhoid fever, for white enlisted men, and estimated rates for male civilians, ages 20-34, 1890-1919____________________________ 19 IV. Typhoid fever. Positive, clinical, and suspect cases, American Expedi- tionary Forces, showing strength, cases reported, and rates per 100,000 of strength, by weeks_________________________________________ 29 V. Comparative trends of mortality rates per 1,000 for pneumonia and influenza, United States registration area for deaths, 1911-1920______ 64 VI. Annual admission rates per 1,000 strength, white enlisted men in the United States for influenza, bronchitis, lobar pneumonia, and broncho- pneumonia, by months, April, 1917, to December, 1919_____________ 71 VII. The relations between the annual admission rates per 1,000 strength, white enlisted men in the United States, of the combined influenza and bron- chitis and the combined lobar pneumonia and bronchopneumonia, by months, April, 1917, to December, 1919_________________________ 72 VIII. Annual admission and death rates per 1,000 strength, for white and colored enlisted men in the United States, total respiratory group of diseases, by months, April, 1917, to December, 1919______________________ 73 IX. Annual admission and death rates for white and colored enlisted men in Europe, total respiratory group of diseases, by months, June, 1917, to December, 1919_____________________________________________ "4 X. Annual admission and death rates per 1,000 strength for white enlisted men in the United States and in Europe, total respiratory group of diseases, by months, April, 1917, to December, 1919--------------- 75 XL Annual admission and death rates per 1,000 strength for colored enlisted men in the United States and in Europe, total respiratory group of diseases, by months, April, 1917, to December, 1919--------------- 76 XII. Case fatality rates, total respiratory group of diseases for white enlisted men in the United States and in Europe, by months, April, 1917, to December, 1919_____________________________________________ " TABLE OF CONTENTS 13 Chart Page XIII. Case fatality rates, total respiratory group of diseases, for colored enlisted men in the United States and in Europe, by months, July, 1917, to December, 1919_____________________________________________ 77 XIV. Incidence of influenza and influenzal pneumonia, by weeks, for certain camps in the United States, June 17 to December 29, 191S. Annua] admission rates per 1,000 strength_____________________________ So XV. Percentage of total deaths from influenzal pneumonia during the war period occurring in each of the specified groups of length of service___ 92 XVI. The relative mortality rates per 1,000 strength from influenzal pneumonia during the war period in each of the specified groups of length of service____________________________________________________ 92 XVII. The relative admission rates for the respirator}- group of diseases for white enlisted men by State of birth_________________________________ 100 XVIII. The relative death rates from the respiratory group of diseases for white enlisted men by State of birth_________________________________ 100 XIX. Case fatality rates (per cent) of the respiratory group of diseases for white enlisted men, by State of birth___________________________ 101 XX. Relative admission and death rates and case fatalities for the respiratory group of diseases in the various groups of States, April, 1917, to Decem- ber, 1919__________________________________________________ 106 XXI. Relative death rates from the respiratory group of diseases by groups of States for the war period with the figures given by Vaughan and Palmer for the early months of the mobilization_________________________ 107 XXII. Comparison of effects of the fall epidemic of influenza on camps of differ- ent size in the United States__________________________________ 112 XXIII. A comparison of the variations in the annual admission rates for the total respiratory diseases, the case fatality of measles, and the percentage of measles cases developing pneumonia, white enlisted men in 36 large camps in the United States, October, 1917, to March, 1919_________ 131 XXIV. The relation between the total respiratory diseases and the pneumonias, annual rates per 1,000 for the 24 large camps in the United States which showed a definite peak for these diseases in the 1918 spring epidemic. 134 XXV. Tuberculosis, by camps. Admissions, white enlisted men, United States, April, 1917, to December, 1919. Ratios per 1,000 _________ 183 XXVI. Admissions and deaths for cerebrospinal meningitis, United States Army, 1900 to 1920. Ratios per 1,000 strength________________________ 204 XXVII. Cerebrospinal meningitis, comparative rates, white and colored enlisted men, United States, April, 1917, to December, 1919_______________ 207 XXVIII. Cerebrospinal meningitis and mobilization. Admissions and number of enlisted men mobilized, United States. Comparative trend by months, April, 1917, to December, 1919_________________________ 210 XXIX. Cerebrospinal meningitis, by camps. Admissions, white enlisted men, United States, April, 1917, to December, 1919____________________ 212 XXX. Diphtheria. Comparative rates, white and colored enlisted men, United States, April, 1917, to December, 1919__________________________ 239 XXXI. Diphtheria, by camps. Admissions, white enlisted men, United States, April, 1917, to December, 1919________________________________ 241 XXXII. Diphtheria, by native States, white enlisted men, United States Army, United States and Europe, April, 1917, to December, 1919. Ratios per 1,000__________________________________________________ 242 XXXIII. Venereal diseases (all) and mobilization. Admissions and number of men mobilized, United States. Comparative trend by months, April, 1917, to December, 1919___________________________________________ 266 XXXIV. Venereal diseases (all) and enlisted strength, white and colored troops, United States and Europe, comparative trend by months, April, 1917, to December, 1919___________________________________________ 267 14 COMMUNICABLE AND OTHER DISEASES Chart Pago XXXV. Venereal diseases (all) and enlisted strength, actual for white troops but both raised for colored troops, United States and Europe. Compara- tive trend by months, April, 1917, to December, 1919-------------- 26S XXXVI. The diarrheal group of diseases. Annual admission rates by months for dysentery (all), diarrhea, and enterocolitis, white enlisted men in the United States_______________________________________________ 313 XXXVII. The diarrheal group of diseases. Admissions and deaths in the United States Army, 1819 to 1919. Annual rates per thousand____________ 316 XXXVIII. Dysentery, incidence by etiologic types by months, annual rates per 1,000, white enlisted men, United States Army, in the United States------- 328 XXXIX. Dysentery. Comparative rates, white and colored enlisted men, United States, April, 1917, to December, 1919__________________________ 333 XL. Dysentery. Comparative trend, enlisted men, United States Army, United States and Europe, admissions and deaths by months, April, 1917, to December, 1919______________________________________ 335 XLI. Smallpox, white enlisted men, United States Army, admissions and deaths, 1840-1919. Ratios per 1,000___________________________ 359 XLII. Smallpox in the United States Army and civil population, April 1, 1917, to December 31, 1919. Occurrence by groups of States. Ratios per 1,000 population_____________ ___________________________ 367 XLIII. Scarlet fever, fey States of occurrence, white and colored enlisted men, United States Army, April 1, 1917, to December 31, 1919. Ratios per 1,000______________________________________________________ 398 XLIV. Measles. White enlisted men, United States Army, admissions and deaths, 1840-1919. Ratios per 1,000___________________________ 410 XLV. Measles. Civil, Spanish American, and Philippine Insurrection, and World Wars, white and colored enlisted men, United States Army, by months. Ratios per 1,000____________________________________ 412 XLVI. Measles and mobilization. Admissions and number of enlisted men mobilized, United States. Comparative trend by months, April, 1917, to December, 1919___________________________________________ 415 XLVII. Measles, by camps. Admissions, white enlisted men, United States, April, 1917, to December, 1919. Ratios per 1,000_________________ 416 XLVIII. Measles, by native States, white enlisted men, United States and Europe, United States Army, April, 1917, to December, 1919. Ratios per 1,000... 418 XLIX. Measles. Comparative rates, white and colored enlisted men, United States, April, 1917, to December, 1919___________________________ 420 L. Measles. Comparative trend, enlisted men, United States Army, United States and Europe. Admissions and deaths by months, April, 1917, to December, 1919_____________________________________________ 426 LI. German measles. Comparative trend, enlisted men, United States Armv, United States and Europe. Admissions by months, April, 1917, to December, 1919_____________________________________________ 455 LII. Scabies. White and colored enlisted men, United States, by months. Rate per 1,000______________________________________________ 554 LIII. Scabies. White and colored enlisted men in Europe, by months. Rate per 1,000--------------------------------------------------- 555 CHAPTER I TYPHOID AND THE PARATYPHOID FEVERS a Typhoid and paratyphoid fevers were of but minor importance as causes of sickness in the United States Army during the World War. This negative condition, however, is of all the more present interest in view of the fact that in previous wars, as is shown below, our experience with typhoid fever was quite different. Prior to the World War enteric fever (typhoid) was one of the greatest scourges of armies mobilized for war. In the British Army in the South African War (1899-1901), approximately 59,750 cases of typhoid fever occurred (average annual strength, 209,404), with a case mortality rate in excess of 10 per cent (8,227 deaths.)1 During the Spanish-American War (1898), with a mean annual strength of 147,795 men, there were reported 20,926 cases of typhoid fever in our Army, with 2,192 deaths.2 Prior to the development of the fairly simple laboratory technique (Widal reaction) for the identification of the B. typhosus, the diagnosis of typhoid fever was based on clinical manifestations. Consequently, the medical statis- tics of the Army prior to and even during the Spanish-American War, as well as all other statistical records for like periods, whatever their source, are not accurate in so far as typhoid fever is concerned. The}7 are sufficiently reliable, however, to justify their use in reviewing, for comparative purposes, the prevailing trend of the disease. Since the Spanish-American War the Medical Department has devoted special attention to the prevention of typhoid fever, and the regulations for many years have provided that its diagnosis, for record purposes, must be based on the clinical picture, confirmed by laboratory findings. During the World War, when it became necessary to mobilize approximately 4,000,000 men within a relatively short period of time, it mani- festly was impracticable to confirm all clinical diagnoses of typhoid and para- typhoid fevers by laboratory methods; but the laboratory and clinical investi- gations were quite searching, and the probability of error in recorded diagnoses was undoubtedly small; however, the recorded mortality rates during the World War are somewhat exaggerated. The explanation for this is that in tabulating causes of death during the World War, it was the practice in the Surgeon General's Office, to charge deaths to the primary cause of admission. Thus, individuals who were admitted to hospital for typhoid fever, and who developed influenzal pneumonia concurrently, during the pandemic of influenza, and who actually died of that complication, were recorded as having died of typhoid. Careful studies of a large series of cases occurring in the American Expeditionary Forces, demonstrate that the case mortality did not exceed 11 per cent,3 whereas the basic statistical tables of the Surgeon General's Office, which are used in Volume XV of this history, indicate that it was approximately 13.7 » Unless otherwise stated, all figures for the World War period are derived from sick and wounded reports sent to the Surgeon General.—Ed. 16 COMMUNICABLE AND OTHER DISEASES per cent. Some mild cases of typhoid fever also were overlooked, having been confused with the intestinal type of influenza prevailing so generally during the late fall and early winter of 1918. The morbidity rates in the tables presented herein are slightly less, therefore, than the actual rate of occurrence of typhoid fever, and mortality rates are considerably in excess of the actual death rate. As the subject matter herein deals principally with the limited occurrence of diseases of this group, rather than their fairly common occurrence, and with the facts underlying and accounting for such limitation, the material reviewed is analyzed principally from an epidemiological point of view. TYPHOID AND TYPHUS FEVERS. WHITE ENLISTED MEN U. S. ARMY ADMISSIONS AND DEATHS, 1820 - 1919 ,.,,. ADMISSIONS---------- DEATHS Chart I TYPHOID FEVER IN THE UNITED STATES ARMY PRIOR TO THE WORLD WAR, AND AS COMPARED WITH WORLD WAR INCIDENCE In so far as the earliest records of the American Army are concerned typhus fever was the disease with which typhoid fever was most frequently confused,4 and it was not until 1851 that the nomenclature used by the Medical Department of the Army separated the two and accepted the diagnosis "febris typhoides." Furthermore, in the first few months of the Spanish-American War, Army surgeons failed clearly to separate typhoid fever and malaria, and it was only when the disease assumed the proportions of an epidemic that its character was understood.5 It is quite evident, therefore, that, as stated above, the Army typhoid statistics prior to the Spanish-American War are not accurate and the grouping together of admissions and deaths from both typhoid and typhus fever will more nearly approximate the actual prevalence of typhoid fever in the Army. This method of presentation, therefore, has been adopted in discussing the prevalence of typhoid in the Army prior to the World War. TYPHOID AND THE PARATYPHOID FEVERS 17 The trend of typhoid fever in the Army from 1820 to 1919, is plotted on logarithmic scale in Chart I. Records are not available from 1832 to 1837, nor for a part of the period of the Mexican War (1846-1848). Prior to 1910 the admission rates, although irregular, were high, ranging—except for war periods—from 2 to 10 per 1,000 per annum, and the death rate ranged from about 0.30 to 1.50 during the same period. The very low ratio recorded for 1844 is inexplicable, notwithstanding a careful search of War Department records. The mean strength of the Army during 1844 was about 8,500 men and the reported admissions for all diseases were less than for the year 1843. But few troops were on field duty during 1844, the Florida Indian War having come to an end during 1842. Two striking and significant peaks of occurrence are shown in Chart I, the first marking the Civil War and the second the Spanish-American War. From an epidemiological and practical point of view the fact of greatest import- ance shown in the chart is the precipitate downward trend in typhoid admission rates which commenced in 1909. This reduction coincided with the introduc- tion of typhoid vaccine in the Army, as a preventive measure, the value of which is more clearly visualized in Chart II. As typhoid rates always increase markedly during war periods, it will be well to examine in greater detail, the rates in the Army during such periods. The admission and death rates for typhoid fever during the Civil, Spanish- American, and World Wars are shown in Table 1; comparable rates for the British Army during the South African War also are included for purposes of discussion. Table 1.— Typhoid fever. United States Army by war periods; also the British Army (South African War), showing admissions and deaths. Absolute numbers, rates per 1,000 per annum, and case mortality rates a Average annual strength Admissions Deaths Case mortality rate (per cent) War Absolute numbers Rates per 1,000 per annum Absolute numbers Rates per 1,000 per annum Civil War (1861-1866)—All troops Northern Army_____ 532,198 147, 795 209,404 1, 501,265 79,462 20, 926 59, 750 1,529 29.86 141. 59 114.13 .37 29,336 2,192 8,227 227 11.02 14.83 15.72 .05 36.92 10 47 South African AVar 0899-1901)—BritishArmy (2.5 years) -World War (1917-1919)—U. S. Army (2.75 years)_______ 13.77 14 85 ° Source of information: (1) Medical and Surgical History of War of the Rebellion, Part I, Medical Volume. (2) Report of the Surgeon General of the Army, 1900, p. 402. (3) Official History of the War, Medical Services Diseases of the War, Vol. I, London, His Majesty's Stationery Office, 11. (4) Monthly sick and wounded reports, Office of the Surgeon General, 1917-1919. The recorded morbidity rates for the Civil War do not give a true picture of the actual occurrence of the disease. Experience has taught that the case mortality rate for typhoid fever ordinarily is about 10 per cent. Calculation of the case mortality rate from the recorded morbidity and mortality for the Civil War gives a case fatality rate of 36.9 per cent which, manifestly is much too high. Reversing the process and calculating the morbidity rate from the 56706—2S—2 IS COMMUNICABLE AND OTHER DISEASES TYPHOID FEVER, ADMISSIONS AND DEATHS BY YEARS 1897-1919 ENLISTED MEN IN CONTINENTAL U.S., EXCLUDING ALASKA ANNUAL RATES PLR 1,000 HaX( >t per 1000 4 5 l 6 7 10 11 1837 1698 1999 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1910 1914 1915 1916 1917 1918 1919 z^? ::::::::::':':::::!:: ^F ^////////^^///^ v^////y//////y/////////////////y/////^^^ w//W/^^ gf/W^//W^^^^ ^/^^/V^^^^ y/y/yy/y^////^////^ WMMMWW'M/'. *>^ w;/;////;;/////m p _2 p World Wars Teriod 65.46 ► VoluTita,ri[ PropkuUctic Vaccination, "Compulsory Prophylactic Vaccination, Admissions D cases of typhoid fever occurred among enlisted men in camps in the United States during the World War, and in a large proportion of these cases the disease was contracted prior to reporting at camps. When we turn, however, to comparable conditions confronting our troops on the Western Front in France, the picture is a different one. The water sup- plies, as a rule, were not above suspicion of contamination, typhoid fever was of no uncommon occurrence in the civilian population, it was known to have occurred in troops occupying sectors in which most of our divisions operated,9 large numbers of cases of typhoid fever occurred in the relatively unprotected British Expeditionary Force in France during the early stages of the war,10 and the rates of incidence in the partially protected French armies for the first two years (1914-15) of the war were very high.9 The possibility of acquiring the disease from outside sources in France therefore, was, almost unlimited, and had our preventive measures not been effective the disease undoubtedly would have prevailed quite extensively. TOTAL NUMBER OF CASES It is necessary to have clearly in mind that this discussion relates to the occurrence of typhoid fever in individuals who had been protected against the disease by prophylactic vaccines, in so far as it was possible to carry out this procedure efficiently during the stress of hurried mobilization. In a consider- able number of instances the service records of individuals failed to bear notation that three doses of antityphoid-paratyphoid vaccine had been given; but investigation of the administrative procedures adopted in carrying out this protective measure and the safeguards instituted to prevent troops going over- seas without such vaccinations, warrants the statement that but few individuals received less than three doses of the saline vaccine or one of the lipovaccine. Prior to July 1, 1918, it was the custom to administer three doses of saline vaccine and after that date either three doses of saline vaccine or one of lipo- vaccine.11 All drafted men received protective vaccines immediately after reporting at mobilization camps. Examination of Table 3 indicates that during the World War (April, 1917 to December, 1919) the aggregate of the mean annual strength of our military forces was 4,128,479; during the same period, 1,529 primary admissions for typhoid fever were reported, the typhoid rate per 1,000 of strength being 0.37. The progress made in the control of typhoid fever since the Spanish-American War can be visualized more clearly when it is realized that, whereas during the Spanish-American War the total typhoid rate was 141.59 per 1,000, during the World War it fell to 0.37 per 1,000, the relative proportions being approximated 382 to 1. TYPHOID AND THE PARATYPHOID FEVERS 23 Table 3.— Typhoid fever and typhoid vaccination—Admissions, deaths, discharges for disa- bility, and days lost from duty, officers and enlisted men (white, colored, and native troops), United States Army, April 1, 1917, to December 31, 1919. Absolute numbers and ratios per 1,000 per annum Typhoid fever Total Admissions Deaths Discharges for disability Days lost annual strengths Abso-lute num-bers Ratios per 1,000 Abso-lute num-bers Ratios per 1,000 0.05 .06 .03 Abso-lute num-bers Ratios per 1,000 Abso-lute num-bers Non-effect-ive rates per 1,000 Total officers and enlisted men, includ-ing native troops_________________ -Total officers and enlisted men, Ameri-can troops______ _.- ... _ - ____ 4,128,479 4,092,457 206,382 1,529 1,527 49 0.37 .37 .24 227 227 24 24 0.01 .01 109,374 109,315 4,367 0.07 .07 .06 Total enlisted American troops: White____________________________ 3, 599,527 286,548 1,348 68 62 .37 .24 182 25 13 .05 .09 24 .01 97,104 3,904 3,940 .07 .04 .38 Total___________________________ 3,886,075 1,478 220 .06 24 .01 104,948 .07 36,022 2 .06 59 .00 Total Army in the United States (in-cluding Alaska) : Officers_________ ______________ White enlisted________ 124,266 18 .14 | 3 .02 1,132 .02 1,965,297 145,826 483 45 .25 .31 54 17 .03 .11 11 .01 25,020 2,435 .03 .05 2, 111, 123 528 .25 .24 71 .03 11 .01 27,455 .04 Total officers and men___________ 2,235,389 546 74 1 .03 11 .00 28,587 .04 United States Army in Europe, exclud-ing Russia: Officers_____---------- --- - --- White enlisted------------ ---- 73,728 27 .37 4 .05 2,844 .11 1,469,656 122,412 776 23 59 .53 123 .19 8 ______ 13 .08 .07 13 .01 68,407 1,469 3,929 .13 .03 Total enlisted. —_ ------------ 1,592,068 858 .54 144 .09 13 .01 73,805 .13 Total officers and men....._- -. 1,665,796 885 .53 148 .09 13 .01 76,649 .13 Officers, other countries____________ 8, 388 4 .48 ______ 391 .13 United States Army in Philippine Is-lands: 16, 995 4,456 Colored enlisted... .__ _----- Total enlisted___......- ----- 21,451 United States Army in Hawaii: 16,161 3,319 50 3.09 4 .25 3,305 .56 19,480 50 2.57 | 4 .21 3,305 .47 United States Army in Panama, white 19,688 1 1 United States Army in other countries not stated: 38 3 343 _______ 11 1_______ 14,232 41 2.88 354 .07 Transports: 97,498 108,033 18,576 5,615 11,831 1 1 1 .01 .01 .05 1 .01 29 .00 1 .01 29 .00 Native troops enlisted: 8 .00 1 1 51 i .01 1 24 COMMUNICABLE AND OTHER DISEASES Table 3.—Typhoid fever and typhoid vaccination—Admissions, dea lis, discharges for• disa bilitii, and days lost from duty, officers and enlisted men (white colored, and natuctwops). United States Army, April 1, 1917, to December 31, 1.919. Absolute numbers and ratios per 1,000 per annum—Continued Typhoid vaccination Admissions Discharges for disability Days lost 1 Absolute numbers 35, 552 35,149 Ratios per 1,000 Absolute numbers Ratios per 1,000 Absolute numbers Ratios per 1,000 Total officers and enlisted men, including native troops._ S. 61 8.59 5 5 0.00 .00 156,548 155,614 2,325 0.10 .10 593 1 2.87 .03 Total enlisted American troops: 30,915 , 8.59 3,606 12.58 4 1 .00 .00 129,713 23,277 299 .10 .22 1 34,556 8. 89 5 .00 153,289 .11 403 11.19 934 .07 Total Army in the United States (including Alaska): 564 4.54 2,220 .05 30,080 15.30 3,562 24.42 4 1 .00 .01 121,528 22,885 .17 .43 33,642 15.94 5 .00 144,413 .19 34,206 15.30 5 .00 146,633 .18 United States Army in Europe, excluding Russia: 14 .19 72 .00 363 11 34 .25 .09 6,633 306 298 .01 .01 408 .26 7,237 .01 ----- 422 .25 7,309 .01 15 1.79 33 .01 United States Army in Philippine Islands: 39 12 2.29 2.69 189 19 .03 .01 51 2.38 208 .03 United States Army in Hawaii: 230 21 14.23 6.33 656 67 .11 .06 251 12.89 ! 723 .10 United States Army in Panama, white enlisted___ 41 2.08 122 02 United States Army in other countries not stated: 10 1 95 1 Total____________________________________ 11 | .77 96 .02 Transports: White enlisted. _ ... ... 152 ' 1. 56 152 | 1.41 86 ' 4.63 17 1 3.03 300 1 2K 3fi ,---------- 490 490 91 568 .01 .01 .04 .04 .13 Total enlisted____ . . ___ ..._________. Native troops enlisted: 1 RELATIVE IMPORTANCE OF TYPHOID FEVER AS A CAUSE OF ADMISSION TO HOSPITAL FOR DISEASE AND OF DEATHS FROM DISEASi. The fact that typhoid fever, comparatively speaking, was of minor impor- tance as a cause of admission to hospital for disease during the World War is well shown in Table 4. TYPHOID AND THE PARATYPHOID FEVERS 25 Table 4.—Typhoid fever. By country of occurrence, showing percentage relationship to total admissions and deaths from disease, and relative standing among the 30 most common causes of admissions and deaths, April 1, 1917, to December 31, 1919 Officers: United States___________________ Europe_________________________ Total officers (including other countries). American enlisted men, United States... E urope_________________________ Hawaiian Islands________________ Total enlisted (including other countries) Native troops: Filipino________________________ Porto Rican_____________________ Total native troops__________________ Total, U. S. Army___________________ Admissions Deaths Percentage relation-ship to total diseases Relative standing among 30 most common diseases Percentage relation-ship to total diseases Relative standing among 30 most common diseases 0.02 .07 0.35 .71 22 11 .04 .47 15 .02 .10 .42 .21 .69 10.26 19 10 2 .04 .39 13 .01 .01 .01 _______ .04 _________ .39 13 Typhoid fever contributed only 0.04 per cent of the total admissions to hospital for all diseases, and in no country in which our military forces served did it prevail to such degree as to give it a rating in the list of the 30 diseases of most frequent occurrence. Of all deaths from disease during the World War only 0.39 per cent were attributable to typhoid fever, and in the list of the 30 diseases most frequently resulting in death, in order of importance (1 to 30), it occupied the thirteenth place. DISTRIBUTION BY GRADE (COMMISSIONED AND ENLISTED PERSONNEL) The admission rate for commissioned personnel was appreciably lower than for enlisted—officers, 0.24, and American enlisted, 0.38 per 1,000. This is explicable on the basis of better education, higher degree of intelligence, a more comprehensive knowledge of personal hygiene and sanitation and their corol- laries, more intelligent compliance with instructions and orders, and better personal hygienic and environmental sanitation. RACIAL DISTRIBUTION The morbidity rate for white enlisted personnel was considerably higher than for colored—white American, 0.37; colored American, 0.24 per 1,000. The most probable explanation of the higher rate in white American troops is that it was due to the fact that a relatively larger proportion of white troops were engaged in operations in highly contaminated areas (combat areas), with a correspondingly greater exposure to infection. DEATH RATE The general death rate from typhoid was 0.05 per 1,000 per annum. The recorded case fatality rate was approximately 15 per cent. For the reasons pointed out elsewhere this is considerably higher than actually occurred. 20 COMMUNICABLE AND OTHER DISEASES Complete investigation of localized outbreaks and comprehensive studies of large groups of cases indicate that the case fatality rate was approximately 11 per cent and were exact data available it doubtless would be found to have been less than 10 per cent. DISCHARGE ON ACCOUNT OF DISABILITY A total of 24 men were discharged from the service on account of disability resulting from an attack of typhoid. Of the total number of individuals dis- charged for disabilities resulting from diseases, only 0.014 per cent were dis- charged for disabilities incident to typhoid, and in the list of the 30 diseases most frequently resulting in discharge for disability typhoid does not appear. NONEFFECTIVE RATES A total of 1,529 primary admissions for typhoid were reported and these men were absent from duty a total of 109,374 days. The average loss of time from duty per case of typhoid was, therefore, 72 days. SEASONAL DISTRIBUTION In general, the seasonal distribution in troops during the World War con- formed to the well-known seasonal distribution of typhoid fever in temperate and cold climates—highest incidence in the late summer and fall months, particularly for cases developing in the United States. In Europe, however, a very considerable proportion of the cases arose during the winter months— November, 1918, to March, 1919, inclusive—due, doubtless, to increasingly constant exposure to massive doses of the infective agent. GEOGRAPHICAL DISTRIBUTION The recorded mortality rate for the civilian population of Manila, Philip- pine Islands, for the period 1917 to 1919, inclusive, was 1.84 12 per 1,000 per annum, while that for American and Filipino troops serving in the Philippines during the same period of time was practically nil (1 case, or 0.05 per 1,000, for the period). The admission rate per 1,000 for total enlisted strength for the period was 2.57 for Hawaii, 0.54 for Europe, and 0.25 for the United States. Expressed in comparative ratios these figures mean that for every one case of typhoid fever occurring in troops in the United States approximately two cases occurred in troops in Europe and ten cases in troops serving in Hawaii. TYPHOID FEVER IN HAWAII An explosive outbreak of typhoid fever, definitely traced to the water supply, occurred at Schofield Barracks, Hawaii, in the fall of 1917. The follow- ing abstract summarizes the epidemiology of this outbreak: 13 Schofield Barracks, the largest Army station in Hawaii, is located on the northern end of the island of Oahu, about 23 miles from Honolulu. The regular water supply for the station was obtained from two sources. The old section of the station was supplied mainly with water collected in tunnels and brought down through a system of tunnels and pipes from a range of mountains adjacent TYPHOID AND THE PARATYPHOID FEVERS 27 to and to the west of the station. The new section of the station, about 1 mile distant, was supplied by a gravity system having its main intake in the Koolau Mountain Range in the headwaters of the fork of the Kaukonahua River on the opposite side of the island. This supply was not subject to con- tamination except that certain sections of the tunnels in the upper reaches were open. Overflow and additional small streams came together, below the intake for the regular supply, forming a stream at the bottom of the ravine. On this stream, below the intake for the permanent water supply, was located a pumping station to augment the permanent supply, when necessary. This auxiliary supply was not supposed to be used without previously informing the sanitary authorities, through whom instructions would emanate as to the proper treat- ment of the water. At times water from the auxiliary supply for the new post also was pumped to the old post to augment the permanent supply, but at no time was this done during the course of the epidemic to be reviewed. The pumping station for this auxiliary supply was located at the lowest point of the watershed and the water itself was subject to constant contamination from camps of Japanese laborers engaged in construction work on the water supply system at the time the outbreak of typhoid occurred. These camps were on the hillside below the water mains and about 45 feet above and 55 to 100 yards distant from the bed of the stream constituting the auxiliary supply. In the early days of August, 1917, a Japanese laborer arrived at one of the camps and, though he did not report for treatment, it was learned at a later date that he was ill for some time with a continued fever that doubtless was typhoid. While ill, he was visited by a Japanese friend (Mizusawa) employed at one of the construction camps. Mizusawa had not been inoculated against typhoid fever and came down with typhoid fever during the latter part of Au- gust. He worked for several days after he became ill, continuing to live at the camp, and he failed to report for treatment. He stopped work on September 1, but remained at camp until September 7. He was admitted to hospital in Honolulu on September 15 and was having hemorrhages from his intestines at that time. This patient was interrogated at the time the epidemic was under investigation and examination of his blood gave a positive agglutination reaction with B. typhosus in high dilution. While at the quartermaster con- struction camp this man had used an insanitary privy located on the drainage shed of the stream constituting the source of the auxiliary water supply for the new section of Schofield Barracks. From the middle of August to the middle of September, 1917, the rainfall on the watershed of the regular water supply system for the newer part of the post was so low that it became necessary, more or less constantly, to supplement the regular supply with water from the auxiliary system. The sanitary authori- ties at Schofield Barracks had no knowledge of the fact that this was being done. On September 13 and 14 rather heavy rains occurred on the watershed used as an auxiliary water suppy and following these rains it was noted at Schofield Barracks that the water from the source was quite muddy. Within 10 days after these heavy rains fell cases of typhoid fever began to appear, and within a comparatively short period of time 100 cases had occurred. All individuals who contracted the disease gave a history of drinking the contaminated water 28 COMMUNICABLE AND OTHER DISEASES within the incubation period of the disease. Of the total population—military and civilian—exposed to infection, 4,087 had been vaccinated with antityphoid- paratyphoid vaccine and 812 had not been so protected. No persons living in the older section of the post contracted typhoid except an occasional individual who gave a definite history of drinking water in the newer section of the post on the evening of September 14 or the following day. The comparative mor- bidity and mortality rates from typhoid fever in these two groups are shown in Table 5. Table 5.—Typhoid fever. Schofield Barracks, Hawaii. Vaccinated and unvaccinated groups, population, admissions and deaths. Absolute numbers, with rates per 1,000 and case fatality a Popula-tion Admissions Deaths Case Groups Absolute numbers Rate per 1,000 Absolute numbers Rate per 1,000 fatality per cent Vaccinated groups.......___________________________ Unvaccinated groups______________________________ 4,087 812 55 45 13.46 55.42 4 7 0.98 8.62 7.27 15.56 ° Source of information: Russell, F. F.: Typhoid fever in the American Army during the World War. The Journal of the American Medical Association, Chicago, lxxii, Dec. 20, 1919, 1863. These statistics demonstrate conclusively the protective value of pro- phylactic vaccination, the relative morbidity rate for the nonvaccinated to vaccinated being approximately 4 to 1. They show also that the complete eradication and prevention of typhoid can be accomplished only by a com- bination of prophylactic vaccination and efficient environmental sanitation and personal hygiene. The lower case mortality rate in the vaccinated group is confirmatory of other observations that appear in medical literature. TYPHOID FEVER IN EUROPE (RUSSIA EXCEPTED) The greater frequency of occurrence of typhoid in American troops on active service in France than in the United States justifies a somewhat detailed discussion of the epidemiology of the disease in the former area of activity. In the United States many of the cases occurred in unvaccinated individuals, but all troops in Europe presumably had been vaccinated; in the United States environmental sanitation in mobilization camps was excellent, while in Europe many defects existed, particularly so in the battle areas where the military objectives necessary of attainment prevented proper attention to sanitation; and general exposure to typhoid infection was much greater in France than in the United States. The prevalence of typhoid fever in American Expeditionary Forces for the period of the World War is shown in Table 3. The total number of cases recorded as primary admissions was 885 (0.53 per 1,000). The occurrence of the cases by months is presented graphically in Chart IV. The data incorporated in Chart IV pertain to all bacteriologically proven as well as clinically diagnosed but not bacteriologically proven, cases of typhoid fever reported to the chief surgeon's office, A. E. F. They include also cases reported as primary admissions for typhoid fever as well as cases of typhoid TYPHOID AND THE PARATYPHOID FEVERS 29 TYPHOID FEVER note: hath O.ven /„- POSITIVE, CLINICAL AND SUSPECT CASES CLUDE ALL CASES REPORTED- -_.««„„- _~-_,-i!? THE V*7" SHOWING STRENGTH, CASES REPORTED AND RATES TER 100,000 OF STRENGTH TOR. -WEEKS ENDING POSITIVE, CLINICAL ANP SUSPECT Q JUSPECT E3 Ci/W/CAZ, ■ POSITIVE^ YEAR JAN. 19 10 FE.& MAR. APR..MAY JULYAUQ 3| DAY GERMAN OFFENSIVE MAR.El CAHTIGNV CHATEAU ST.MIHIEl AR&ONKE abmij- OCCUPATION OF THE MAYZ8 THIERRY 5EPT.IZ JEPT.Zb Tic" COB-EMTZ -RlMiEHEAD NOV. II DEC. 17 JULY 16 Chart IV 30 COMMUNICABLE AND OTHER DISEASES complicating, or concurrent with, other diseases or battle injuries, and represent very closely the actual prevalence of typhoid fever in France. This chart shows that, prior to June, 1918, practically no typhoid fever occurred in American troops in France (there was a total of nine cases only); that an increase in the disease occurred in June, 1918, bringing the morbidity rate up to 0.03 and that again in December, 1918, and January to March, 1919, increases in rates oc- curred. The various elevations of the morbidity curve referred to above correspond with the occurrence in a few organizations located in various parts of France and more particularly the somewhat widespread but limited occurrence of the disease from November, 1918, to January, 1919, inclusive, in certain of the divisions that had taken part in the Meuse-Argonne operation. That the origin and spread of typhoid fever in the American Expeditionary Forces were due to defects in sanitation that usually operate to initiate and disseminate the disease is well shown in the review of the epidemiology of the more important of the outbreaks, namely, those occurring in— Case- Company No. 4, Camp Cody replacement unit, July, 191S_____________________ 95 77th Division, December, 1918, to January, 1919____________________________ 122 79th Division, December, 1918, to March, 1919_____________________________ 61 88th Division, January, 1919, to March, 1919_______________________________ 21 Medical Department units at Curel, December, 1918, to January, 1919_____________ 72 Motor Transport Camp, Marseille, March, 1919_____________________________ 64 Typhoid Fever in Company No. 4, Camp Cody Replacement Company On June 15, 1918, three replacement units left Camp Cody, Deming, N. Mex., for Camp Merritt, N. J., en route to France.14 Company No. 4, with an enlisted strength of approximately 248 men, was a provisional one, both com- missioned and enlisted personnel being made up of individuals casually attached by transfer. All three companies arrived at Camp Merritt, N. J., on June 21, and none reported any serious illness. Company No. 4 was the only one of the three in which typhoid fever occurred. Company No. 4 sailed for England on June 28, arriving in Liverpool on July 11. During the passage across the Atlantic many cases of so-called sea- sickness were reported, of which doubtless a considerable proportion were in reality typhoid fever. The company left Liverpool on July 11 and arrived in St. Aignan, France, via Cherbourg, shortly thereafter. During this trip, typhoid suspects transferred to hospital were as follows: July 11, Liverpool] England, 3; July 12, Romsey, England, 4; July 14, Southampton, England] 34; July 15, Cherbourg, France, 17; July (date unknown), St. Aignan, France] 3. Men continued to be taken ill for a period of 10 days after the arrival of the company at St. Aignan, the last case of typhoid having been admitted to hospital on July 28. The following information is summarized from reports of investigation of the outbreak in England 14 and France.15 The incubation period of a large proportion of the cases was of such length as to indicate that most of the men contracted the disease while traveling by train from Camp Cody, N. Mex., to New York. The three companies trav- eled on the same train, but cases of typhoid arose in Company No. 4 only So far as could be ascertained by inquiry, general sanitary conditions on the train were alike for the three companies. TYPHOID AND THE PARATYPHOID FEVERS 31 The data on the service records and other evidence obtained indicated that antityphoid-paratyphoid vaccines had been given to all men in Company No. 4 at Camp Cody. Two of the men first taken ill in England stated that they had not felt well prior to their departure from Camp Cody, but had not reported themselves to a medical officer because of their eagerness to go to France. One of these men developed a severe diarrhea, with cramps, while en route to New York. The other man who did not have typhoid during the outbreak was later proven to be a typhoid bacillus carrier. A kitchen car was used in common by Companies No. 3 and No. 4, the personnel of one company being located in tourist sleeping cars in front of the kitchen car and that of the other company behind the kitchen car. The drinking water used by Com- pany No. 4 was distributed from the usual type of water tank used on American railway cars and was not readily subject to contamination on the train. There was, however, a supplementary supply for Company No. 4, consisting of a large open barrel filled with water and placed in the vestibule between two of the sleeping cars. This could very easily have become con- taminated, as the only means for obtaining water was by dipping the tin cup or canteen in the barrel. Washing and toilet facilities aboard the train were taxed to the limit. Available evidence suggests that two of the men in the company were in the early stages of typhoid during the railway trip, that there was one bacillus carrier in the company, and that in all probability the unprotected drinking water in the open barrel was grossly contaminated by an individual or individ- uals in the early stages of the disease or by carriers of the organism. Certain it is that the defects in environmental sanitation were more marked during the railway trip than at any other stage of the journey to France. In no other instance during the World War did such a large number of cases of typhoid fever occur in any one company, and in no other outbreak was the spread of the infection so sharply restricted. Ninety-five cases occurred in an organization with a total strength of 248 men and the case death rate was 8.3 per cent (8 deaths). The outbreak in this organization was most care- fully studied both clinically and bacteriologically and the diagnosis was con- firmed bacteriologically in a large proportion of the cases. Typhoid and Paratyphoid Fevers in the 77th Division This division took an active part in the Meuse-Argonne operation. Typhoid fever was known to have prevailed previously in endemic form in this sector, having been reported in both allied and enemy troops. The initial cases of typhoid fever in the division appeared during November, 1918, and failure to enforce sanitary discipline resulted in further spread of the disease during December, 1918, and January, 1919. An epidemiological investigation of the occurrence of typhoid and paratyphoid fevers in this division was made,16 the report of which is the source of the following summary: During the period November, 1918, to January, 1919, inclusive, a total of 97 cases of typhoid and 25 of paratyphoid fevers occurred in the division. Eighteen of the cases appeared in November, 1918; 79 inDecember, 1918; and 25 in January, 1919. So far as could be determined, typhoid-paratyphoid 32 COMMUNICABLE AND OTHER DISEASES vaccine had been administered to the entire division. Of the total number of cases of typhoid and paratyphoid fevers, 74 occurred in one regiment, namely, the 307th Infantry, and most of the cases arising in this regiment were reported from the 2d and 3d Battalions. These two battalions, after the armistice, were stationed in small towns along the river Aube. These valley towns were flooded during the entire period from December, 1918, to January, 1919, and great difficulty was experienced in providing proper latrines, particularly in the town of Clairvaux, at which place it was necessary to move one of the latrines four times because of high water. All organizations of the divisions, except the 2d and 3d Battalions, 307th Infantry, and Company E, 305th Infantry, were located on somewhat higher and better drained ground during this period. Investigation of the outbreak indicated that sanitary discipline in the divi- sion was poor, that some units were without company water bags for several days, and that after water bags were obtained and the water was chlorinated many men continued to use water from unauthorized sources, claiming that the water furnished was overchlorinated and unpalatable. Inspection of the chlorination of water supplies used by the division disclosed the fact that in 35 per cent of the supplies no trace of excess chlorine could be demonstrated and in approximately 20 per cent of the water bags such great excess of chlorine was present as to render the water unpalatable. The evidence collected indicated that a few men in this division picked up typhoid or paratyphoid in the Argonne, that after the armistice the division was stationed in areas of typhoid endemicity, that the gradual spread of the disease was due to poor sanitary discipline, and that in the organizations in which lowered morale and poor discipline were most evident and sanitary defects were most difficult to remedy the disease gained greatest headway and was most difficult to eradicate. Typhoid Fever in the 79th Division Diarrhea prevailed somewhat extensively in the 79th Division during October and November, 1918, diminishing during December and January. All regiments were involved, particularly the 315th and 316th Infantry.17 Troop movements of the division are of interest as during the latter part of October and the first part of November the regiments occupied territory around Etraye, Reville, Crepion, and Gibercy. This region had been occupied by German troops, and that diseases of the intestines were common in this area is shown by the fact that the German hospital near Damvillers had special latrines reserved for "intestinal cases." All regiments of the division, at one time or another, occupied the Etraye and Crepion areas. The 313th Infantry was removed from this locality on November 23 and the 314th on November 11, while the 315th and 316th remained until December 26, 1918. While in action during the first part of November the troops drank water from shell holes, springs, wells, and surface water wherever found. Diarrhea became so general that 50 per cent or more of the personnel of the division was affected and 61 of the cases were diagnosed definitely as being typhoid fever An investigation for typhoid carriers was undertaken in the 315tri Infantry, the cooks and permanent kitchen police (336) being examined Of these, 57 gave a history of diarrhea. Nine carriers were found (eight typhoid TYPHOID AND THE PARATYPHOID FEVERS 33 and one paratyphoid A). Samples of water from various sources in and about Crepion, Etraye, and Reville gave positive tests for B. coli. The evidence gathered indicated that the initial cases were acquired by drinking contaminated water and that the spread of the disease was due mainly to carriers. Sanitary discipline in this division was not good. Typhoid Fever in the 88th Division An outbreak of typhoid fever occurred in the 88th Division in the early part of 1919, limited very largely to the 2d Battalion, 350th Infantry, located at Morlaincourt.17 A total of 12 cases occurred, the highest number for a single week having been reported during the week February 12-18, 1919. The investigation of this outbreak disclosed the fact that there were three sources of water to which this organization had access. One source was found to be potable, and no cases of typhoid fever arose among the men using this water ex- clusively. The two remaining sources were found to be grossly contaminated, one of them arising as a spring under a house in which there was a case of typhoid fever. There were at least 27 cases of the disease among civilians, and soldiers were billeted in a number of houses in which cases of typhoid were present. Eleven soldiers living in such houses contracted the disease. Typhoid Fever in Medical Department Units at Curel, France In December, 1918, and January, 1919, there occurred among troops bil- leted at Curel (Haute Marne), France, an outbreak of typhoid fever with 72 cases.18 Twenty-one deaths occurred, but it is known that a large number of secondary pneumonias developed as complicating factors, and the case mortality rate from typhoid itself was not excessive. The troops stationed at Curel numbered about 70 officers and 1,782 men, constituting the personnel of Evacuation Hospitals Nos. 25, 31, 32, 33, 34, and 35; Mobile Hospitals Nos. 100, 101, 102, 103; and the 106th, 113th, and 301st Sanitary Trains, the first and third of these being skeletonized. All had one or more cases of typhoid fever except Mobile Hospital No. 101 and the skeletonized sanitary trains. Evacuation Hospital No. 33 had 28 cases, 39 per cent of the total, and Evacuation Hospital No. 25, 15 cases, or 21 per cent of the total. The first organization arrived in this area November 29, the others con- tinuing to arrive until December 8, 1918. Water was not chlorinated from November 29 to December 9 because of lack of supplies of hypochlorite. The supply of hypochlorite was again exhausted December 20, and did not again become available until December 27. The water supply of the village was from four springs and many wells. No sanitary survey of the water supply was made by American medical authori- ties until after the epidemic was under way; a survey made at that time indi- cated that all the village water was nonpotable in its raw state. The chief source of water supply for the troops was a spring, within a radius of 125 feet of which were six privy vaults, four being on ground higher than the spring. All were overflowing with fecal matter. 56706—28—3 34 COMMUNICABLE AND OTHER DISEASES Some cases of diarrheal disease were reported among the inhabitants of Curel, but no typical typhoid fever was seen. There was no diarrhea or gastro- intestinal disturbance among any of the organizations prior to their arrival at Curel and none of the organizations stationed there had seen service in any of the front areas. Approximately 75 per cent of the troops suffered with diarrhea during their stay at Curel. Gastrointestinal disturbance coininenced a few days after arrival of each contingent and persisted until January 7, when it began to diminish, finally disappearing altogether on January 18. As a rule, the diarrhea was not severe in character, persisted for a few days only, the stools were not bloody, and there was no fever. Cases of typhoid fever began to appear on December 19, reaching the maximum in number on January 2, declining thereafter but persisting until January 15. No contact relationships could be established. The organiza- tions having the largest number of cases were billeted in sections of the village far distant the one from the other. The individual service records of the personnel and other information available indicated that all men had been vaccinated against typhoid and paratyphoid fevers. Some of the men were among the later draftees and had received lipovaccine, but there appeared to be no relationship between the prevalence of typhoid fever in the various units and the type of vaccine used or the length of time elapsing since vaccination. The general character of the epidemic, its rapid rise to a peak and sharp decline, with no definite remis- sions, pointed to a water-borne epidemic. Confirmatory of this interpretation is the fact that the incubation period for most of the cases indicated that infec- tion was acquired during the time when the water was not treated. When regular and continuous chlorination of the water was begun, on December 27, the incidence rate dropped rapidly and the outbreak came to an end. Typhoid Fever in the Motor Reception Park, Marseille Typhoid fever occurred in motor reception park No. 752 in Marseille from the latter part of February to the latter part of April, 1919.19 There were 64 cases with 7 deaths (case mortality, 11 per cent). The epidemic was clearly proved to be of water-borne origin. The camp was divided into three sections, A, B, and C. All cases occurred in section C. The water supply for sections A and B was the regular supply used by the city of Marseille, which passed through a central sedimentation plant before use. It was probably not above reproach, but the sedimentation process reduced the contamination to a minimum. The water supply for section C was an offshoot from the regular city supply. It was piped into camp from an open canal which wound for many kilometers through villages, past farm houses, and country roads. Along the banks of this canal deposits of human feces frequently were observed. These disappeared after rainstorms, being washed into the canal. The water as it arrived at camp was full of worms, snail shells, and much organic sediment. Three open taps were installed in section C, for the purpose of washing trucks and filling their radia- tors. On investigation it was found that 31 of the first 33 patients admitted having drunk the raw water from these taps more than half the time, despite warnings issued against drinking this raw water and ready access to Lyster bags in which was an abundance of treated water. Correction of existing defects in the water supply in section C brought the outbreak to an end. TYPHOID AND THE PARATYPHOID FEVERS 35 Minor Outbreaks of Typhoid Fever Of minor outbreaks of typhoid fever that occurred in various parts of France the following were the more important: In an Engineer detachment at Bazoilles,20 15 cases, August, 1918; 323d Infantry, 81st Division, 10 cases, December, 1918; Battery E, 321st Field Artillery, 82d Division, 22 cases, January and February, 1919. These and other minor outbreaks were care- fully investigated and their epidemiology was of like nature to that of the outbreaks reviewed above. In the American Third Army in Germany.—The discussion of typhoid fever in our armies in Europe would be incomplete without brief reference to its occurrence in the American Third Army in Germany, which is summarized in the following quotation:21 Typhoid fever has been present in the Third Army since its formation, but the incidence of this disease has fallen off noticeably since the army has settled down and opportunity has been afforded for the establishment of improved sanitation. During the interval, Decem- ber 22 to March 11, 63 cases of typhoid fever were reported from organizations of the Third Army. An analysis of these cases with reference to date of onset of the disease brought out the fact that in the majority infection was acquired either during the march to the occu- pied territory or in the days immediately following the arrival of organizations at their destinations. Since that time the incidence of typhoid fever in the army has been in no sense alarming, and in one or two instances the infection was known to have been acquired outside the occupied territory. Revaccination of the army with lipovaccine was commenced in March. TYPHOID FEVER IN THE UNITED STATES The total number of cases of typhoid fever recorded as primary admis- sions in the United States during the World War was 546 (0.24 per 1,000 strength). The morbidity rates for all the large mobilization camps are tabulated in Table 6. Table 6.— Typhoid fever. Admissions, enlisted men, by camps, September 1, 1917, to Decem- ber 31, 1918. Absolute numbers and rates per 1,000 a Camps Beauregard, La- Bowie, Tex____ Cody, N. Mex.. Custer, Mich__ Devens, Mass.. Dix, N.J______ Dodge, Iowa___ Doniphan, Okla Fremont, Calif.. Funston, Kans.. Gordon, Qa____ Grant, 111______ Greene, N. C___ Hancock, Ga___ Jackson, S. C___ Johnston, Fla... Lee, Va_______ Lewis, Wash___ 1917 (September- December) 1918 Logan, Tex_______ I Mac Arthur, Tex... McClellan, Ala____ Meade, Md______ Mills, N. Y_______ Pike, Ark________ Sevier, S. C........ I Shelby, Miss_____ [ Sheridan, Ala_____ Sherman, Ohio____ Syracuse, N. V____ Taylor, Ky_______ Travis, Tex______ Upton, N. Y______ Wadsworth, S. C... Wheeler, Ga______ Total_______ 1917 (September- December) 1918 1919, pp. 922,923. 1 Source of information: Annual Reports of the Surgeon General, U. S. Army, 1918, pp. 118,119, and Abso- lute num- bers Rates per 1,000 strength Abso-lute num-bers Rates per 1,000 strength Camps lute Rates num- Pf1'!™ bers strength Abso-lute num-bers Rates per 1,000 strength 0.51 1.78 Abso-lute num-bers Rates per 1,000 strength 2 13 3 4 1 4 0.19 .24 .06 __ _ .15 1 20 1 .12 3.15 .16 .98 2 2 1 2 4 11 S 3 17 5 .06 .07 .05 .13 1 1 1 .10 .13 . 14 .10 .25 .03 .54 4 2 .45 .25 2-< .14 .Ill- 2 2 .26 . 19 .42 .16 iformation: Annual Reports of the Surgeon ( 36 COMMUNICABLE AND OTHER DISEASES The tabulation includes the years 1917 September to December and 191S only, as many of the mobilization camps were closed by the early months of 1919. No cases whatsoever of typhoid fever occurred in one-third (10) of the camps listed in Table 6 during 1917 and in one-fifteenth of the camps in 191S. In 33 per cent of the camps less than three cases were reported in 1917, while 44 per cent of the camps reported less than three cases during the year 1918. More than 50 per cent of the cases recorded in this table occurred in individ- uals who reported at mobilization camps in the incubatory stage of the disease. The conclusion to be drawn from the information set forth in this table is that, compared with our experience during the Spanish-American AVar, scarcely any typhoid fever occurred in our mobilization camps. It also evi- dences the fact that very rapid progress has been made in the eradication of typhoid fever in the civil population throughout the United States of America since the Spanish-American War. The other very important reversal of our Spanish-American AArar expe- rience is that while one or more cases of typhoid fever occurred in all camps— Camp Kearny, Calif., excepted—at some time during the AAorld AATar, the disease did not become disseminated throughout the commands as was so universally the case during the Spanish-American AArar. That a large proportion of the 546 individuals who had typhoid fever in the United States had contracted the disease before protection could have been afforded by vaccination is evident from the following abstracts from reports on file in the Office of the Surgeon General of the Army. The surgeon at Camp Devens, Mass., reported that the case of typhoid fever reported from that camp in 1917 occurred in a drafted man five days after his arrival at camp.22 The surgeon at Camp Dix, N. J., reported that the 14 cases of typhoid occur- ring in that camp during October, 1917, were probably brought in by the September increment of drafted men.23 The surgeon at Camp Sherman, Ohio, reported that the one case of typhoid fever in that camp in 1917 was contracted by the soldier at Prospect, Ohio, and the man never had been vaccinated.24 The same surgeon reported 12 cases (not included in Table 6, as the cases arose prior to federalization) in Company H, 3d Ohio Infantry, that were charged to sources other than those for the camp. None of the men had been protected by vaccination, and had probably contracted the disease by drinking water from a condemned well at Springfield, Ohio. There were seven cases at Camp Travis in 1917, all brought in from outside sources. The triple vaccine offered general immunity.25 The 10 cases reported at Camp McClellan in 1917 occurred in the 5th New Jersey Infantry. The cases were brought into the camp, and examination of the individual service records of the command showed that in practically every instance protective inocula- tion had not been completed. The camp surgeon at Camp Gordon, Ga., reported that a few cases of typhoid fever were treated in the hospital during 1918, but it was possible to establish in every instance the fact that the individual brought the infection to camp with him.26 The camp surgeon at Camp Shelby, Miss., reported that this relatively rare disease in the Army camps was introduced in this camp when there appeared 4 cases in July and 4 cases in August who were either TYPHOID AND THE PARATYPHOID FEVERS 37 suffering from clinical typhoid fever when they entrained or gave manifesta- tion of the disease after being in the camp only a few days.26 Among the 8 cases of proved typhoid fever, 4 cases had received no typhoid inoculation, 2 cases only one dose, and 2 had two inoculations. The camp surgeon at Camp Greene, N. C, reported that typhoid fever occurred in a small number of cases, particularly in a small epidemic in June and July, 1918, and mostly in recruits who had not been inoculated.26 Of 74 deaths from typhoid fever among enlisted personnel serving in the United States, 41, or 55 per cent, occurred in individuals who had been on active service for less than two months and these doubtless were deaths from typhoid fever in individuals who either had not been given protective inocula- tions or in whom no active immunity had been produced for one reason or another. In so far as the military forces serving in the United States are concerned there is ample justification for the statement that no epidemics of typhoid fever occurred throughout the period of the war. This triumph in preventive medicine is attributable to three factors—antityphoid inoculation; excellent environmental sanitation; and the progress made in the gradual elimination of typhoid fever from the civil population during the two preceding decades. The one outbreak of typhoid fever among civilians under governmental but nonmilitary control in the United States that assumed epidemic propor- tions occurred at one of the camps for interned enemy aliens at Hot Springs, N. C, in the summer of 1918.27 The essential epidemiological features of this outbreak are as follows: The epidemic, consisting of a total of 183 cases, was limited to enemy aliens in the internment camp, and the cases were transferred for treatment to United States Army General Hospital No. 12, located at Biltmore, N. C, about 50 miles distant. The epidemic was directly traceable to accidental contamination of the water supply of one section of the camp, which was connected, for fire-prevention purposes only, with an intake from the French Broad River, afterward found to be contaminated. The epidemic began July 1, 1918, when 4 men became ill with typhoid fever. During the month of July, 88 cases occurred and during August, 95. August 23 marked the onset of the last case. At the beginning of the epidemic none of the interned aliens had been protected by inoculation against typhoid. Prophylactic inoculations with antityphoid vaccine first were offered as a voluntary measure, but the response was so poor that it was decided to make the vaccination compulsory. This was done August 1. The cases studied in this epidemic fall into four groups: The first consisted of uninoculated, 70 patients; the second of 73 who had received 1 inoculation; the third of 21 who had received 2 inoculations; and the fourth of 4 cases with 3 inoculations. The degree of protection furnished by the belated effort to immunize men at the internment camp at Hot Springs is uncertain. Efforts were made to determine the relative degree of protection afforded by vaccina- tion during the epidemic, the comparative study being based on the four groups mentioned above. The average duration of fever in uncomplicated cases 38 COMMUNICABLE AND OTHER DISEASES in the first group (unprotected) was 37 days, hi the second group (1 inoculation) 31 days, and in the third and fourth groups 24 and 29 days, respectively. In the first group 18 per cent of the cases developed complications, in the second group only 12 per cent, and in the third and fourth groups no complica- tions appeared. In the 13 noninoculated cases with complications the average duration of fever was 80 days, and in 9 patients with complications who had received 1 inoculation the average duration of fever was 64 days. OCCURRENCE OF TYPHOID FEVER IN THE ARMIES OF SEVEN OF THE NATIONS PARTICIPATING IN THE WORLD WAR A comparison of the rates of prevalence of typhoid in the armies of the various nations engaged in the AA'orld AA'ar (Great Britain, France, Italy, Belgium, Germany, Austria, and the United States) is of more than passing interest, particularly if analyzed from the viewpoint of the preventive measures initiated by the armies of each nation. Complete statistical data are not available; however, sufficient information is at hand to warrant its tabulation and discussion. This information is given in Table 7. Table 7.—Typhoid fever. By years of occurrence in the armies of seven of the important nations involved in the World War, showing number of cases and deaths with ratios per 1,000 per annum, and case fatality rates, 1914 to 1919 a Country Cases Abso- lute num- bers Ratio per 1,000 United States________ ... . Great Britain______________ France____________________ Italy______________________ Belgium__________________ Germany_____________________ Austria_______________________ 7, 388 45, 450 Country Cases Abso- lute num- bers Ratio per 1,000 United States. Great Britain. France______ Italy________ Belgium_____ Germany____ Austria______ 25 2. 568 12.656 28, 142 335 0.23 2.02 1915 Deaths Cases Abso- lute num- bers Case------ fatality, Ah Ratio (per *b_o- per cent) lu^_ 1,000 ! I ™™ Ratio per 1,000 3 ! 0.03 42.86 47 _______ 12.11 8, 170 ;___. ... 17.98 121 1.42 ! 23. 09 844 ___'__ .11 "ll.74 8 0.08 2,351 4.00 64,561 _____ 18, 655 18. 01 1, 900 10.30 43,681 _____ 125,771 ... . Deaths Abso- lute num- bers 3 30 484 11.95 ;____ 1.72 | 22 31,180 '_____' 1,892 24,292 I______ 1,570 ~ i Case ifatality Ratio I (per per I cent) 1,000 0.03 .02 12.00 1.17 3.82 6.07 6.46 Cases Abso- lute num- bers 297 1,166 1,659 7,773 240 16, 571 9,551 Ratio per 1,000 0.44 .61 2. 58 1.13 Deaths Abso- lute num- bers 130 6,312 Ratio per 1,000 324 7,964 13, 573 Case fatality (per cent) 5.53 9.78 17.05 18.23 10.79 Deaths Abso- lute num- bers 23 33 135 "13 623 Ratio per 1,000 0.03 .01 06 Case fatality (per cent) 7.74 2.83 8.14 "-."42 3.76 7. 83 m-i,!ri™ i?\ nffiiS w9 ; (1) ¥t°^}7 S1(* and wounded reports of the Surgeon General, for the years 1914 tn iqio inclusive (2) Official History of the War, Medical Services, Diseases of the War, vol. 1, p. 11. (3) _w-BP14A0 1?19, Maladies Infectieuses pendant a Guerre, Librairie Felix Alcai., Paris, 1921, p. 45. (4) Document on, fik>_£Pthp'wA ^1 ?«\V w0nH°K thh HUrgAe°n^nera1J % ^mce- (5) Document on file in the historical division of theburgeon^Generlrf nS™1 (6) Handbuch der Arztlichen Erfahrungen im Weltkriege, Band iii, Inner Medizin, Leipzig, 1921 87' (7) Dornm?^1Ce' file jn the historical division of the Surgeon General's Office w; .Document on TYPHOID AND THE PARATYPHOID FEVERS 39 Table 7.—Typhoid fever. By years of occurrence in the armies of seven of the important nations involved in the World War, showing number of cases and deaths with ratios per 1,000 per annum, and case fatality rates, 1914 to 1919—Continued 1918 1919 Ca ses Ratio per 1,000 0.30 .12 1.31 .89 Dea Abso- 1 lute num-bers ths Cases , Deaths Case fatality (per cent) Country Abso-lute num-bers Ratio per 1,000 fatality Abso- „ f. (per lute K*£° cent) num- ,yZ.n bers 1,uou 17.32 467 0.47 lute" ! R*ti0 nbTs" | $0 768 334 665 3,881 187 20, 932 4,799 133 20 110 0.05 .01 71 0 07 15.20 Great Britain... _ .........______ 5.99 , ....... 16.54 ! Italy__________............._____ 24 926 664 .11 12.83 31 ,........ 4.42 .. .. :___ 19 61.29 Germany_________________ 13.84 TOTAL FOR THE PERIOD ry ,< Cases Deaths Case Count .bsolute Ratio per lumbers 1,000 Absolute numbers Ratio nev fatality l)0ooPU (Per cent) United States___............ _ 1,572 | 0.35 6,807 : 1.02 124,991 ! 14.86 58,451 6.24 3,217 3.59 112,364 i________ 171,601 ________ 233 260 15,211 0.05 14.82 .04 3.82 1.81 ! 12. 17 Italv________________ B elgium______________________ Germany______________________ ..... 523 11,405 17,399 .57 16.26 10.15 10. 14 The interpretation of the data compiled in the table is somewhat compli- cated by the fact that the figures given for France and Italy include not only typhoid but also the paratyphoid fevers, while those for the remaining five nations are confined to typhoid. It may be assumed, however, that the vast majority of the cases occurring in both the French and Italian Armies were typhoid. A further complication arises from the fact that Italy did not engage in hostilities until 1915 and the United States not until the spring of 1917. It should be noted, however, that the statistics for the United States Army include the cases occurring during 1919, while those for the armies of the other nations (except Italy and Germany) cover the period 1914-1918, inclusive. It may safely be assumed that the armies of all the nations concerned were well acquainted with the generally accepted principles that form the basis for the control and prevention of the enteric group of fevers, and that all well- known general preventive measures were enforced in so far as military necessity would permit. We will limit ourselves, therefore, to an inquiry as to the extent to which anti-typhoid-paratyphoid vaccines were used as a prophylactic measure by the armies of the various nations and the degree of success— prevention of typhoid fever—attending their use. UNITED STATES ARMY The United States Army was the only one of the seven under considera- tion in which the policy, initiated several years previous to our entrance into the World AVar, was continued and actually carried into effect, of making mandatory the vaccination of all military personnel immediately after their entry into the service and of using a triple vaccine—typhoid-paratyphoid A and paratyphoid B—for protective purposes. Our admission (morbidity) rate per 1,000 for typhoid fever was the lowest attained by the armies of any of the nations participating in the conflict. 40 COMMUNICABLE AND OTHER DISEASES Approximately one-fourth of the cases arose after the cessation of hostilities, and the assumption is justified that though an exceedingly high degree of protection was afforded our troops by this measure the immunity was not a lasting one. It follows, therefore, that even though three consecutive doses of vaccine are given for protective purposes the repetition of the scries of inoculations may become necessary or desirable in time of war at less than three-year intervals. This procedure was actually adopted by our Army in the early months of 1919 and approximately 350,000 men were revaccinated in France. BRITISH ARMY During the course of the war (1914-1918), among approximately 4,970,902 28 British (excluding colonials) called to the colors, about 20,149 cases were recorded as having had the typhoid fevers.1 Leishman10 reported that the British were able to inoculate, with a single dose of vaccine, about 25 to 30 per cent of the original expeditionary force before they crossed the channel, and that it was not long before the inoculation strength of their troops in France rose to a figure that fluctuated between 90 and 98 per cent The regulations of the British Army at the outbreak of the war in 1914 provided for antityphoid inoculation for troops embarking for foreign service.29 In consequence of the existing emergency, the first expeditionary force of 100,000 troops dispatched to the AA^estern Front had been incompletely protected and soon after arrival in France typhoid fever began to appear. In 1915 and thereafter approximately 90 per cent of the troops dispatched for foreign service had received protective inoculations. Prior to departure from home territory it was the custom to give two consecutive doses of vaccine and repeat the series every two years. At no time was the use of this protective measure made mandatory for all troops. During 1914 and 1915 the vaccine consisted of typhoid bacilli alone, but the undue prevalence of the paratyphoid fevers A and B in troops in various theaters of activity made necessary the addition of the paratyphoid organisms, and from the beginning of 1916 to the end of the war the vaccine in use was a triple one (B. typhosus, and B. paratyphosus A and B). As will be seen from Table 7 the rate of prevalence (morbidity per 1,000) decreased from year to year and, while in 1915, 4 men in every 1,000 had typhoid fever, by 1918 the rate had been reduced to 0.12 per 1,000. This reduction coincided with an increasingly widespread use of antityphoid vaccines as a preventive measure, and there is ample justification for the statement that the gradual elimination of typhoid fever from the British armies was attributable to protective inoculation. FRENCH ARMY Since no official figures from the French AA^ar Office relative to the prev- alence of typhoid and the paratyphoid fevers, or with reference to the status of protective inoculations with typhoid-paratyphoid vaccines during the World AA'ar, are available, the data used herein were obtained from a report made by Dopter;30 the statistics include both typhoid and the paratyphoid fevers. During the course of the war approximately 8,410,000 31 men were called to active service by France, and during the same period of time approxi- mately 125,000 cases of typhoid and the paratyphoid fevers occurred in the TYPHOID AND THE PARATYPHOID FEVERS 41 French Army 30 (approximate rate per 1,000 for typhoid and the paratyphoids for the period, 14.86). Antityphoid vaccine as a prophylactic measure was used in the French Army to a certain extent at the outbreak of the war (1914) but was not a com- pulsory measure for all troops. On acccunt of the existing emergency only a small percentage of the military personnel was given protective inoculations during 1914, and as a consequence approximately 45,000 cases of typhoid and paratyphoid fevers occurred, most of which were typhoid.30 Until September, 1915, an antityphoid vaccine was used, but a large porportion of the troops still were unprotected. It was noted in 1915 that, while some progress was being made in the control of typhoid, the cases of paratyphoid fever were increasing rapidly. In consequence of this fact a triple vaccine containing typhoid and paratyphoid A and B organisms was adopted and used from September, 1915, to the end of the war. During the first two years of the war, and particularly so during 1914, when a considerable proportion of the French military forces had not received protective inoculations of antityphoid vaccine, large numbers of cases of typhoid occurred. Subsequent to September, 1915, however, when a triple vaccine was adopted and when military conditions permitted its more widespread use, both typhoid and the paratyphoid fevers were gradually brought under control, as is evidenced by the fact that during the first two years of the war (1914 and 1915) there were approximately 110,000 cases of these fevers, whereas during the last two years the total was approximately 2,000 cases. ITALIAN ARMY During the AATorld AA7ar approximately 5,615,000 Italian subjects were called for active service with the Italian Army,31 and of this number approximately 65,000 had typhoid or the paratyphoid fevers.32 (Approximate rate per 1,000 for typhoid and the paratyphoid fevers for the period 6.24.) The use of anti- typhoid vaccine as a preventive measure was technically obligatory for the Italian Army when Italy entered the war in 1915, but it was found to be not feasible to carry it into effect during that year on account of the rapidity and urgency of mobilization. During 1916 and 1917 somewhat similar conditions obtained and though some progress was made a large proportion of the forces still remained unprotected.32 During 1918 still greater efforts were made to inoculate the new drafts and not until that year were the enteric fevers con- trolled to any marked extent. Though during 1915 the vaccine consisted of the typhoid bacillus alone, from 1916 to the end of the war both typhoid and para- tvphoid vaccines were used. BELGIAN ARMY During the course of hostilities approximately 267,000 Belgian subjects were called to the colors with the army,31 and of this number approximately 3,200 had tj^phoid or paratyphoid fevers.33 (Approximate rate per 1,000 for typhoid and paratyphoid for the period 13.1.) Approximately 90 per cent of the cases were typhoid and 10 per cent paratyphoid. Prophylactic vaccination was not carried out in the Belgian Army prior to or at the beginning of the war in 1914, but was introduced in 1915, and by the end of that year 10 per cent of the forces had been protected.33 During 1914 and 42 COMMUNICABLE AND OTHER DISEASES 1915 approximately 2,500 cases of typhoid and the paratyphoid fevers occurred. From 1916 onward to the end of the war about 96 per cent of the personnel was protected, and during this three-year period approximately 1,000 cases were observed as compared with 2,500 for the preceding year and a half. GERMAN ARMY From 1915 to the end of the war approximately 112,000 cases of typhoid fever occurred in the German Army.34 No information is available to us as to the extent to which prophylactic vaccines were used, the content of such vac- cines, or the prevalence of the paratyphoid fevers in the German Army. Total mobilized forces amounted to 11,000,000 men.31 AUSTRIAN ARMY From the beginning of the war in 1914 to the end of 1918 approximately 171,000 cases of typhoid occurred 35 among the 7,800,000 men Austria mobilized for the war.31 The extent to which paratyphoid prevailed is not known nor is there available information concerning the extent to which prophylactic vac- cination was practiced, or the type of vaccines used. The data outlined above demonstrate most conclusively the value and importance of prophylactic vaccines (typhoid-paratyphoid) in the prevention of the enteric fevers and the very great importance of carrying this measure into effect at the time that troops are called to the colors. PREVENTIVE MEASURES INAUGURATED IN THE ARMY DURING THE WORLD WAR The general and special preventive measures carried out in the American Army for the control of typhoid fever and other communicable diseases are con- sidered in detail in the volume on sanitation of this history; therefore, only brief reference is made to them in this chapter. In so far as general preventive measures are concerned, it may be said that instruction in hygiene was made a matter of routine and every effort was made to safeguard the environment in accordance with modern conceptions of disease prevention.36 To protect against the intestinal group of infections—typhoid, dysentery, and diarrhea—special attention was directed to the proper disposal of excreta and to the supply of potable drinking water. In the field the pit latrine system with fly-proof box seats was used generally, except in the battle areas. To each company or other organization of like nature was to be issued one or more canvas water-sterilizing bags, capacity 30 gallons, for the storage and distribution of drinking water. Sealed ampules of calcium hypochlorite were available for use in sterilizing supplies of water for drinking purposes. Investigation of outbreaks of typhoid and medical inspections of organizations frequently disclosed the fact that organizations either had no water-sterilizing bags or no calcium hypochlorite, or were provided with neither. Many com- pany commanders apparently failed to appreciate the importance of havin» water-sterilizing bags and tubes of calcium hypochlorite always with the organi- zation. In France the general distribution of tubes of calcium hypochlorite was a difficult problem and very unsatisfactorily solved until about the date of the signing of the armistice, when this item was issued as part of the ration. There TYPHOID AND THE PARATYPHOID FEVERS 43 also was wide variation in the quantity of calcium hypochlorite in the tubes and the amount of available chlorine in the individual tubes varied within wide limits. Had all organizations in France had water-sterilizing bags and chlorine constantly available, together with good water discipline, and in addition, had it been possible to supply each soldier with a sterilizing agent to be carried on the person and to be used in emergency for the sterilization of water in the can- teen, it is extremely doubtful if more than a hundred or so cases of typhoid would have occurred among the nearly 2,000,000 men in the American Expedi- tionary Forces. The experiences of the Army with vaccines in the World AA'ar have their lessons for the future. The history of this subject may therefore be divided into several periods. In this connection it should be remembered that this account relates only to the manufacture of vaccines and does not correspond exactly to the actual use of the various products. INTRODUCTION OF THE USE OF VACCINES (1908-16) MONOVALENT SALINE VACCINE After the experience of the Army with typhoid fever during the Spanish- American War, the officers of the Medical Corps in charge of the bacteriological laboratories of the Army Medical School devoted much attention to the prob- lems of the prevention of the spread of typhoid. In 1908, Russell 37 took up the problem of typhoid vaccination on account of its sound theoretical basis and because of partial success of the use of vaccines in the British and German Armies. He worked out the technique of the production of a vaccine for sub- cutaneous injection, using the agglutinating power of rabbit's serum as an index of immunity. The procedure finally decided upon was a modification of the English broth vaccine and the German agar vaccine methods. The aim was to change the typhoid bacillus as little as possible by killing it at a minimum temperature of 53° C. for one hour. The organisms were suspended in salt solution and 0.25 per cent tricresol was added to prevent contamination. This amount of antiseptic was found not to injure the antigenic properties of the vaccine. The English strain "Rawlings," from a soldier of the Boer AVar, was selected from several strains as being most suitable for vaccine purposes. The strength of the vaccine was 1,000 million bacilli per cubic centimeter as determined by the AYright method of counting. The doses were 0.5 c. c, 1.0 c. c, and 1.0 c. c. at 7 to 10 day intervals. PARATYPHOID A AND B SALINE VACCINES (1916-17) During the first period, while cases of typhoid were exceptional, several cases of paratyphoid xV and B occurred each year in troops along the Mexican border, and these cases seemed to indicate a lack of cross immunity and the possible necessity of a mixed vaccine. In 1916 this problem became more acuts as a small epidemic of paratyphoid A infections occurred in the Mexican expeditionary forces and also in the National Guard units stationed in Texas.38 Paratyphoid B infections also occurred, but were less numerous. Under these conditions, several cultures were sent from the Army laboratories at Fort Sam Houston, Tex., and El Paso, Tex., to the Army Medical School, where they 44 COMMUNICABLE AND OTHER DISEASES were tested for suitability as vaccine strains. Paratyphoid A vaccine No. 1 was made on September 10, 1916, 1,000 million per cubic centimeter, for local use of our troops in Texas and Mexico. Six of the strains were used at first in different proportions in different lots. The first paratyphoid A and B mixed vaccine was made in 1916.37 Two hundred million paratyphoid B organisms were added to the paratyphoid A vaccine. The reactions were reported as severe and from January 20 to May 22, 1917, only a paratyphoid A vaccine was issued. In the meantime, the British had been suffering from paratyphoid infec- tions in France for two years and had finally adopted a mixed vaccine. The cultures used were sent to the school by our observer with the British Army. "Alears" A and "Rowland" and "Cools" B were tried out experimentally. THE PERIOD OF THE WORLD WAR (1917-18) SALINE TRIPLE TYPHOID VACCINE After the declaration of war by the United States on April 6, 1917, it was decided to use paratyphoid vaccine, and at first, on account of fear of severe reactions, a separate vaccine was introduced, made up chiefly of "Rogers" and "Mears" A and "Rowland" and "Cools" B. The strength of this vac- cine was 750 million per cubic centimeter of each fraction, a total of 1,500 million per cubic centimeter. The administration of 6 doses of vaccine, 3 of monovalent typhoid, and 3 of paratyphoid seriously complicated the training schedules and the possibility of a mixed triple vaccine was again taken up. Such a vaccine, consisting of 1,000 million typhoid and 750 million each A and B, a total of 2,500 million per cubic centimeter, was made up and tested at Fort Leavenworth. Kans.39 The reactions were not severe and the agglutina- tion response was satisfactory. The vaccine was made of "Rawlings" typhoid, "Rogers" and "Mears" A, and "Rowland" and "Cools" B. The first lot was made on July 11, 1917, and this kind of vaccine constituted the bulk of the vaccine used in the war. LIPOVACCINE (SEPTEMBER 30, 1918, TO MARCH 12, 1919) In 1916 several French workers reported on the use of oils in the place of salt solution as a medium for bacterial vaccines. The advantages claimed for this method were, slow absorption, larger dosage with less reaction, and especially the efficiency of a single dose. These claims attracted the attention of the director of laboratories at the Army Medical School, Washington, D. C, and he, with his assistants, in the spring of 1918, conducted preliminary experi- ments in the manufacture and use of lipo-triple-typhoid vaccine.40 Their experience apparently confirmed the claims, and the single dose was an especially strong administrative argument in preparing the Army quickly for action in France. In the fall of 1918 lipovaccine was officially adopted by the Surgeon General's Office.41 The first lot was made on May 23, 1918, of para B. The technique, briefly, was to grow the organisms in the regular way in Kolle flasks; the growth was washed off in a minimum of salt solution and centrifugalized to collect the bacteria. After November, 1918, a Sharpies centrifuge was used for this purpose, and the organisms were grown in tryp- TYPHOID AND THE PARATYPHOID FEVERS 45 broth. The centrifugate was collected and dried in a hot-air oven at 60° C. It was then weighed, ground up in a ball mill to a fine powder, and olive oil was used for suspension. The doses were in milligrans of dried organisms. The dose was 1 c. c. Each cubic centimeter contained 0.3 mg. of typhoid, para A and para B bacilli, representing a total of 7,500 million organisms. The plant at the school was greatly enlarged by a special apparatus for this work. After the armistice was signed, and there was enough leisure to study the subject more thoroughly at the school, it was found that to prepare an entirely sterile product on a large scale was most difficult. Some of the typhoid organ- isms were not killed, and contaminating organisms from the air were difficult to exclude. It was also found that absorption was not slow; the organisms were rapidly extracted from the oil by the body fluids. Even more important, it developed that a single dose did not give the antibody response that follows the use of two and three injections. On March 1, 1919, therefore, a return was made to saline vaccine, and the following circular letter was issued from the Surgeon General's Office:42 1. Beginning with date of receipt of this letter, saline triple typhoid vaccine and saline pneumococcus vaccine, Types I, II, and III, will be used in place of the corresponding lipo- vaccines used to date. 2. Lipovaccines were adopted as a war measure on account of their obvious advantages and have served their purpose. The technique of manufacture, however, needs further improvement, and the duration of their protective power as compared with that of saline vaccines needs further investigation. Saline vaccines will therefore be used as a routine and lipovaccines will be reserved for emergencies. LOCAL AND SYSTEMIC REACTION FOLLOWING PROPHYLATIC VACCINATION There is nothing to indicate that any permanent disability followed the vaccination of troops during the war. Furthermore, the temporary disability produced by the triple typhoid vaccine was not great. Of the approximately 4,000,000 men who were mobilized for our war Army, all of whom were inoculated with typhoid vaccine soon after enlistment, only 35,552 were admitted to sick report for reactions following vaccination. Foster, working at Camp Meade, Md., made an exhaustive study, from the clinical point of view, of the effects of triple typhoid vaccine on a large number of troops in that camp and reported as follows on the unusual reactions to typhoid and paratyphoid vaccination:43 The reaction which is usually experienced from prophylactic doses of typhoid vaccines amounts only to a slight discomfort. At worst the subject is seldom more uncomfortable than he would be with an acute tonsilitis, and he has the consolation that 18 to 24 hours will mark the termination of the symptoms. There seems to be a consensus of opinion, however, that vaccination with the mixed typhoid-paratyphoid culture is not so apt to be passed unnoted as vaccination with the single typhoid strain. The symptoms commonly varying somewhat in degree, are slight fever, chilliness, muscular pains and backache; not so usual, but still relatively frequent, are severe headache, vomiting or diarrhea, or both, epistaxis, and bronchitis, which last may continue for days or even a couple of weeks. This list includes all the symptoms which occur in the average cases, and from these deviations are not unusual. Occasionally, of course, bizarre cases are noted due, perhaps, to some accident in technic. 46 COMMUNICABLE AND OTHER DISEASES Differentiated from the above-mentioned majority, of over 40,000 vaccinated troops, was found a group of cases, admitted to the wards of the base hospital at Camp Meade on account of rather severe symptoms. These symptoms at least suggested certain specific diseases. On account of the diseases simulated this group may be subdivided into meningeal, appendiceal, and purpuric types. These cases were sufficiently frequent to afford opportunity for study, and because of the diagnostic embarrassment which we experienced in the beginning no little attention was given to them. The reaction which bore resemblance to appendicitis was most common. At least 50 of these cases were studied, and of the other types a some- what smaller number. The meningeal type of reaction is alarming because of the resemblance to meningitis. When, as happened with two cases, there were in addition to other signs a few fine purpuric spots on the body, the resemblance to an early stage of "spotted fever" was complete. The usual course of events with my cases was initiated by headache, commencing a few hours after vaccination and gradually increasing to an almost unbearable intensity. With severe headache photophobia is the rule. There was pyrexia up to 102° F. and sometimes vomiting. When put in bed the patient assumes the meningitis posture—lying on the side, knees up, and head thrown a little back. On examination one finds invariably with these cases some stiffness of the neck, a positive Kernig sign, and a mild hyperajsthesia. In the absence of history, diagnosis can hardly be made without lumbar puncture. When lumbar puncture is done the cerebro-spinal fluid is found under considerable increase of pressure, often dropping too fast to be counted. The fluid is clear and normal. There is no significant cell increase. Withdrawing 10-15 c. c. of fluid almost invariably relieves the headache. In brief, the con- dition is one of meningismus. The appendicitis picture is definite enough as a clinical picture with localized pain and tenderness, slight fever, and some increase in the leucocyte count (due to vaccine). A num- ber of these cases were operated upon. The appendices removed, however, did not present the conditions expected, and an agreement between the surgeon and the pathologist on this point was impressive. With this experience a conservative attitude developed and none of the cases of this type was operated upon. At a somewhat later period, while at General Hospital No. 14, I found that Lieut. Col. Edward Martin had become interested in the surgical aspect of this problem but had come to a different conclusion in that with his cases the appendix did show more evidence of acute inflammatory change. Colonel Martin's cases gave a history suggesting repeated attacks of appendicitis in the past, and it has been proposed in explanation that the vaccination excited an acute process in an indivisual thus predisposed. Neither the immediate practical question involved nor the underlying one of scientific principle can be clarified by evidence now available. It will be recalled that shortly after typhoid vaccination began to be somewhat extensively used among our civil population in the cities the statement was made and repeated that latent tuberculous foci in the lungs might be thus fanned into activity. Some scattered attempts were made to ascertain the truth, but these studies bear analysis as badly as the statements to be examined. At present there are opinions, but little evidence. Similar opinions are current as to the effects of vaccination on latent chronic urethritis, arthritis, and some other conditions. The whole subject requires careful reexamination. It is of interest in passing to recall that vaccines made from typhoid cultures have been advocated for the treatment of some of these condi- tions—arthritis, urethritis—which we are now assured are aroused into activity by the same measure. There is so much obscurity surrounding the etiology of purpura that the cases follow- ing vaccination had for me an especial interest. The first of these cases to receive recog- nition was admitted from a regimental infirmary on account of epistaxis. * * * On the morning of admission to hospital he had epistaxis, and for this reported at sick call. The epistaxis was obstinate and required "packing." Examination showed a purpuric eruption covering the body. The spots were small and discrete, varying from one-sixteenth inch to one-eighth inch, and purplish in color. There was no bleeding of the gums; no blood found in urine or feces. We had not at this time facilities for exact measurement of clotting time, but no abnormality was noted by means of improvised apparatus. The bleeding time and cell counts were normal. The rash gradually faded to a tawny brown stain, and the patient was returned to duty. TYPHOID AND THE PARATYPHOID FEVERS 47 On inquiry, stimulated by this case, it was found that a number of cases had been admitted to the otology service of the hospital because of epistaxis following vaccination, and it was recognized that many of these had hematuria and a few had purpuric eruptions. A number of cases of varying degrees were studied subsequently in both these services. Epistaxis with transient hematuria was not uncommon. Some of these showed also hemor- rhages and purpuric rashes. In one case there was violent epistaxis, hematuria, melena, and extensive purpura and hemorrhage into some of the joints. The left elbow had later to be opened and the clot removed. All of these cases made perfect recoveries. Since an understanding of this condition would be helpful for an understanding of purpura, examinations were made of blood in respect to the clotting and bleeding times, cell counts, and platelet counts. So much normal variation was found in the platelets that no evidence could be recured in this direction. The other estimations were normal, except a slight leucocytosis observed in many cases after vaccination without special symp- toms. Statistical tables of the Surgeon General's Office for the AVorld AA7ar period show that five soldiers were discharged from the Army for disability following triple typhoid vaccination. A further investigation of the clinical records of these cases, however, revealed an error in tabulation; although some tempo- rary disability resulted from vaccination, a careful search of the records failed to reveal any cases that terminated in permanent disability or death. The use of typhoid vaccine as a protective measure having been a routine procedure in the United States for a number of years prior to the AArorld War, the American military authorities appreciated the fact that the reactions following its administration not infrequently (approximately 10 per cent) were moderately severe during a period of from 24 to 48 hours after inocu- lation. For this reason it was the custom to recommend that all personnel be excused from all duties, except the necessary roll calls, for a period of 24 hours after vaccination. The experience gained in the vaccination of 4,000,000 men during the World War further confirms the wisdom of carrying this pro- cedure into effect, and it is now required by Army Regulations. FACTORS THAT MAY BE RESPONSIBLE FOR THE OCCURRENCE OF TYPHOID IN INDIVIDUALS PRESUMABLY PROTECTED BY VACCI- NATION As noted, a large proportion of the cases of typhoid in troops in the large mobilization camps in the United States occurred in individuals who had not been protected by prophylactic vaccines. Approximately 885 cases occurred in approximately 1,900,000 men serving in France, and it is highly improbable that any appreciable number of these men were uninoculated. Vaughan,3 in a careful study of the records of 270 cases of proven typhoid in France, found that all had received prophylactic inoculations, and that in 207 of the 270 cases there was a record of the dates of vaccination and types of vaccine used. Why did prophylactic vaccination occasionally fail to pro- tect against typhoid? Concerning this matter we have no definite informa- tion. Vaughan, who gave it considerable attention, made the following com- ments on this phase of the problem:3 1. Absence of vaccination, either total or partial.—-By this I refer to failure not because of impotent vaccine but because of failure to react in certain individuals. It is well known that after the same doses of vaccine different persons form different amounts of agglutinins. But agglutinin titer is not a measure of immunity. We have no criterion that will tell 4S COMMUNICABLE AND OTHER DISEASES us when an individual is actually immunized, nor have we any means of determining the degree of immunity present. 2. New strains of the organisms against which the vaccine does not immunize.—Serologic and cultural determinations made in the various laboratories have not consistently pro- duced anything to suggest such a condition. 3. Failure of proper inoculation.—Among the cases of true typhoid studied, vaccination had been performed in 50 different camps and posts in the United States. This fact, com- bined with the really excellent results in most individuals vaccinated, renders such a possi- bility rather remote. 4. An overwhelming dose of the infecting organism.—Absolute immunity to human disease does not exist in man. The highest immunity that can be produced by artificial methods will protect against the antigenic virus only up to a certain limit. I am of the opinion that the greater number of cases of typhoid and paratyphoid in France occurred as a result of massive infection with a dose great enough to overwhelm the forces of immu- nity. This, I presume, was most frequently associated also with the first cause enumerated, "absence of vaccination, either total or partial," in that it occurred in those possessing a lower degree of immunity than their more fortunate comrades. As Bernard has so suc- cinctly expressed it, vaccination raises against the typhoid bacillus a great barrier—high, but not insurmountable. 5. "Back-handed typhoid," "antibody exhaustion," or "immunity exhaustion."—I include the second designation of this condition as being the most readily comprehensible in view of the existing nomenclature and conceptions of immunity, while I prefer the third as being more scientifically correct. I developed the first term as I recognized more and more of this type in the field, and it has the particular advantage that it emphasizes the assumption that the successive stages of typhoid infection are therein, in a manner, reversed. The present-day conception of typhoid is that it is of primary systemic infection. The organisms entering by way of the gastrointestinal tract are absorbed into the circulation and do not primarily grow as saprophytes in the alimentary canal. After passing through the gastrointestinal mucosa, the organisms reach the liver through the portal circulation, where they may be excreted through the bile; or some may pass into the general circulation, where they multiply and, after the usual period of incubation, cause typhoid fever. The organism excreted in the bile may lodge in the gall bladder and there, growing, produce the carrier condition, even though the host has not had typhoid fever. In a vaccinated person, the organisms entering the portal circulation are either broken up and destroyed by the body ferments or excreted into the bile, or both. In the gall bladder they may find lodgment and continue to grow, in reality outside the body organism, multi- plying profusely even though the host be highly immune. The number of organisms that are continually discharged in the bile and resorbed through the intestinal mucosa call on the immunity mechanism for constant and exhausting action. There may be superimposed on this local enteritis caused by one of the typhoid-colon group or any other organism, or even by the typhoid member of the group itself. This subacute or chronic condition render- ing toxic absorption more facile, serves gradually to undermine the constitution. Finally, added to all this, are the hardships of war and army life—exposure, food not always well balanced, fatigue, and perhaps at last some intercurrent infection—and all the conditions required to wear out a body immunity are then present. It is this reversed process—a local infection or carrier state followed by systemic disease instead of the usual typhoid followed by a carrier condition—that I have chosen to call "back-handed typhoid." Overwhelming doses of the infecting organism and this exhaustion reaction were in my opinion two of the chief causes of typhoid among our troops. From the nature of the condition it has been impossible to obtain convincing experimental evidence of its presence in France; but a certain amount of indirect evidence appears to warrant our assuming its presence. Our first case occurred in a colleague who, preceding his illness, had been billeted with a French family and who had been drinking unchlorinated water while at his billet. For two weeks or more he had been complaining of general malaise and a moderate diarrhea, but not sufficient to keep him from his work. At the end of two or three weeks the illness became acute, the usual symptoms of typhoid developed, he became progressively worse, and he died within one week from the onset of the exacerbation. TYPHOID AND THE PARATYPHOID FEVERS 49 These cases present the usual clinical histories of ambulatory typhoid, with the definite addition of a local gastrointestinal pathologic condition and symptoms preceding the disease proper. Otherwise there is nothing unusual about the symptomatology. Especially frequent was this syndrome among the men who had seen active service at the front. From nearly all, a history was obtained of having drunk Avhatever water they could get, even from the stagnant mud of the shell holes. To check up on the impression I had gained, I questioned 104 patients as to previous history of chronic local gastrointestinal disturbance. All were straight typhoid cases. Forty-four denied attacks of diarrhea antedating the diarrhea of the disease itself. Thirty- nine admitted a continuous preceding enteritis varying from one week to three months in duration, and of these, 23 had it for over a month. Fifteen had had diarrhea for from one week to three months while at the front, which had subsided and from which they had been free for from two to three months. Seven additional patients admitted having had a transient diarrhea of from one to five weeks duration in the two months preceding their disease. Subacute diarrhea is not a necessary, or the usual, antecedent of typhoid fever. The disease begins frequently even with constipation. I would compare the foregoing figures, in which more than 60 per cent had been afflicted with enteritis, with the statements of the Typhoid Comnaission in the Spanish-American War, that in that epidemic "More than 90 per cent of the men who developed typhoid fever had no preceding intestinal disorder." I do not believe that the figure of 60 per cent would hold for all men attacked by this malady in the American Expeditionary Forces, but do assert that it was the case in a representative number of those who had been at the front. There is no proof that these men were harboring the typhoid bacillus in their intestinal tract previous to coming down with the disease. It is here that my hypothesis fails of abso- lute proof. Such proof would have necessitated a survey of the stools of all members of a division, to be followed by weeks or months of watching to see whether the carriers discovered would develop the disease. Moveover, had this been done, the carriers would have been hospitalized and treated, thus defeating the object of the experiment. But corroborative evidence is not lacking. Several observers have reported the finding of typhoid bacilli in the stools of patients a few days or more previous to the onset of the disease, while Battlehner has reported four cases in whose excreta the bacilli were discovered from 21 to 117 days before the onset of the disease. These had been considered as healthy carriers. I have a record of one patient who one and a half months previous to admission cared for a typhoid patient and shortly thereafter developed diarrhea, which persisted for six weeks until the typical acute onset of typhoid. In the discussion of typhoid carriers I have called attention to 10 out of the 32 carriers, with history of diarrhea, none of whom had had preceding typhoid, and one carrier with no history of typhoid and no diarrhea, who nine months previously, at Camp Dodge, had had negative stools for the typhoid group. I have shown, then, that carriers have been produced in France; that diarrhea is often associated with the carrier condition; that among 104 men, diarrhea preceded the disease in 60 per cent; that in one instance exposure to the disease was followed by enteritis which per- sisted for six weeks, until the onset of typhoid. Before absolute proof of back-handed typhoid is produced, I must show that all these facts find sequence in individual cases. 6. Unsatisfactory vaccine, either as regards antigenic properties or number of doses adminis- tered.—Considerable experimental evidence has accumulated to show that with increasing numbers of inoculations the immunity increases. Four inoculations confer a greater degree of immunity than do three. One of the advantages of the method in use in the United States Army is that the men nearly all receive the same vaccine in the same dosage and with the same number of inoculations. Observers in other armies were sometimes forced to draw their conclusions from patients who had received different kinds of vaccine and all numbers of injections, from one to four or more. The fact that our vaccine did protect in the great majority of the cases demonstrates the efficiency of our preparation and of the dosage. It may not be ideal, but it is thoroughly practical. 56706—28----4 50 COMMUNICABLE AND OTHER DISEASES CLINICAL COURSE OF TYPHOID FEVER IN THE VACCINATED INDIVIDUAL The general impression prevailed at the outbreak of the World AA'ar that the clinical manifestations of typhoid fever in the vaccinated individual differed from those found in the unvaccinated. The statement is made by Gay44 that not only is the mortality rate decreased but the disease itself is found to undergo a very distinct modification when it occurs in the vaccinated individual, so much so, that it frequently is so mild as to offer great difficulty in diagnosis. A^aughan, in a study of a series of 373 cases occurring in vaccinated individuals in the American Expeditionary Forces, France,3 found that the most striking feature of the disease in the inoculated was its almost classical resemblance to the old typhoid fever as one knew it in the unvaccinated individual. Not only was this resemblance noted in the clinical history but also at the bedside. In the majority of cases in which the typhoid bacillus was isolated there was no difficulty in the clinical diagnosis. Typhoid facies, coated tongue, rose spots, palpable spleen, rigid and slightly tender abdomen, and dicrotic pulse were the rule rather than the exception; however, as in the uninoculated, all grada- tions of the disease were found. One has long been acquainted with mild and ambulatory cases, with difficulty in diagnosis on account of the mildness of the disease, and frequent absence of many of the usual symptoms of typical typhoid fever. Many such cases probably occurred among our troops in France and remained undiagnosed. It is further possible that the number of cases that would fall under this class had been greatly increased by previous inoculation. But of those patients whom we have seen sick in hospital there could be no doubt as to the clinical diagnosis.3 Leucopenia was not as marked as in the classical typhoid fever. The average white count on successive days was about 7,000. In a few cases from 2,000 to 4,000 white cells per cubic millimeter were noted. The above average agrees with the report by Hawn, Hopkins, and Meader.14 The average white count during hemorrhage was 4,500; in perforation, 6,000; in lobar pneumonia complicating the disease, 12,000, and in bronchopneumonia 9,000. These figures, however, agree with those occurring in typhoid fever in the unvacci- nated.3 What has been said relative to the white blood count applies to the febrile course of the disease; that is, the type of fever in vaccinated patients did not differ remarkably from that in unvaccinated. The average day of cessation of fever was 26.9; relapse occurred in 10 per cent of the cases and the average date of onset was the 35th day. Death occurred in 11 per cent of 270 of the cases studied and the 21st day was the average day of death. The foregoing clinical findings are in accord with those reported by other observers. Labbe45 remarks that the symptomatology has nothing character- istic and the same elements are present and appear in the same order among vaccinated and unvaccinated individuals. The onset is not marked by special symptoms and during the fastigium, diarrhea has the usual occurrence. How- ever, it may be that this symptom occurs somewhat less frequently in the vaccinated. Bernard and Paraf,46 in describing the clinical symptomatology among French troops, remarked that typhoid fever among the vaccinated has no particular characteristic which might indicate a modification of the disease. TYPHOID AND THE PARATYPHOID FEVERS 51 The different classical forms are seen with their usual characteristics. Campani and Gallotti47 reported that in a series of cases of typhoid and paratyphoid fevers occurring in 144 nonvaccinated civilians and 341 vaccinated soldiers on the Italian front the case mortality rate from typhoid fever in the vaccinated patients was 8.6 per cent and in the paratyphoid A and B cases 4.6 and 7.8 per cent, respectively. Among the unvaccinated the case death rate for typhoid was 20 per cent and for the paratyphoid cases nil. They found that in both groups about 42 per cent of the patients had a febrile period lasting into the fourth week and that the average duration of fever was, among the soldiers, 24.5 days and among civilians 28 days. They state that the febrile curve instead of being irregular and low in the vaccinated, was high and decidedly more regu- lar than among the nonvaccinated. Splenomegaly and nervous phenomena were more frequent among the vaccinated. These workers concluded that vaccination had lessened both the mortality and the severity of the disease. Freund48 reported typhoid infection in the German Army and concludes that among the vaccinated cases there were more remissions and intermissions as well as a great number of mild cases. The fever was milder but the total duration of the disease was not shortened. No change in the frequency of the complications or relapses resulted on vaccination, and mortality given among the vaccinated was 8.3 per cent. Hawn, Hopkins, and Meader,14 in describing the 38 cases studied in an outbreak among American troops in England, found clinical symptoms similar to the cases described by Vaughan. The initial chill occurred in 16 per cent, diarrhea in 58 per cent, constipation in 21 per cent, abdominal pain in 6 per cent, and epistaxis in 2.6 per cent. Rose spots were described in 19 cases, splenomegaly in 9 per cent. Blood cultures were positive in 12 cases and the mortality was 13.15 per cent. There was a somewhat progressive increase in severity with lapse of time after inoculation in individuals to whom vaccine had been administered from one to six months before the patient was taken sick (11.6 per cent severity). When from 13 to 18 months had elapsed, 15.9 per cent were classified as severe. It appeared that the average severity of the disease was fairly constant through- out the first eight months following inoculation, after which it gradually increased. The proportion with relapse did not appreciably differ. COMPLICATIONS, SEQUEL/E, AND CONCURRENT DISEASES The complications and sequelae of typhoid fever during the war afforded nothing new from either a clinical or pathological point of view. Among the more important of these were 4 cases of general septicemia, with 4 deaths; 2 cases of acute endocarditis, with 2 deaths; and 7 cases of myocardial insuffi- ciency, of which 2 resulted fatally. Important complications of the respiratory tract were 26 cases of bronchitis, with 6 deaths; 59 cases of bronchopneumonia, with 39 deaths; 29 cases of pneumonia, of which 24 terminated fatally; and 18 cases of pleurisy, with 6 deaths. Hemorrhage was recorded in 11 instances, with 8 deaths; and diarrhea as a complication in 5 cases, of which 3 terminated fatally. Enteritis and colitis occurred in 12 instances, with 2 deaths; and peri- tonitis in 8. with 7 deaths. There were 2 deaths among the 4 cases of acute 52 COMMUNICABLE AND OTHER DISEASES nephritis. Altogether 209 complications were deemed as being of sufficient importance to be reported, with 151 deaths. Typhoid fever was reported as concurrent with other diseases in 368 instances. Of these, 60 terminated fatally, giving a case mortality of 16 per cent. The more important diseases with which it was concurrent are given in Table 8. Table 8.—Typhoid Fever. Concurrent with other diseases, enlisted men, United States Army, serving in the United States and Europe, April 1, 1917, to December 31, 1919 Primary cause of admission Influenza.........______ Tuberculosis of the lungs Bronchitis. ___________ Pneumonia, broncho-___ Pneumonia, lobar______ Abso- lute num- bers Case .eaths mor- tality 33 20.37 3 75.00 1 3.45 6 20.69 5 31.25 Primary cause of admission Abso-lute num-bers Deaths 4 Case mor-tality 25 16.00 Intestines, other diseases of----- 5 98 2 i 40. 00 6 6.12 368 60 16.30 CARRIERS Nichols,49 who made a somewhat exhaustive study of the "carrier" state during the World War, classified carriers as "incubationary," "convalescent," and "contact." The percentage of cases that develop the carrier state of one class or another has been variously estimated as being from 9 to 50 per cent, women constituting the majority, three-fourths of the carriers being of the intestinal type. The bacteriological examination of the stools and urine of food handlers at stated intervals, and examination of convalescents from typhoid for the carrier state prior to their discharge from hospital, was a matter of routine during the AA^orld AAar, and by means of this administrative procedure a few carriers were detected. According to Nichols, the results of examination of about 30,000 food handlers during the war demonstrated less than 0.1 per cent carriers among healthy males. Gay44 states that 7,500 carriers are being added to the civilian population in the United States each year. There were 64 recorded carriers among the primary admissions to hospital during the war. Instructions governing medical officers, A. E. F., in the determination of a carrier state were as follows:50 Typhoid and paratyphoid patients excrete the bacilli, frequently with their urine and practically always in their feces. This is most likely to occur during the third and fourth week of the disease, the condition may persist throughout convalescence and not infrequently longer. It is, therefore, important not to release the convalescent typhoid or paratyphoid fever patient until he ceases to excrete these bacilli. Three negative cultures of the urine and feces at six-day intervals should be required before release of patient, the first not earlier than one week after temperature curve has become normal. Some persons who have never had a clinical history of the disease may excrete typhoid or paratyphoid bacilli. It is important to detect such carriers in any occupation, but espe- cially among cooks and handlers of foodstuffs. In such a carrier survey, two examinations should be done on each individual. TYPHOID AND THE PARATYPHOID FEVERS 53 No definite lesions were found in incubationary and contact carriers. The liver and kidney showed lesions in convalescent carriers. In intestinal carriers with lesions in the gall-bladder, bile-ducts, or both, the organism was demonstrable in the stools. In urinary carriers the focus was found in the kidney, especially in the pelvis. According to Nichols,49 carrier strains did not differ from others and could not be differentiated by cultural or other tests. In determining the carrier state serological examinations were suggestive, as more than 50 per cent gave positive agglutination tests. Such examinations, however, were of little value in the case of convalescents from the disease or in the recently vaccinated subject. The organism was found in the duodenal contents or feces in the intestinal type of carriers and in the urine in urinary carriers. It was the cus- tom to require at least three consecutive examinations of the feces and urine of convalescents from typhoid before dismissing the possibility of an existing carrier state. In the United States it was the policy to collect all chronic typhoid carriers in the Army at the Walter Reed General Hospital, Washington, D. C, for further observation and treatment.51 At the time the armistice went into effect arrangements also had been completed for the establishment of a special hos- pital in France, near Dijon, for the treatment and study of chronic "carriers" of all types in the American Expeditionary Forces. An essential in the successful treatment of typhoid carriers was location of the focus of infection which, though usually single, sometimes was multiple. Where the focus was a single one, as for example, the gall-bladder, treatment by excision usually effected a cure. Where the foci were multiple, as for example in the gall-bladder and in the bile-ducts, removal of the gall-bladder did not result in a cure. Nichols, Simmons, and Stimmel52 reported on the surgical treatment of typhoid carriers at the AATalter Reed General Hospital in 1919. Seven cases are included in this report; 6 were intestinal carriers and 1 urinary. Four of the former were cured by removing the infected gall-bladder, and the urinary carrier was cured by removal of the infected kidney. In two of the intestinal carriers failure was attributed to the gall-duct being infected as shown by cul- tures of the duodenal contents. Operation was not recommended for at least six months after recovery from the primary disease, as in many instances the carrier state was of temporary duration. Henes53 reported favorably upon the surgical treatment of typhoid bacillus carriers at the United States xlrmy Gen- eral Hospital No. 12 during the war. In spite of all known methods of treatment, some chronic carriers continued to excrete bacilli. The commanding officer of the AValter Reed General Hospital reported several such cases to the Surgeon General in April, 1919.54 These cases had been operated upon, but foci of infection remained. The pro- cedure followed in such instances was to discharge the individual from the Army, at the same time notifying the State board of health having jurisdiction.65 54 COMMUNICABLE AND OTHER DISEASES DIAGNOSIS For many years, particularly since prophylactic vaccination was made mandatory, the Medical Department of the Army has stressed the importance of the scientific and early diagnosis of typhoid fever. Before we entered the World AA^ar it was required that the diagnosis be based on isolation of the organism and that a culture of the isolated organism be sent to the Army Medical School at Washington for confirmation. This practice was continued during the World War except that organisms isolated in France were sent for confirmation to the central medical department laboratory at Dijon. A prompt report of cases of enteric fevers was insisted upon by the chief surgeon, A. E. F.56 For purposes of classification a division was made into proven cases, clinical cases, suspects, convalescents, and healthy carriers. Diagnoses were reported by telegram to the chief surgeon, A. E. F. With the development in France of several foci of infection—December, 1918, and January, 1919—the chief surgeon, A. E. F., issued a special circular letter relating to the typhoid and paratyphoid fevers. The following notes on diag- nosis were incorporated in this letter:50 In individuals previously vaccinated against typhoid but who have completely lost their immunity, infection similar to that found in the unvaccinated occurs, giving rise to the symptom complex * * * characteristic of typhoid fever. Infections occurring in the vaccinated individuals who still possess a certain degree of resistance to infection results in the appearance of atypical clinical pictures, such as abortive types of typhoid and paratyphoid in which the constitutional symptoms are mild but with slight febrile reaction of atypical type and few if any rose spots. The onset may be either insidious, with headache, loss of appetite, and fatigue, or acute and associated with chills, vomiting, intestinal cramps, and diarrhea. Fever may be wholly absent or evanescent in character and determined only if observations are made within the first 48 to 72 hours. A low type of temperature, with daily fluctuations of from 98.6° to 100.4°, suggestive of the presence of tuberculous disease, may persist for a week or 10 days. It is in this class of cases that blood cultures taken early in the course of the disease, and repeated if negative, frequently give definite information concerning the nature of the infection. Ambulatory types of typhoid are not uncommon and the first indication of the existence of the disease may be furnished by the occurrence of intestinal hemorrhage or perforation. The vaccinated individual protected against general systemic infection may still act as a carrier of typhoid infection and frequently shows clinical manifestations of local disease of some portion of the gastrointestinal tract, while the characteristic symptom complex of typhoid fever due to general infection, namely, continued fever, rose spots, and enlarged spleen, may be wholly absent. * * * Atypical modes of onset.—(a) Acute onset with symptoms simulating meningitis. Lumbar puncture differentiates, (b) Acute onset with intense, usually generalized bronchitis or symptoms suggestive of lobar or bronchopneumonia, (c) With chills, fever, vomiting, cramplike pain in abdomen, sometimes localized in right iliac fossa and suggesting appen- dicitis, (d) With symptoms of acute nephritis. Attack begins suddenly, with nausea, vomiting, pain in lumbar region, diminution in secretion of urine, which is highly colored and contains albumin and casts, (e) Special mention should be made of the ambulatory type of typhoid in which the symptoms are slight, consisting simply of headache and lassitude associated with mild gastrointestinal disturbances. The patient is at no time confined to his bed, and intestinal hemorrhage or perforation may furnish the first clue with regard to the existence of typhoid. (J) In the above atypical modes of onset early blood cultures are of importances in differentiation. * * * In the differential diagnosis influenza, acute miliary tuberculosis, sepsis, and malarial fevers must be differentiated. Local and unexplained gastrointestinal derangements as TYPHOID AND THE PARATYPHOID FEVERS 55 gastritis, diarrhea, dysentery, enteritis, appendicitis, and inflammation of the bile passages, occurring with or without fever should be regarded with suspicion when cases are admitted from commands in which cases of typhoid or paratyphoid fever have occurred. Laboratory diagnosis of typhoid and paratyphoid fevers.—Bacteriological procedures are of great value (1) for the certain and early diagnosis of suspected cases; (2) to determine carrier s tate in convalescent positive cases; (3) to detect carriers in otherwise normal individuals. Blood cultures offer the most certain method for early diagnosis of undetermined fevers, and it should be kept in mind that the earlier in the disease the blood culture is taken the more likely is the result to be positive; thus, in positive typhoid fever the chance of successfu blood culture declines from 90 per cent during the first week to 40 per cent during the third week. In paratyphoid A fever, because of the frequently short and mild febrile period, the p rompt and early blood culture is all the more necessary. Relapses are more common in paratyphoid than in typhoid, and taken at such a time, blood culture yields positive results in every case. The following method of blood culture is recommended as being suitable in all cases of fever of undetermined etiology. (a) When laboratory facilities are at hand, take 10 c. c. of blood from a vein at the elbow. Place 3 c. c. in each of two flasks containing 100 c. c. of plain broth. Place 1 c. c. in tube of agar (melted and cooled to 45° C); immediately mix and pour plate. Place remainder of blood in dry sterile test tube to separate serum for such serological tests as may be suggested. The two flasks and plate are incubated and examined the following day. Transplants are made to plain agar slants, or, better, Russell's double sugar agar. In cases of develop- ment of Gram-negative motile bacilli on agar slants, emulsions should be made and agglutina- tion tests done with immune sera for final identification. Frequency of nonagglutinability of recently isolated typhoid cultures should be kept in mind. Negative blood culture in suspected typhoid fever means little. Repeat if clinical conditions indicate. (a) If the blood culture specimen can not be taken directly to the laboratory, filtered sterile ox bile is most useful, 5 c. c. in a tube. To such sterile ox bile 5 c. c. of blood is added, the tube closed with a sterile paraffin cork, carefully packed, and sent for examination to the nearest laboratory. Bile medium is furnished in chest No. 1, transportable laboratory, United States Army, expeditionary force model. Additional supply of this medium may be obtained as needed from central Medical Department laboratory, A. P. O. 721. Bacteriological examination of feces is second only to blood culture as an important means of positive diagnosis. It is especially important in paratyphoid B fever. * * * The Widal test—In view of previous vaccination with T. A. B., vaccine has been generally held of little or no value; however, it should be stated that the determination of agglutinin titer of patient's serum at intervals of one week and the demonstration of progressive and marked increase of agglutinin content of the blood offer, especially in the absence of positive blood culture, excellent evidence as to the etiology of the disease. Thus, in typhoid fever an agglutinin titer (Widal test) of 1 to 40 during the first week of the disease may advance to 1 to 1280 during convalescence. In paratyphoid B fever the titer frequently advances to 1 to 2,560; however, in paratyphoid A fever it may not reach 1 to 640. Formalinized and stand- ardized bacterial suspensions of B. typhosus B, paratyphosus A and B, paratyphosus B may be obtained on request from the central Medical Department laboratory, A. P. O. 721. In the series of cases studied by Araughan,3 blood cultures were made from 274 cases and typhoid or paratyphoid bacilli were isolated in 180 cases, or 65. 7 per cent. Of these 180 positive results, 143 were positive on the first culture, 25 on the second culture, 3 on the third, 9 on the fourth, and none on the fifth, showing the value of repeated culturing. In the case of the epidemic occurring in the Camp Cody replacement unit, 32 per cent of the blood cultures taken in England were positive and 88 per cent of those taken at Cherbourg; in the Prauthoy epidemic 16 per cent were positive; in the Curel epidemic 88 per cent; and in the Marseille epidemic 28 per cent were positive. This is a 56 COMMUNICABLE AND OTHER DISEASES very wide range of positive cultures and indicates, in the low percentages, either delay in resort to laboratory diagnosis or lack of skill on the part of the laboratory personnel. A blood culture is manifestly of much greater value than a stool or urine culture. In the Curel epidemic, which was handled promptly by a skilled laboratory force, the per cent of positive blood cultures was high (88 per cent); consequently, it was necessary to resort to cultures of the urine and stools and there were reported only 14 per cent positive feces and 3 per cent positive urine. In the case of the Marseille epidemic with a low percentage of positive blood cultures the gravity of the situation was not at first appreciated. The local laboratory personnel was reinforced and sub- sequently there were reported 53 per cent positive stool and 14 per cent positive urine culture. Likewise in the Nevers epidemic and for the same reason there were but 15 per cent positive blood and 38 per cent positive stool and 31 per cent positive urine cultures. Marris,57 of the British Army, during the course of an extended study of typhoid patients, developed the so-called atropin diagnostic test. He held that when the human body is so invaded by bacilli of the typhoid group as to exhibit typhoid, paratyphoid A, or paratyphoid B fever, a toxin is formed which effects the heart in a peculiar manner; the presence of this toxin can be detected by observing the abnormal yet characteristic reactions of such hearts to a certain drug, notably atropin. This reaction consists in the failure of acceleration of the pulse beat more than 15 beats per minute after the hypoder- mic injection of a large dose (one thirty-third gram) of atropin. Marris based his observations on 111 cases of proved typhoid or paratyphoid. The test was positive in 92 per cent of cases in the first week of the disease; 89 per cent in the second week; 83.7 per cent in the third week; 88 per cent in the fourth, and in the later stages the reaction was not characteristic. He found the test to be negative in the case of typhoid carriers and in a list of other diseases such as trench fever, meningitis, bronchitis, pneumonia, tuberculosis, dysentery, malaria, influenza, etc. The same results were noticed with amyl nitrate and adrenalin as with atropin. In Vaughan's3 series the atropin test was made in a small number of cases and was usually found to be positive, more markedly so during the first week, when the pulse was slow. It was often negative after the pulse rate increased. In 38 cases reported from England14 an acceleration of pulse rate Occurred in 33 cases, a decrease of rate occurred in 1, and no alteration in 2 cases. Of the 33 showing acceleration, 23 showed a positive reaction. The earliest day on which the test was performed in this positive group of 23 cases was the seven- teenth day; the latest the thirty-first day. The positive reaction for the group was 68 per cent. Of the 10 cases showing a negative reaction, the test was per- formed after the twenty-first day of the disease—seven of them being after the thirtieth day of the disease. If the seven cases occurring in the later stages of the disease, when the reaction is not supposed to be characteristic, are elim- inated, the result would stand, as 81.5 per cent positive tests. Friedlander and McCord,58 at Camp Sherman, Ohio, tested the effect of atropin in other diseases than typhoid and found that in 170 cases, 62, or 36.5 per cent, gave a positive reaction. Their list of diseases included measles, influenza, scarlet TYPHOID AND THE PARATYPHOID FEVERS 57 fever, and pneumonia. These investigators are of the opinion that a test which gives such a high percentage of positive results in other diseases than typhoid can not be depended on. The statement is justified that the Widal reaction is of somewhat doubt- ful value in the diagnosis of typhoid fever in the recently vaccinated. This con- tention is supported by Hamilton59 and Fennel.60 Dreyer, Walker and Gibson,61 and Davison62 present arguments in support of their opinion that microscopic Widal tests, with a standardized agglutinable culture, made at intervals, to demonstrate fluctuations upward or downward, in agglutinin content, have a definite diagnostic value. It may be stated that agglutination tests in the vac- cinated, while suggestive of the presence or absence of specific infection, can not replace in diagnostic value the recovery of the specific organism from the blood, urine, feces, or bile. The agglutination reactions performed in the Army followed the Dreyer technique closely.63 In Vaughan's3 series of 206 cases, in which the tentative or provisional diagnosis was noted, 120 bore a diagnosis of respiratory disease, while only 49 were diagnosed as gastrointestinal. This is in accordance with previous knowl- edge of the disease, the initial symptoms being not local but the general symp- toms of acute infection frequently with a concomitant bronchitis. The pandemic of influenza prevailing at the time also tended to render difficult a proper diagnosis. Vaughan's report that the onset was generally gradual and misleading is confirmed by a study of the period elapsing between onset and hospitalization. In the 123 cases occurring in the 77th Division, the cases were hospitalized on an average of 8.1 days after the onset of the disease, the extremes being 1 to 57 days. The laboratory diagnosis was made on an average of 19.6 days after the onset, the extreme being 7 and 60 days. This gives an average of 11.5 days spent by a case in the hospital before a laboratory diagnosis was made. In the 38 cases occurring in England (infected in the United States en route to England) the average date on which the cases were hospitalized was 13 ^H_ days after initial symptoms; in the Prauthoy epidemic it was 52.5 days. THE PARATYPHOID FEVERS Recognition of the paratyphoid group of fevers (A and B) as disease entities is a fairly recent development of scientific medicine, antedating the AArorld War by only a few years. The experience of the Medical Department of the United States Army with this group of fevers prior to the World War was limited very largely to a sharp outbreak of paratyphoid fever A in National Guard troops on active duty on the Mexican border of Texas during 1916 and the early part of 1917, and an outbreak of paratyphoid A that occurred in the expedition- ary force of the Regular Army dispatched into Mexico during the summer of 1916.38 These epidemics were very quickly brought to an end by the use of para- typhoid A vaccine. As paratyphoid fevers were being reported as of not uncom- mon occurrence in all allied armies in France when the United States entered the war, steps were immediately taken to incorporate the paratyphoid A and B organisms in prophylactic vaccines to be used by the American Army. This i^roup of fevers was a negligible factor as a cause of illness in the United States Army, as is indicated in Table 9. 5S COMMUNICABLE AND OTHER DISEASES Table 9.—Paratyphoid fevers. Officers and enlisted men, April 1, 1917, to December 31, 1919, by country of occurrence, admissions, and deaths. Absolute numbers and rate per 1,000 per annum Para A Para B Country Total mean Admissions annual strengths Abso- lute num- bers United States______________________ 2,235,389' 32 Europe________________........____ 1,665,796 i 95 Other countries____________________ 227,294 7 Total primary cases____________ 4,128,47 Additional cases as associated diseases___________ 134 41 Grand total. 175 Rate per 1,000 0.01 .06 .03 .03 Deaths Admissions Abso- -R-t- i Abso- lute i "g£ lute 1,000 num bers num- bers 95 per 1,000 Deaths Abso- lute num- bers Rate per 1,000 1 4 The death rate for cases occurring in the United States is the more reliable one. Most, if not all, of the deaths from paratyphoid recorded for troops in Europe actually were due to causes other than parat37phoid, but were charged back to the paratyphoids for the reasons stated elsewhere (p. 15). The clinical characteristics of the paratyphoid fevers as they occurred in American troops during the World War can be summarized as follows: On the whole, the disease followed a much milder course than did typhoid. The individual case could not be distinguished from typhoid fever by clinical mani- festations alone. Both diarrhea and initial constipation were somewhat more common than in typhoid cases. No relapses were reported, and the duration of the febrile stage was approximately the same as for typhoid. The only certain method of differentiation was identification of the causative organism. REFERENCES (D His Official History of the War (British) Medical Services, Diseases of the War. Majesty's Stationery Office, London, 1922, Vol. I, 11. (2) Annual Report of the Surgeon General, U. S. Army, 1900, 402. (3) Vaughan, Victor C, jr.: Typhoid Fever in the American Expeditionary Forces. Journal of the American Medical Association, Chicago, 1920, lxxiv, No. 16, 1074. (4) Annual Report of the Surgeon General, U. S. Army, 1856, 6. (5) Ibid., 1899, 273. (6) Ibid., 1910, 46. (7) General Orders, No. 76, W. D., June 9, 1911; also General Orders, No. 134, W. September 30, 1911. (8) Annual Report of the Surgeon General, U. S. Army, 1900, 223 and 347. (9) Emerson, Haven: General Survey of Communicable Diseases in the A. E. F. Military Surgeon, 1921, xlix, No. 4, 389. (10) Leishman, W. B.: Enteric Fevers in the British Expeditionary Force, 1914-1918. The Glasgow Medical Journal, Glasgow, 1921, xcv, 81. (11) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1254. (12) Annual Reports, Philippine Health Service, Manila, 1917, 1918, 1919. (13) Annual Report of the Surgeon General, U. S. Army, 1918, 228. (14) Hawn, C. B., Hopkins, J. D., and Meader, F. M.: Outbreak of Typhoid Fever Among American Troops in England. The Journal of the American Medical Association Chicago, 1919, lxxii, No. 6, 402. The D. The TYPHOID AND THE PARATYPHOID FEVERS 59 (15) Van Valzah, S. L.: Report of an Epidemic of Typhoid Fever in Company 4, June Automatic Replacement Draft, Camp Cody, September 7, 1918. On file, Historical Division, S. G. O. (16) Neal, Marcus, P., Maj., M. C: Investigation of an Epidemic of Typhoid-Paratyphoid Fever in the 77th Division, U. S. Army, December 22, 1918, to February 25, 1919, May 10, 1919. On file, Historical Division, S. G. O. (17) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1541. (18) Taylor, R. M., Capt., M. C, and Bailey, Wm. H., Capt., M.C.: Report upon Epidemic of Typhoid Occurring among Troops Billeted at Curel (Haute Marne) March 20, 1919. On file, Historical Division, S. G. O. (19) Effier, Louis R.: History of Typhoid Epidemic at Motor Reception Park 752, Base Section No. 6, Marseille, A. E. F., May 23, 1919. On file, Historical Division, S. G. O. (20) Neal, Marcus P., Maj., M. C: Report upon an Investigation of Typhoid in the 81st Division, A. E. F., December, 1918, April 8, 1919. On file, Historical Division, S. G. O. (21) Annual Report of the Surgeon General, U. S. Army, 1920, 371. (22) Ibid., 1918, 54. (23) Ibid., 1918, 56. (24) Ibid., 1918, 65. (25) Ibid., 1918, 88. (26) Ibid., 1919, Vol. I, 916. (27) Garbat, A. L.: Typhoid Carriers and Typhoid Immunity. Monographs of the Rocke- feller Institute for Medical Research No. 16, New York, May 10, 1922, 1. (28) Statistical Report No. 169, Statistics Branch, General Staff, War Department, Wash- ington, April 9, 1921. ^29) Official History of the War (British): Op. cit., 55. (30) Dopter, M.: Les Maladies infectieuses pendant la Guerre, Librairie Felix Alcan, Paris, 1921, 50. (31) Military Casualties—Certain Countries—World War, Special Report No. 178. Feb- ruary 25, 1924. Statistics Branch, General Staff, War Department. On file, His- torical Division, S. G. O. (32) Occurrence of Typhoid and Paratyphoid Fevers in the Italian Army, Special Report. On file, Historical Division, S. G. O. (33) Occurrence of Typhoid and Paratyphoid Fevers in the Belgian Army, Special Report. On file, Historical Division, S. G. O. (34) Goldscheider, Alfred: Typhus Abdominalis. Handbuch der Arztlichen Erfahrungen im \Veltkriege. Band III, Innere Medezin. Verlag von Johann Ambrosius Barth in Leipzig, 1921, 64. (35) Occurrence of Typhoid and Paratyphoid Fevers in the Austrian Army, Special Report. On file, Historical Division, S. G. O. (36) Report on the activities of the chief surgeon's office, A. E. F., to May. 1, 1919, from the chief surgeon, A. E. F., to the Surgeon General. On file, Historical Division, S. G. O. (37) Russell, F. F.; Nichols, H. J.; and Stimmel, C. O.: Directions for Making Triple Typhoid Vaccine. The Military Surgeon, 1920, xlvii, No. 4, 359. (38) Annual Report of the Surgeon General, U. S. Army, 1917, 68. (39) Craig, Charles F.: Triple Typhoid Vaccine. Journal of the American Medical Associ- ation, 1917, lxix, No. 12, 1000. (40) Whitmore, E. R.; Fennel, E. A.: and Peterson, W. F.: An Experimental Investigation of Lipo-vaccine. Journal of the American Medical Association, 1918, lxx, No-. 7, 427. (41) Circular Letter, Surgeon General's Office, November 4, 1918. (42) Circular Letter, Surgeon General's Office, March 12, 1919. (43) Foster, N. B.: Unusual Reactions to Typhoid-Paratyphoid Vaccination. Contributions to Medical and Biological Research, Paul B. Hoeber, New York, 1919, i, 491. (44) Gay, F. P.: Typhoid Fever. The MacMillan Company, New York, 1918, 188. (45) Labbe, Marcel: Les Infections Typhique et Paratyphiques chez les Vaccines. Annales de Medecine, Paris, 1916, iii, 13. 60 COMMUNICABLE AND OTHER DISEASES Bernard, L., and Paraf, J.: Les Infections Typhoides chez Les Sujets Vaccin6s contre la Fievre Typhoide. Annales de Mtdecine, Paris, 1914, ii, 443. Campani, A., and Gallotti, A.: Confronto fra il decorso clinico del tifo nei vaccinati e nei non vaccinati. Giornale di Medicina Militare, Roma, 1918, 66, (ill. Freund, Ernst: Ueber den Verlauf des Bauchtyphus bei Schutzgeimphten. Wiener Klinische Wochenschrift, Wien, 1916, xxix, No. 39, 1232. Nichols, Henry J., Maj., M. C, U. S. A.: Carriers in Infectious Diseases. Williams & Wilkins Company, Baltimore, 1922, 45. Circular Letter, chief surgeon's office, A. E. F., 1919. Letter from the Surgeon General, U. S. Army, to the commanding officer, Walter Reed General Hospital, April 14, 1919, subject: Typhoid carriers. On file, Record Room S. G. O., 710 (Typhoid Carriers, W. R. G. H.) (K). Nichols, H. J.; Simmons, J. S.; and Stimmel, C. O.: The Surgical Treatment of Ty- phoid Carriers. The Journal of the American Medical Association, Chicago, 1919, lxxiii, No. 9, 680. Henes, Edwin, jr.: The Surgical Treatment of Typhoid Carriers. The Journal of the American Medical Association, Chicago, 1920, lxxv, No. 26, 1771. Letter from the commanding officer, Walter Reed General Hospital, to the Surgeon General, April 7, 1919, subject: Typhoid carriers. On file, Record Room, S. G. O., 710 (Typhoid Carriers, W. R. G. H.) (K). Letter from the State health commissioner, Richmond, Va., April 8, 1919, to Col. S. J. Morris, M. C, Office of the Surgeon General, subject: Typhoid carriers. (Letter from the Department of Health, State of Maryland, Baltimore, March 24, 1919, to Col. S. J. Morris, M. C, Office of the Surgeon General. On file, Record Room, S. G. O., 710 (Typhoid Carriers).) Circular No. 69, Office of the Chief Surgeon, A. E. F., February 17, 1919. On file, Historical Division, S. G. O. Marris, H. F., Capt., R. A. M. C: A Report upon the Use of Atropine as a Diagnostic Agent in Typhoid Infections. Medical Research Committee. Special Report Series, No. 9, His Majesty's Stationery Office, London, 1917. Friedlander, A., and McCord, C. P.: The Atropin Test in the Diagnosis of Typhoid Infections. The Journal of the American Medical Association, Chicago, 1918, lxx, No. 20, 1435. Hamilton, C. D.: The Effect of Typhoid Vaccination on the Widal Reaction. The Journal of the American Medical Association, Chicago, 1915, lxv, No. 22, 1873. Fennel, E. A.: Agglutinin Response after Army Triple Typhoid Vaccination. The Journal of the American Medical Association, Chicago, 1918, lxx, No. 25, 1915. Dreyer, G.; Walker, E. W. A.; and Gibson, A. G.: Typhoid and Paratyphoid Infec- tion in Relation to Antityphoid Inoculation. The Lancet, London, 1915, i, 324. Davison, W. C: The Superiority of Inoculation with Mixed Triple Vaccine (B. Ty- phosus, B, Paratyphosus A, and B, Paratyphus B). The Archives of Internal Medicine, Chicago, 1918, xxi, No. 4, 437. Dreyer, G., and Inman, A. C: Persistence of Antibodies in the Blood of Inoculated Persons as estimated by Agglutination Tests. The Lancet, London, 1915, ii, 225, and Fennell, E. A.: The Dreyer Method of Agglutination. The Journal of the American Medical Association, Chicago, 1918, lxx, No. 9, 590. CHAPTER II INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT (BRON- CHITIS, INFLUENZA, BRONCHOPNEUMONIA, LOBAR PNEUMONIA) a In approaching the consideration of the serious and fatal inflammations of the respiratory tract which formed by far the most important factor in the sickness and death records of the Army during the World War, it is first neces- sary to take a general view of the subject in the attempt to determine, if possible, the causes that led to the large morbidity and mortality from respiratory diseases in general, rather than to limit ourselves to the consideration of each form of disease separately. The mortality from respiratory diseases during the World War was due almost entirely to pneumonia, primary or secondary.1 In any set of communi- ties the size of the mobilization camps of the Army during the war, pneumonia is to be expected to some extent. The usual type of pneumonia occurring among young male adults in civil life is of course primary lobar pneumonia, running a fairly definite course and, usually, recognized easily both clinically and post mortem. That such cases occurred among the troops is beyond question. The proportion of such cases, however, is impossible to determine. McCallum expressed the opinion, after studying the pneumonias at Camp Travis, Tex., in the late winter of 1917-18, that they were relatively few in number and distinguished mainly by their mildness as compared to those seen in civil communities.2 However, it was early recognized clinically that in the larger number of cases observed in the camps the pneumonia was of an atypical nature. The onset tended to be slower than that of the lobar pneu- monia of civil life; the course more prolonged. Crisis was relatively rare; physical signs were slow of development and of patchy distribution and scat- tered in several lobes. These facts led careful observers to consider a large proportion of the cases as bronchopneumonia rather than as the usual lobar type. The results of post-mortem study of fatal cases lent confirmation to this distinction: The typical croupous consolidation of lobar pneumonia was relatively rare, patchy consolidation of a suppurative character more frequent. Even when the consolidation involved nearly or quite an entire lobe, careful study often showed evidence of the formation of such lobar consolidation by the confluence of smaller areas, lobular in origin. Inasmuch as bronchopneumonia is almost invariably a complicating or secondary, rather than a primary infection, and its incidence in men of military age, generally speaking, is very low as compared to that of the lobar type, attention was at once focused on the coincident epidemic of measles as the probable primary cause of the pneumonias. That this disease was indeed a large factor in the causation of the pneumonias of the early days of the mobili- zation camps of the World War is shown in the consideration of that disease. ° Unless otherwise stated, all figures for the World War period are derived from sick and wounded reports sent to the Surgeon General.—Ed. 62 COMMUNICABLE AND OTHER DISEASES However, in many, if not in most camps, the peak of the pneumonia incidence did not coincide with that of the measles and in the light of subsequent events attention is directed to the possible occurrence in the camps at this time of another disease also complicated by fatal pneumonia, namely, influenza. It will be shown that influenza, at least in its so-called endemic form, was a considerable factor in the sick rates of the Army for some years before the World War. It has always been held responsible for a small but varying mortality in the civil population according to the reports of the Census Bureau. It is the consensus of opinion of those who have investigated the subject that minor but distinct epidemic waves of this disease have occurred every few years, in each instance accompanied by an increase in the pneumonia mortality. Cases of influenza were reported from the camps from the earliest days of the mobiliza- tion; doubtless many more cases were not recognized owing to the mildness of the type prevailing during the fall of 1917. It is impossible, therefore, to esti- mate the number of influenza cases that occurred among the troops during these early months. But that the disease was present will be shown iD a manner that will leave very little room for doubt, and its fluctuations from month to month, as shown by its effect on the number of admissions for the total respir- atory diseases and by its effect on the amount and character of the prevalent pneumonia, can be shown with some definiteness. Unfortunately for the exactness of our records in this class of diseases the clinical characteristics of mild influenza are such as to lead to its ready con- fusion with several of the milder so-called common respiratory diseases. Of these, bronchitis, tonsillitis, and pharyngitis are the leading diseases with which many of the earlier cases of influenza were confused. When the outbreak was at its height the uniformity of symptoms presented by large numbers of cases made confusion almost impossible and at the time of an epidemic wave in the majority of instances the cases were correctly diagnosed. However, in certain camps there were pathological purists who refused to give sanction to the diag- nosis of influenza unless it was possible to demonstrate the presence of the bacil- lus of Pfeiffer. This attitude was evidently extreme, in view of the doubt cast in recent years on the specificity of the role of this organism in influenza; but the fact remains that in all of the epidemic waves to be described, even in the generally recognized fall outbreak of 1918, there was not only an increase in the number of cases diagnosed as influenza but also a corresponding increase in the ;'other respiratory diseases." One camp reported a preponderant number of influenza cases, another simultaneously suffering from the same epidemic wave reported few influenza cases, but a great increase in the common respiratory diseases. Even in the 1918 fall wave, three camps—Fremont, Calif.; Gordon, Ga.; and Wheeler, Ga.3—apparently insisted on a bacteriological diagnosis, which was not forthcoming, and reported their epidemic cases as "other respir- atory diseases." These two factors then, the impossibility of making an exact clinical diagnosis of influenza in the absence of the great outbreak, and the insistence by some on the bacteriological diagnosis even in the presence of undoubted waves of the disease, make it impracticable to base conclusions as to the varying incidence of influenza in the Army camps on the reported cases of that disease alone. In studying the varying incidence of influenza, therefore, INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 63 it becomes necessary to use not only the figures for that disease as reported, but also tliose for certain other acute respiratory infections. In using this combined figure we are undoubtedly including a certain number of noninfluen- zal cases. In view of the number of cases involved, however, and of the more or less constant incidence of these diseases as usually observed, it is believed that the use of this figure will give the most reliable comparative index of the month- to-month incidence of influenza that it is possible to obtain. The study of the relations between the incidence of the common respira- tory diseases and of the pneumonias, therefore, should serve to throw light both on the causation of the high pneumonia incidence and mortality as well as on the character of the responsible primary infection. For this reason, it seems impossible to consider separately the epidemiology of the pneumonias and of influenza. It should be understood in studying the various charts presented that the system of recording admissions for disease in use in the Army during the World War referred each case back to date of admission. Thus, if a man was admitted with measles during one month and his complicating pneumonia did not develop until the following month, the pneumonia would be reported as occurring in the former month, the date of the original admission. This simplifies the reading of the graphs as, for instance, the peak of measles admission and of the com- plicating pneumonias will thus appear in the same month. No allowance is necessary for the lapse of time between the development of the primary disease and the onset of the complication. As to the accuracy and completeness of the figures used in the following pages, it must be said that doubtless many cases of pneumonia escaped record in the monthly tables used, by reason of the fact that the disease of record was taken to be the one given as the cause of the original admission. Complica- tions and intercurrent diseases were included in the tables of concurrent dis- eases, solely for enlisted men in the United States and Europe, and when complicating disease, not injury, but were not classified by months, except to some extent those occurring in influenza, and in measles. However, for the present study the figures are very satisfactory and while doubtless many pneumonia cases were recorded under some other heading this error was un- doubtedly a nearly constant one and the important facts, the fluctuations in the rates from month to month, are believed to be shown with substantial accuracy. EPIDEMIOLOGY The history of epidemic influenza dates back to the dark ages of medicine and much of it is involved in the obscurity of uncertain diagnosis. It is outside the sphere of this chapter to consider this even in the most cursory manner. Suffice it to say that the records of periodic visitations of epidemic acute respiratory disease of such character as to be reasonably supposed to have been influenza go back almost as far as does written history. These outbreaks have been of varying character and the descriptions sometimes lead to doubt as to the influenzal character of the disease. Some outbreaks were associated with large numbers of fatal cases of pneumonia while others equally widespread were accompanied by relatively slight fatality. Before the pandemic of 1918 the 64 COMMUNICABLE AND OTHER DISF.ASES latest general outbreak of the disease was that of 1S89-90,4 involving very large numbers of cases but, compared to the more recent outbreak, a small loss of life. Even in this outbreak the fatality of the various waves varied greatly. Since that pandemic several minor outbreaks of less general distribution have occurred, notably in the winter of 1907-08 4 and in that of 1915-16.5 Neither of these led to enough excess mortality to make any considerable impression on the mortality curves although it is evident on careful study. The mortality figures for the United States registration area, 1911-1920,6 show a regularly varying curve for deaths from influenza and from the pneu- monias, highest during the winter months, although at times the highest point was reached in March. (Chart V.) The highest monthly rates for influenza prior to 1918 were reached in the winter of 1915-16, and were accompanied by some increase in the pneumonia death rates. This increased death rate for pneumonia continued with slight remission during the succeding years up to the great pandemic of 1918, after which the death rates for influenza for the '»" "1Z <»" «"> '9i5 1916 w ijTa----------^----------^75-----°01 Chart V.—Comparative trends of mortality rates per 1,000 for pneumonia and influenza, United States registration area for deaths, 1911-1920 whole area dropped back to normal. It was noted, however, that certain cities, New Orleans for example, showed an even higher death rate for influenza in the winter of 1917-18 than had been the case two years earlier. There appears to have been then a certain possible increase in the prevalence of influenza andjto a greater extent of pneumonia in the few years preceding the great outbreak of 1918. For the Army, statistics are available since 1840, except for the period of the Mexican War. There is little evidence in the records of any exceptional prevalence of influenza during the Civil War. From the end of the Civil War to the beginning of the World War there was an almost uninterrupted slow decline in the admission rates for pneumonia in the Army.7 This was broken only by two considerable elevations, one in 1888, the year before the outbreak of the 1889-90 influenza pandemic, and a second^ almost as high, coinciding with the mobilization for the Spanish-American War in 1898, from 1913 there has been a very slight tendency for the rates to rise. The figures for influenza are less satisfactory owing to the confusion as INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 65 to the exact diagnosis of the condition. Following the Civil War relatively low rates prevailed for a few years to be succeeded by a period of some 15 years when the reported rate ran nearly as high as that reached during 1890, when the peak of the pandemic reached the Army. Immediately preceding the pandemic, however, several years were recorded with as low a rate as was the case later. Following the 1889-90 pandemic the rates gradually descended; low points were reached in 1902 and in 1914. The case fatality of the pneumonias was high during the Civil War and again reached almost the same point in 1918. The high point in the intervening years was reached in 1887, after which time there was a tendency to a gradual decline. In 1904, 1907, and 1915, all years in which influenza was noted as more than usually prevalent in the civil popu- lation, there is a simultaneous rise. In the years previous to the 1889-90 pan- demic there appears to be no easily traceable relation between them. With the exceptions of these relations, shown both in the civil and military statistics between the incidence and the mortility for influenza and pneumonia, it would appear that the really significant fact brought out by these figures is that there is present at all times even in the interepidemic periods a disease of such a character clinically as to lead large numbers of physicians, both in the Army and in civil practice, to call it influenza. Whether this disease is the same as that occurring in epidemic outbreaks remains for the future to decide, and the deci- sion will be made when etiologic studies have progressed to the point that will render it possible to make a diagnosis based on the identity of the inciting agent. PREVALENCE AND IMPORTANCE DURING THE WAR PERIOD General tables for the period of the war have been prepared showing the total number of admissions and deaths from influenza, bronchitis, bronchopneu- monia, and lobar pneumonia in the various racial groups comprising the Army, and for the different countries in which our troops were stationed. Rates have also been calculated for each of these groups based on a strength which was obtained by the addition of the mean annual strengths for each of the years of the war. The resulting rate is an average of the annual rates weighted for the varia- tions of strength from year to year. The figures thus obtained possess decided comparative value; they show the results that may be expected from different races and in the different climates over a considerable period of time in the pres- ence of epidemic outbreaks of influenza. On the other hand, they are open to the objection that applies to all single figures purporting to represent aver- ages—the details are inevitably obscured. For the detailed study of the epidemi- ology of these conditions the rates by months for the different groups are vastly preferable. These monthly rate are given in the study of the effect of race and of length of service on the incidence and the mortality of the diseases under consideration. The consideration of these general tables, however, will serve to give an outline of the respiratory disease situation in the Army during the World War, and certain general conclusions may be drawn from them as to the relative prevalence and fatality of these diseases in the different groups. 56706—28----5 66 COMMUNICABLE AND OTHER DISEASES Table 10.—Respiratory diseases. Primary admissions, officers and enlisted men, United States Army, by countries, April 1, 1917, to December 31, 1919. Absolute numbers and annual ratios per 1,000 strength Influenza Bronchitis Bronchopneu-monia Lobar pneu-monia Total Absolute numbers 791,907 783,895 28, 621 Annual ratios per 1,000 Absolute numbers 255,148 253,323 11,876 Vnnual ratios per 1,000 61.80 61.89 57.54 Absolute numbers 32,572 32, 386 1,021 Annual ratios per 1,000 7.89 7.91 4.95 Absolute numbers 45, 774 45,525 975 Annual ratios per 1,000 Absolute numbers Annual ratios per 1,000 Total officers and enlisted men (including native 191. 82 191. 56 138. 68 11.09 11.12 4.72 1,125,401 1,115,129 42,493 272. 60 Total officers and enlisted men, American troops...... 272. 48 205.89 Enlisted men, American: White ______.....-- 671,322 59,448 24, 504 186. 50 207.46 214, 561 20,045 6,841 59.61 69.95 24,422 4,825 2,118 6.78 16.84 31,903 11,482 1,165 8.86 40.07 942,208 95, 800 34, 628 261. 75 334. 32 Total --- ________ 755,274 194. 35 241,447 8,062 148,401 12,963 62.13 64.88 75.51 88.88 31,365 444 13,297 2,759 8.07 3.57 6.77 18.92 44,550 527 21, 886 7,016 11.46 4.24 11.14 48.10 1,072, 636 27,003 660,400 61,601 276.01 U. S. Army in the United States (including Alaska): 17,970 476,816 38,863 144. 61 242.62 266. 51 217.30 Enlisted men-White - -- -- -- 336. 04 422. 41 Total ______ ____ 515, 679 244. 27 161,364 76.43 16,056 7.61 28,902 13.69 722,001 342. CO Total officers and enlisted men---- 533,649 238. 70 169,426 75.79 16, 500 7.38 29,429 13.16 749,004 335. 03 U. S. Army in Europe (ex-cluding Russia): 9,743 132.15 3,517 47.70 552 7.49 7.32 16.32 424 9,000 4,149 1,076 5.75 6.12 33.89 14, 236 256, 099 31,435 33, 714 193.09 Enlisted men-White __________ 176,240 18,619 23,859 119. 92 152.10 60, 098 6,681 6,679 40.89 54.58 10,761 1,986 2,100 174. 25 256 89 Color not stated----- Total ________ 218, 718 137. 38 73,458 46.14 14, 847 9.33 14, 225 8.93 321, 248 201 78 Total officers and enlisted men---- Officers, other countries------ 228,461 908 1,055 465 137.15 108. 25 62.08 104.35 76,975 297 713 70 46.21 35.41 41.95 15.71 15,399 25 14 6 9.24 2.98 .82 1.35 14,649 24 8.79 2.86 355,484 1,254 201. 39 149. 50 Philippine Islands (including China): White enlisted men------ Colored enlisted men---- 49 5 2.88 1.12 1,831 546 107. 73 122. 53 Total -.- ---___ 1,520 70.86 783 874 146 36.50 54.08 43.96 20 11 6 .93 .68 1.81 54 2.52 2,377 110.81 Hawaii: White enlisted men------ Colored enlisted men---- 1,012 183 62.62 55.14 58 11 3.59 3.31 1,955 346 120. 97 104. 22 Total ___________ 1,195 3,272 5,250 127 587 61.35 166. 18 1,020 866 52.41 17 .87 .36 69 8 3.54 .41 2,301 4,153 118. 17 Panama: White enlisted men. 43.99 7 210. 94 Other countries: White enlisted men------ Colored enlisted men---- Enlisted men, color not 1,857 30 153 99 12 11 235 34 17 7,441 203 768 Total_____________ 5,964 2,040 122 286 8,412 Transports: White enlisted men.-..... Colored enlisted men---- Enlisted men, color not 7,677 1,191 58 78.75 113. 05 1,752 155 9 17.97 14.71 233 56 2.39 5.32 667 267 72 6.84 25.34 10, 329 1,669 146 105.95 158. 42 Total_____________ 8,926 2,517 1,052 4,443 82.62 135. 51 187. 35 375. 51 1,916 17.74 296 2.74 8.18 .89 2.45 1,006 122 49 78 9.31 12,144 112. 41 Native enlisted men: 761 230 834 40.97 40.96 70.49 152 5 29 6.57 8.73 6.59 3,552 1,336 | 5,384 191. 23 237. 93 455. 04 Total- - __________ 8,012 222. 40 1, 825 50.66 186 5.16 249 6.19 10,272 '---- INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 67 Table 10 shows the absolute number of primary admissions for racial groups and for totals. Thus it is seen that influenza, bronchitis, broncho- pneumonia, and lobar pneumonia were responsible for 1,125,401 primary admissions in the entire Army. Of these, influenza is credited with 791,907 admissions; bronchitis, 255,148; bronchopneumonia, 32,572; lobar pneumonia, 45,774. These diseases occurred also concurrently with, or secondarily to, other diseases or surgical conditions for which patients primarily were admitted to hospital, and were, in many instances, probably responsible for much of the mortality which occurred and was otherwise reported. It is not now possible to discover the total number of instances in which influenza, bronchitis, bron- chopneumonia, and lobar pneumonia occurred concurrently with other diseases or as complications of surgical conditions; however, partial results are possible. Thus, it is possible to account for 798,509 cases of influenza, 279,597 of bron- chitis, 96,495 of bronchopneumonia, and 76,147 of lobar pneumonia. Allowing for the instances where diseases of this group complicated other diseases of the same group, it is possible to account for 797,993 cases of influenza, 272,735 of bronchitis, 37,334 of bronchopneumonia, and 51,115 of lobar pneumonia, a total of 1,159,177 cases of respiratory diseases; which, as stated above, can be only an approximation. There were in all, during the World War, 3,515,464 admissions to sick report for disease. Of these, 32 per cent were primarily for respiratory disease, while an additional 0.96 per cent of the total suffered from these diseases secondarily. The comparison of the annual ratios per thousand also is shown in Table 10. The total mean annual strength of the Army for the years 1917- 1919 was 4,128,479.8 It can be said, then, that 18.33 per cent, or 1 man to every 5.17, contracted influenza in the service, 6.27 per cent, or 1 to every 15.14, contracted bronchitis, 0.86 per cent, or 1 to 110.58, contracted broncho- pneumonia, and 0.17 per cent, or 1 to 80.77, contracted lobar pneumonia. The 1,159,177 cases of respiratory diseases represent 26.63 per cent of the total number of men in the Army, or 1 to every 3.5 men. Venereal disease was responsible for the next largest number of admissions (357,969), followed by mumps with 230,356 primary admissions and acute tonsillitis with 176,408. As to group incidence, the figures show that the incidence was in general higher among the American enlisted men (276.01) than among officers (205.89). The highest admission rates shown by any group was for the enlisted men from Porto Rico. Of their total rate of 455.04 per 1,000 for respiratory diseases, however, 375.51 was for influenza. Their primary admissions for the pneu- monias, especially for bronchopneumonia (2.45), were relatively low. The next highest admission rate was shown by the colored enlisted men in the United States (422.41). The colored rates were consistently higher than those for the whites under the same conditions except for the colored enlisted men in Hawaii, who had the lowest rate fgr total respiratory disease (104.22) shown by group. The rate for the enlisted men of the Philippine Scouts (191.23) was lower than that of the Army as a whole (272.60), while that for the enlisted Hawaiians (237.93) was also below the average. The rate for the Philippine Scouts (191.23) was higher than that for the white enlisted men in the Philippine Islands (107.73) and also higher than that for colored troops (122.53) in the same territory. 68 COMMUNICABLE AND OTHER DISEASES In general, troops serving in the Tropics showed lower admission rates than those in temperate climates. However, the rate for white enlisted men in Panama (210.94) was higher than the corresponding rate in Europe (174.25). The explanation of this is not forthcoming unless it be based on the fact that the troops in Europe had passed through the preliminary waves of the epidemic in the United States and had acquired an immunity which was not possessed by the troops in Panama where the earlier waves of the influenza invasion made little impression. This fact possibly accounts for the relative immunity of the troops in Europe as compared to the corresponding groups in the United States. It is not believed that the rates as given for men on transports are comparable fairly with the others, since the difficulty of obtaining a satisfactory strength basis of computation or admission rate is insuperable. The strengths used appear to have been too high and the corresponding rates low. It is generally admitted that during the fall wave of influenza (1918) the incidence and mortality on the transports was high, undoubtedly due to the necessarily limited space available per man. Among the military personnel during the World War there were 44,270 deaths, occurring in cases having a primary diagnosis of influenza, bronchitis, bronchopneumonia, or lobar pneumonia.1 Of these, 24,664 are charged to influenza, 439 to bronchitis, 9,022 to bronchopneumonia, and 10,145 to lobar pneumonia. There were, however, large numbers of cases of these diseases reported, secondary to other diseases as previously stated. If to these associ- ated cases we apply the same case fatality rates as shown by the primary admissions and deaths, we find that there were, in addition to the deaths given above, 189 from influenza, 30 from bronchitis, 1,319 from broncho- pneumonia, and 1,184 from lobar pneumonia. This method gives an estimated total of 24,853 deaths from influenza as recorded, 469 from bronchitis, 10,341 from bronchopneumonia, and 11,329 from lobar pneumonia, a grand total of 46,992. This is nearly as large a total as that of the battle deaths, American Expeditionary Forces—50,38s.1 The disease responsible for the next largest number of deaths was tuberculosis, as a primary admission, with 2,766, followed by measles with 2,370 (also mainly due to pneumonia) and epidemic meningitis, with 1,836. Of all the deaths charged to influenza, 99.4 per cent were recorded as due secondarily to pneumonia, of which 66.1 per cent of the total were described as bronchopneumonia and 33.3 per cent as lobar pneumonia. It appears that less than 1 per cent of the influenza deaths showed no recognized signs of pneumonia; that a very few cases are fatally overwhelmed by the primary infection appears probable. Of the deaths charged to bronchitis 84.5 per cent were recorded as secondarily due to pneumonia, of which 52 per cent were described as bronchopneumonia and 32.5 per cent as lobar pneumonia, a pro- portion of 1.6 to 1 as compared with almost exactly 2 to 1 in the cases recorded as secondary to influenza. It is evident that, in so far as the bronchitis cases were of an influenzal nature, the cases were evidently of a much milder average than those diagnosed frankly as influenza; the greater number of them too occurred in the earlier months of the war period. That this was largely true will be shown later. The men, then, who suffered from this infection in a form INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 69 severe enough to induce pneumonia and death were presumably the more susceptible individuals. The proportion of lobar pneumonia to broncho- pneumonia is seen to be higher in this group than in those frankly diagnosed as influenza. This agrees with the relations of these types of pneumonia as noted for the white and colored races, in which the more susceptible race showed a much larger relative proportion of lobar pneumonia both in admissions and in deaths. The total deaths from disease during the war were 58,119, of which those from respiratory diseases (as computed above) were 46,992, or 80.85 per cent. Nearly all of these deaths from respiratory diseases, as has been shown, were the result of pneumonia. Table. 11.—Respiratory diseases. Deaths, officers and enlisted men, United States Army, by countries, April 1, 1917-December 31, 1919. Absolute numbers and ratios per 1,000 Influ Abso-lute num-bers enza Ratios per 1,000 Bronchitis Broncho pneu-monia Lobar pneumonia Total Abso-lute num-bers Ratios per 1,000 Abso-lute num-bers 9,022 8.992 192 Ratios per 1,000 2.19 2.20 .93 Abso- i-D t. „ lute !**£» bers 1,uuu 10,145 2.46 10,099 2. 47 194 .94 Abso-lute num-bers 44, 270 44,105 1,004 Ratios per 1,000 Total officers and enlisted men (includ- 24, 664 24,575 596 5.97 6.00 2.89 439 439 22 0.11 .11 .11 10.73 10.78 4.87 Total officers and enlisted men, Ameri- Total officers_______.....________ Enlisted men, American: White................ 20,888 2,287 804 5.80 7.98 334 42 41 .09 .15 6,480 1,063 1,257 1. 80 3.71 7, 073 1. 96 2, 222 7. 75 610 ______ 34, 775 5,614 2,712 9.75 19.59 Total________________________ 23,979 6.17 417 .11 8,800 2.26 9,905 , 2.55 43, 101 11.09 U. S. Army in the United States (includ-ing Alaska): 387 3.11 12 .10 80 .64 94 .76 573 Enlisted men— White.. . ___________..... 14,617 1,567 7.44 10.74 24 3 .01 .02 3,429 634 1.74 4.35 4,330 1,363 2.20 9.35 22,400 3,567 11 39 24 46 Total__________....._________ 16, 184 7.67 27 .01 4,063 1.92 5,693 2.70 25,967 12 30 Total officers and enlisted men. 16, 571 7.41 39 .02 4,143 1.85 5, 787 2.59 26,540 11.87 U. S. Army in Europe (excluding Russia): 191 2.59 10 .14 108 1.44 93 1.26 400 5.43 Enlisted men— White____......_______________ 5,753 628 794 3.91 5.15 304 38 40 .21 .31 2,919 395 1,244 1.99 3.23 2,414 778 534 1.64 6.36 11,390 1,839 2,612 7.75 Colored______________.......... 15.05 Total________________________ 7,175 4.51 382 .24 4,558 2.86 3,726 2.34 15,841 9.95 Total officers and enlisted men. 7, 366 4.42 392 .24 4,664 2.80 3, 819 ' 2. 29 16, 241 9.75 18 2.15 6 .72 7 .83 31 14 5 3.70 .41 Philippine Islands (including China): 2 .12 1 .03 4 ■1 .24 .90 7 .83 1 | .22 1. 12 Total........__________________ 2l .09 1 .05 s .37 8 .37 19 .88 Hawaii: 3 2 .06 3 .19 1 .30 6 5 .25 2 .60 .90 Total 5 .06 2 .10 4 .21 11 .37 Panama: White enlisted men......----- 9 .45 2 .10 ___!! .56 70 COMMUNICABLE AND OTHER DISEASES Table 11.—Respiratory diseases. Deaths, officers and enlisted men, United States ^rmy> & countries, April 1, 1917, to December 31, 1919. Absolute numbers and ratios per 1,000 Continued Influenza Bronchitis Bronchopneu- Lobar monia pneumonia Total Abso-lute num-bers Ratios per 1,000 Abso-lute num-bers Ratios per 1,000 Abso-lute num-bers Rati°s|1ute0" iPooo num" 1,uuu bers ______ 54 ______ 8 5 Ratios per 1,000 Abso-lute num-bers Ratios per 1,000 Other countries: White enlisted men_____.......... 137 2 3 48 13 9 242 28 19 Total.................... 146 _____1 3 70 ___ . 67 ....... 286 Transports: White enlisted men______________ Colored enlisted men_____________ Enlisted men, color not stated_____ 367 83 8 3.76 7.88 2 1 1 .02 .09 80 15 4 .83 1.42 263 71 71 2.70 6.74 712 170 84 7.31 16.13 Total_____________________ Native enlisted men: Philippine Scouts__.. _____... 458 4.24 4 .04 99 .92 405 3.75 966 8.95 17 8 .92 1.42 5.41 27 1.45 25 5 16 1.35 .89 1. 35 69 13 83 3.72 2.31 64 3 .89 7.6; Total_________......______ 89 30 46 165 Table 12.—Respiratory diseases. Officers and enlisted men, United States Army, by countries, April 1, 1917, to December 31, 1919. Case fatalities and ratios of bronchopneumonia to lobar pneumonia Total officers and enlisted men (including native troops)_____________________________ Total officers and enlisted men, American troops________________________,____________ Total officers________________.....___________ Enlisted men, American: White______________ Colored____________ Color not stated_____ Total. U. S. Army in the United States including Alaska): Officers________________________________ Enlisted men- White______________________________ Colored____________________________ U. S. Army in Europe (excluding Russia): Officers________________________________ Enlisted men— White______________________________ Colored____________________________ Officers in other countries__________________ Philippine Islands: White enlisted men_____________________ Colored enlisted men_________________ Hawaii: White enlisted men______.....__________ Colored enlisted men......___________~~~~ Panama: White enlisted men__________ Case fatality Influ- enza 3.1 3.1 2.2 3.1 3.8 3.3 Bronchi- tis 3.2 3.1 4.0 2.0 3.3 3.4 2.0 .30 1.1 .27 0.17 .17 .18 .16 .21 .60 Broncho- pneu- monia .15 .16 .02 27.7 27.7 18.8 26.5 22.0 59.3 18.0 35.8 23.0 19.2 27.1 19.9 24.0 28.6 66.6 33.3 Lobar pneu- monia 22.2 19.9 Total 3.9 4.0 2.4 22.2 19.3 52.3 3.7 5.9 7.8 Ratio, bronchopneu- monia to lobar pneumonia Admis- sions 0.71 22.2 17.8 19.8 19.4 21.9 26.8 18.8 29.1 14.3 20.0 5.'2 9.1 25.0 2.0 3.4 5.8 4.4 5.8 2.5 .92 .3 .9 .27 .71 1.05 Deaths 0.89 .76 .42 1.82 .61 .39 1.30 1.19 .49 1.04 .29 1.20 .19 .55 .87 .89 .99 .91 .48 2.06 .85 .79 .46 1.14 1.21 .51 1.17 57 4.00 2.0 INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 71 Of the race groups, the colored troops show consistently higher rates of death than the whites. The death rates for Porto Rican troops (7.65) is much lower than that of the total colored (19.59) and lower also than the total white rate (9.75). It about equals the rate observed for the white troops in Europe (7.75). In view of their high admission rate, their low fatality emphasizes APRIL-DECEMBER. 1917 1918 1919 Chart VI.—Annual admission rates per 1,000 strength, white enlisted men in the United States, for influenza, bronchitis, bronchopneumonia, and lobar pneumonia, by months, April, 1917, to December, 1919 the influence of the climate in which a large proportion of these men were stationed. This applies also to the low rates for the Philippine Scouts (3.72) and the Hawaiians (2.31). The death rates for officers (4.87) were lower than for enlisted men (11.09). This difference is more marked in the United States than in Europe. The influence of environment is markedly shown in 72 COMMUNICABLE AND OTHER DISEASES the lower death rates for the tropical countries even in groups that show rela- tively high admission rates as in the case of white troops in Panama (0.5b) and in that of the Porto Rican troops (7.65). In attempting to trace the various waves of the influenza epidemic, use has been made of the admission and death rates of influenza, bronchitis, broncho- pneumonia, and lobar pneumonia, combined in each case into a single rate. From the number of admissions and the number of deaths, the case fatality has been calculated. Tables 13 to 22, inclusive, and Charts VIII to XIII 1000 APRIL - DECEMBER 1917 I9IS I919 Chart VII.—The relations between the annual admission rates per 1,000 strength, white enlisted men in the United States, of the combined influenza and bronchitis and the combined lobar pneumonia and bronchopneumonia, by months, April, 1917, to December, 1919 show^ these factors for various specific groups of the Army. The epidemic prevalence of influenza in a certain month shows itself on the charts referred to in one or more of three ways, increases being in the admission rate, in the death rate, or in the case fatality. Differences in race or in length of service are accompanied by differences in the way in which a group reacts to the presence of influenza. When the epidemic is at its worst all three factors are INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 73 markedly affected, but in the case of milder waves only that factor to which the group responds most sensitively may show indications of the presence of the epidemic wave. Thus, in general, the colored race shows less variation 3QOO |------—-----------------,---------—-------------------,---------------------------——---1 0.11-----1----1----------------1—-------------------------------1------------------------------1---1 APRIL-DECEMBER 1917 191S 1919 Chart VIIL—Annual admission and death rates per 1,000 strength for white and colored enlisted men in the United States, total respiratory group of diseases, by months, April, 1917, to December, 1919 in case fatality and more in morbidity than does the white race. So, too, the process of "seasoning" alters the relation of the case fatality and the admission rates to the death rates. With these preliminary facts in mind it is possible 74 COMMUNICABLE AND OTHER DISEASES to examine the charts of annual rates by months and to determine with degree of probability those months in which an epidemic wave had its < JUNE-DECEMBER, 1 >—rf' \ / K ^ / / \ \ p 1 1 \ \ INF PNE LUENZAI .UMONIA r V \ \ \ ^V* / / / WEEK ENDING V> % 7 14 21 28 4 II 18 25 I 8 15 22 29 6 13 20 27 J 10 17 24 I 8 15 ZZ 29 JUNE JULY AUGUST SEPTEMBER. OCTOBER NOVEMBER DECEMBER 1918 Chart XIV.—Incidence of influenza and influenzal pneumonia, by weeks, for certain camps in the United States, June 17 to December 29, 1918. Annual admission rates per 1,000 strength based on weekly reports of current med- ical statistics the troops at home and abroad seem to preclude the idea of the transmission of these waves from one command to another. The peak months varied in some instances but the evidences of the beginning of the rise for each wave were usually coincident in the two groups. This observation is of fundamental importance in the epidemiology of the disease. 86 COMMUNICABLE AND OTHER DISEASES Epidemiologists have usually approached the study of epidemic influenza from the point of view that the disease had originated in some distant land and reached any given point by certain fairly definite routes. The Medical Depart- ment figures, as summarized above, show that the fatal wave of the fall of 1918 was preceded by several preliminary outbreaks, and followed by a number of recurrences, and that the rates of incidence and mortality for widely separated commands were so nearly synchronous in their rise and fall for each wave as to impress the student with the probability that the virus of the disease had achieved a world wide distribution months before the mortality records forced recognition of its prevalence. It must follow from this observation that the disease once established in a community passes through alternating phases of increasing and decreasing activity, due either to changing qualities of the virus itself or to variations in the susceptibility of the population. And here again we are led to speculate as to the possibility that this disease may in fact be constantly present in all populations, making its presence felt only through cases of such mildness as to attract little attention unless such cases are indeed the usual predisposing condition needful for the production of the endemic pneumonias of the interepidemic periods. COMPARISON OF ARMY AND CIVIL DEATH RATES The high incidence and mortality from pneumonia in the earlier days of mobilization, together with the explosive character of the fall epidemic (1918), as it appeared in the camps in this country, with the appalling number of deaths concentrated in a very few weeks in each camp, have led to the idea that the death rate from respiratory disease was enormously higher in the Army than was the case in civil life. While this was true, to some extent, especially as regards the newly recruited troops in the camps in this country, it is believed that the actual figures do not bear out the general impression. The closely knitted communi- ties of the camps afforded the greatest opportunity for the epidemic to spread, but while the rates in these camps were higher than those of civil life, they were not as high as some apparently have believed. The comparison of death rates in the Army and in civil life is rather a complicated matter and many factors must be taken into consideration before fairly comparative figures can be adduced. In the first place, the usually pub- lished rate for a civil community is a gross one, taking into consideration no difference in the specific rates for race, age, and sex. The Army rate, on the contrary, is based on a population exclusively male and of an age grouping quite different from that of a civil community. For present purposes it may fairly be assumed that for the period of greatest mortality during the World War the proportion of colored and white troops in the service was the same as that in the corresponding age groups of the general population. In order to make a comparison, then, it becomes necessary to apply the specific rates for the various age groups of males in the civil population to the strength of the corresponding age groups in the Army, and to compare the number of deaths thus arrived at with the number that actually occurred in the military service. For the purpose of comparison, the year 1918 has been selected, as this was the time of the greatest strength of the Army, also because for that period monthly figures are available on which to base the rate calculation for INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 87 the Army. These monthly compilations, however, have been made only for enlisted men in the United States and Europe and the comparison, therefore, is based on data which show a rate somewhat higher than that of the whole Army, which included officers, and also enlisted men in various tropical stations, both of which classes showed a decidedly lower death rate than did the enlisted men in this country and in Europe. Figures, by months, for the entire Army, how- ever, are not available, and inasmuch as the figures used include the great majority of the Army, the comparison seems a fair one. The proportion of men of different ages in the Army during the war is not a matter of direct record; however, from the records of the War Risk Insurance Bureau it is possible to show the ages of 3,673,125 men, obtained from their applications for policies of Government insurance. Since it is fair to assume that the average period of service was in the neighborhood of one year, and that the insurance policy was taken out at or near the beginning of the service period, the ages of these men have been advanced six months each to obtain an average figure for the war period. The following table shows the age grouping thus obtained. Age group 15-19 years 20-24 years 25-29 years 30-34 years Number of men Percent-age of total 138, 267 1,644, 952 1, 345, 679 448,631 3.76 44.80 36.60 12.20 Age group 35-39 years 40-44 years 45-49 years 50-64 years Number of men 54,975 24,975 9,990 5,656 Percent- age oftotal 1.50 .27 .15 It is believed that these figures are fairly representative of the actual con- ditions, although the fact that officers as well as enlisted men are included somewhat increases the percentage of the older age groups. It has been shown that when the strength of a command varies greatly from month to month, and at the same time the death rates vary greatly, a death rate based on the total number of deaths for the year and the mean annual strength will not give a figure fairly comparable to that of a command of nearly uniform strength having the same monthly death rates.10 If it happens that the months of greatest strength are also those of the highest death rates, the effect on the annual death rate, calculated as above stated, is to make it too high, while, if the high death rates coincide with a period of low strength, the rate will be too low as compared with a command of uniform strength having the same monthly rates. The average of the monthly rates for the year, how- ever, gives a truly comparable figure whatever variations there may be on the part of the strength or of the monthly death rates. In comparing the military and civil rates, then, it is important to take this factor into consideration, for while the Army increased to a maximum strength in the months of the highest death rates due to the influenza epidemic, the number of males of military age who remained at home and contributed to the civil death rates correspondingly diminished. These fluctuations were great enough to have a very marked effect on the rates. The rates for months but not by age groups are available for the Army. The rate for the age groups but not by months are available for the civil population (registration States). Hence some method must be devised to reduce the two sets of data to a common basis. 88 COMMUNICABLE AND OTHER DISEASES The average of the monthly death rates from disease of all kinds for enlisted men in the United States and Europe was 16.1 per thousand.1 The total num- ber of deaths from disease was 44,924.! If this total number of deaths during the year be divided by the death rate and multiplied by one thousand it will give a figure representing the strength that would have given the same number of deaths during the year had the strength and the death rate remained uniform throughout the year.^ The figure in this case is 2,788,000. This is an average of the monthly strengths weighted by the death rates for the corresponding months. For the reasons given above this is the best figure to use for the average strength of the Army when comparing its rates with those of the civil population. The next factor to be estimated is the proportion of the various age groups of the male population as estimated for 1918 that were not in the services (Army, Navy, and Marine Corps) and so remained to contribute to the civil rate. The usual arithmetical method of estimating population based on the census returns of 1910 and of 1920 can not be applied to the years previous to 1919 without taking into consideration the excess deaths in the various age groups due to the influenza epidemic and to battle casualties. If these be estimated as carefully as possible and added to the population as found in 1920 the estimate for 1918 becomes satisfactory. If, then, from the population of each age group, as thus estimated, is subtracted the number of men of each age in the service the remainder will represent the number in each age group that contributed to the civilian death rates. It is estimated that the Army repre- sented 87.5 of the total military forces during the war, the balance being the Navy and the Marine Corps. Hence the weighted mean strength of the services during 1918 was 3,180,000 men. The registration States furnished 76.51 per cent of this total or 2,435,000. If these men be divided into age groups accord- ing to the percentages shown in the table of ages the results will represent the number of men in each age group furnished to the services by the registration States. These numbers subtracted from the estimated population of the registration area in each group will give the civil population in each group during 1918, and from these last figures the death rates for each group may be calculated from the number of deaths in each group in the registration states as furnished by the Census Bureau. The following specific death rates from disease for males of the indicated age groups were arrived at by the method given. Age 15-19 years 20-24 years 25-29 years 30-34 years Age 35-39 years. 40-44 years. 45-49 years. 50-64 years. Death rate from disease 14.12 13.23 14.03 22. 58 If these rates are applied to the weighted mean strength of the Army and the latter divided into age groups according to the age table given, the total result is 42,184 deaths, or 15.1 per thousand on the weighted mean strength. INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 89 The comparative rate for the Army as given above was 16.1, a difference that, if occurring from one year to the next in the same population, would not be regarded as highly significant. When, however, the rates for the total respiratory diseases are treated in the same manner the rates obtained are 12.59 for the Army and 9.96 for the civil population. It is evident that the Army had a decidedly higher reported death rate for the respiratory diseases than was found in civil life and equally evident that the reverse was true for other causes of death. In fact, the figures indicate that at civil rates the Army would have lost nearly seven thousand more men than was actually the case from causes other than the respiratory diseases. The reasons for these differences are probably several. It will be shown later that men from rural districts, when introduced into the conditions of barrack life, are much more susceptible to respiratory infections than are their urban brethren. Urban rates for respiratory diseases are always markedly higher than those of rural districts. In the Army hundreds of thousands of young men from rural districts were living in the Army camps in conditions of closer contact than in ordinary city life. The majority of these men in this country at the time of the great epidemic were comparatively new to the service, 76 per cent had seen less than four months' service,0 and had little or no time for "seasoning." Certain cities in the country showed rates during the epidemic higher than those of the Army. For the last four months of 1918, had the rates that obtained in Philadelphia been applied to the Army strength there would have been 39,894 deaths from disease and 33,287 from the respiratory diseases as compared with 36,858 and 33,136, respectively, which actually occurred in the Army. Again, there is seen the greatly larger number of deaths from causes other than the respiratory diseases occurring in the civil population even during the epidemic months. So great a disparity suggests some differences in the standards of diagnosis in the two sets of figures. That many deaths occurring in the registration area were really due to influenza or pneumonia while otherwise reported, is suggested by the notable and unsea- sonable increases during the epidemic period in deaths from a number of other causes. It is undoubtedly true also that during this period, the country over, a great number of deaths occurred that were never reported. The conditions in many places were such that the keeping of accurate records was an impos- sibility. In the Army, however, every man had to be accounted for and the death records are as nearly accurate as it is possible to make them. It is to be recalled, too, that the Army rates as used in this comparison, excluded cer- tain groups of the Army which showed a decidedly lower death rate than those given herein, and that the total rate for the Army would have been somewhat lower had the complete monthly figures been available for comparison. The conclusion seems justified, then, that the disparity existing between the two rates was not more than is accounted for by the assembling of large numbers of country boys in camps under urban conditions. » Estimate made in manner described under "The effect of length of service in the Army," p. 90. 90 COMMUNICABLE AND OTHER DISEASES FACTORS TENDING TO MODIFY THE INCIDENCE AND MORTALITY OF THE RESPIRATORY DISEASES In the following pages an attempt is made to glean from the available figures such facts as may show the effect of a number of varying factors on incidence and mortality of the respiratory group of diseases during the war. These varying factors have been considered in connection with different groups of the troops concerned, and the attempt finally is made to correlate the knowl- edge thus gained into a concrete conception of the pandemic as a whole; they include age, length of service in the Army, race, nativity, climate and weather, and housing. AGE As to the effect of age on the incidence of respiratory disease, we are able to present figures for deaths only, classified according to age.1 These apply to the whole Army, wherever located, and include the deaths of officers as well as of enlisted men. Deaths from influenza, bronchitis, and the pneumonias Age group Under 21 years 21-25 years___ 26-30 years___ 31-35 years___ 36^0 years___ Number of Per cent of deaths total 1,951 4.9 21,439 <53.9 13,310 33.4 2,637 6.5 319 .8 Age group Number of deaths 41-45 years. 46-64 years. Total 39, 827 Per cent of total 0.24 .19 100. 00 If the above percentages be applied to the age groups as determined in the calculation of the relative death rates for the Army and for civil life and to a total of 37,002 deaths, the total for these diseases reported for 1918, the following rates per thousand per annum may be deduced. Age Under 21 years. 21-25 years____ 26-30 years---- 31-35 years---- Death rates per 1,000 per annum 8.77 14.30 14.20 11.10 Age 36-40 years 41-45 years 46-64 years Death rate per 1,000 per annum 7.51 5.88 7.25 These rates show nearly the same relations between the age groups as those published from civilian sources, though here the group 21-25 has a rela- tively higher rate than is usually given. LENGTH OF SERVICE It has long been known that men new to the military service are more liable to contract disease, especially disease of the classes under consideration, than are men long in the service. It is possible with the data at hand to pre- sent certain facts showing the degree of this increased susceptibility of the recruit. The report cards of 34,446 deaths from influenza pneumonia show the length of service of the patient at the time of his admission to hospital.1 Of INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 91 these deaths 9,847 or 28. 56 per cent occurred in men of less than two months' service, 10,990 or 31. 90 per cent in men of 2 to 4 months' service, 6,107, or 17. 73 per cent in men of 4 to 6 months' service, 2,629, or 7. 66 per cent in men of 6 to 8 months' service 1,663, or 4. 83 per cent in men of 8 to 10 months' service, 1,198 or 3. 48 per cent in men of 10 to 12 months' service, and 2,012 or 5. 84 per cent in men of over 12 months' service. These relations are graphi- cally shown in Chart XV. It is impossible accurately to estimate the propor- tion of men of each service group in the Army for the entire period of the war, inasmuch as the proportion was constantly changing with the passage of time; however, an attempt has been made to average the proportions found in differ- ent months. The resulting relative strengths probably approximate the dis- tribution of men at the time of the greatest mortality in the fall of 1918. Based on these relative strengths, rates have been calculated showing the relative differences in death rates of the different length of service groups; these are given in Chart XVI and show the same general relations as Chart XV. The former gives a better relative idea of the importance of short service as a cause of death. It is seen that 60.46 per cent of all deaths occurred in soldiers of less than 4 months' service. It is to be noted also that the second bimonthly period shows a larger proportion than does the first. This is an unexpected finding and may be due to other factors than increased incidence among the men concerned. It is obvious that if there had happened to be an unusually large proportion of men of the two to four months' group service in the Army at the time of the fall wave (1918) of influenza, and a correspondingly small number of men of less than two months' service, the number of deaths charged to the latter group would be relatively small in the total and those of the former would be too large. The same principles apply as to the estimation of death rates in commands of varying strength. As a matter of fact the number of two to four months' men was considerably larger in September and October, 1918, than was that of the less than two months' service men. This conclusion has been arrived at by studying the relations of the total enlisted strength of the Army from month to month. Thus, if the total strength was greater by 200,000 one month than in the month previous there must have been in that month 200,000 men of less than one month service. This gives us means of checking up on the figures already given. It is available only during the period of progressive increase in Army strength, and takes into account no losses from death or dis- charge, but it is believed that it is roughly satisfactory as a check. If the num- ber of men of less than two months' service in each month from October, 1917, to October, 1918, inclusive, be compared with the total enlisted strength in the United States the same month, the percentage of recruits of that length of service may be obtained for each month. If, then, for each month the cor- responding percentage of deaths among enlisted men in the United States be calculated and the results added the sum shows the number of deaths that should have occurred among these men had their rate been the same as that of all the other men. This forms a certain percentage of the total deaths in the whole Army, in the case of the less than two months' service men, 20.45 per cent. As a matter of record, as has been stated, these men actually had 92 COMMUNICABLE AND OTHER DISEASES 35 30 25 20 15 a. 10 10,990 TOTAL NO. OF DEATHS 34,446 ^^ 9,847 ^%>> m S y///} 6, 107 n y//// 4m HI ////// yM\ 2,629 /4% I,6b3 2,0»2 '///// Ji m>, 41 11 'iW 1,198 LESS THAN 2 2 TO 4 4 TO 6 6 TO 8 8 TO 10 10 TO "2 OVER 12 LENGTH OF SERVICE IN MONTHS Chart XV.—Percentage of total deaths from influenzal pneumonia during the war period occurring in each'of.thejspeci- fied groups of length of service 25 20 15 10 __; LESS THAN 2 A 10 TO 12 OVER 12 a TO 4 4 TO 6 6 TO 8 8 TO 10 LENGTH OF SERVICE. IN MONTHS Chart XVI.—The relative mortality rates per 1,000 strength from influenzal pneumonia during the war period in each of the specified groups of length of service INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 93 28.56 per cent of the total deaths, or one and four-tenths times their pro rata share. Applying the same methods to the two to four months' men, it is found that their pro rata share was 12.83 per cent of the deaths, while the records charge them with 31.9 per cent, or two and forty-eight hundredths times the former figure. It is impossible to carry calculation to older service groups inasmuch as after four months' service considerable numbers began to go abroad, and the calculation of strength becomes less accurate. However, it is seen that the figures conform to those of the former series in showing that the man of two to four months' service apparently showed a higher mortality from respiratory disease than did those of less than two months. As stated above, there were about 30 per cent more men of the longer service group in the service during the fall outbreak of influenza than there were of the less than two months' service men. This undoubtedly is the factor increasing their rate in the total. The unfavorable effect on camp rates of the presence of a number of recruits is mentioned in a large number of reports of the fall epidemic (1918).u Camp Sherman, Ohio, had the highest mortality rate of any large camp; 46 per cent of its strength were classed as recruits. The rate of Camp Cody, N. Mex., was almost as high, with 69 per cent recruits; Camp Grant, 111., 40 percent; Camp Forrest, Ga., 55 per cent; Camp Devens, Mass., 30 per cent; Camp Custer, Mich., 33 per cent; Camp Greene, N. C, 50 per cent; Camp Syracuse, N. Y., 90 per cent. In the lower part of the mortality scale are found Camp Travis, Tex., with 4 per cent recruits; Las Casas, Porto Rico, with 5 per cent; Camp Sheridan, Ala., with 6 per cent; Camp Eustis, Va., with 7 per cent; and Camp McClellan, Ala., with 10 per cent. If the larger camps be divided into four groups according to mortality, we find the group with the highest mortality had 41 per cent recruits, the second 31 per cent, the third 22 per cent, and the fourth 16 per cent. This relation is the most clean cut of any found among the factors influencing the comparative rates of the camps. Many specific instances of the high mortality of new men as compared to those of longer service are on record. At Camp Grant, 111., for instance, the September inductants lost 4 per cent of their strength, while the loss for the balance of the camp was less than 2 per cent. Vaughan said:12 "If recruits had not been sent to Grant in September, the camp mortality rate from the epidemic would have been 1.7 per cent; 16,000 recruits raised the rate to 2.6 per cent an increase of 53 per cent." The report of the influenza commission working at Camp Pike, Ark., showed similar relations, as follows:13 Seasoned men. Recruits...... Strength 28, 782 23, 749 Percentage of influenza 15.5 30.6 Percentage of influenza cases having pneumonia 11.1 13.9 94 COMMUNICABLE AND OTHER DISEASES At Camp Funston, Kans., the relations were as follows: " Admissions Deaths Seasoned men_________________________________ ______________ _______ New men___ . _____ . __ ......_.___ 33.8 30.3 1.39 2.29 Ratio 1.0 1.65 From Camp Lee, Va., the following report was made:14 In camp_______ Epidemic deaths- Months service Less than 1 Per cent 9.2 30.1 1 to 3 Per cent 45.2 46.2 Over 3 Per cent 45.6 23.7 At Camp Upton, N. Y., recruits were scattered among companies of the 2d Battalion in the proportion of three recruits to two older men, but no less than 167 recruits became sick before the first of the men who had been in camp prior to September 6.14 Eight recruits died to each man of longer service. Analysis of 494 cases of pneumonia made by the laboratory officer at Camp Grant, 111., showed the distribution of cases as follows:16 During the first month of service, 192; second month, 42; third month, 42. A report from Camp Bowie, Tex., shows the large incidence of respiratory disease among recruits comprising a relatively small proportion of the strength of the camp, during the months of April, May, and June, 1918.16 At Camp Lewis, Wash., of 140 cases of pneumonia occurring during September, 1918, 107 were in men of less than one month's service and of 316 cases of influenza, the men of less than one month's service had 237.n RACE Of the various races shown in the general tabulations given herein, only the white and colored can be compared under corresponding conditions. The Philippine Scouts, the Hawaiians, and the Porto Ricans were so largely sta- tioned in tropical or nearly tropical countries and in such comparatively small numbers that comparisons are of relatively little value. Suffice it to say that the Porto Ricans showed the highest admission rates for the total respiratory diseases of any group in the Army, while their death rate was well below the average.1 The Philippine Scouts showed relatively low rates for admissions and deaths as compared to the Army as a whole, but had a higher admission rate and a very much higher death rate than those of the white enlisted men in the Philippine Islands.1 The same general relations hold for the Hawaiians.1 Owing to the effect of the favorable climate the mortality was not high but was higher in these native races than in whites living under the same conditions. The comparison of the white and negro races, however, can be carried out under a great variety of conditions. The rates for admissions of the colored troops, as shown in the general tabulations, are higher than those for the whites INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 95 for every group except the troops in Hawaii. The death rates are higher in all cases, and usually very much higher. Thus the case fatality of the colored is seen to be much higher than was the case with the whites. More valuable deductions, however, may be made from the study of the monthly annual rates for admissions and deaths by races in the United States and Europe (see Tables 13-22). If the averages of the monthly annual rates in each group be taken for comparison it is seen that in the United States the total admission rate for respiratory diseases in the colored troops was slightly lower than that for the whites; however, this difference is due entirely to the small proportion of cases admitted with a primary diagnosis of influenza. The cases showing respiratory symptoms more markedly, the bronchitis and the pneumonias all showed a higher rate for the colored than for the white. It is possible that the colored recruit was slower on the average in reporting his illness, but inasmuch as the total figure is practically the same as that of the white the more probable explanation would seem to be that when attacked, the colored man averaged a much more severe case than did the white man. In Europe the colored troops showed an admission rate over double that of the whites for the same period and much higher than that of the colored troops in the United States. The highest admission rates then were those of the colored troops in Europe, followed in order by those of the colored troops in the United States, the white troops in the United States and the white troops in Europe. The rates of the latter are probably given too low in the tables quoted inasmuch as a considerable number of cases of respiratory disease were reported under the heading "Color not stated," somewhat over 24,000 in all, most of which occurred in Europe during the months of September and October, 1918. The comparison of the case fatalities of these cases and of the relative proportion of lobar to bronchopneumonia leads to the conclusion that most of these men were white. However, if all of these were added to the white admissions the relations would not be very materially changed and it has seemed better to deal with the figures as shown. The relations between the death rates of the different groups is somewhat different. Here the highest average rate is that of the colored troops in the United States, 16.06 for the months covered by statistics for the colored in Europe. During the same period the colored troops in Europe showed a death rate of 11.78 per thousand per annum. For the 31 months for which we have figures for the white troops in Europe their rate was 3.72 as compared to 7.16 for the whites in the United States for the same months. Reverting to the effect of length of service then, it appears that while the seasoned white soldier shows to marked advantage both as to admission and death rates compared to the recruit, the effect of seasoning on the colored soldier is much less marked, and indeed under the conditions he was called upon to face in Europe his admis- sion rate was higher than that of the relatively untrained men in this country. The seasoned colored soldier, however, did show a small gain in the matter of deaths, though even here the difference is by no means so marked as is found in the whites. The effect on case fatality of length of service as deduced from the figures for the troops in Europe and in the United States, is to increase the 96 COMMUNICABLE AND OTHER DISEASES figure for the white troops and to decrease it for the colored. It is to be remem- bered that these conclusions are drawn from the averages of monthly annual rates and not from the total group figures shown in general tabulations. For reasons already explained this method is believed to give the more reliable results. While, as has been stated, the admission rates for the colored troops aver- aged slightly lower than those for the whites in this country for the period of the war, it is noticeable that this was due not only to a relatively small number of the milder cases but was influenced as well by the stage of evolution of the pandemic. Previous to the fatal wave of September and October, while the virus may be assumed to have been gathering virulence, the rates for the colored troops are shown to be decidedly higher than those for the whites. During the peak wave the whites showed more cases, and following this the two curves remain much closer together, the differences being hardly significant until a point well on in 1919 when the short-lived immunity conferred by the disease had begun to wear off. The colored rate then again began to rise above that of the whites. In other words, the colored soldier is seen to have been relatively more susceptible to the infection in that he contracted it in larger proportions in the preliminary waves, thus acquiring an immunity that served to protect him against the more fatal wave which followed. A somewhat similar relation is to be noted between the white soldier of the North and of the South, as will be brought out later. Another point in which interesting racial differences are shown by the figures is the relative proportion of bronchopneumonia to lobar pneumonia. It is well known that clinically the differentiation between these two types of disease is not always possible. Confluent types of lobular pneumonia may produce physical signs indistinguishable from those of lobar consolidation. Even post-mortem examinations may leave one in doubt. However, as was pointed out in an earlier paragraph, it was noted early in the war period that a large number of cases of pneumonia presented clinically and anatomically the characteristics of bronchopheumonia rather than those of lobar type. Granting the impossibility of accurate differentiation in many cases, still it must remain true that in the observation of thousands of cases the figures obtained are sig- nificant and variations in the proportion of one type of pneumonia to another between different groups of soldiers, or from month to month in the same group, may prove to be important in the study of the effect of race and length of service. Table 12 shows the ratio of bronchopneumonia to lobar pneumonia for the different subdivisions of the Army for the period of the war. These figures, like those for case fatality, are independent of any strength estimations and so are strictly comparable. They are, however, summation figures for the entire 33 months and hence, since the great majority of the cases and deaths occurred in September and October, 1918, they more nearly represent the values for those months than an average. These figures show that for the entire Army the pneumonia ratio for officers was 1.05, for the white enlisted men 0.76, and for INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 97 the colored enlisted men 0.42. For the Army in the United States the corre- sponding figures were 0.84, 0.61, and 0.39, while for the Army in Europe, 1.30, 1.19, and 49. It is seen that the values of these ratios correspond inversely in a general way with the relative resistance of the various groups, the officers suffering least from the epidemic, the white enlisted men next, the colored enlisted men having the greatest losses. It is also seen that the corresponding groups show a higher ratio in Europe than in this country. STATE OF NATIVITY Figures are available showing the number of admissions and deaths from all the respiratory diseases according to the State of birth of the patient as given by him at the time of his admission into the hospital.1 From these it is possible to calculate directly the case fatality by States. The question of calculating rates of incidence and mortality from these figures is complicated by the fact that we have no knowledge of the number of men born in each State who served in the Army. Comparative rates have been published based on the total inducted strength from each State and probably in many cases this results satisfactorily. However, such rates take no account of foreign-born inductants, of whom there was a large number from some States, nor of the effect of migration from State to State. Certain of the Western States showing very low rates when treated in this way can be shown to have had in 1918 over three times as many men of military age as there were children 18 years younger in 1910. A similar effect on the rates is produced by the presence from a State of a large proportion of foreign-born inductants. Mani- festly the excess is the result of immigration, and to base nativity rates on such an increased number of men results in a rate far too low. The reverse is true of States losing population by emigration. In order to obtain figures on which it might be possible to base comparisons of incidence, it seems best to prorate the inducted strength of the Army between the States in the same proportion as the States had boys under 10 years of age in 1900. This should result in a fair approximation to the number of men born in each State who served in the Army. Inasmuch as this method takes no account of the foreign- born soldiers the rates are of value only for comparisons between themselves. The method should allow us to state that the death rate in natives of one State was higher than in natives of another, but it does not permit of compari- sons with other rates based on more complete data. Table 24 shows the number of admissions and deaths for total respiratory disease by native State for white enlisted men with rates calculated according to the method described, and the case fatalities. In the first column of Table 25 the States have been arranged in the order of incidence rates for white enlisted men beginning with the State having the lowest rate, while the second column shows the order with respect to mortality and the third case fatality. It is seen that there is a general correspondence between the two columns, though some differences are noted. 56706—28---7 98 COMMUNICABLE AND OTHER DISEASES Table 24. -Relative admission and death rates, and case fatality for the respiratory group of diseases for white enlisted men, United States Army, by State of birtli State Alabama__________ Arizona___________ Arkansas__________ California_________ Colorado__________ Connecticut________ Delaware__________ District of Columbia. Florida____________ Georgia___________ Idaho_____________ Illinois____________ Indiana___________ Iowa______________ Kansas____________ Kentucky__________ Louisiana---------- Maine. Maryland____ Massachusetts. Michigan____ Minnesota____ Mississippi___ Missouri----- Montana_____ Nebraska____ Nevada______ New Hampshire. New Jersey_____ New Mexico____ New York_____ North Carolina.. North Dakota... Ohio. Oklahoma.___ Oregon_______ Pennsylvania. - Rhode Island.. South Carolina. South Dakota.. Tennessee_____ Texas________ Utah_________ Vermont_____ Virginia______ Washington___ West Virginia.. Wisconsin____ Admissions Rate 34S 061 0-16 481 032 349 387 644 319 955 964 876 301 548 451 208 800 871 591 870 886 692 865 803 650 390 562 684 502 324 508 267 163 021 907 543 435 312 558 554 399 324 963 281 457 056 240 208 312.2 194.3 M0.3 330.0 270.0 242.0 182.0 183.2 453.0 276.0 240.0 252.5 273.0 300.0 349.2 189.0 339.5 281.5 248.0 236.5 233.2 260.4 329.5 277. 5 262.4 297.2 389. C 256.0 210.5 220.3 218.0 248.5 236.9 236.1 287.3 335.0 219.0 202.0 274.7 316.6 219.8 347.0 254.0 260.0 254.7 280.2 284.0 264.3 Deaths Rate 545 9.29 30 5.49 506 9.46 415 8.12 261 11.70 311 9.02 35 4.59 67 7.46 282 17.45 613 8.92 67 8.19 1,973 9.25 992 9.26 1,309 11.81 937 13.95 920 9.55 596 13.67 292 11.97 387 9.05 928 8.82 955 9.22 1,127 12.92 454 10.79 1,424 9.93 90 8.91 606 11.70 30 20.78 143 9.92 689 8.75 100 9.48 2,250 7.85 626 8.51 201 11.51 1,772 10.47 394 8.78 169 10.22 2,361 8.55 129 7.87 360 10.34 322 15.57 784 8.45 1,417 9.98 165 10.58 188 14.88 595 9.20 178 8.24 530 10.55 1,184 11.95 Charts XVII, XVIII, and XIX are outline maps of the United States showing the relative rates for admissions, for deaths and the case fatality of respiratory disease, the rates calculated as described above. The death rates in particular and to a lesser extent the admission rates are fairly consistent, in that neighboring States of similar topography and similar density of population show similar rates. The extremely high rates of Nevada and the low rates of Arizona and of Delaware were based on relatively much smaller numbers of cases than was the case for most of the other States and possibly are conse- quently less reliable. The fact, however, that in all three of these States the figure for the case fatality falls in the same relative position tends to strengthen the admission and death rates. INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 99 Table 25.—Relative position of the States in respect of rates of natives for admissions, deaths, and case fatality from the respiratory group of diseases, white enlisted men, United States Army. Arranged in order from lowest to highest. The State showing the mean rate is italicized Admission rates 1 ' Delaware__________ 2 ' District of Columbia. 3 i Kentucky__________ 4 j Arizona___________ 5 j Rhode Island_______ 6 New Jersey________ 7 I New York_________ s i Pennsylvania______ 9 Tennessee__________ 10 i New Mexico_______ II Michigan____ 12 Ohio______________ 13 Massachusetts. 14 North Dakota______ 15 Idaho_____________ 16 Wyoming__________ 17 Connecticut________ 18 Maryland__________ 19 North Carolina. ._. 20 Illinois______ 21 Utah______________ 22 Virginia___________ 23 New Hampshire____ 24 Vermont__________ 25 Minnesota_________ 26 Montana__________ 27 Wisconsin_________ 28 Colorado___________ 29 Indiana___________ 30 South Carolina_____ 31 Georgia___________ 32 Missouri__________ 33 Washington________ 34 Maine_____________ 35 West Virginia______ 36 Oklahoma_________ 37 Nebraska__________ 38 Iowa______________ 39 Alabama.........___ 40 South Dakota______ 41 Mississippi_________ 42 California__________ 43 Oregon____________ 44 Louisiana__________ 45 Arkansas__________ 46 Texas_____________ 47 Kansas____________ 4H Nevada___________ 49 Florida____________ Death rates Case fatality Delaware----------------------------- Delaware. Arizona------------------------------ California. District of Columbia_________________ Arkansas New York----------------------------j Arizona. Rhode Island__________________ j Texas California---------------------------- Washington. Idaho.------------------------------- Alabama. Washington---------------------------: Oklahoma. Tennessee---------------------------- Oregon. North Carolina_______________________ Georgia. Pennsylvania-------------------------j Mississippi New Jersey---------------------------' Indiana. Oklahoma----------------------------! Montana. Massachusetts____________ . Idaho Montana----------------------------- North Carolina. Oeorgia------------------------------ Missouri. Connecticut__________________ . . . New York Maryland---------------------------- Virginia. Virginia------------------------------ Maryland. Michigan----------------------------- Illinois. Illinois------------------------------- West Virginia. Indiana------------------------------1 Connecticut. Alabama-----------------------------1 Massachusetts. Arkansas----------------------------- South Carolina. New Mexico__________________________ Florida. Kentucky---------___________________; Tennessee. New Hampshire.._________________,___ Iowa. Missouri----------------------------- New Hampshire. Texas-------------------------------- Rhode Island. Oregon------------------------------- Pennsylvania. Ohio-------------------------------- Nebraska. South Carolina________________________ Michigan. West Virginia_________________________ Kansas. Utah-------------------------------- Louisiana. Mississippi--------------------------- District of Columbia. North Dakota_________________________ New Jersey. Colorado_____________________________ Utah. Nebraska_____________________________ Maine. Iowa--------------------------------- New Mexico. Wisconisn---------------------------- Colorado. Maine_______________________________ Ohio. Minnesota____________________________ Wisconsin. Louisiana---------------------------- North Dakota. Kansas------------------------------- South Dakota. Wyoming...........------------------- Minnesota. Vermont----------------------------- Kentucky. South Dakota.....--------------------- Nevada. Florida______________________________ Vermont. Nevada______________________________ Wyoming. Consideration of these figures shows that for the period of the war there was no such preponderance of disease and death from respiratory disease among the natives of the Southern States as was brought out by Vaughan and Palmer for the pneumonias of the early months of the mobilization.18 In all three columns (Table 25) the States showing rates above the average (indicated by italics) represent practically every general section of the country. It is not noticeable, moreover, that the States with the largest cities tend to have lower rates in both admission and mortality columns. The relation between the three series of data is interesting. The variability of the rates is not the same. Of 100 COMMUNICABLE AND OTHER DISEASES - >99-9 - 299-9 " 399-9 - 453.0 Chart XVII.—The relative admission rates for the respiratory group of diseases for white enlisted men by State of birth Chakt XVIIL—The relative death rates from the respiratory group of diseases for white enlisted men by State of birth INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 101 the three series the case fatality shows the least variation between the States with a coefficient of variation of 0.16, admission rates were most variable, coefficient 0.26 and the mortality rates stood between with a coefficient of 0.20. It is evident that the mortality rate must bear a direct relation to both the admission rate and the case fatality. For the series as a whole the coefficient of correlation between the rates for admissions and for mortality is + 0.67 ± 0.052. This is a high correlation especially when the variability of fatality rates is considered. It is thirteen times its probable error. Of special interest is the fact, however, that the coefficient calculated for the death rate and the case fatality figures is practically identical, namely, +0.677 ± 0.052. The influence on the death rate of the two factors, admission rates and case fatalities, was then about the same. This would be easily understood if the admission rate and the Chart XIX. -The case fatality rates (per cent) of the respiratory groupof diseases for white enlisted men by State of birth case fatality could be referred to the same set of cases. That this is improbable, however, is shown by the fact that there is no correlation between these two series of rates. The coefficient of correlation between the admission rates and case fatalities is —0.0962 ±0.0955. The probable error is almost equal to the coefficient and the figure is entirely without significance. It appears then that two sets of causes, one affecting the admission rate or morbidity and the other the case fatality, were active in determining the differences in the death rates. It is evident from study of the outline maps that neither Northern nor Southern States, Eastern nor Western, mountainous nor flat, showed any preponderance of either admissions, deaths, or case fatality. It has been a commonplace observation for years that when numbers of individuals were gathered together from various places and held under common conditions, 102 COMMUNICABLE AND OTHER DISEASES tliose from cities showed a lower rate of incidence from the sputum-borne diseases than did those from the rural districts. This has been noted especially for military concentrations of population but also has been shown to hold for students in universities and other similar assemblages. The reason for this presumably lies in the greater exposure to contact infection in the ease of the city dweller, and the consequent development of an immunity specific or non- specific which tends to protect against invasion by the germs of disease. A com- parison is possible between the rates of the different States and the relative urbanity of their population. The United States Census Bureau classes a^ rural all communities of less than 10,000 inhabitants. This figure is probably too high for the purposes of this comparison, but is the only one available for use. Taking the percentage of rural inhabitants of each State as given by the 1910 census, which is the median census for the average age for the troops involved, and comparing the figures thus obtained with the rates for admission, death, and case fatality we find that between the admission rates for the war period and the percentage of rural population there is a definite positive correlation, the coeffi- cient being +0.362 ±0.083. This coefficient is large enough to be statistically significant and is over four times its probable error. It is not a high correlation but in view of the fact that the dividing line between rural and urban is probably too high for our purpose we are justified in drawing the conclusion that a rural population will show a higher morbidity from respiratory disease when inducted into the military service than will an urban one. A similar but smaller coeffi- cient is found for the correlation between the rural population and the death rates. In this case the figure is +0.311 ± 0.087. When the percentage of rural population is compared with the case fatality rates, however, all significant correlation disappears. The coefficient of correlation between these two series of data is +0.16 + 0.09; the low coefficient and the fact that it is not twice its probable error, deprive it of all significance. It would appear then that at least one of the factors entering into the admission and death rates is the relative urbanity of the population from which the troops are drawn, and that this variable affects the death rates through its effect on admissions and not by any demonstrable effect on case fatality. If the relative immunity enjoyed by the city dweller when inducted into the military service be of specific character for the diseases under consideration it should follow that the rates for troops should vary inversely with those of home populations if both were exposed to great danger of infection. The death rates for influenza and pneumonia for the age group 20-29 have been calculated foi the registration States of 1918. The specific rate for males of this group is not available from published figures of the Census Bureau, but it is believed that for comparative purposes the combined rate for both sexes will be equally signifi- cant. The correlation between these rates and those of natives of the corre- sponding States in the Army during the same period is low -0.0639 ±0.12 and it is less than its probable error. No inverse correlation is found to exist. The inverse correlation between the Army admission rate and the civil death rates for the registration States is slightly higher, -0.2 + 0.12, but still of such value as to be without statistical significance. That, however, infections of the character of those mentioned are more prevalent in urban communities is shown by the INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 103 correlation between the death rates for the registration States and the percentage of rural population. The figure obtained in this case is — 0.44 ± 0.098. This is a coefficient comparable in significance with the positive figure obtained for natives of the various States when serving in the Army. It may be that the actual fact will prove to be that the negative correlation between the Army and civil death rates should have shown a higher figure than that given, as two States,Vermont and Colorado, were responsible for nearly half of the plus values in the "xy" column of the computation. Both these States had death rates well above the average and in both instances this was due to an abnormally high case fatality rather than to a high morbidity. Inasmuch as the factors leading to high case fatality remain obscure it may well prove to be the case that these States are influenced strongly by some factor at present unknown which throws them out of alignment and destroys the correlation. However, there is no justification for throwing them out of consideration at present, and the only conclusion justified by these figures is that there is practi- cally no inverse correlation between the rates of the home populations and the natives of corresponding States when serving in the Army. From this would follow that the civil population had previously developed no immunity to influ- enza and influenza pneumonias, in proportion to its urbanity, and that conse- quently such relative immunity as was shown by the relatively urban soldiers was not of a specific nature. If the civil rates for a nonepidemic period, 1913, 1914, and 1915 (same age group), are compared with the Army rates in 1918, similar results appear. The coefficient of correlation here is —0.167 + 0.134. While the coefficient has the minus sign its size and its relation to its probable error are not such as to give it statistical significance. It seems probable, there- fore, that the relative immunity enjoyed by the city dweller in the Army was the result of nonspecific rather than specific factors. This is of course borne out by the fact that the city dweller also shows a relative immunity to such diseases as epidemic meningitis which are not known to be at any time so prevalent in a population as to induce any appreciable specific immunity. Following the suggestion in the work of Pearl,19 who showed that there was a definite relation between the explosiveness and fatality of the influenza epidemic in cities and the total death rate and especially the rates for pulmonary tuberculosis, organic heart disease, and nephritis, the attempt has been made to correlate the Army death rate with the rate for the States in this regard. The death rates for the registration States in 1913 for tuberculosis, organic heart disease, and nephritis (age 20-29) were calculated and coefficients computed. That for the correlation between these rates and the case fatalities in the Army was +0.179 ±0.11, a coefficient without significance statistically. The same is true of the correlation between the tuberculosis, organic heart disease, and nephritis rates of the civil population and the Army admission rates. The coefficient here is —0.20 ±0.11. This failure of correlation may be due to the fact that the element of the population whose organic weakness leads to this relation between the rates in civil life was almost entirely weeded out of the Army by the examining boards. Further the figures are not complete as the registration States of 1913 represent less than half of the States of the Union. 104 COMMUNICABLE AND OTHER DISEASES Certain other factors very probably entered into the production of the variations of rates between States. There may have been differences between the States in the matter of relative number of recently inducted men at the time of the fall epidemic of influenza, which was responsible for the greatest number of admissions and deaths. An attempt to determine this factor from the records fails to reveal any significant differences. Another factor, however, also difficult or impossible of demonstration, undoubtedly had its effect. This was the fact that the recently inducted men of some States were assembled at camps which showed much higher mortality during the pandemic wave of the disease than was the case for others. The comparison between the camps is brought out elsewhere. Inasmuch as the greater part of the mortality was among the recently inducted, this difference between the States is one that must have had its effect. It is probably impossible to evaluate it accurately, but it undoubtedly was one of the factors that tended to throw certain States off in the various correlations that have been recorded. For the period of the war, then, it can not be said that the inhabitants of any one section of the country showed a marked advantage over those of any other in the matter of morbidity or mortality from influenza and pneu- monia. The evidence in the figures indicates that there are two sets of causes acting separately to produce the mortality rates, one acting through the admis- sion rates and the other through the case fatalities. One of the causes tending to increase the morbidity rate is the relative proportion of rural inhabitants in the States from which the troops come. No general cause has been discovered to account for the variations in case fatality between the States. It has proved impossible to show any correlation between the rates for tuberculosis, organic heart disease, and nephritis in the States and either the admission or case fatality rates of the corresponding troops. The fact that there was no sig- nificant negative correlation between the Army rates and civil rates for the same State during the year of the influenza epidemic is interpreted to indicate that the civil population had not acquired any specific immunity to influenza in proportion to its urbanity and that the relative immunity shown by men from more urban States was of a nonspecific character. During the earlier months of the mobilization the relation of the nativity to morbidity from respiratory disease was much more marked. In the exhaust- ive study of the subject made by Vaughan and Palmer 18 it was possible to show that the total mortality and, in particular, the admission and death rates for the pneumonias were much higher in camps that drew their troops from the South Atlantic and Gulf States. They show the camps located not in their geographi- cal position but placed in the center of the area from which they drew their troops; also that camps drawing their troops from Florida, Georgia, Alabama, Mississippi, Louisiana, and Arkansas exhibited rates much higher than the average. The camps showing the lowest rates drew their men from the North- eastern, North Central, Northwestern, and Pacific States. Of the Northern States, those sending troops to Camp Bowie and Dodge showed the highest rate. These States, Minnesota, North and South Dakota, Nebraska, and Iowa, are all shown to be above the average for mortality for the period of the war in Table 26. The Southern States, however, show no such marked agree- INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 105 nient between the figures for the war period and those of the first six months of the mobilization. The figures given by Vaughan and Palmer 18 show enormous disparities between the rates of these States and the others; however, these figures appear to be without value for comparative purposes, inasmuch as no allowances have been made for increased susceptibility of the negro troops at this time. During this period the liability of the negro troops to contract lobar pneu- monia was eight and one-half times that of the white troops.20 In Alabama there were of military age in 1918 approximately 58 per cent of whites and 42 per cent colored.21 If these percentages contracted pneumonia in the proportion given above, a simple calculation shows that the white, 58 per cent, furnished only 14 per cent of the pneumonia and the colored, 42 per cent, furnished 86 per cent. There are no data available on which relative nativity rates for the white troops can be calculated for the early months. The nativity tables in the Annual Report of the Surgeon General, United States Army, for the year 1918, do not separate the white and colored. However, the conclusion seems justified from the study of the camps mentioned above that the Southern States showed a much higher morbidity and mortality from the respiratory diseases during the last three months of 1917 and for the first three months of 1918 than did the other States and, further, a relatively much higher rate than the South- ern States themselves showed for the whole war period. This relation of their rates will be discussed later and a tentative explanation advanced. If the rates for the war period for groups of States are calculated the results are found to be as follows: Group New England________________...... Middle Atlantic_________________..... East North Central____________....... West North Central_____________..... Mountain and Pacific________________ East South Central and South Atlantic West South Central_________________ These relations are shown graphically in Chart XX, which also shows a line indicating the percentage of rural population in each group of States. This chart shows, as did the correlation, that there is some relation between the percentage of rural population and the admission rates, but none between the percentage rurality and the case fatality. Chart XXI compares the death rates for the groups of States as calculated for the war period with the rates for the same sections of the country given by Vaughan and Palmer 18 for the early months of the mobilization. It is seen that the greatly higher rates for the rural States shown in the early months did not hold for the whole war pe- riod. It must follow, then, that in the later months when the virulence of the influenza epidemic was at its height, the relative rate for the more urban States exceeded that for the rural ones. The figures for the colored troops as regards the effect of nativity on inci- dence and fatality from respiratory disease are given in Table 26. States fur- nishing an insignificant number of colored troops are not included in this table. Relative admission rate 243 217 241 291 279 257 335 Fatality 3.96 3.60 3.97 4.50 3.38 3.66 3.07 106 COMMUNICABLE ANT) OTHER DISEASES The States included furnished over 99 per cent of the colored troops in the serv- ice. Owing to the well-known difficulty in obtaining accurate information for record from members of this race, it is believed that the figures are probably not as satisfactory as those for the whites. A comparison of the death rates by States for the two races, however, shows that in general the same relative LOGARITHMIC SCALE z _5 * < < ^ Chart XX.—Relative admission and death rates and case fatalities for the respiratory group of diseases in the various groups of States, April, 1917, to December, 1919. For facility of comparison, the different rates are drawn to a different scale. The percentage of rural population for each group is also shown positions hold. If the correlation between the death rates by States for the two races be calculated, a coefficient of +0.613 ±0.086 is obtained. Appar- ently the same conditions that lead to a high mortality in the whites from a certain State when serving in the Army also tend to produce a high mortality among its colored soldiers. INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 107 Table 26.—Relative admission and death rates and case fatality for the respiratory group of diseases for colored enlisted men by State of birth. April, 1917, to December, 1919. Only those States showing one thousand or more admissions are included State Alabama______ Arkansas______ Florida________ Georgia_______ Kentucky_____ Louisiana_____ Maryland_____ Mississippi____ Missouri.....__ North Carolina- Pennsylvania. . South Carolina. Tennessee_____ Texas.....____ Virginia_______ Relative Admissions admission rate Deaths 7,751 234 466 4,325 269 229 3,547 391 213 11,602 267 718 2,250 268 114 8,275 328 615 2,019 276 106 7,584 200 417 1,051 242 72 6,121 230 328 1,017 235 39 10, 530 279 638 4,467 262 307 9,299 364 338 5.865 240 348 Relative death Fatality rate 15.0 6.0 14.3 5.3 23.4 6.0 16.4 6.2 13.1 5.07 24.6 7.44 14.5 5.25 11.0 5.5 16.6 6.85 12.0 5.36 8.7 3.84 18.1 6.05 18.0 3.87 13.3 3.64 14.0 5.93 LOGARITHMIC SCALE 30 20 to _J < 0- 10 ( ) WAR F ERIOD / ✓ / / / / ,.__< < / / / * s * < EARLY MONT US Q Z < <3 Z LLl UJ z _: < Chart XXL—Relative death rates from the respiratory group of diseases by groups of States for the war period with the figures given by Vaughan and Palmer for the early months of the mobilization. The differences shown in the early months are largely obliterated in the longer period CLIMATE AND WEATHER Tables 10, 11, and 12 show that the effect of the influenza epidemic in increasing mortality was felt much less in troops stationed in tropical or sub- tropical climates than in the temperate regions. The effect on incidence of influenza of the warmer weather was much less than upon the death rate. Comparable groups of troops showed nearly if not quite as high an incidence 108 COMMUNICABLE AND OTHER DISEASES rate in tropical stations as in the United States, but the case fatality of the epidemic was far lower. The case of the white troops in Panama, with an incidence rate of 166.18 per 1,000 (higher than for the American Expeditionary Forces) and a case fatality of only 0.27 per cent, is a good example. The experience of the Porto Rican troops at Camp Las Casas is also to the point. During the October epidemic 16 per cent of its strength contracted influenza, and but 0.52 per cent died. These troops when transported to the United States showed at least as high a fatality as the whites with whom they served. The experience of the white troops in the Philippine Islands and in Hawaii was similar. In these comparisons, however, the element of length of service is difficult to eliminate, as in general the troops at these distant stations were more permanent and averaged longer service than the troops in the training camps in the United States. The effect of climate on the incidence and mortality of troops in the United States, however, is fairly well seen. Of camps of over 5,000 strength, 16 were situated in the North and 24 in the South. The incidence of influenza as compared to the average was as follows:22 16 northern camps. 24 southern camps. Above average Below average 15 In camps of a strength between 1,000 and 5,000 the relations were as shown below: 24 northern camps 20 southern camps Above average Below average 10 11 14 9 In stations of less than 1,000 strength the following relation held: 37 northern camps. 31 southern camps. Above average Below average It is seen from the above tabulations that in the larger, northern camps there was a tendency to a higher incidence of influenza, but that this relation did not hold in the smaller camps. The greatly larger size of the camps of the first group thus impresses itself on the totals, and as a whole the incidence of influenza was higher for camps in the northern part of the country. There were, however, notable exceptions even among the larger camps. Camp Beauregard, La.; Camp Bowie, Tex.; and Camp Cody, N. Mex., were the three camps having the highest percentage incidence of influenza, and all three were southern camps. The same variable that interferes in so many INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 109 comparisons, and which is so difficult of evaluation, seems to apply here. What was the relative proportion of recruits in these camps? We know that as a class the larger camps contained almost all of the short-service men. The men at the smaller stations were usually selected for special service, and the personnel of these stations had passed through the larger camps. The con- clusion that seems justified by the reported facts is that there is very little differ- ence between the nothern and southern camps as far as the incidence of influ- enza goes. What difference there is appears to be confined to the larger camps and is perhaps due to a greater proportion of recruits in the northern camps, a factor that can not be estimated, or perhaps to the fact that the recruit was more susceptible to influenza in a northern climate. When the mortality rates are considered, however, the advantage of the southern camps becomes evident. The corresponding figures for mortality follow: Above average Large camps:« 16 northern camps__________________________________________________________ 24 southern camps__________________________________________________________ Medium camps: 23 northern camps_____________________________________________________________ 13 21 southern camps___________________________....._____________________________ 9 Small camps: 38 northern camps_____________________________________________________________ 27 30 southern camps_____________________________________..............____________[ 7 Below average « The discrepancies between the number of camps listed in the incidence and mortality tables is due to the fact that in each case only camps reporting complete figures are included. Hence the camps are not absolutely the same in the two sets of tables. The comparative value of the figures is not affected thereby. From these figures it becomes evident that the mortality from the influ- enza epidemic was decidedly greater in the North than in the South. Inasmuch as the mortality has been shown to have been entirely due to the complicating pneumonias, we may say that while a soldier in a southern camp was just about as likely to contract influenza during the epidemic as his comrade in the North, his chances of complicating pneumonia and of death were very much less. This corresponds very well with the reports from tropical stations, and it is possible to infer the generalization that while troops in warmer climates have about as much influenza during an epidemic as those in colder climates, their mortality from complicating pneumonia may be expected to be much less. During the earlier months of the mobilization the camps that suffered most from pneumonia have been shown to have been without exception south- ern camps. That this was not due, however, to their location is shown by the fact that other camps, often only a few hours' travel distant, showed low pneumonia rates. The mortality in these camps, such as Camp Pike, Ark.; Camp Wheeler, Ga.; and Camp Travis, Tex., was due to the special suscepti- bility of their personnel; the controlling factors have been studied under the heading of influence of nativity. The effect of weather on the epidemic is one that is difficult to estimate. Expressions of opinion by individual officers, sometimes even in the same camp, are at variance. In general it may be said that the weather at the time the great epidemic first put in its appearance in September, 1918, was fine 110 COMMUNICABLE AND OTHER DISEASES throughout the country. The month was somewhat cooler than the average for some years past, but even a cool September would not he expected to be cold enough to cause hardship. In some camps rainy weather prevailed during the epidemic wave; in others fair weather was reported. Of 111 stations report- ing, 89 characterized the prevailing weather at the time of the outbreak as mild, 22 as severe. Of those reporting mild weather, 43 showed a mortality above the average of their respective groups, 46 below average. Of those report- ing severe weather, 12 showed a mortality above average and 10 below. It is evident that weather conditions were favorable, as a rule, during the epidemic and that the mortality was little if at all influenced by severe weather when it occurred. HOUSING CONDITIONS It is possible to study the effect of housing conditions on the course of the epidemic from two points of view: First, the space assigned to each man in the barracks, the effect of crowding; second, the effect of the type of quarters, whether tents or barracks. It is difficult by any ordinary methods to obtain figures for either of these variables that are clean-cut and are not influenced by other factors known to complicate the situation. It is impossible to estimate with any degree of accuracy the proportion of short-service men in the different camps and as has been shown a considerable difference in this respect would introduce a factor in the comparison that would materially alter results. The same may be said of the geographical situation if comparisons are based on mor- tality though this is less a factor when incidence rates are compared. However, certain conclusions may be justified and, accordingly, the results of the study are given briefly. It is evident from the study of the death rates, reported by the Census Bureau, that, in general, cities suffered from the influenza epidemic more than did the rural communities. This accords with the general experience in pneu- monia mortality over a number of years. Therefore, it is to be expected that concentration of population, affording increased facilities for the transmission of the virus, would increase the incidence of the disease. Vaughan has divided the various camps existing during the epidemic into three groups—those over 5,000 men, those between 1,000 and 5,000, and those under 1,000.23 In general it may be said that the larger the command the greater the chance for dissemina- tion of infection and the greater the probability of crowded conditions. Chart XXII shows the result of his study in this respect. It is seen that while the size of the camp shows little effect on the incidence of influenza, the proportion of cases developing pneumonia and the number of deaths are greatly affected, the smaller camps showing a much smaller proportion of complications. A more detailed study by comparing not only the arithmetic means of the camp rates but the medians and modes as well shows that the incidence rate of influ- enza also was decidedly higher in the larger camps. How much of this is due to differences in physical surroundings and how much to the well recognized fact that the men in the smaller camps averaged much longer service than those in the larger, can not definitely be said. Data as to the degree of crowding in the various large camps during the epidemic are difficult or impossible to obtain in reliable comparable form. INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 111 Figures that are obtainable seem to indicate little if any difference in incidence or mortality between those reporting crowded conditions and those showing the reverse. Such results, however, are open to the disturbing influence of the other variable factors mentioned above. It would seem that the influence of this factor is best estimated by comparisons made between different organizations in the same camp whose surroundings are substantially the same and which show practically the same proportion of recruits. A study of this character was made at Camp Humphreys, Va., during the fall epidemic.24 The organizations reported on are divided into two groups—those in existence some time and those newly formed. The results are tabulated as follows: Organization Older organizations: 7th Regiment____________ 3d Regiment_____________ 5th Regiment____________ 2d Regiment_____________ Engineer Officer's Training School_____......_______ 4th Regiment____________ 6th Regiment____________ Floor space Sick with per man Square feet influenza Per cent 45 26.7 46 28.6 47 16.0 50 9.1 70 8.8 75 7.4 78.5 2.5 Organization Newer organizations (sapper regiments: 217th Regiment__________ 218th Regiment__________ 219th Regiment__________ 220th Regiment__________ 215th Regiment__________ Floor space per man Square feet 55 59 68 103 114 Sick with influenza Per cent 24.5 20. 8 19.3 13.6 9.3 The inverse correlation between the amount of floor space per man and the percentage of infection in comparable organizations is striking. While this is the only detailed study of this kind of which record is available, suggestions of a similar relation are found in the reports from a number of camps. It is believed that such reports, dealing with otherwise comparable groups, are of more value than the massed figures from a number of camps. It seems fair to conclude, therefore, that there is to be expected a definite relation between the degree of crowding and the amount of respiratory infection. There appears to have been little difference in influenza incidence between the tent camps and the barracks camps. If the mortality rates for all the tent camps are compared with those of all the barracks camps, there is a decided difference in mortality in favor of the former. However, as with one exception all the tent camps were situated in the South, while the barracks camps were about equally divided, it is seen that the climatic difference elsewhere discussed interferes with the comparison. If all the northern camps be excluded from comparison it is seen that there is little or no difference in mortality for the two groups. Camps with relatively high and relatively low mortality are found in both classifications. MODE OF TRANSMISSION The actual mechanics of the mode of transmission of the virus of influenza is a point over which argument has taken place. There is to-day substantial agreement that the disease is transmitted from individual to individual, rather than by aerial convection, although the latter hypothesis has found many pro- ponents in the past. The known facts of the matter may all be explained with- out recourse to the theory of spread by the air. The generally accepted idea of the method of spread of this and similar diseases has been expressed in the general term applied to them, that of 112 COMMUNICABLE AND OTHER DISEASES "sputum-borne diseases." Most of the preventive work directed against influenza and the pneumonias has been based on this idea of the principal method of spread. The obvious fact that infective material is constantly sprayed into the air by the coughing patient, from which it is equally readily inhaled by those near by, has tended to render us oblivious of other possibilities COMPARISON OF EFFECTS OF THE FALL LPIDEM1C OF INFLUEN- ZA ON CAMPS OF DIFFERENT 5IZE IN THE UNITED STATES INDEX GROUP AMT. RATIO RATIOS PLOTTED 0 10 20 30 40 50 60 70 80 90 wu 110 120 AVERAQt STRENGTHS OF CAMPS A 26,800 1 1 ^^^^^_ 100 B 2 290 9 ^ C 46* 2 ] PER CENT OF STRENGTH HAVING INFLUENZA A 2 3.6 100 1 1 1 1 1 1 1 1 B 188 80 v//////)///)///)/////////(//)//A C 21.5 91 1 i i i i i i i i PER CEHT OF INFLUEJUACASK DEVELOPING PNEUMONIA A 18.5 loo 1 1 1 1 1 ^^^^1 B 15.1 82 '/////, C 95 50 1 1 1 1 PER CENT OF PNEUMONIA CAW DYING A 30.9 J B 36.7 119 v/////////////)///////////^/////////)////^ C 34.6 112 1 1 1 1....... PER CENT OF STRENGTH DYING A 1.36 ^^^^1 I I 1 1 B 1.04 76 ///////////(/////)////(, C .69 51 1 i i 1 1 l' EXPLANATION: GROUP A OVER 5000 MEN, GROUP B 1000-5000 MEN, GROUP C LESS THAN 10OO MEN Chart XXII perhaps as important. The role of the hand in the spread of these diseases has been emphasized, particularly by Lynch and Cumming,25 and the importance of "hand-to-mouth" routes in disseminating infection has received much study. It can not be said that any agreement has been arrived at as to which method is of the greater importance in spreading disease. It is entirely probable that both methods play their part in the process. INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 113 That the number of new cases depends to a great extent on the closeness of contact between infected and noninfected individuals is shown in a number of ways. Though figures as to the crowding of camps during the epidemic are inconclusive, special studies made of the relation between floor space and influ- enza incidence in different units of the same camp, as shown above, indicate that there is a definite relation between crowding and the spread of the respira- tory disease. The influence of varying degrees of closeness of contact is shown by figures reported from Camp Custer, Mich., during the fall epidemic (1918).26 Influence of contact on incidence and mortality, Camp Custer, September-October, 1918 Total camp______...........___________ Medical and dental officers______________ Other officers.............._____________ Ward men in base hospital______________ Other Medical Department men in hospital Army nurses.,....._______............... Civilian nurses_____.......-.....__........ Percentage Percentage contracting1 contracting influenza i pneumonia Deaths 1.7 1.2 0.0 0.8 1.5 1.4 0.8 This tabulation shows plainly the increased incidence in groups coming in closest contact with infected individuals. Vaughan (Warren) showed a similar relation among civilians in Boston.27 His figures showed that "sleeping contact" was over twice as apt to result in infection as the less intimate forms of contact in the famihv. These figures seem to have some significance in the question of the relative importance of the hand and droplet in transmission. Apparently the latter method is more concerned in sleeping contact than the former. Lynch and Cumming 25 main- tained that the indirect transmission of infection from hand to hand by means of infected dishwater in the dipping method of washing mess kits was the major route of transmission. The figures presented in their report taken from organ- izations of the port of embarkation, Newport News, Va., support their con- tention satisfactorily. They have also shown by experimental methods that the route they suggest is a feasible one. Their conclusions have been criticized, however, on the ground that other factors known to be concerned in the inci- dence of the disease, such as length of service, crowding, etc., were not elim- inated in making their comparisons. Other officers have failed to show a similar relation between their organizations.28 At Camp Jackson, S. C, a group of organizations, carefully using boiling water in the washing of mess kits but composed of men of short service, showed a very much higher incidence rate during the fall outbreak than did another organization of much longer service that took no special care to effect thorough sterilization of dishes. Both used the dipping method.29 Here apparently the element of length of service was far more important in determining morbidity than was the sterilization of the mess kits. Special bacteriologic experiments conducted at Camp Meade, Md., showed that, even when relatively cool, the soap in the dishwater was sufficient to kill the usual organisms found in respiratory infections, such as the pneumococci 56706—28---8 114 COMMUNICABLE VXD OTHER DISEASES and streptococci.30 These experiments, however, did show the possibility of the transference of organisms of the colon group by this means. As far as the influenza virus is concerned, the results are entirely inconclusive, as the exciting agent of this disease is not yet definitely recognized. The consensus of opinion, based on the experience of the epidemic, would seem to be that while the role of the hand in the direct and indirect transmission of respiratory disease should receive careful study and fullest consideration, the claim that this represents the major avenue of spread of these diseases can hardly be regarded as proved, and attention to this possible means of travel of the virus should not be allowed to draw attention from methods of prevention based on the more usually accepted theories of the method of transmission. In spite of all evidence pointing to the importance of contact, attempts to transmit the disease experimentally under controlled conditions have uni- formly failed. The United States Public Health Service sponsored two experi- ments of this character during the fall outbreak in 1918.31 One experiment was carried on in Boston, with 100 volunteers from the Navy, of the most susceptible age. None were known to have had influenza previously. These men were treated with influenza bacilli, with nasopharyngeal secretions, with and without filtration, by intranasal sprays, and by direct swabbing from patient to volunteer. The attempt was made to induce the disease by the injection of citrated blood from patients and the injection of filtrates of naso- pharyngeal secretions. Finally these men were exposed to the most intimate personal contact with patients in wards, all with the complete failure to produce the disease. A similar experiment was conducted with the same result in San Francisco. The explanation of this result is lacking. Either the proper method of transmitting the disease was not used, which seems very unlikely in view of the diversity of methods employed, or the volunteers themselves were immune to the disease either naturally or through previous infection in spite of their negative history. This latter hypothesis is hardly satisfactory though seemingly more probable than the former. It can only be said then that the experience of the war has confirmed our previous belief that influenza is carried by infected persons and not for any distance through the air. The exact means by which the virus is transmitted from person to person, as well as the usual portal of entry in each case, remains unknown. While other means of transmission can not be excluded, and doubtless play their part, the known facts are not inconsistent with the gen- erally accepted idea that the secretions of the respiratory tract expelled into the air by the act of coughing and inhaled by susceptible persons in the imme- diate neighborhood constitute the most important route. As to the duration of the period of infectivity of the individual case, no reliable deductions may be made. The negative attempts at transmission experiments already quoted suggest the possibility that the infective period is very short, possibly even limited to the period of incubation or invasion. This idea is also supported by the observation that different methods adopted by different commands in the handling of their influenza cases apparently produced little effect on the incidence of the disease. Some camps attempted INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 115 the immediate hospitalization and isolation of all suspicious cases, others reserved their hospitals for the seriously ill only, leaving the lighter cases for treatment in regimental infirmaries or in quarters where opportunities for transmission to the uninfected would appear to be much more numerous. It is not possible to show that this latter method of handling the situation resulted in any increase in the relative number of cases. The possible explana- tion may lie in a very brief period of infectivity, limited to the period of invasion or the earliest hours of the demonstrable presence of the active disease. PREVENTION With the preceding studies in mind, it appears evident that the prevention of the fatal pneumonias that attack armies may be approached from two points of view. First, the classical one that pneumonia is a primary disease directly due to the dissemination of the various organisms to which pulmonary inflammations may be attributed, aided by such well-recognized predisposing causes as chill- ing and exhaustion. Second, the point of view developed in the preceding pages which seems to show that during the period of an influenza cycle at least the great majority of pneumonia cases bear a direct relation to the prevalence of the so-called common respiratory diseases which during such a period appear to be definitely influenzal in origin. The second point of view is evidently the one applicable to the period of the World War. The figures cited and the relations shown make the conclusion inevitable that had it been possible to exclude the action of the influenza virus from the Army, the pneumonia mor- tality would have been so far less than it actually was as to have been of very little importance in the death records of the war. This statement holds for the months preceding and following the great fall outbreak as well as for that period. While it may be shown that certain measures tend to diminish the pro- portion of influenza cases complicated by pneumonia, the prevention, or limi- tation, of the number of such cases remains the fundamental problem in the prevention of such pneumonia as was seen during the war period. This problem has not been solved. Before proceeding to a short resume of the various means by which the prevention of influenza was attempted during the war, and the attempt to assign to them their relative value, it may be admitted that as far as the experience of the last pandemic goes, no practicable preventive measures have shown themselves to be of decisive value. Such measures as have shown some value appear to serve the purpose mainly of delaying the spread of the infection, of lessening the explosiveness of the outbreak. In a military camp this is an accomplishment of no small value inasmuch as it serves to reduce greatly the daily number of admissions during an outbreak, and correspondingly to lessen the strain on hospital facilities and personnel, with the result of giving to the individual patient the possibility of better care and increased chance of recovery. Preventive measures accordingly should be judged by the measure of their ability to prolong an outbreak by the diminution of its explosiveness, as well as by their ability to lessen the percentage of persons attacked. 116 COMMUNICABLE AND OTHER DISEASES MEASURES DESIGNED TO PREVENT THE ENTRANCE AND SPREAD OF INFECTION' IN A COMMAND Quarantine Absolute quarantine has been shown definitely to exclude influenza. The experience of Fort St. Philip, on the Mississippi River below New Orleans, is a case in point. This post was able to maintain an effective isolation and entirely escaped infection during the fall wave of the disease.32 The San Francisco naval training station, situated on an island, carried 4,950 men through the height of the epidemic without a case.33 However, very few stations are so situated as to be able to maintain perfect isolation, certainly none of the size of the great war training camps. Certain camp commanders, recognizing the futility of attempting quarantine in the face of the necessary supply problem, troop movements, etc., made no attempt to enforce isolation. Others restricted intercourse between their commands and adjacent communities in so far as it was possible to do so. There does not appear to be any significant difference between the two groups of camps thus divided. Vaughan's studies showed the following relations in this respect.22 Large camps: 34 quarantined... 6 not quarantined Medium camps: 27 quarantined... 7 not quarantined Influenza incidence Above average Below average Influenza incidence Above average Small camps: 38 quarantined____ 8 not quarantined .. Total: 99 quarantined____ 21 not quarantined. Below average It is seen that the totals show that 53 of 99 quarantined camps showed an incidence below the average, while 11 of 21 unquarantined camps were also below average in this respect. The respective percentages were 53.5 and 52.4. There is here no significant difference leading us to believe that such quarantine regulations as proved practicable during the war are of any value in reducing the total incidence of disease. In the six large camps that did not attempt to enforce quarantine, the duration of the epidemic was as follows: Camp Sheridan, Ala., 3 weeks; Camp Jackson, S. C, and Camp Taylor, Ky., each 4 weeks; Camp Forrest, Ga., 5 weeks; Camp Humphries, Va., 6 weeks, and Camp Logan, Tex., 7 weeks, an average of 4.8 weeks as compared with 4.9 weeks for the 36 large camps for which information is available.34 There is no evidence here that quarantine availed to prolong the outbreak and thus distribute the cases over a longer period. To be of avail in excluding influenza, quarantine must more nearly approach perfection than proved practicable in the large camps of the war period. The experience of certain civilian institutions too, from which the disease was excluded by quarantine until the subsidence of the outbreak, only to have it appear promptly as soon as restrictions were removed, seems to indicate the futility of general quarantine as a military measure! That certain camps, where great stress was laid upon quarantine, had little influenza is true. The experience of Camp Wheeler, Ga., has been quoted in INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 117 support of this measure.22 The Camp Wheeler report states that quarantine was effective in limiting the disease almost entirely to recruits who brought it with them. The personnel of Camp Wheeler, other than the new men, was very small and was composed almost entirely of men who had passed through the relatively severe spring outbreak in that camp, when indeed the influenza rates were higher than they were in the fall. The fact that these men were all of long service and had passed through one well defined outbreak less than six months before is a more probable explanation of their immunity than the insti- tution of quarantine. On the other hand, Camp Humphries, Va., which insti- tuted no quarantine, had a lower incidence of the disease than did Camp Wheeler. The prohibition of mingling of commands within the camp has received rather general indorsement. Its value appears to lie in the reduction of the explosiveness of the outbreak. The following extract from a report from Camp Lee, Va., illustrates this point:35 It is very doubtful whether any measures taken reduced the incidence of the disease. The quarantine seemed to have no ultimate effect, but did delay the appearance of the disease in the organizations so isolated. For instance, the veterinary training school of about 3,800 men established a most rigorous quarantine and all members of the command had their noses and throats sprayed daily with argyrol, consequently they had very few cases, until October 5, when the epidemic reached a sudden peak and then rapidly declined, they being practically free from the disease in one week thereafter. Therefore, it would seem that the only benefit from the measures taken was that this camp was not overwhelmed at any one time by the number of sick. The disease was spread over five or six weeks, allowing better care of the sick. It would appear, therefore, that experience during the World War indicated that while quarantine regulations are powerless to protect a large command from infection during epidemic outbreaks of influenza, the restriction of inter- course between the different organizations of a command may be of great value in prolonging the outbreak, thus permitting better care of the sick. Of the 34 large camps that instituted quarantine, 23 conducted a special medical examination of all new men entering camp with a view to the detec- tion of infected individuals and their prompt separation from the uninfected; 19 of the latter also placed the new men in a detention camp, and 8, in addition to the above measures, gave all men joining a prophylactic spray.34 These 8 camps showed an influenza incidence, during the epidemic, of 22 per cent as compared to the 23 per cent average incidence of the large camps as a whole. It is not evident that these measures availed materially in preventing the entrance of infection. Although no figures are available to support the con- tention, it would appear that physical examination of new arrivals in a camp should tend to diminish the explosiveness of an outbreak, as the principles are similar to those that govern in the matter of interorganization quarantine. The objection found to measures of this character, however, was the practical one that in times of epidemic the number of officers available for duties of this character is very small, and the rush of work such as, almost inevitably, to result in hasty, more or less perfunctory examination. Such examinations are of little value and take medical officers away from other, possibly more im- portant duties. 118 COMMUNICABLE AND OTHER DISEASES Medical Inspection Medical inspection, carefully performed, is of unquestioned value in securing early treatment of the sick. It is well known that during an epidemic men are often slow to report for treatment and frequently persist in going about their duties for hours or days when actually ill. The better the morale of the troops, especially in the face of the enemy, the greater the danger of this taking place. It is mentioned in reports from the American Expeditionary Forces that men kept their places in the ranks until forced to fall out, often with fully developed pneumonia. Daily, or twice daily, medical inspection of the men, taking temperatures in suspicious cases, serves to detect such cases early and to reduce the likelihood of serious complications. There is, however, nothing to show that the institution of this measure materially reduced the incidence of influenza in the camps employing it. Under practical conditions the difficulty of devoting to this measure the time necessary to render it effective makes its satisfactory application almost impossible. Of the 78 camps employ- ing daily inspection of the troops, half were above the average in incidence and half below. The same results were obtained in the 30 camps that did not institute it.22 Use of the Mask The value of face masks worn by the whole of a command has been the subject of much argument. In the first place, if we hold with those who main- tain that the main route of infection is "hand to mouth " most of the theoretical value appears to disappear, though it may limit to some extent the number of times the hand visits the mouth. It appears to be generally conceded that the use of the mask by attendants on the sick, exposed constantly to infection, is of value. That the use of the mask was universal among hospital attendants is a fact. It is equally true, as shown by the Camp Custer figures given above, that such attendants, especially nurses, were attacked in a much higher per- centage than the average. They were of course constantly exposed and were undergoing severe strain in the performance of their duties. Under these circumstances judgment as to the value of the mask becomes difficult. Reports from the Durand Hospital in Chicago indicated great value in protecting attendants and in preventing cross infection among patients.36 It appears that masks, to be effective, should be of a certain definite thick- ness of material and that there are differences in the value of different materials used for their construction. Reports from Camp Grant, 111., in the earlier months of the mobilization, while confirming the impression that cross infection may be limited by this means, have shown that a certain critical thickness of gauze must be used to prevent the passage of bacteria.37 Too great a thick- ness was found to result in an uncomfortable mask that in many instances did not allow the free passage of the breath, necessitating the passage of the latter around the mask rather than through it. The experiments showed that if the number of threads in the warp of the gauze be added to the number in the woof and the sum multiplied by the number of thicknesses used, the resulting figure, to insure efficacy, should be at least 300. Experiments carried on by medical officers at the Rockefeller Institute for Medical Research indicated INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 119 that gauze was a relatively inefficient material for the construction of masks.38 They recommended the use of a three-layer mask of butter cloth. The Camp Grant experiments showed that if a mask be temporarily removed, allowed to dry, and then resumed in the reverse position it becomes a disseminator of bacteria rather than a filter. It was therefore recommended that each mask be marked in such a way as to indicate the side to be placed next the face. When worn for their protection by the uninfected the nose should be covered as carefully as the mouth. Further experiments performed at the instance of the National Research Council tested various mask materials against a dry suspension of B. prodigiosus in air, the suspension being passed through a filter and the bacteria recovered in absorption bottles containing saline.39 The latter was then plated out and the count after incubation compared with that of the same suspension run without filtration as a parallel control. These experiments showed that the three-layer butter-cloth mask, shown by the experiments at the Rockefeller Hospital to be efficient in preventing the projection of infected droplets by the person wearing it, is by no means satisfactory in protecting the wearer from the inhalation of bacteria suspended in the air after the bacteria have lost their original coating of moisture. In different experiments from 44 to 76 per cent of the bacteria passed this mask when used dry. It was found that its efficiency was greatly increased by moistening, and they suggest the use of a mask based on this principle. This work suggests that the care used by many to avoid the use of a mask dampened by the breath or by perspiration was misapplied. These workers also tested certain grades of felt which they found to restrain the passage of bacteria perfectly. Masks of this material would have to be made over a frame to obtain sufficient filtering surface. There is no report of the actual use of masks of this design. It is evident that the mask may be an efficient means of limiting the spread of infection. It is equally evident that unless the necessary conditions are fulfilled in the construction and wearing of the mask it may be useless and in some cases even harmful. For this reason statistics as to the results attained in the general use of the mask in the Army camps during the epidemic are of doubtful value. The classification of the camps in this respect follows:22 Large camps: 19 using masks___ 15 not using masks Medium camps: 6 using masks...... 37 not using masks Percentage incidence of influenza Above Below average average 9 10 7 S 1 5 20 17 Small camps: 16 using masks___ 25 not using masks Total: 41 using masks___ 77 not using masks Percentage incidence of influenza Above average Below average The mass statistical evidence shows no benefit in general masking. How- ever, the considerations given above lead to caution in accepting this negative evidence. The expressions of opinions by medical officers are decidedly conflicting It is apparent in the consideration of this matter, as in so many others, that the 120 COMMUNICABLE AND OTHER DISEASES preponderant influence on camp rates of the relative proportions of recruits and longer service men, and, especially when comparing mortality, of geographical position, determines the camp rates and that other factors have had relatively little effect. No one has expressed the opinion that the mask properly used can do harm. Experimental evidence points to the probability of its useful- ness. Practical experience shows that the necessary conditions for its proper use are rarely attained except when used by trained hospital attendants for their own protection. The conclusion is that the mask is probably of great value potentially but that the difficulties in securing its proper use by the mass of a command are such as to render its general employment of doubtful utility. Use of Prophylactic Sprays The use of prophylactic sprays or gargles, not only by newcomers but as a general measure throughout the camp, was practiced in many commands. The antiseptics used varied greatly. Perhaps the most generally used were dichloramine-T, quinine solutions, and silver nucleinate or argyrol. The value of the measure and the relative value, if any, of the different solutions recom- mended have not been determined by controlled observations. When the spray was used in a camp, lightly affected by the epidemic, local opinion was favorable; when it failed to prevent a high incidence it was condemned as ineffective. There is no general evidence that prophylactic treatment reduced the incidence of disease in the commands employing it. The figures for the camps follow:22 Percentage incidence of influenza Percentage incidence of influenza Above average Below average Above average Below average Large camps: 7 12 7 8 5 13 6 9 Small camps: 13 11 27 31 8 25 not using it_____________ 13 Medium camps: 13 using prophylaxis________ Totals: 19 17 not using it......________ 35 These figures appear to indicate an increased incidence in camps using prophylactic methods. While, as indicated above, other factors may have been responsible for the difference shown in the two groups, the result is sug- gestive of possible danger in the use of general spraying. When used on large numbers of men the danger of conveying infection from throat to throat would appear to be very real, especially as the necessities of the case during an epi- demic require that this work be delegated to hastily trained personnel. From Camp Funston, Kans.,34 it was reported that spraying of the nose and throat with antiseptics as a prophylactic for contacts and attendants predisposed to infection rather than protected. This was proved by a group experiment of 25 attendants on influenza cases who were not sprayed. One contracted the disease. Of 25 sprayed with protargol solution 17 contracted the disease. All 50 attendants wore masks and worked under the same conditions in the same temporary hospital. INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 121 At Camp Cody, N. Mex., daily spraying was employed in many organiza- tions but not in all.22 Its use was discontinued upon discovering the incidence of disease to be much greater in organizations in which its use was carefully employed than in others in which it was not used. At Camp Upton, N. Y., a control experiment was carried out with two battalions of the depot brigade; 800 men were treated daily by spraying the nose and throat with a solution of dichloramine-T.34 A like number were held untreated as controls. Over a period of 20 days the incidence in the two groups was the same. The experience of the epidemic thus shows that not only is there no evi- dence of benefit to be derived from the general use of the prophylactic spray but there is definite evidence from certain quarters that its use may at times distinctly increase the incidence of disease. Protection of Troops from Undue Fatigue The effect of fatiguing drills and other duties, especially on newly joined recruits, has been the subject of considerable study. When a number of drafted men arrived at a training camp the necessary processes of enrollment and equip- ment, of physical examination, of vaccination against smallpox, and of inocula- tion against the typhoid fevers involved a period of several hours during which the men were constantly standing in line, much of the time with little or no clothing on. This strain after a long journey by troop train, often ending at camp during the night, and followed by the reaction from the inoculations has been held by some to be responsible for the high incidence of disease among recruits. Much of the fatigue and strain thus imposed upon the recruit is possibly a military necessity, although this is a debatable question. During the summer of 1918 repeated waves of influenza and pneumonia occurred at Camp Funston, Kans., each wave in turn practically confined to recently inducted troops. In one such outbreak a study of the effect of varia- tion in the training schedule was made.40 Recruits were quartered in two separate parts of the camp, for convenience called A and B herein. Owing to local conditions the amount of drill and fatigue duty in camp A was not over half that in camp B. Owing to congestion at the receiving station the troops at camp A were held from two to four days before undergoing the ordeal of physical examination, inoculation, and equipment. During the first two weeks of camp life this contingent had 3.7 per cent of its strength reported sick, while the men at camp B on the fuller schedule reported 6.5 per cent during the same period. The author of the report suggested that "the whole period of inoculation be regarded as one in which the body is being called upon for a severe biological effort," that consequently all other effort should be reduced to a minimum, and that recruits should not be expected to reach a point where hard work on full time is possible for at least a month.40 That the great difference in incidence among recruits as compared to seasoned troops is not the result of the inoculations against typhoid and para- typhoid is the conclusion drawn from a study of this point made at Camp Funston coincidentally with the work above mentioned.41 It was shown that the curve of pneumonia incidence was a fairly regular one of the usual fre- 122 COMMUNICABLE AND OTHER DISEASES quency type, with its highest point near the end of the second week in camp. There was no detectable relation between this curve and the dates of the typhoid vaccinations and no grouping of extra cases on or following the inocu- lation dates. This agrees with the result of a series of experiments on mice carried on at the Army Medical School which showed that animals inoculated with typhoid vaccine were less susceptible to streptococcus infection than were control animals.42 The pneumonia commission at Camp Wheeler, Ga., in the fall epidemic (1918) were unable to trace any relation between pneumonia incidence and inoculation dates.43 The conclusion is that the association of disease with the inoculations is merely coincidental and that if the latter in any way increases susceptibility to respiratory infection it has proven impossible to demonstrate it by statistical methods. That the Camp Funston figures, showing the effect of fatigue on disease incidence, are probably of general value is indicated by the numerous reports of high sick rates in newly inducted troops during the fall epidemic. Some of these have been noted above in the consideration of the effect of length of service. The effect of fatigue and exposure on seasoned troops is seen in the high proportion of pneumonias and the high case fatality of the American Expeditionary Forces.1 It seems well established, then, that during the prev- alence of respiratory disease in a command, training schedules, especially those for the newer men, should be reduced to the minimum permitted by military necessity. Indeed it would seem that military objectives would in the long run be furthered by this course. Limitation of Public Gatherings Almost all the large camps prohibited the gathering of large numbers of men indoors at entertainments and the like.44 Such a ruling would naturally follow the adoption of interorganization quarantine, which appears to be of distinct value in slowing the spread of an epidemic. An interesting instance of increased incidence of influenza following such gatherings was recorded at the San Quentin Penitentiary in California,45 where the weekly moving-picture show was shown to be followed regularly by an increase in the number of new cases of the disease. That gatherings indoors may also be the cause of dis- semination of the virus is suggested by the fact that on the substitution of outdoor band concerts for the indoor show at this institution the number of cases two days later was still significantly larger than during the rest of the week. This suggests that the massing of men in close-order drill may have elements of danger. However, men associated in drill are usually together in mess and barracks, and the drill can hardly be expected to exert much extra influence. Use of the Cubicle The consideration of the advantages of separating men's beds by means of hanging sheets or halves of shelter tents does not differ whether the system be used in hospital wards for the limitation of secondary infections or in the sleep- ing quarters of the men to prevent or limit the dissemination of bacteria during sleeping hours. Facts tending to show the value of the system in the hospital INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 123 are equally applicable to its use in barracks. There is no evidence in the mass statistics that the lack of the use of the cubicles in the few hospitals that failed to utilize this precaution was of any influence on their mortality rates. Nor is there any statisical evidence that screening between beds in barracks lowered the rate of incidence. Indeed, of 19 large camps using the cubicle in barracks, 12 showed an incidence rate above the average to 7 below it; of 19 not using the screen, 7 were above the average and 12 below.22 However, if the average per- centage incidence of the two groups is calculated it is found that the two figures are practically the same. The studies of the special commission at Camp Pike, Ark., during the fall epidemic of 1918, furnished definite evidence as to the value of the cubicle in preventing cross infection in hospital wards.13 Similar reports were made earlier from Camp Dodge, Iowa,46 and Camp Taylor, Ky.47 A report from Camp Hospital No. 1 at Camp Upton, N. Y., gives additional evidence.22 Due to lack of material certain beds in this hospital were not separated by sheets. The percentage of pneumonia cases among occupants of these beds was 23.36, while among those in cubicles the pneumonia incidence was 19.3 per cent. Such studies as these appear to indicate that the degree of isolation procured by the installation of the cubicle system is sufficient to have some effect on the distri- bution of bacteria. Certain other measures having the same general object were adopted here and there. In some places sheets were hung down the centers of mess tables, or men were allowed to sit on one side only. Seats at mess were separated by a wider space than usual. The regulations as to the distance between beds and requiring the men to sleep head to foot were more strictly enforced. There is little evidence of any practical results from these measures during the severe epidemic. In summary, of the measures instituted to prevent the entrance of influenzal infection into a camp and to limit its spread once it has obtained a foothold, it has been shown that strict quarantine may prevent the disease entirely. This is rarely practicable in large commands, and the most that can usually be expected is to delay the outbreak somewhat. Interorganization quarantine within the camp and the prohibition of unnecessary gatherings undoubtedly serve to diminish the explosiveness of an outbreak and to enable the individual cases to be better cared for. Medical inspection of commands daily or oftener, with prompt removal of discovered cases, should serve the same purpose. The use of the mask by the command in general, while theoretically sound, is beset with so many practical difficulties in application that until properly constructed masks can be supplied in quantity and their use in an efficient manner enforced, decisive results from their use can not be expected. Masking of hospital attend- ants and of patients has been shown to be of great value. The mask is more effective when moist than when dry. The use of prophylactic sprays has been shown to be not only useless but dangerous. Troops should be spared all un- necessary fatigue and exposure during an epidemic. The avoidance of crowding in barracks is undoubtedly of great importance, and the use of the cubicle in sleeping quarters as well as in hospital wards may be regarded as of proven value. When all is said, however, the best result to be expected from any or all 124 COMMUNICABLE AND OTHER DISEASES of these measures is a slowing of the progress of an epidemic rather than any considerable diminution in the number of cases. The differences in admission rates of different commands depend primarily on differences in the relative numbers of susceptibles, mainly recruits. This being the case, the development of means of individual prophylaxis or immunization becomes of prime importance. Prophylactic Vaccination With the coming of the severe fall wave of the influenza epidemic, attention was very generally directed to the possibility of individual protection by means of inoculation of bacterial vaccines. Though reports had indicated great uncertainty on the part of the bacteriologists as to the primary etiological relationship of the Pfeiffer bacillus to the disease, most vaccines used contained this organism. It was usually combined in varying proportions with type pneumococci, hemolytic streptococci, and even staphylococci. Many appar- ently favorable reports were made, but owing to the explosive character of the epidemic and its appearance nearly simultaneously in all parts of the country, most extensive vaccination experiments were made after the epidemic was on the wane or at least well under way. If, then, it be remembered that the case fatality is greatest during the earlier part of an outbreak, and if the results in persons vaccinated relatively late in an outbreak are compared with a control group whose cases and deaths were counted from the beginning, it is seen that it is easy to obtain figures more favorable to the vaccine than the facts warrant. Many such reports were published. The results of vac- cination with any of the organisms used during the war period in reducing the incidence of the primary influenzal infection may be regarded as negative. With the development of knowledge of the specific differences in the types of pneumococci, hopes were aroused that vaccination with the types responsible for the greater number of cases might reduce the incidence of pneumonia. The first large-scale experiment in this country was undertaken at Camp Upton, N. Y., in the spring of 1918.48 Over 12,000 men were inoculated with a saline vaccine containing pneumococci, types I, II, and III. In the 10 weeks subsequent to this treatment the vaccinated men remained free from pneumonia due to these types, while the 19,000 unvaccinated men furnished 18 such cases. There was also shown a marked reduction in the rates of the vaccinated troops for Group IV pneumonias and especially for streptococcus pneumonias. The total pneumonia incidence was 1.33 per thousand for the vaccinated for the 10-week period, and 5.29 per thousand for the control group. It proved impossible to compare the groups further, owing to their departure for France. The vaccine used in this experiment contained equal parts of each of the three fixed types of pneumococci, 1,000,000,000 of each for the first dose, 2,000,000,000 for the second, while the third and fourth doses con- tained 3,000,000,000 each of Types I and II and 1,500,000,000 of Type III. The injections were made at weekly intervals, the majority of the men receiving 3 or 4 doses, some only 1 or 2. A similar experiment was carried on at Camp Wheeler, Ga., in the fall of 1918.49 In this instance the vaccine was a lipovaccine containing io 000 - 000,000 cocci of each of the three fixed types, 30,000,000.000 in all It was INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 125 prepared at the Army Medical School. It was given in one dose of 1 c. c The reactions, general and local, were not unduly severe and no serious dis- ability resulted therefrom. The troops vaccinated included both white and colored, both seasoned men and recruits. The period of observation following the inoculation included the period of the fall epidemic of influenza. The results are tabulated below. The vaccination of the older men had been ac- complished prior to the arrival of the recruits. The latter were inoculated immediately on arrival in camp. Recruits (less than one month's service): Seasoned men: te— Per thousand White- Per thousand Vaccinated _ _______ 38.6 Vaccinated _____ 5.2 Unvaccinated _______ 64.0 Unvaccinated _____ 40. 0 red— Colored— Vaccinated _______ 125. 0 Vaccinated___ _____ 14. 8 Unvaccinated _______413. 0 Unvaccinated- _____ 78. 4 il recruits— Total seasoned men— Vaccinated _ _______ 58.2 Vaccinated___ _____ 7.2 Unvaccinated _______ 115. 2 Unvaccinated- _ _____ 46.4 The same pneumococcus lipovaccine prepared at the Army Medical School was tried to a considerable extent on volunteers in other camps following the promulgation by the Surgeon General of a circular letter, dated October 25, 1918, authorizing its general use. It was not used, however, until a time when the accurate estimation of results was interfered with by the shifting of troops incidental to the demobilization. Favorable reports were received from the vaccination of large numbers of men at Camps Funston, Kans.; Dodge, Iowa; Dix, N. J.; Sherman, Ohio; Wadsworth, S. C; and Devens, Mass.22 In Camp Devens, it was estimated that the pneumonia rate in vaccinated men was about one-fourth that of the unvaccinated. Camp Custer, Mich., reported unfavorable results on a small group. On the whole the reports received from camps in this country were decidedly favorable. In the Ameri- can Expeditionary Forces, a carefully controlled experiment was made at Camp Lusitania.50 Here, 5,000 men were vaccinated and 3,861 held as controls. Several varieties of vaccine were used, a lipovaccine containing pneumococci types I and II, and one containing all three types, both having been prepared at the Army Medical School, and a saline vaccine prepared by the Pastuer Institute, Paris, containing "pneumococci, streptococci, staphylococci and B. influenzas." There was little respiratory disease in the command during the period of observation January to June, 1919. The results, however, indicated that the lipovaccines reduced the incidence of pneumonia to about one-fourth that of the controls. The saline vaccine showed no such result. All vaccines showed a reduction in the incidence of influenza and common respiratory dis- eases, the saline vaccine in this instance showing as good a result as the others. A careful series of serological observations was made on representative numbers of the vaccinated men. Blood was taken from these men semimonthly for the period of observation. Antibodies were demonstrated for pneumococci types I, II, and III, beginning the second week after inoculation, reaching a high point at the end of four weeks, then gradually decreasing during the balance of the period. The response to type I was most marked, type II next, and 126 COMMUNICABLE AND OTHER DISEASES type III least. The sera were tested by agglutination and by complement fixation methods. The men inoculated with the saline mixed vaccine gave substantially the same reactions as those on whom the Army Medical School lipovaccine was used. Protection experiments with mice also demonstrated the value of the treatment. SUSCEPTIBILITY AND IMMUNITY During a great pandemic outbreak of influenza the disease is so wide- spread and affects so large a proportion of the population at one time as to lead very naturally to the impression that practically 100 per cent of the population has been exposed to the disease. If this be so, we must assume that certain individuals, perhaps the majority, possess immunity against this infection, as the figures do not indicate that the entire population becomes infected. The figures given in previous pages, which, as stated, probably constitute a minimum estimated number of the cases of respiratory disease that can be attributed to the influenza virus in the Army during the World War, show that 26. 6 per cent of the men in the military service contracted some form of this disease. The reverse of this proportion is that 73.4 per cent, while equally exposed, escaped infection. It would appear that practically three-fourths of the men, living under conditions as favorable to the trans- ference of infection as can well be imagined, failed to contract the disease. Does this mean that these men were naturally refractory to this infection, that they acquired an immunity at some prior date, or that they failed to come in contact with the active virus? That the lost supposition could be true to any considerable extent in the Army seems too improbable for argument; it might have held some place in the population at large, where the individuals are not in such constant contact with each other and particularly are not habitually associated in relatively large groups. It may be safely assumed for present purposes that practically every soldier had the opportunity to contract influenza if his physical condition was such as to render him susceptible to it. Assuming this, then we are forced to choose for our explanation of the immunity shown by the majority of the men one of the other two possibilities though granting that both may have had their part in producing the effect. The possibility must be borne in mind that many cases may have occurred of such mildness as to have attracted no particular attention, but still leaving an acquired immunity This is largely an academic distinction, however, as such persons must have possessed marked resistance to the infection, or its manifestations would have been more severe. The disease common among us which in many ways is most like influenza is measles. Immunity to this disease is rarely congenital It is generally admitted that practically all persons are susceptible to it unless protected by previous attack. With measles, however, the immunity con- ferred by an attack is usually permanent. Bearing in mind the analogy of measles, we should naturally feel that immunity to influenza was most prob- ably acquired and due to a previous attack, but here we find that the ques- tion of acquired immunity itself has been called into question. Earlier writers on the subject were inclined to deny the existence of im- munity after an attack of influenza. Parkes51 in 1870 said, "There is some INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 127 discrepancy of evidence; but, on the whole, it seems clear that, while persons seldom have a second attack in the same epidemic (though even this may occur), an attack in one does not protect against a subsequent epidemic." This opinion has been repeated in substantial agreement by many authorities since, and it is a familiar observation that the same individual may have repeated attacks of "grip" from year to year. Whether these repeated attacks are indeed due to the same virus is, as has been said before, still open to argument. On the other hand, it seems necessary to assume that convalescence from influenza involves some degree of immunity, as otherwise we should be faced with a condition wherein each susceptible person would contract attack after attack in rapid succession. Moreover, the usually accepted explanation for the passing of an epidemic wave, that of the exhaustion of susceptible material, depends on the assumption that those who recover from the disease are at least temporarily immune. While we must grant that such immunity in the case of influenza does not last for life, or even perhaps for any considerable period of time, a number of observations were recorded during the World War that tend to throw light on this problem and to make possible a fairly definite answer. First, we have the general observation that troops who passed through the epidemics in the winter and spring preceding the great outbreak of the fall of 1918 showed a decidedly lower attack rate than was the case in the newer troops. To give value to this observation we must assume that these earlier outbreaks affected the Army more extensively than they did the general popu- lation. This is a fair assumption, as we have shown that this was true to a considerable extent even in the fall of 1918. We should also have to discount the effect of "seasoning," in so far as this may be shown to be a nonspecific immunizing process, as suggested by the analogy between the effect of service and of relative urbanity of troops, as shown above. Hence the relative im- munity of the American Expeditionary Forces, for instance, may have been due more to a nonspecific seasoning process than to the development in its men of a specific immunity. If this be true, it is fair to add that the degree of protection thus afforded is probably as great as could be expected from this process. The average admission rate for the American Expeditionary Forces from respiratory diseases was 143.4 per 1,000, the corresponding rates for the troops in this country was 227.7, a figure about one half again as high as that of the American Expeditionary^Forces.1 If we can show for various units a degree of protection greater than this following a previous outbreak of the disease we shall be justified in assuming that specific immunity entered into the case. At Camp Shelby, Miss., there was in April, 1918, a division of troops numbering about 26,OOO.52 An epidemic of mild influenza struck this camp at this time, and within 10 days there were about 2,000 cases, including not only men who were sent to the hospitals but also men who were cared for in barracks. This was the only division that remained in this country from April until the fall of 1918. During the summer this camp received 11,645 recruits.52 In late August, 1918, the virulent form of influenza struck this camp. It confined itself almost exclusively to the recruits of the summer and scarcely touched the men who had 128 COMMUNICABLE AND OTHER DISEASES lived through the epidemic of April. Not only the 2,000 who had the disease in April but the 24,000 who apparently were not affected escaped the fall epidemic. Vaughan stated:53 "It appears from this that the mild form of influenza of April gave a marked degree of immunity against the virulent form of October." This observation points to the existence of both possible types of immunity: A natural type possessed by the body of the above command that failed to contract the disease on either exposure, and an acquired type in those who passed through the April attack. The surgeon of the 11th Regiment of Engineers, A. E. F., reports in some detail a parallel occurrence.54 During May and June, 1918, this organization, already a seasoned body of men, was attacked by an epidemic of influenza which involved 613 men in a strength of about 1,200. There were two deaths from pneumonia. Company B, the unit first attacked, had almost all of the cases for the first two weeks, when the other companies were also attacked. This regiment thus showed an attack rate of over 50 per cent at this time, the company first attacked showing the lowest incidence. During the succeeding five months, the period of greatest mortality from influenza, this regiment was working in the St. Mihiel and Argonne sectors. About 150 men had colds of varying degree, usually attributed to the conditions under which they were living and working. There were 3 cases of pneumonia, of which one died. The regiment thus passed through the worst of the influenza epidemic with practi- cally no sickness. In early January, 1919, the regiment was grouped at Com- mercy and moved to Bordeaux for shipment home. Here it was again attacked by influenza, then present in the civilian population with a daily mortality of about 1 to 2,000 inhabitants. During January and February there were 270 cases of influenza in the regiment, with 35 cases of pneumonia and 5 deaths. These cases tabulated by companies with those of the earlier outbreak show that the companies that suffered most in May and June, 1918, had the least disease in January and February, 1919. May and June, 1918, influenza Company A_________________________________________________ 78 Company B_______________________________________--------- 74 Company C___.......________________________________________] 126 Company D__________________________________________.......J 128 Company J..............._____________________________________\ 123 Company F_____________________............__________________ 84 Total__________....._______.....________________________| 613 Percentage of command______________________________....._____! 51 January and February, 1919 Influenza Pneumonia Deaths 65 120 25 270 22 35 The regimental surgeon stated: "One feels justified in assuming that the early epidemic had conferred sufficient immunity to keep the regiment free from influenza for six months, and partial immunity extended through January and February." He noted further, that some of the men attacked in the winter had also had influenza in May or June, but as a rule these proved to be mild cases. INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 129 Vaughan 53 says: "Those who had influenza in September and October were not affected by the recurrent waves. In the recurrence of influenza at Dorr Field during January, 1919, Squadron A, which was affected most severely in the first epidemic, had no cases. From Camp McClellan we get a report of a similar incident. Speaking of influenza during December, the report goes on to say that Battery A, which had very few cases during the October epidemic, sent more cases to the hospital than any of the other units in this organization, while Battery G, which was affected most during the epidemic, had very few cases this month. Camp Jackson reported a recurrence of influenza in January, which was localized largely in the 48th Infantry, a regiment which had passed through the autumn epidemic with very few cases at Camp Sevier." An interesting comparison is reported from Camp Dodge, Iowa.55 In this case the influence of seasoning, or length of service, may be eliminated. There were in this camp at the time of the fall outbreak, two regiments of Regular Infantry. The 2d Infantry had been in Hawaii and there had encoun- tered the earlier wave of influenza, reporting 300 cases. The 14th Infantry, partly from Alaska and partly from Fort Lawton, Wash., arrived in camp dur- ing the fall outbreak, with no history of previous exposure to the disease. The 2d Infantry reported influenza in 6.6 per cent of its strength, the 14th Infantry, in 48.5 per cent. They were indeed the organizations having the lowest and highest incidence of all camp organizations, respectively. If this observation be of general significance it would point to the fact that seasoning in regard to this disease is a specific rather than a nonspecific process. These more or less fragmentary observations might be multiplied almost indefinitely, but enough has been quoted to show that an organization which had passed through one outbreak of influenza was much less likely to suffer as severely a second time, indeed had apparently, for some months at least, received a substantial measure of protection, much more than difference in length of service would imply, especially as in cases like that of the Engineer regiment described above the organizations were already seasoned when the first epidemic appeared. It would appear, however, that in any organization there are many men who do not take the disease in recognizable form, even in a succession of epidemics. The question of the duration of the immunity acquired by an attack of influenza becomes of great interest at this point. We have seen above that it is the consensus of opinion among authorities on the subject that an attack in one pandemic outbreak is powerless to protect against another attack years thereafter. Some, indeed, as West, think that an attack predisposes to subse- quent attacks:56 "It seems more likely that an individual may never have influenza at all than that having had it once he should never have it again." It appears entirely probable from what has gone before that a definite specific immunity is induced by an attack of influenza. That this immunity is not of long duration appears equally well established. The instance of the 11th Regiment of Engineers serves to illustrate both these points. 56706—28---9 130 COMMUNICABLE AND OTHER DISEASES THE INFLUENZAL CYCLE DURING THK WAR PERIOD It was pointed out above that we are apparently justified in assuming the incidence, during the period studied, of seven separate waves of acute respiratory disease associated with pneumonia. The first of these, coming before the mobilization of the National Army, is perhaps the most doubtful and careful studies of its characters are lacking. With the advent in December, 1917, of the second well-defined wave of this character, attention was forcibly drawn to the situation by the occurrence of large numbers of cases of pneu- monia with a high mortality. These were at first regarded as secondary to the epidemic of measles which was then on its decline, but as the number of cases of pneumonia continued to increase it became evident that many, if not most of them, had no relation to the former disease. The fact that there were, concurrently, large numbers of cases diagnosed as influenza, bronchitis, etc., was not at the time given the significance that study of the relations between this class of diseases and the pneumonias shows to be its due. Indeed, a com- parison between the incidence of acute respiratory disease and the case fatality of measles or with the percentage of measles cases developing pneumonia, shows such a marked degree of correlation that it seems more than probable that even the post-measles pneumonias were due in large measure to concurrent infection with the virus of influenza. Chart XXIII shows these relations graphically. Such a relation would serve to explain the unprecedented high incidence and fatality of measles pneumonia. It has been shown that groups exhibiting greater susceptibility to infec- tion by the influenza virus also tend to show a greater proportion of lobar pneu- monia, while the groups more resistant to the primary infection show increasing proportions of bronchopneumonia. In the gradual evolution of virulence and invasiveness on the part of the virus by which it worked up to the peak of its activity in September and October, 1918, it is probably true that in each suc- cessive wave of increasing invasiveness it attacked the most susceptible of the soldiers first, and that each wave attacked men whose resistance could be over- come at that stage of its evolution, leaving those that recovered temporarily immune from later and often more fatal attacks of the disease. With each wave the relation between the virulence and invasiveness of the virus, on the one hand, and the susceptibility or resistance of the population, on the other, determined the incidence and fatality of the disease. The pneumonias of the first winter (1917-18) of the period under con- sideration resembled those of the interepidemic period more closely than was the case later, and the proportion of lobar pneumonias was greater than in sub- sequent outbreaks. Bacteriologically, the findings in pneumonia sputa and lungs varied greatly in different camps. Thus in Camp Travis, Tex., the majority of the winter pneumonias were associated with infection by the hemo- lytic streptococcus, while at Camp Wheeler, Ga., which also had a very high pneumonia rate at this time, this organism did not make itself felt until the advent of the third or spring wave of infection, the pneumococcus in its vari- ous types being found in the pneumonias and empyemata.2 INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 131 It is shown below, in the consideration of the etiology of the pneumonias, that, during this early period, the pneumococci which were found, though exhib- iting a considerably larger proportion of the so-called mouth types, Types Ha, 3000 2000 .000 500 LOGARITHMIC SCALE. 100 50 OCTOBER TO DECEMBER, 1917 1918 JANUARY TO MARCH, 1919 Chart XXIII.—A comparison of the variations in the annual admission rates for the total respiratory diseases, the case fatality of measles, and the percentage of measles cases developing pneumonia, white enlisted men in 36 large camps in the United States, October, 1917, to March, 1919 III and IV, than was the rule in preepidemic times, still showed a much smaller proportion of these types than was the case later when influenza had attained its maximum virulence. The proportion of the fixed epidemic types, I and II, 132 COMMUNICABLE AND OTHER DISEASES was correspondingly larger at this time. These latter types are undoubtedly more invasive than the mouth types and so require less predisposition on the part of their victims, while later, when resistance was still more reduced by infection with the more virulent virus, the invasion by mouth types became almost universal. At this time the high incidence of respiratory disease accompanied by pneumonia obtained among the troops in France as well as in the United States. Though the curve began to rise in both groups at the same time, the peak was reached in the American Expeditionary Forces a month earlier than was the case at home. Our small body of troops in France at this time did not cover as much territory as was the case later and the infection could involve the whole command more quickly than was possible in the widely separated camps at home. Probably for the same reason the peak was higher, though the duration of the outbreak was shorter than in the United States. In both groups at this time the death rates were very much higher for colored soldiers than for white, the disparity being greater in France than at home. The admission rates for colored troops were also much higher abroad but at this time were about the same as those for white troops in this country. Both here and abroad there was a decided drop in the rates during the month of February, 1918. Taking any one small group, such as a single camp, the interval between waves is seen to be greater than the one month, but owing to the fact that the outbreaks varied in their time of onset and subsidence in the different camps, sometimes by several weeks, the curve for the whole is smoothed and the interval between waves, shortened. In March, 1918, there began to be observed in the United States decided epidemic outbreaks of respiratory disease that was generally called influenza. Descriptions of the disease at this time both here and abroad leave no doubt as to the clinical and pathological identity of the epidemic with that which appeared in the fall. The immunity later shown by groups which passed through this spring out- break shows that the infection was the same. It was, in most camps, explosive in its onset and it involved a large proportion of the men in each camp attacked, though in the majorit}^, by no means as many as was the case in the fall wave. Of 36 large camps in the United States, 24 showed a distinct peak of acute respiratory disease occurring either in March or April.1 The other camps showed increases but in such a way as to divide their cases between the two months. The rates for the concurrent pneumonia present a strict parallelism to those of the acute respiratory disease as is shown in Chart XXIV. Now, too, for the first time, pneumonia was recognized as secondary to influenza in considerable numbers of cases. In several camps, Camp Wheeler, Ga., and Camp Dodge, Iowa,44 for instance, the character of the secondarily invading organisms showed a decided change, the hemolytic streptococci replacing the pneumococci with increasing case fatality. At this time the fulminating pneumonia, with wet hemorrhagic lungs, fatal in from 24 to 48 hours wTas first observed. This was regarded at the time as characterizing the strepto- coccus at the height of its virulence. Later experience showed the lesion to be influenzal. The 24 camps having a distinct peak month (admission and death rates) are shown in the following tabulation; the month of highest incidence is also indicated for each camp: INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 133 Admission and death rates in 24 camps exhibiting a distinct peak month during the spring epidemic of influenza, 1918 Camp Month Funston, Kans_______' March... Wheeler, Ga_________ April___ Shelby, Miss_____________do___ Logan, Tex__________'___do___ Dix, N. J____________' March... Dodge, Iowa......____'___do___ Fremont, Calif_______' April___ Sheridan, Ala________'___do___ Bowie, Tex__________'___do___ McClellan, Ala_______I___do___ Sherman, Ohio_______'___do___ Doniphan, Okla______ March... Admis-sion rate Death rate 1,907 26.99 13 1,486 12.46 14 1,420 1.50 15 1,184 2.30 16 1,180 7.06 17 1,172 25.80 18 1,045 .88 19 908 3.70 20 *96 3.56 21 875 1.70 22 837 8.30 23 7S5 9.22 24 Camp Month Greene, N. C________ April. Upton, N. Y_____ _! March. Beauregard, La Gordon, Ga Jackson, S. C Meade, Md Lee, Va_______ Kearny, Calif____ Sevier, S. C_____ Wadsworth, S. C. Greenleaf, Ga____ Hancock, Ga____ Admis-: sion rate 775 652 649 612 584 5S1 565 560 425 381 371 Death rate 10.20 10.37 3.72 4.66 .84 1.60 2.70 2.40 3.90 4.83 .00 .93 In this tabulation the camps are arranged in the order of admission rates, beginning with the highest. It is seen that the death rates and admission rates are not closely correlated. If the rates of the camps showing a March peak are compared with those in which the peak came in April, the following figures are obtained. Month MX D-*rate|Ad™n| Fatality March. April.. 12.9 3.86 993 759 1.3 .52 Thus the camps having an April peak had nearly as high an admission rate, but much lower death rates and case fatality, than camps having a March peak. This parallels the relation found in September and October, as will be seen later. The order in which these camps were attacked roughly corre- sponds to the sequence of attack in the fall outbreak. Almost all the camps in the lower half of the table are southern camps. Of the southern camps having high death rates, Camp Wheeler, Ga., Camp Doniphan, Okla., and Camp Greene, N. C, all had high rates during the winter and were evidently composed of highly susceptible material. In this wave, for the first time, men from Northern States were seriously affected. This wave of the epidemic was very much less explosive in the American Expeditionary Forces.1 The rise after the February remission was less notice- able and the incidence of influenzal infections with some complicating pneu- monias continued well into the summer. The mild character of the disease, together with lack of agreement as to its exact nature led to the designation of "three-day fever," by which it was generally known at that time. The fact that the troops were now widely scattered for training purposes doubtless made its spread less rapid. It is seen, then, that undoubted influenza appeared at this time in both Europe and America so nearly at the same time as to render its transference from one area to the other very unlikely. That it was present as well in other parts of the world is indicated by a report of the camp surgeon at Camp Kearny, Calif., who attributed the outbreak at that station to the visit of a Japanese fleet which arrived with several cases on board.57 During the spring epidemic, 134 COMMUNICABLE AND OTHER DISEASES both here and abroad, colored troops suffered decidedly more than did white troops. Following the outbreak of March and April there was a marked fall in admission and death rates for respiratory diseases in the United States. As has been stated above, the disease remained sporadically active in France 1000 500 LOGARITHMIC SCALE X O z uJ Q_ \r «0 o o o 0_ uU ex. __ tt„_--^^u Cases devel- White blood cells Uncompli- cated cases Per cent i Per cent 16. 5 I 2S. 8 52. 7 i 39. 0 19. 5 i 17. 7 Per cent 12,000-16,000___________________ 8.3 16,000-20,000____________________ 2.5 Over 20,000___________________ . 0.5 Cases de- veloping pneumonia I'rr cent s.3 2.0 3.3 In both series the mode falls in the 6,000-8,000 group. This coincides with the usual experience. Of all cases at Camp Jackson, S. C, 42.2 per cent had counts of less than 5,000, with an average of 6,344.72 This included complicated sis well as uncomplicated cases. The average of cases that developed pneumonia was 7,141. A report from Camp Hancock, Ga., at the time of the spring epi- demic summarizes the results of 202 counts as follows:85 Leucocyte counts in influenza, Camp Hancock, Co., April, 1918 Day of disease Average count 6,166 5,378 7,522 Day of disease Average count 8,158 8,959 7,855 The results of differential counting of the leucocytes are also concordant in the different reports. There is general agreement that the polynuclear ele- ments are relatively reduced and the percentage of lymphocytes increased. The lymphocyte percentage during the spring epidemic often exceeded 50. In the later days of the outbreak this disproportion was not so marked, but still remained evident. Experience in the severe fall outbreak did not show so high a percentage of lymphocytes. Thus from Camp Jackson, S. C, it was reported that there was an average of 35.5 in uncomplicated cases, 27.8 in those that developed pneumonia.72 The opinion was generally expressed that there was no relative increase of polynuclear elements unless secondary infection impended. In general the statement is almost universal that the differential count was normal or showed a relative lymphocytosis. The clinical types of pneumonia occurring during the 1918 cycle of influ- enza differed so decidedly from those usually seen in interepidemic periods and even from those described for previous pandemics that some description of these cases seems necessary here. A general view of the pneumonia situation during the World War shows that there was a gradual change in the predom- inating clinical type of the disease from the early cases, which were in no way noticeable as different from the usual type of pneumonia, to the very atypical pneumonias of September and October, followed by a distinct tendency to revert to the types of earlier months as the epidemic declined. This change was mani- fested in the relative proportions of lobar and of bronchopneumonia, in changes in the proportion of cases developing secondary suppurations, notably empyema As stated above, prior to December, 1917, cases of pneumonia, either primary or complicating measles, were regarded bv our medical officers as differing in no essential from such cases occurring previous to the World War INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 157 Pneumonia complicating measles was not of unusually frequent occurrence. Particularly was this true as regards the earlier weeks of the great measles epidemic in the camps. However, by December, 1917, when there was a sudden increase in incidence of mild respiratory infections, variously recorded as influenza, bronchitis, coryza, etc., the number of cases of pneumonia appar- ently primary, as well as cases associated with measles, rose suddenly to alarm- ing proportions especially in some of the southern camps. The pneumonia of this period was carefully studied by a special commission of medical officers working at Camp Travis, Tex.2 They noted the presence at the time of an "epidemic of coryza, laryngitis, and mild bronchitis" in both the civil and military population of San Antonio. The report of the commission states that clinically the pneumonias studied could be divided into three groups: Bronchopneumonia, associated as a rule but not invariably with a recent measles attack; (2) lobar pneumonia, giving the familiar signs and symptoms of that disease and sometimes following measles; (3) a group showing clini- cally and anatomically a combination of groups 1 and 2. The description of the bronchopneumonia found there is of especial interest not only because it was the unusual feature of the outbreak, but because it is of value in comparing it with the bronchopneumonia of later waves. The cases at San Antonio were nearly all associated with the hemolytic streptococcus, though nearly half of them showed the presence of the Pfeiffer bacillus as well. Onset was gradual and without definite chill or sudden elevation of temperature, whether occurring during the course of measles or only after an interval of several weeks. The temperature rarely exceeded 104° F., and was frequently irregular even in the absence of empyema. The pulse rate was not extremely rapid even in cases near death. Respiration, too, was not extremely rapid but was characterized by extreme respiratory difficulty. Cyanosis was constant even in early cases." The cough was troublesome and the sputum varied in char- acter, though not showing the tenacious rusty type, typical of lobar pneumonia. Pain was usually marked and w^as associated with the frequency of pleural infection. When noted, consolidation was usually at the base. Rales, musi- cal, squeaking, or moist, were usually heard throughout the chest. In some cases characteristic signs of consolidation in a certain area persisted for a few days and then entirely disappeared. In uncomplicated bronchopneumonia, wide areas of dullness and tubular breathing were never observed. When such signs were found there was invariably a concurrent lobar pneumonia. Empyema complicated about one-half of the cases studied and its fatality was at least 50 per cent. The lobar pneumonia studied showed the presence of pneumococci, the epidemic types being demonstrated in two-thirds of the cases. In the series showing combined lesions both pneumococci and strepto- cocci usually were demonstrated. During the 1918 spring epidemic, pneumonia was for the first time attrib- uted to antecedent influenza in any considerable number of cases, although the diagnosis previously had been made. The clinical types of pneumonia seen in March and April corresponded well with those seen in the camps show- • Other observers have stated that cyanosis on admission for measles characterized cases that developed pneumonia later. 15S COMMUNICABLE AND OTHER DISEASES ing a high death rate during the winter months. At this time the camps were much more generally affected. Empyema was still common and the mortality was generally associated with this complication. A small number of cases of a new type of the disease was seen for the first time during this outbreak. A patient with an attack of typical influenza of two or three days' duration would, after a day or two of normal temperature, develop acute pneumonic symptoms and die within 48 hours. This was the fulminant type of influenzal pneumonia familiar in the fall outbreak. The proportion of cases recorded as lobar in type was lower in the spring than in the winter and the case fatality of pneu- monia was higher.78-79 During the period of lower incidence of respiratory infections following the spring outbreak and lasting throughout the summer, this increased case fatality of pneumonia cases persisted and even increased as is seen in the monthly tables. The increase culminated in the month of September, 1918, with the violent outbreak of the most severe influenza wave, which first showed its great virulence in the northeastern camps. The percentage of influenza cases developing pneumonia at this time varied in different localities. The maximum figures were about 25 per cent. The usual case fatality at this time was around 30 per cent. Though the disease, as seen in different camps, varied somewhat in its clinical manifestations due to the various factors that have been discussed, the general characteristics of the complication were very constant. Few observers were able to distinguish clinically with any definiteness in the early stages of the disease between cases which showed later lobar lesions and cases of bronchopneumonia. The follow- ing condensed description of influenzal pneumonia of the most fatal type is drawn largely from a series of studies made at the Walter Reed General Hospital, D. C.82 86 The onset of the pneumonic complication occurred either after two or three days of normal temperature following an attack of influenza, or it developed gradually without there being an afebrile interval. In the former group the onset was often characterized by chill and sudden rise of temperature. The severity of the disease was correlated with the amount of lung involvement, unilateral cases doing much better than those with both lungs affected. Fulminant cases with severe toxemia showed rapid involvement of the entire lung. In nonfatal cases, usually presenting a unilateral lesion, the temperature ranged from 100° to 103° F. The pulse was characteristically slow; the blood pressure low, the systolic figure often below 100 mm.; respiration was only slightly accelerated. Nonfatal cases usually recovered after an illness of about a week and defervescence was by crisis in some series, by lysis in others. In cases with bilateral lesions the cyanosis was more marked, even to an indigo blue color, the temperature ranged somewhat higher than in the unilateral cases and often showed variations paralleling the advance and recession of the pul- monary lesion as shown by the X ray or by physical signs. Cough was fre- quent and exhausting; the sputum, blood tinged or mucopurulent. In the more toxic cases, terminating fatally, the color of the patient from the first was either that of an intense cyanosis or a muddy, claylike pallor. The pallor was of particularly bad prognostic import. Nervous symptoms appeared early, rest- INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 159 lessness and delirium being marked. The respiration became very rapid and dyspnea was pronounced. Physical signs of irregular consolidation and of edema filled the entire chest. The temperature ranged to 105° F. or higher, and death occurred in from three days to a week. It is evident that these groups were not clean-cut and that all degrees of varying severity intervened. Inas- much as such a proportion of severe pneumonia has in the past seldom been associated with influenza, it is important to record in somewhat greater detail the peculiarities of this outbreak. The first point to strike the observer was the universal occurrence of cyanosis. This condition appearing in an apparently uncomplicated case of influenza, if of a degree at all marked, usually presaged the onset of pulmonary inflammation. Whether due to toxic changes in the composition of the blood or to mechanical interference with oxygenation by the exudate in the lungs, the intensity of the cyanosis was, in general, an index to the severity of the case. In milder cases of influenza, a peculiar shade of "pink cyanosis" was observed, an erythematous flush of an unusual shade. The well-established case of pneu- monia showed a shade that was usually described as heliotrope, and in the most asthenic group, usually associated with coma vigil, a muddy clay-colored pallor prevailed. In some series of cases the tendency to hemorrhages from the mucous membranes was very notable. Epistaxis, which occurred in 10 per cent or more of the cases, was of all degrees, but often severe, recurrent, and debilitating in the extreme. Purpura, intestinal, and renal hemorrhages also occurred. Of respiratory symptoms proper it may be said that these differed relatively little from the respiratory symptoms of the usual pneumonias. Pleuritic pain was frequent, cough was distressing, and frequently there was so much expecto- ration as to make resorting to narcotic relief seem dangerous. The character of the sputum varied from the tenacious rusty expectoration of typical lobar pneumonia, through varying degrees of mucopus, and frothy blood-stained material to the profuse pink froth in the mouth and nose which characterized the fulminant cases. The typical rusty sputum was rare, but the presence of some amount of blood was the rule. From the beginning the physical signs were confusing. Typical signs of consolidation were seldom found, and then late. After some experience with these cases most observers concluded that the diagnosis of pulmonary involve- ment was better made from the general course and symptomatology than from physical signs. Here, too, the X-ray examination proved very valuable, as was stated above. The early signs of pneumonia were confined to the presence of fine scattered rales, and as these rales were found in many apparently uncom- plicated influenza cases their significance was not clear. As the involvement proceeded, dullness became evident on percussion, and breath sounds, voice, and fremitus were diminished, thus suggesting fluid in the pleura. Areas of tympany were also observed. After several days the confluence, or extension of consoli- dated areas, often produced typical signs of consolidation. Pleuritic friction was often heard. The heart action was slow in proportion to the temperature, and right- sided dilatation was not the rule even in severe and fatal cases. Low blood 160 COMMUNICABLE AND OTHER DISEASES pressure was noted, in some cases the systolic blood pressure falling as Ion as 80 mm. without a necessarily fatal issue. The temperature was very variable, usually of a fairly continous type, but in some cases remissions with sweating were frequent even without suppurative complications. The leucocyte counts were also variable, some fatal cases showing no change from the initial leucopenia. In others a marked polynucleosis supervened. Pneumococcus cases showed this rise earlier than did cases infected with streptococci. Blood cultures were positive in a relatively small proportion of cases, and pneumococcus infection gave the great majority of the positive results. Toxic nephritis, varying in degree, occurred in nearly every case. The presence of large numbers of casts was almost invariably of fatal import. Gastro- intestinal symptoms were rare, though early and persistent vomiting occurred in the highly toxic cases. Constipation was the rule. Toxic involvement of the nervous system was evident in all the more severe cases. There was sleep- lessness, restlessness, severe headache and, to a greater or lesser degree, delirium. The delirium appeared to be related to the degree of toxemia rather than to the temperature. Two types of delirium were noted: A restless talkative type, hard to control, but unassociated with a lack of orientation when the patient was questioned; the coma vigil type. The talkative type was not of very bad prognostic import, but almost all cases who had the coma vigil type of delirium died. Skin eruptions were prominent in some series of cases and hardly mentioned in others. At the Walter Reed General Hospital a reddish eruption of a macu- lopapular character, occurring typically on the chest and back, was seen in about two-thirds of the cases. It differed from acne in the absence of pustules, and from sudamina in the absence of vesicles. It persisted into convalescence and was followed by scaling. Profuse sweats occurred in the highly toxic and in convalescents. The case fatality of the pneumonias of this outbreak varied from 19 per cent in some of the southern camps to 51 per cent at Camp Sherman, Ohio. Certain camps in the same State and having apparently the same class of troops showed variation in this respect, thus suggesting that different standards were adopted in the diagnosis of pneumonia. From the account of symptoms and physical signs given above it is easily seen how this could have happened. During the fall wave the greatest percentage of total strength dying as a result of the epidemic was 3.3 (Camp Sherman, Ohio, and Camp Cody, N. Mex.). From this figure it ranged down to less than 0.5 per cent. COMPLICATIONS AND SEQUEL.E Aside from the pneumonias which have been considered above, there was a notable absence of complications of influenza. Of 734,397 cases admitted with a primary diagnosis of influenza from our troops in the United States and in Europe, the following secondary diagnoses were recorded.1 INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 161 Epidemic cerebrospinal meningitis. _ Acute articular rheumatism_______ Pulmonary tuberculosis__________ Acute miliary tuberculosis________ Arthritis______________________ Hyperthyroidism_______________ Neurocirculatory asthenia________ Neuralgia_____________________ Neuritis______ _______________ Psychasthenia__________________ Psychoneurosis_________________ Psychosis, manic-depressive_______ Conjunctivitis__________________ Amaurosis_____________________ Iritis____________________________ Otitis media_____________________ Laryngitis (acute catarrhal)_______ Acute tonsillitis__________________ Acute pharyngitis________________ Mastoiditis______________________ Otitis externa________ ___________ Sinusitis (all)____________________ Pericarditis______________________ Acute endocarditis________________ Cardiac dilatation________________ Myocarditis and myocardial insuffi- ciency _________________________ 542 396 956 21 916 143 465 89 143 14 114 25 299 2 31 3,431 490 2,617 678 423 48 1, 023 139 50 109 330 Phlebitis_________________________ 225 Bronchitis_______________________ 5, 081 Bronchopneumonia_______________ 52, 463 Lobar pneumonia_________________ 21, 742 Empyema_______________________ 2, 129 Serofibrinous pleuritis____________ Pulmonary emphysema__________ Asthma________________________ Ulcer of the stomach_____________ Ulcer of the duodenum___________ Diarrhea_______________________ Enterocolitis____________________ Hernia_________________________ Anal fistula_____________________ Cholecystitis_____________________ Peritonitis_______________________ Acute nephritis__________________ Pyelitis_________________________ Cystitis_________________________ Epididymitis (nonvenereal)_______ Abscess, subcutaneous____________ Furuncle________________________ Cellulitis________________________ Erythema_______________________ Herpes_______________ _______ 904 61 229 22 15 366 553 516 30 80 46 313 41 69 163 370 205 164 44 60 Though it is undoubtedly true that, in the press of work occasioned by the epidemic, many minor complications were not recorded, the above figures probably represent with some accuracy the incidence of complications and sequela? important enough to have an effect on the clinical course of the case. It is seen that, with the exception of the respiratory complications, the number recorded under any heading is very small in proportion to the total number of admissions. A number of reports on the incidence of otolaryngological complications have been published. Reports of the symptomatology of the disease indicate that catarrhal otitis media without perforation was of frequent occurrence, though exact figures are not available. The figures in the above tabulation probably represent fairly accurately those cases of otitis that required special attention or operation. It is seen in the tabulation that this complication occurred in 3,431 cases out of 734,397, or only 4.68 instances per 1,000 influenza admissions. The rate of secondary otitis media for all medical cases, exclusive of influenza, is 5.01 per 1,000. Measles had a rate of 41.9 per 1,000, scarlet fever 35.2, and epidemic meningitis 21.6. There is no doubt that there is some slight tendency toward lowered resistance in parts other than the lungs during the course of influenza, but were the statistics available it is certain that it would appear that the vast majority of these infections were associated with influenzal pneumonias of corresponding bacterial origin rather than with the primary disease itself. 56706—28----11 162 COMMUNICABLE AND OTHER DISEASES In general, complications were less frequent proportionately during the height of the fall outbreak than was the case during the earlier waves and during the period of decline after the fall wave. This is particularly true of the incidence of empyema.a Several complications, while not numerically impor- tant, are of great interest on account of the fact that they appear to have attracted particular attention for the first time during this pandemic. The first of these is subcutaneous emphysema.87 In this condition the subcutaneous areolar tissue becomes infiltrated with air over a greater or lesser extent of the body. It usually began above the clavicles or manubrium and extended in some instances until practically the entire body was affected. Its occurrence was extremely irregular, some large series of cases being reported without noting it and others reporting several cases in a comparatively small number of admissions. Camp Hospital No. 12, A. E. F., reported 13 cases, of which 5 occurred in the same ward and the first 3 in adjoining beds. This dis- tribution led to the consideration of an infective origin for the complication and from 4 of the cases an anaerobic spore-bearing gas former was isolated. However, the great majority of cases failed in other hands to show any such origin, and the generally accepted theory of the pathogenesis of the emphysema, based on careful autopsy studies, is that it is the result of rupture of the dilated bronchioles, the air passing along the vessel sheaths to the mediastinum and thence to the subcutaneous tissue. The slow dissection thus accomplished by the air is remarkably painless; and while its occurrence is prognostically bad, by no means all of the extensive cases were fatal. Another interesting complication is the degeneration of the rectus muscle, usually accompanied by rupture and hemorrhage. After attention was called to this occurrence a few instances were reported in almost every autopsy series. McCallum79 noted it in the 1918 spring epidemic. The primary lesion appears to be a hyaline degeneration of the muscle fibers with loss of striation, similar to if not identical with the condition known as Zenker's degeneration. When rupture and hemorrhage are added, bacterial invasion of the area may result in the formation of abscess. This condition doubtless accounts for many of the instances of abdominal pain and rigidity, simulating peritonitis, that were observed during the epidemic. Inflammation of the accessory sinuses of the nose, while rarely giving rise to clinical symptoms, was almost invariably found post-mortem. The post- orbital headache of the early days of the disease has been attributed to sphen- oidal sinusitis. There has been a fairly prevalent belief that influenza was frequently followed by pulmonary tuberculosis. It is seen from the tabulation given above that in 956 instances the diagnosis of tuberculosis, secondary to influenza, was recorded. This amounts to 1.3 instances per 1,000 admissions. In all noninfluenzal admissions this diagnosis was recorded secondarily in 1.5 of every 1,000. These figures should perhaps be accepted with caution owing to the fact that the great majority of the men affected by influenza were discharged from the service within a few months time and late-developing tuberculosis might have been missed. However, the mortality statistics of the registration area for the years following 1918 have shown a progressive decrease in the death 0 Empyema is given separate consideration in Pt. II, Vol. XI, of this history. INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 163 rate from tuberculosis in civil life. It seems very improbable that any great number of cases of tuberculosis owe their origin to the influenza epidemic. The same general conditions hold for neurocirculatory asthenia. Here, again, although 465 cases are recorded as following influenza, the rate per 1,000 is lower than that for cases that were not influenzal. TREATMENT In the absence of definite knowledge of the etiology of influenza, no specific remedies are available for its cure. The current conception of this disease as a relatively mild respiratory infection, short in duration and leading to fatal results only when complicated by secondary infections, usually pulmonary, results in a treatment logically directed to shorten its course, to limit the amount or degree of primary pulmonary damage, to protect the patient against secondary infection from his fellows, and to reduce if possible by these means the pro- portion of fatal pulmonary complications. Further treatment aiming to pro- mote the comfort of the patient is the second line of attack. When pneu- monia has developed there are several methods of treatment in influenzal cases that do not apply in interepidemic periods, but in general the disease is best treated along orthodox lines. INFLUENZA Since the main aim of treatment in the uncomplicated early influenza case is the avoidance of pulmonary complications, the results of treatment are best estimated by consideration of the percentage of recoveries without pneumonia. The principles of treatment best adapted to this end have been well established, although definite statistical evidence of the same can not be given here owing to the fact that other factors predominated in determining the severity of cases as occurring in different localities. These factors have been included in the consideration of the epidemiology and of the prevention of the disease (vide supra). Experience, however, led to the crystallization of the general opinion that certain measures resulted in reducing the proportion of pneumonia cases. Of these the first and perhaps most important was the early institution of treat- ment. Men who continued on duty after definite symptoms had developed were much more likely to develop pneumonia. The excellent morale of the com- batant troops in the face of the enemy, which led many soldiers to refuse to re- port themselves sick until forced to do so, is believed to be one great cause of the greater proportion of pneumonias and relatively high fatality shown by the troops in the American Expeditionary Forces.88 The important elements of treatment, once the patient comes under medical care, were found to be rest in bed, warmth, and a light, hot diet. It is the consensus of opinion that under such treatment the great majority of cases are convalescent within two to three days. The question of open-air treatment has been much debated, but the weight of opinion is to the effect that open-air treatment is only permissible when it may be maintained without sacrificing the warmth of the patient. Drug treatment is of a palliative character. Aspirin was largely used for the pains of onset, though it was criticized by some as being depressant. Dover's powder, or morphine, to promote rest; sprays, preferably oily, to relieve naso- 164 COMMUNICABLE AND OTHER DISEASES pharyngeal discomfort, and laxatives as needed comprise most of the drugs used. One report is available of the use of serum from convalescents in early cases. This showed that of 26 cases so treated only one-third the proportion of pneumonias resulted as in the untreated series and the average duration of fever was over 50 per cent longer in the controls.83 PNEUMONIA The general principles applicable to the uncomplicated influenza cases in regard to rest, warmth, and ventilation apply equally here. The usual drug medication was generally used without striking success. Specific treatment with antipneumococcus serum in type I cases was generally used and showed generally satisfactory results.89 Other attempts at specific treatment directed against the pneumococcus included the use of polyvalent antipneumococcus sera, the use of the Kye's antipneumococcus chicken serum, the autolyzed pneumococcus antigen of Rosenow, and the therapeutic use of bacterial vac- cines.90 Favorable reports on all these measures have been made by those who used them, as was also the case with the use of the serum or citrated blood of convalescents. It is to be noted that all except the last of these measures involves the introduction into the circulation, usually intravenously, of protein products foreign to the human system. This is also true of the type I serum, the effects of which, however, are so much more clean-cut than those of the others that its specific action may hardly be questioned. These considerations have led many to the belief that a nonspecific protein reaction is of benefit and some have aimed in their treatment to obtain a sharp reaction. To quote a report from Camp Greene, N. C.:91 It was the impression of some observers that not a few cases reported as other than type I showed benefit from the serum treatment. It was also the prevalent belief that in cases in which a chill follows the administration there was increased likelihood that 12 hours later the temperature would be much lower and the general condition improved. Reports of the intravenous use of bacterial vaccines in doses sufficient to induce sharp reactions, repeated daily, show definitely good results.92 It appears to be quite definitely proven that such induced reactions do good. No harmful effects have been reported, and the claim is that the temporary dis- comfort of the chill is followed by a feeling of comfort and well being very grate- ful to the patient.70 93 The intravenous use of hypertonic glucose solutions, while lacking the protein element, also results in a similar type of reaction in a certain proportion of cases. The advocates of this method of treatment, after extensive trials, claim that its use promotes comfort, produces rest and sleep, reduces tempera- ture, increases elimination through kidneys and skin, slows the heart, and increases the volume of the pulse. It also supplies nutriment in a readily assimilable form and furnishes an excellent vehicle for the administration of specific sera, digitalis, morphine, or other medication. Comparisons showing reduction of mortality under strictly controlled conditions as a result of this treatment are not to be had. The method was used most extensively at Camp Travis and Fort Sam Houston, Tex., situated in the region where relatively low fatality prevailed. It has already been noted, however, that the case INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 165 fatality there was appreciably lower than in neighboring camps under appar- ently the same climatic conditions and made up of the same type of men. The solution, from 5 to 25 per cent in strength, was given in amounts of 250 c. c. intravenously once or twice daily. Notes were made of marked improvement following several cases of lung puncture for diagnostic purposes. The induction of artificial pneumothorax resulted in recovery in two cases apparently moribund.82 The suggestion was made on the ground of autopsy findings that aspiration of the chest should be performed early when signs of pleural fluid were noticed.94 Venesection was used to some extent in the severe cases of hemorrhagic edema of the early stages of the 1918 fall outbreak. The excellent results obtained by this means in gas pneumonias, together with the similarity of the pathology in the two conditions, lead to the expectation of marked benefit.95 There is decided dif- ference of opinion as a result of experience. Some have reported marked benefit, while others state that no results were obtained. In general it may be said that the experience of the World War has con- firmed the position of the antipneumococcus serum, type I, when given in sufficiently high titre and proper dosage; it has led to a widespread belief in the beneficial effect of nonspecific protein reactions however induced and an equal belief in their essential harmlessness; it has shown the beneficial effect of the intravenous use of hypertonic glucose solutions, although experience with this agent was not general; and, lastly, owing to the universal agreement of the many who made use of convalescent serum in some form as to the good effect of this treatment, it appears established that the serum of convalescents contains curative antibodies.96 This last observation encourages the hope that with the discovery or recognition of the primary etiological agent of influenza a hyperimmune serum may be developed in animals which may at least prove effective in limiting the amount of pulmonary damage done by the primary disease and thus prevent the pneumonic complications. REFERENCES (1) Based on sick and wounded reports made to the Surgeon General. (2) Cole, R., and MacCallum, W. G.: Pneumonia at a Base Hospital. Transactions of the Association of American Physicians. Philadelphia, 1918, xxx iii, 229. (3) Report of the pneumonia commission at Camp Wheeler, Ga., made to the Surgeon General, October, 1918. On file, Record Room, S. G. O., 334.8-1 (Camp Wheeler) D. (4) Osier, Sir William, and McRae, Thomas: Modern Medicine. Lea and Febiger, Phila- delphia and New York, 1913, Vol. I, 534. (5) Based on Mortality Statistics, prepared by the Department of Commerce, Bureau of the Census. (6) Based on Mortality Statistics, prepared by the Department of Commerce, Bureau of the Census; also Thirteenth Census of the United States, taken in the year 1910 Vol. I, Population 1910, Bureau of the Census. (7.) Based on Annual Reports of the Surgeon General, U. S. Army, 1865 1917. (8) Based on sick and wounded reports made to the Surgeon General; also on strength reports made to The Adjutant General. (9) Brownlee, J.: The Next Epidemic of Influenza. Lancet, London, Nov. 8, 1919, ii, 856. (10) Hall, Milton W., Maj., M. C: A Possible Fallacy in the Calculation of Annual Death Rates. The Military Surgeon, 1923, lii, No. 2, 157. 166 COMMUNICABLE AND OTHER DISEASES (11) Reports on influenza epidemic, 1918, made by the camp surgeon, to the Surgeon Gene . On file, Record Room, S. G. O., 710-1 (name of camp) D. (12) Vaughan, V. C: Epidemiology and Public Health, St. Louis, C. V. Mosby Company, 1922, I, 357. , • r. • . (13) Opie, E. L.; Blake, F. G.; Small, J. C; and Rivers, J. M.: Epidemic Respiratory Diseases. St. Louis, C. V. Mosby Co., 1921. (14) Vaughan, V. C, op. cit., 358-9. (15) Report of the influenza epidemic at Camp Grant, 111., made by the camp surgeon to the Surgeon General. On file, Record Room, S. G. O., 710-1 (Camp Grant) D. (16) Letter from Maj. E. L. Opie, M. C, to the Surgeon General, July 29, 1918. Subject: Pneumonia in Camp Cody among newly drafted men. On file, Record Room, S. G. 0., 710-1 (Camp Cody) D. (17) Sanitary report, Camp Lewis, Wash., for September, 1918. Copy on file, Record Room, S. G. O., 721-1 (Camp Lewis) D. (18) Vaughan, V. C, Col. M. C, and Palmer, G. T., Capt, S. C: Communicable Diseases in the National Guard and National Army of the United States During the Six Months from September 29, 1917, to March 29, 1918. The Journal of Laboratory and Clinical Medicine, St. Louis, 1918, iii, No. 2, 635. (19) Pearl, Raymond, Public Health Reports, August 8, 1919. (20) Annual Report of the Surgeon General, U. S. Army, 1918, 178. (21) Census Reports, 1918. (22) Analysis of the course of epidemics in Army camps, made by Col. V. C. Vaughan, M. C, undated. On file, Record Room, S. G. 0., 701 (Influenza). (23) Vaughan, V. C, op. cit. (Ref. 12), 401. (24) Brewer, I. W.: Report of epidemic of Spanish Influenza, which occurred at Camp A. A. Humphries, Va., during September and October, 1918. The Journal of Labora- tory and Clinical Medicine, St. Louis, 1918, iv, 87. (25) Lynch, C. and Cumming, I. G.: The Role of the Hand in the Distribution of Influenza Virus, and the Secondary Invaders. The Military Surgeon, 1918, xlii, 597; also, The Journal of Laboratory and Clinical Medicine, St. Louis, 1918, v, 364. (26) Blanton, W. R., and Irons, E. E.: A Recent Epidemic of Acute Respiratory Infection at Camp Custer, Michigan. The Journal of the American Medical Association, 1918, lxxi, No. 24, 1918. (27) Vaughan, W. T.: Monograph No. 1. The American Journal of Hygiene, 1921. (28) Jackson, Thomas W.: The Other Side of the Question of Indirect Contact Infection in Acute Respiratory Diseases. The Military Surgeon, Washington, 1920, xlvi, No. 5, 570. (29) Hall, Milton W.: A Note on the Epidemiology of Influenza. The Military Surgeon} Washington, 1920, xlvi, No. 5, 564. (30) Nichols, H. J.: Bacteriologic Data on the Epidemiology of Respiratory Diseases in the Army. The Journal of Laboratory and Clinical Medicine, St. Louis, 1920, v. 502. (31) Rosenau, M. J.; Keegan, W. J.; Goldberger, J.; and Lake, G. C.: Some Interesting Though Unsuccessful Attempts to Transmit Influenza Experimentally. Public Health Reports, 1919, xxxiv, No. 2, 33. Also, McCoy, G. W., and Richey, De Wayne: San Francisco Experiments. Public Health Reports, 1919, xxxiv, No. 2, 34. (32) Vaughan, V. C, op. cit. (Ref. 12), 400. (33) Minaker, A. J., and Irvine, R. S.: Prophylactic Use of Mixed Vaccines against Pan- demic Influenza and its Complications. The Journal of the American Medical Association, Chicago, 1919, lxxii, No. 12, 847. (34) Vaughan, V. C, op. cit. (Ref. 12), 402-3. (35) Report on influenza made by the surgeon, Camp Lee, Va. On file, Record Room S. G. O., 710-1 (Camp Lee) D. (36) Weaver, G. H.: The Value of the Face Mask and Other Measures in Prevention of Diphtheria, Meningitis, Pneumonias, etc. The Journal of the American Medical Association, Chicago, 1918, lxx, No. 2, 76. (37) Capps, J. A.: A New Adaptation of the Face Mask in Control of Contagious Disease The Journal of the American Medical Association, Chicago, 1918, lxx, No. 13 910. INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 167 (38) Doust B. C, and Lyon, A. B.: Face Masks in Infections of the Respiratory Tract. The Journal of the American Medical Association, Chicago, 1918, lxxi, No. 15, 1216. (39) Protection afforded by various filters against bacterial suspension in air—Tolman, Guernsey, Charleston and Dougherty. On file, Record Room, S. G. O., 729.2-1. (40) Draper, G.: Some Observations on the Susceptibility of the Recruits to Disease. The Military Surgeon, 1919, xlv, 99. (41) A summary of the epidemiological evidence as to the relation between typhoid inocu- lation and the incidence of pneumonia, made by Maj. A. W. Freeman, M. C. On file, Record Room, S. G. O., 334.8-1 (Camp Funston) D. (42) Medlar, E. M.: Effect of Typhoid Lipovaccine in increasing Susceptibility to Other Diseases. The Journal of the American Medical Association, Chicago, 1918, lxxi, No. 26, 2146. (43) The relation of typhoid vaccination to the incidence of pneumonia. On file, Record Room, S. G. O., 334.8-1. (Camp Wheeler) D. (44) Based on monthly sanitary reports, made by camp surgeon. On file, A. G. O., World War Division. (45) Stanley: Public Health Reports, May 9, 1919. (46) Miller, J. L., and Lusk, F. B.: Epidemic of Streptococcus Pneumonia and Empyema at Camp Dodge, Iowa. The Journal of the American Medical Association, Chicago, 1918, lxxi, No. 9, 702. (47) The streptococcus epidemic at Camp Zachary Taylor, Ky., by Majs. H. Fox, M. C, and W. W. Hamburger, M. C. On file, Record Room, S. G. O., 710-1 (Camp Zachary Taylor) D. (48) Cecil, E. L., and Austen, J. H.: Results of Prophylactic Inoculations against Pneu- mococcus in 12,519 men. The Journal of Experimental Medicine, 1918, xxviii, 19. (49) Cecil, R. L., and Vaughan, H. F.: Results of Prophylactic Vaccination against Pneu- monia at Camp Wheeler. The Journal of Experimental Medicine, 1919, xxix, 457. (50) Report of vaccination of personnel of Camp Lusitania, A. E. F., with pneumococcus and B. influenza; vaccine, July 2, 1919. On file, Record Room, S. G. O., 720.3-1 (A. E. F., France) Y. (51) Reynolds, J. R.: A System of Medicine. J. B. Lippincott & Co., Philadelphia, 1870, Vol. I, 36. (52) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. I, 504. (53) Vaughan, V. C, op. cit.(Ref.l2), 367. (54) Bradbury, S.: The Occurrence of Influenza in a Regiment. The Military Surgeon, Washington, 1920, xlvii, No. 4, 471. (55) Report from Camp Dodge. On file, Record Room, S. G. O., 710-1 (Camp Dodge) D. (56) West, S.: Some General Remarks on Epidemic Influenza. The Practitioner, London, January-June, 1919, cii, 44. (57) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. I, 746. (58) Chesney, Alan M., and Snow, F. W.: A Report of an Epidemic of Influenza in an Army Post of the American Expeditionary Forces in France. On file, Record Room, S. G. O., 710-1 (A. E. F.; France) Y. (59) Special report from Camp Shelby, Miss. On file, Record Room, S. G. O., 700-1 (Camp Shelby) D. (60) Report from the base hospital, Camp Devens, Mass., relative to influenza, pneumonia, and respiratory diseases. On file, Record Room, S. G. O., 710 D. (61) Special report from Camp Logan, Tex. On file, Record Room, S. G. O., 710-1 (Camp Logan) D. (02) Special report from Camp Cody, N. Mex. On file, Record Room, S. G. O., 710-1 (Camp Cody) D. (63) Report from the base laboratory, Base Section No. 5, Brest, A. E. F. On file, Record Room, S. G. O., 710-1 (A. E. F., France) Y. (64) Brown, O. G.: Problems in the Control of Communicable Diseases at Replacement Depots. The Military Surgeon, Washington, 1919, xlv, No. 1, 59. 16S COMMUNICABLE AND OTHER DISEASES (65) Cornwall, E. E.: Spanish Influenza; Cases of Influenza and Pneumonia taken off S. S. Bcrgernsfjord, arrived in New York, August 12, 191s, from Norway. Xew York Medical Journal, August 24, 191S, cviii, 330. (66) Freedlander, A.; McCord, C. P.; Sladen, F. J.; and Wheeler, G. W.: The Epidemic of Influenza at Camp Sherman, Ohio. The Journal of the American Medical Association, Chicago, 1918, lxxi, No. 20, 1652. (67) Lyon, J. P.; Tenney, C. F.; and Szerlip, L.: Some clinical observations on the Influenza Epidemic at Camp Upton. The Journal of the American Medical Association, Chicago, 1919, lxxii, No. 24, 1726. (68) Report from the camp surgeon, Camp Grant, 111., relative to influenza epidemic. On file, Record Room, S. G. O., 710-1 (Camp Grant) D. (69) Report from the camp epidemiologist, Camp Devens, Mass., relative to influenza epidemic. On file, Record Room, S. G. O., 710-1 (Camp Devens) D. (70) Report from Camp Travis, Tex., relative to influenza epidemic. On file, Record Room, S. G. O., 710-1 (Camp Travis) D. (71) Based on reports from base hospital laboratories, relative to typing the pneumococcus. On file, Record Room, S. G. O., 710 (Pneumonia). (72) Chickering, H. T., and Park, J. H.: Staphylococcus Aurens Pneumonia. The Journal of the American Medical Association, Chicago, 1919, lxxii, No. 9, 617. (73) Nichols, H. J., and Stimmel, C. O.: Pneumobacilli as Complicating Organisms in Influenzal Pneumonia. The Journal of the American Medical Association, Chicago, 1919, lxxii, No. 3, 174. (74) MacCallum, W. G.: Pathology of the Epidemic Streptococcal Broncho-pneumonia in Army Camps. Monograph of the Rockefeller Institute for Medical Research, 1919, No. 10; also The Journal of the American Medical Association, Chicago, 1918, lxxi, No. 9, 704. (75) Opie, E. L., Freeman, A. W., Blake, F. G., Small, J. C, and Rivers, T. M.: Pneumonia Following Influenza at Camp Pike. The Journal of the American Medical Association, Chicago, lxxii, No. 8, 556. (76) Winternitz, M. C, Wason, I. M., and McNamara, F. P.: The Pathology of Influenza, The Yale University Press, New Haven, Conn., 1920. (.77) Opie, E. L., Freeman, A. W., Blake, F. G., Small, J. C, and Rivers, T. M.: Pneumonia at Camp Funston. The Journal of the American Medical Association, Chicago, 1919, lxxii, No. 2, 108. (78) Report on pneumonia at Camp Dodge, Iowa, by Maj. D. F. Dick, M. C. On file, Record Room, S. G. O., 710-1 (Camp Dodge) D. (79) McCallum, W. G.: Pathology of the Epidemic Streptococcal Bronchopneumonia, in Army Camps. The Journal of the American Medical Association, Chicago, 1918, lxxi, No. 9, 704. (80) Le Count, E. R.: Pathologic Anatomy.of Influenzal Broncho-pneumonia. The Journal of the American Medical Association, Chicago, 1919, lxxii, No. 9, 650. (SI) Wolbach, S. B.: Comments on the Pathology and Bacteriology of Fatal Influenza Cases As Observed at Camp Devens, Mass. Johns Hopkins Bulletin, Baltimore 1919, xxx, No. 338, 104. (82) Horkavy, J., and Selby, John H.: Report on a Clinical, Pathological, and Several X-ray Studies of the Influenza Epidemic at Walter Reed General Hospital. On file, Record Room, S. G. O., 710-1 (Walter Reed G. H.) K. (S3) Francis, F. D., Hall, M. W., and Gaines, A. R.: Early Use of Convalescent Serum in Influenza. The Military Surgeon, Washington, 1920, xlvii, 177. (84) Blanton, W. B., Burhans, C. W., and Hunter, O. W.: Studies in Streptococcal Infections at Camp Custer, Michigan. The Journal of the American Medical Association Chicago, 1919. lxxii, No. 21, 1520. [S5] Forbes, Roy P, and Snyder, Helen A.: A Study of the Leucocytes in An Epidemic of Influenza at Camp Hancock, Ga. On file, Record Room, S. G. O., 710-1 (Camp Hancock) D. i (86) Report on a clinical study of influenza pneumonia by Lieut. A. D. Rood M C On file Record Room, S. G. O., 710-1 (Walter Reed G. H.) K. INFLAMMATORY DISEASES OF THE RESPIRATORY TRACT 169 fS7) Subcutaneous emphysema complicating broncho-pneumonia, Lieut. D. M. Nyquist, M .C. On file, Record Room, S. G. O., 710-1 (A. E. F., France) Y; also, Influenza pneu- monia cases showing gas in the fascial tissues, Majs. E. Clark and M.J. Synnott, M. C. On file, Record Room, S. G. O., 710-1 (Camp Dix) D; also, Generalized interstitial emphysema and spontaneous pneumothorax as complications of broncho-pneumonia, Capts. H. K. Berkley and T. H. Coffen. On file, Record Room, S. G. O., 710-1 (Camp Lewis) D. (88) Brooks, H., and Gillette, C: The Argonne Influenza Epidemic. New York Medical Journal, New York, 1919, ex, No. 23, 925. (89) Spooner, L. H., Sellards, A. W., and Wyman, J. H.: Serum Treatment of Type I Pneu- monia. The Journal of the American Medical Association, Chicago, 1918, lxxi, No. 16, 1310. Also, A group of 68 cases of Type I pneumonia occurring in 30 days at Camp Upton, with special reference to serum treatment. Maj. C. F. Tenney and Lieut. W. T. Riverburgh, M. C. On file, Record Room, S. G. O., 710-1 (Camp Upton) D. (90) Antipneumococcus serum (Eyes') in the treatment of pneumonia, Maj. A. W. Gray, M. C. On file, Record Room, S. G. O., 710-1 (Camp Grant) D. Also: Antipneumococ- cus serum (Eyes') in the treatment of lobar pneumonia, John H. McClellan, M. D. On file, Record Room, S. G. O., 710-1 (Camp Grant) D. (91) Brown, C. P., and Palfrey, F. W.: Influenzal Pneumonia at Camp Greene, N. C. New York Medical Journal, August 23 and 30, 1919, ex, 316, 368. (92) Roberts, D., and Cary, E. G.: Bacterial Protein Injections in Influenzal Pneumonia. The Journal of the American Medical Association, Chicago, 1919, lxxii, No. 13, 922. (93) Snyder, R. G.: Spanish Influenza; Its Treatment by the Use of Intravenous Injections of a Non-Bacterial Split Protein. New York Medical Journal, New York, 191S, xviii, 843. Also, The use of intravenous injections of hypertonic glucose solutions in the treatment of influenzal pneumonia. Capt. C. W. Wells and Lieut. R. C. Blankenship. On file, Record Room, S. G. O., 710-1 (Camp Travis) D. Also: Glucose as an adjunct measure in the therapy of pneumonia, Capt. Henry J. John, M. C. On file, Record Room, S. G. O., 710-1 (Ft. Sam Houston) N. (94) Report of the pathology of influenza and pneumonia, Capt. James F. Coupal. On file, Record Room, S. G. O., 710-1 (A. E. F., France) Y. (95) O'Malley, J. J., and Hartman, F. W.: Treatment of Influenzal Pneumonia with Plasma of Convalescent Patients. The Journal of the American Medical Association, Chicago, 1919, lxxii, No. 1, 34. (96) McQuire, L. W., and Redden, W. R.: Treatment of Influenzal Pneumonia by the Use of Convalescent Human Serum. The Journal of the American Medical Association, Chicago, 1918, lxxi, No. 24, 1992. Also: Ross, C. W., and Hund, E. J.: Transfusion in the Desperate Pneumonias Complicating Influenza. Journal of the American Medical Association, Chicago, 1918, lxxi, No. 24, 1992. Also: Kahn, M. H.: Serum Treatment of Postinfluenzal Broncho-pneumonia. Journal of the American Medical Association, Chicago, 1919, lxxii, No. 2, 102. Also: Maclachlan, W. W. G., and Fetter, W. J.: Citrated Blood in the Treatment of the Pneumonia Following Influenza. Journal of the American Medical Association, Chicago, 1918, lxxi, No. 25, 2053. Also: Browne, W. L., and Sweet, B. L.: Treatment of Influenzal Pneumonias by Citrated Transfusions. Journal of the American Medical Association, 1918, lxxi, No. 19, 1602. CHAPTER III TUBERCULOSIS a ORGANIZATION FOR ELIMINATING THE TUBERCULOUS FROM THE ARMY Soon after the United States entered into the war against Germany it was decided by the Surgeon General that the United States Army should be reex- amined for tuberculosis by the best available experts.1 The chief reason for this decision was the obvious importance, in view of the difficulties of transpor- tation, of allowing no soldiers to be sent abroad who were doomed in advance to an early breakdown. The fact, however, had been alleged and had been given wide publicity, that the French Army had suffered severe losses from tuberculosis 2 and, as it was generally admitted that that disease was rife among the French civil population, the fear that our Army would suffer in the same way as the French Army was felt by many of the medical profession and of the laity. Whether or not this fear was well founded, it would evidently be advan- tageous, as a matter of policy, to give the public to understand that every pos- sible precaution would be taken to safeguard our Army against tuberculosis, and this consideration was no doubt of weight in the mind of the Surgeon General. The supervision of the accomplishment of these measures was to be the function of the division of internal medicine, Surgeon General's Office. This division was established in the summer of 1917, the tuberculosis section of that division entering upon its task on June 6, 1917.3 The first question to be decided was the manner in which the expert exam- inations should be made. The advice given by a committee of prominent mem- bers of the National Association for the Study and Prevention of Tuberculosis6 in its report to the medical committee of the advisory board of the Council of National Defense, was that the experts should act as consultants, examining such cases as the medical officers of the Army might refer to them.4 This method presupposed painstaking and efficient examinations by examiners competent to detect the cases suspicious, of tuberculosis. It afforded no guaranty that persons with manifest tuberculosis would not be admitted into the Army as the result of hurried or otherwise imperfect examination. Under the circum- stances, however, in which our Army was hastily collected, it was to be expected that cases of tuberculosis would be overlooked. To overcome this it was nec- essary that every man should be reexamined, and, moreover, the examining should be done promptly in order that the claim might not be made with success that such chronic lung affections as were discovered were the result of military service thus permitting the pensioning of the individuals concerned. Therefore, it was at once decided that the examiners should pass upon the lungs of every man who had been admitted to the military service, notwithstanding the stag- gering magnitude of the total of examinations for which this decision called. « Unless otherwise stated, all figures for the World War period are derived from sick and wounded reports sent to the Surgeon General.—Ed. » The members of this committee were Dr. Herman Biggs, Dr. G. M. Kober, and Dr. Charles J. Hatfield. 171 172 COMMUNICABLE AND OTHER DISEASES Medical officers of the Regular Army who were qualified for this work were already engaged with even more important duties, chiefly of an adminis- trative character, and could not be spared; while the Medical Reserve officers already commissioned who wTere competent internists had been assigned to medical organizations from which they could not be withdrawn, as a rule, with- out impairment of the efficiency of these organizations. It was necessary, therefore, to resort to civilian physicians, and the plan was adopted of calling upon prominent experts in internal medicine in each of the largest medical centers to recommend candidates for this work.5 A difficulty was experienced at the outset because the duty of the examiner was to be in the United States, and most ambitious and active men desired service abroad. It was soon seen that the examiners must be chiefly recruited from the class who were physically unfit for the arduous field service. But with this class the difficulty at once arose that the men especially interested in tuber- culosis work had themselves had the disease, a fact which under ordinary con- ditions would debar them from admission into the Army. It became necessary to waive this fact for duty in the United States solely in connection with tuber- culosis work and to accept applicants otherwise fitted for the duty contemplated for them whose physical condition warranted service of this kind.6 This course met with objections on the part of the officer in charge of the personnel division, Surgeon General's Office, who apprehended that it would be advanced as a precedent by the numerous physicians who besought the War Department for commissions in spite of physical defects. These objections were met by the argument that the tuberculosis examiners being a special and limited class, to be used for a specific purpose, their cases were not analogous to those of men with disabilities who sought general service as medical officers and should therefore be capable of enduring hardship in the field. These various difficulties created an enormous correspondence. At one time it seemed as if the plan must fail because examiners in sufficient numbers were not to be found. However, slowly, much too slowly, a corps of examiners was commissioned and set at work, the effort being to reach first the newly appointed officers and the troops about to sail for Europe. Examinations did not begin until July, 1917. By an unnumbered circular of the War Department, dated July 16, 1917, it was provided that the examiners for tuberculosis should be organized into boards.7 The size of the individual boards was governed by the size of the command examined, but no board was to consist of less than three examiners. From the examiners, disability boards were appointed in order that the necessary steps for discharge might be taken at once and without the need of referring the cases elsewhere and thus require- ing a repetition of the examinations. Decision as to the physical signs which should determine rejection on account of pulmonary tuberculosis depends naturally upon our conception of the nature of the tuberculous processes as they affect the lungs. If erroneous ideas lead to the unnecessary rejection of many thousands of men, such errors may have disastrous results in the conduct of military operations. The view- was formerly held by all, and is still much too widely spread, that the population is divided as regards tuberculosis into a healthy majority and a tuberculous TUBERCULOSIS 173 minority and that tuberculosis is infectious for adults, at least for those who are not already labeled tuberculous. It is even believed by some that active forms of tuberculous disease may be made worse by contact with other cases, if this leads to exposure to large amounts of tuberculous virus, or if the tubercle bacilli in these latter cases are of a more virulent type. The elimination of the tuberculous from the Army in this view would be urgently required for the protection of their healthy comrades. What may be called the modern view is based upon the well-established fact that practically every civilized adult has come into contact with the tuber- cle bacillus and has thereby acquired what in a sense is a tuberculous infection. But in the large majority of the population this tuberculous infection remains latent throughout life and amounts to a vaccination against tuberculosis. And in those less successfully protected against tuberculosis the form of the disease which declares itself is chronic and often relatively benign, differing materially from the form of tuberculosis met in young children and others who have had no previous contact with the disease before acquiring an infection with massive dosage. An individual already infected with tuberculosis can be reinfected from without, if at all, only by large amounts of tuberculosis virus. If thus capable of exogenous infection he is likewise subject to endogenous reinfection, or will be unable to prevent the extention of already existing, but perhaps latent, tuberculous processes within his body. Exogenous infection in civilized man is not, therefore, of importance; nevertheless, on account chiefly of unprotected children, every care should be taken to destroy the poisons of tuberculosis. Circular No. 20, Surgeon General's Office, was published on June 13,1917, for the guidance of medical officers in connection with examinations for pulmonary tuberculosis, after having received the approval of eminent clinicians. This circular indicated the duties of medical officers, called attention to physical signs of the chest often erroneously considered as signs of disease, and defined the signs of tuberculosis which should lead to rejection, including within its scope the interpretation of X-ray findings. Because of its comprehensive character it is quoted here in full: Circular No. 20. War Department, Office of the Surgeon General, Washington, June 13, 1917. The following is published for the information of medical officers for use in connection with examinations for pulmonary tuberculosis in the military service. The duties of the examiner are: 1. To exclude cases of manifest tuberculosis from the Army. 2. To hold to service men who allege tuberculosis as a ground for exemption or dis- charge on the basis of insufficient or incorrectly interpreted signs and symptoms. 3. To determine in the case of soldiers accepted for the military service the existence of pulmonary tuberculosis, and to decide whether or not the disease has been incurred in the line of duty. Men who desire to serve their country may conceal, from patriotic motives, symptoms of tuberculosis which they know or suspect to exist. Some tuberculous patients will seek enlistment with a view to obtaining treatment and a pension. Some soldiers who have volunteered may repent their action and allege symptoms of tuberculosis with a view to securing discharge. Some conscripts may be expected to claim the existence of tuberculosis 174 COMMUNICABLE AND OTHER DISEASES as a ground for exemption, and may fortify their claims by certificates of physicians and by radiographs. There will probably be many cases in which pulmonary tuberculosis will have been diagnosticated on the ground of subjective symptoms and of physical signs which are normal or indicate unimportant and healed lesions of some kind. It is necessary therefore that conclusions of the examiner shall be based only on phy- sical signs, sputum examinations, and radiographs. Statements of the subject as to symp- toms will not be accepted as proof of the existence of tuberculosis unless supported by objec- tive evidence. It is the duty of examiners to protect the interests of the Government by preventing men from entering the service who have manifest tuberculosis. It is equally their duty to prevent the escape from service on the ground of tuberculosis of men who present slight or doubtful deviations from the normal. It is therefore necessary to insist that recommenda- tions for discharge for tuberculosis of otherwise apparently healthy and vigorous men shall be based only upon the presence of definite and plainly marked signs of pulmonary lesions. The following signs will not be regarded as evidence of pulmonary disease in the absence of other signs in the same portion of the lungs: 1. Slightly harsh breathing, slightly prolonged expiration over the right apex above the clavicle anteriorly and to the third dorsal vertebra posteriorly. The same signs at the extreme apex left side. 2. Same signs second interspace right anteriorly near sternum (proximity of right main bronchus). 3. Increased vocal resonance, slightly harsh breathing immediately below center of left clavicle. 4. Fine crepitations over sternum are heard when stethoscope touches the edge of that bone. 5. Clicks heard during strong respiration or after cough in the vicinity of the sterno- costal articulations. 6. The so-called atelectatic rales heard at the apex during the first inspiration which follows a deeper breath than usual or a cough. 7. Sounds resembling rales at base of lung (marginal sounds), especially marked in right axilla, limited to inspiration. 8. Similar sounds heard at apex of heart on cough (lingula). 9. Slightly prolonged expiration at left base posteriorly. 10. Very slight harshness of respiratory sounds with prolonged expiration in the lower paravertebral regions of both lungs posteriorly, most marked at about angle of scapula, disappearing a short distance above that point, equal on both sides, or slightly more marked at the angle on one side, more frequently the left. the apices Incipient tuberculosis of the apex is often erroneously diagnosticated: 1. On account of misinterpretation of normal signs. 2. Because the importance of minor differences between the two sides is exaggerated. 3. Because signs of a healed lesion are considered to indicate an incipient lesion. For No. 1, see No. 1, page 2. With regard to No. 2, it is not too much to say that, given a sufficiently minute exam- ination, there would be few men who would fail to show some signs which might be interpreted as having pathological significance. No. 3. The truly incipient tuberculosis of the apex generally escapes detection when in an active state. When healed it constitutes the abortive tuberculosis of Bard. Indura- tion of the apex has been described by Kronig as a nontuberculous affection. The important question here is whether the signs present indicate a healed or active process. They are harshness of respiratory sounds, prolongation of expiration, increased conduction of voice and more or less dullness on percussion. These signs are caused by induration of pulmonary tissue. Induration caused by acute inflammation is relatively rare in tuberculosis. It is not characteristic of a recent but of an advanced process, when present to an extent which permits detection by clinical methods. When it does occur, the subject is usually febrile TUBERCULOSIS 175 and evidently ill. In cases of ambulant subjects in apparently good health the presumption is that the above signs indicate an old, not an incipient lesion. The abortive tuberculosis of Bard and Kronig's apical induration, whether or not it is due to an obsolete tuberculosis, are not causes for rejection in the absence of tuberculous disease at a lower level in the upper lobe. Narrowing of Kronig's isthmus is extremely common. It is not a sign of recent disease but of contraction of the lung from old disease. In consideration of the frequent asymmetry of the bony structures about the apices slight differences in the width of the isthmus on the two sides are unimportant. A distinct contraction of one side points to the existence of a tuberculous focus of the upper lobe; whether or not this focus is of clinical importance must be determined from the signs in the individual case. Contraction of the isthmus per se is not a cause for rejection. The attention of examiners is particularly invited to the necessity of exercising great conservatism in their interpretation of physical signs over the apices. Interpretation of such signs as indicating active tuberculosis would in many cases do the Government great injustice, leading to the exclusion of men who are fit for service. The only trustworthy sign of activity of apical tuberculosis is the presence of persistent moist rales. Diagnosis of Tuberculous Lesions in General the acute lesion If small lesion is manifested by rales with or without changes in breath sounds, per- cussion note, and voice transmission. The more acute the lesion the greater the probability that its presence will be indicated only by rales. If of large extent the process is distinctly a broncho-pneumonia, generally caseous, characterized at first by the usual signs of pneu- monia, crepitant, and subcrepitant rales; when caseated by absence of rales, except coarse and distant rales from the larger bronchi, also by impairment of expansibility of the lung, and more or less dullness or tympanitic resonance; when breaking down by cavity signs and the presence of loud moist rales of varying size. Large acute lesions are rarely found in candidates for enlistment and the small acute lesion is also comparatively rare. Tuberculosis as it pre- sents itself to the Army examiner is usually of a chronic type. THE ARRESTED CHRONIC LESION It is by no means rarely the case that a tuberculous lesion will run its course and become arrested without the knowledge of the subject, who may state in perfectly good faith that he has never had tuberculosis. The arrest of a lesion is indicated by the absence of rales. Such a lesion is characterized by harshness of breath sounds and prolongation of expiration, by increased vocal fremitus and resonance and by more or less pronounced dullness on percussion. THE ACTIVE CHRONIC LOCALIZED LESION Activity is denoted by the presence of rales, together with the other signs described under the arrested lesion. Rales do not necessarily show that the lesion is extending nor that the activity is of much clinical importance, but in military practice the presence of rales accompanied by breath changes and other signs should be an indication for rejection. The more active and recent the chronic lesion the less marked the breath changes and the more conspicuous the rales. DISSEMINATED TUBERCULOSIS True miliary tuberculosis is not likely to come to the attention of the military examiner. The peribronchial type is common and frequently not recognized. In the adolescent the peri- bronchial tuberculosis may be extending from the deep lung without as yet developing a superficial focus. It may be manifested only by the presence of distant rales with or with- out slight changes in the breath sounds which are of a slight bronchovesicular quality. If the case is well marked there will be impairment of expansibility of the affected side and increased vocal resonance. Less pronounced cases are distinguished from chronic bronchitis only by the character of the rales (coarser in bronchitis) and by their topical distribution. 176 COMMUNICABLE AND OTHER DISEASES More frequently the peribronchial type is found accompanying a superficial focus. Bronchovesicular breathing may extend some distance below the limits of the suDerficial focus with or without rales. But the most important manifestation of the peribronchial type is extension to the formerly sound side. There may be a small, obscure, apparently arrested lesion of one side, usually the right, with a peribronchial extension involving the whole or the greater part of the other lung manifested only by the presence of rales after expiration and cough. A definitely demonstrated tuberculous lesion of more than insignificant size below the apex is cause for rejection whether such lesion be active or inactive. But men whose qualifications make their service of especial value to the Government should not be rejected without previous report of their cases to higher authority if the lesion found is not very large and is entirely quiescent. In case of the acceptance of a man with tuberculosis a care- ful record of the case should be made for the protection of the Government. Such cases should be frequently reexamined. In ambulant afebrile subjects harshness of breath sounds and prolongation of expira- tion characterize the old and relatively dry lesion, while the more acute the process the less marked are the breath changes and the greater are the conspicuousness and significance of rales. No examination for tuberculosis is complete without auscultation following a cough. THE METHOD OF "EXPIRATION AND COUGH" It is best executed as follows: Starting from the state of rest of the lung the subject forcibly expels the air from the lungs, reserving the last portion of the expiration for a short cough, after which inspiration immediately follows, but only enough air is inhaled to return the lung to the state of rest. The idea is to diminish the size of the bronchi as much as may be by expiration, then to cough to stir up forcibly such fluid as may be present in them. The moisture is more likely to be moved by the current of air and so produce rales when the tubes are of their least caliber. This procedure should invariably be employed in exam- inations in order to determine the activity of lesions found by other signs and also to detect the existence of fresh disseminated tuberculosis. EXAMINATION OF SPUTUM The presence of tubercle bacilli in the sputum is a cause for rejection. Examiners should, however, take pains to convince themselves that the sputum examined came from the lungs of the person under examination. To this end they should insist that the sputum be coughed up in their presence or in that of the pathologist who makes the microscopical examination. TUBERCULIN It is well recognized that a positive reaction to tuberculin, especially in the young adult, is not a proof of the presence of active clinically important tuberculosis. Tuberculin only demonstrates activity of the tuberculous process in the clinical sense when it can be shown to produce a focal reaction. Such reaction is not without danger. Since, therefore, tuberculin rarely leads to a correct diagnosis and may do injury, its general use in the diag- nosis of tuberculosis in examinations for enlistment is prohibited X RAY Only well-marked pathological changes are revealed by radioscopy. For the accurate diagnosis of tuberculosis recourse should always be had to the study of the X-ray negative. It is not of course practicable to use radiography extensively for the determination of tubercu- losis during the examination of recruits. But the X ray will doubtless be often employed in doubtful or disputed cases, so that it is necessary to consider the rules which should obtain in reading the radiograph. Morbid changes in the lungs are shown by shadows due to two substances: First, blood; second, fully organized connective tissue. Blood imprints a shadow on the negative only when present in abundance. The congestion of lobar pneumonia is typical. Broncho- pneumonia of tuberculosis origin may also cast shadows, but only when the process is acute TUBERCULOSIS 177 the congestion great. Frequently the tuberculous process runs so chronic a course that the inflammatory reaction is insufficient to congest the lung enough to produce a shadow. The shadow of congestion is not sharply outlined; it melts away at its borders. Connective tissue in the parenchyma of the lung away from the hilus is not normally present in sufficient quantity to retard appreciably the passage of the X rays except as it occurs in connection with and as a part of the various tubes, bronchi, blood vessels, and lym- phatics. As a result of proliferative inflammation connective tissue develops as a fibrous thickening of these tubes, particularly the bronchi and the lymph vessels which casts a shadow deeper than normal; the older the process and the better organized the tissue, the denser the shadow and the sharper its outline. Tubercle, caseations as such, cast no shadows dis- tinguishable from the other tissues of the parenchyma. It has been found that cubes, 1 c. c. in size, of caseous tubercle when embedded in a healthy lung are indistinguishable by the X ray. But if the caseations become calcified or are even impregnated abundantly with mineral salts they become opaque to the X ray. In general, and especially if one has to do with the shadows of tubes, it may be said that fuzziness of outline means acute vascular con- gestion, an active process. On the other hand, when the shadows of the tubes are sharp we have a process which, if active at all, is at least not characterized by great acuity, is not con- gestive. There is what is called dry tuberculosis of the lung tissue, which inclines to abun- dant formation of connective tissue, to dry caseations and cicatrizations or to complete trans- formation into fibrous tissue, characterized by sharply outlined granular spots and by more or less sharply marked bands and streaks. Special attention is called to the persistence of the sharply outlined dots and lines when activity of the tuberculous process no longer exists. The sharply outlined thickenings of the bronchi and other tubes may be evidence of an old inflammation now entirely obsolete, may be simply records of the ancient history of the pul- monary tuberculosis. We do not see tubercles in the X-ray negatives. What we see is either sharply outlined calcifications and fibroses, or fuzzy congestions, or a combination of the two conditions. Cases are seen in which the X ray in general gives the same findings in both lungs while the autopsy proves one lung severely, the other slightly, diseased. Such cases illustrate well the limitations of X-ray diagnosis. What is seen in the X-ray negative is the thickened frame- work of old inflammation in the two lungs, in one accompanied by much parenchymatous disease of recent origin, in the other accompanied by little, the said parenchymatous disease being invisible to the X ray because neither sufficiently congested nor sufficiently organized to cast shadows. Extensive systems of lines, many sharply outlined spots, dense streaks do not, then, show an acute process. Persons in good health with nearly or quite arrested tuberculosis are sometimes found by the X ray to present a picture of very extensive changes of this kind. Yet the prognosis in such cases is not good if the subjects be subjected to severe strain. The radiograph is a proof that the lungs have undergone serious changes. The danger is either that hardship will lead to a reactivation of the numerous more or less quiescent tuber- culous lesions or, if the process has been largely of the nature of fibrosis, that the lungs have been so damaged thereby as to unfit the person for an active life. If then the radiograph shows extensive dappled or mossy shadows or numerous spots and streaks the recruit should be rejected however good his health may appear to be. Shadows of a homogeneous opacity result from pleurisy and are not necessarily a cause for rejection in the absence of other signs. Tuberculosis of the bronchial glands is a diagnosis often made from the radiograph on very slight foundation. The fact is that pronounced swelling of the lymph glands is charac- teristic of primary, not of advanced tuberculosis. It is rare that intrathoracic gland tuber- culosis is of any clinical importance in the adult. With few exceptions cases of bronchial gland tuberculosis which lead to true symptoms of disease are confined to the first and second years of life. Only rarely, especially in adults, is so-called hilus gland tuberculosis a purely glandular process; it is rather a more or less pronounced disease of the surrounding hilus tissue in the form of peribronchial and infiltrative processes of the neighboring pulmonary tissues. That is, the interscapular dullness relied upon for the diagnosis of enlarged glands, if caused by lung conditions, is due to tuberculous processes in the region of the hilus, partici- 56706—28----12 178 COMMUNICABLE AND OTHER DISEASES pation in which to anv important extent on the part of the glands is a matter of conjecture The presence of masses in the neighborhood of the hilus as shown by the X ray may indeed be cause for rejection, but rejection on account of relatively small opacities in that region on the ground that they indicate a bronchial gland tuberculosis of clinical importance certainly should not be permitted. RESUME OF INDICATIONS FROM X-RAY NEGATIVES The X ray shows—1. Tuberculous disease confined to region of hilus in deep lung. 2 Extension upward toward apex or downward and outward toward base, confined to deep lung 3 \ fine line or two extending to apex with or without small focus or foci there- condition not determinable by physical signs. 4. Clouding of apex without marked lines from hilus, probably largely pleuritic. 5. Well-marked lines extending to superficies of apex usuallv, but not necessarily, with foci there—lesion accessible to physical examination. 6. Lines extending toward shoulder as well as apex, (a) If confined to deep lung may mean earlv and now obsolete exacerbation, (b) If extending to superficies denote larger lesion and less immunity than 5. 7. More or less widely diffused spots, lines, and streaks through a considerable portion of lower lobe approaching periphery of lung, with few or no ausculta- tory signs—deep peribronchial tuberculosis. S. More extensive streaked opacities involving greater part of one or both lungs and extending to periphery with few or many physical signs— fibrocaseous tuberculosis, fibrosis preponderating in proportion to scantiness of more or less rounded spots or dots. Conditions as shown by 1, 2, 3, 4, and 6 (a) are not causes for rejection. Cases under 5 are to be determined by physical examination. Cases under 6 (.), 7, and 8 are to be rejected. W. C. Gorgas, Surgeon General United States Army. Approved, by order of the Secretary of War, June 16, 1917. (2621428, A. G. O.) The boards first at work were constituted by the specialists of Colorado, who had been prompt in their response, and were engaged in the examination of troops of the Regular Army at that time stationed in the Rocky Mountain region. While these examinations were proceeding in the West, in the East men at the officers' training camps were first examined. Of 53,905 examined, tuberculosis was discovered in 195, or 0.362 per cent. In the aviation service 38,835 men furnished 62 cases of pulmonary tuberculosis, or 0.159 per cent. Combining these figures we have a total of 92,740, with 257 rejections; a per- centage of 0.277.8 Both of these groups consisted, in a sense, of picked men, many of them athletes. The scanty result obtained, which scarcely justified the reexaminations, shows that a sufficiently rigid selection of promising material in itself practically excludes tuberculosis. In the Regular Army in the field 190,396 men were examined, with the rejection of 1,444 cases of tuberculosis, or 0.758 per cent. Examination of 40,396 men of the Coast Artillery Corps discovered 297 cases of tuberculosis, or 0.735 per cent.9 The National Guard was mustered in on August 5, 1917.9 Since not all of the camps, which were in preparation for them, were ready for use in Septem- ber, many of the National Guard organizations were left at home for several weeks subject to call at their armories.10 On account of the scarcity of com- missioned tuberculosis examiners, the expedient was adopted of employing temporarily, as examiners, physicians from the vicinity of the regimental head- quarters, who were given contracts to examine some of these organizations in their armories. Reports show a total of 446,517 men of the National Guard TUBERCULOSIS 179 examined, of whom 1.099 per cent were found to be tuberculous. Of these examinations, 69,273 men were examined at armories; the remainder after arrival at camp.11 In September, 1917, the entrainment of the men of the first call for the first draft was made, other calls succeeding one another rapidly through the remainder of the year. Boards of examiners could not be organized in number sufficient to effect the primary examination in the first draft, but the troops of the National Army were reexamined by special examiners, chiefly in the early part of 1918.12 The reports show that 361,314 men were reexamined, with the detection of 2,435 cases of tuberculosis, or 0.673 per cent. Discharges for pul- monary tuberculosis on certificates of disability, from the entire Army during the war, chiefly as the result of reexaminations by special boards, numbered in all, 11,362. According to the report of the Surgeon General for 1918, up to March, 1918, 1,200,990 men had been reexamined and 9,648 had been recom- mended for discharge for pulmonary tuberculosis, a percentage of 0.803.12 At the time of the second draft, orders were given by the Surgeon General that there should be but one examination of drafted men after their arrival at camp, except in doubtful or deferred cases, the necessary specialists func- tioning in the primary military examination instead of going over the command at a later time as boards of revision.13 All of the procedures necessary for the admission of an individual, comprising the physical examination, the adminis- tration of vaccines, and the entries upon the prescribed blank forms, were to be completed in a single day. This change, so far at least as the physical examination was concerned, was a long step in advance, the examiners by this time having become thoroughly familiar with their duties. A difficulty at once arose, however, from the speed required in the examinations. Circular No. 20 prescribed that each examiner should examine at least 50 men per day. This number, regarded as excessive by many at first, was frequently doubled by the more alert after they had gained experience. The usual size of the board of tuberculosis for the larger camps was 10 members. If such a board examined 1,000 men per day, that was certainly all that could be required of it. Yet in some instances the orders of the War Department or of the camp commander contemplated much greater speed. Representations were made by the Surgeon General to the effect that haste necessarily resulted in insufficient examinations and that, in view of the fact that only one examination was required, it was of the highest importance that that examination should be thorough. This resulted in some improvement in the conditions, but in general the work that was required remained excessive. In some instances the boards worked all day and far into the night, or again worked all night instead of all day in order to complete their tasks within the time prescribed.11 The number of examinations made at times seems almost incredible. Thus, 1 team of 3 examiners examined 1,763, 1,854, and 1,944 men in 3 successive days. Rapid work of this kind was made possible only by the assistance of enlisted men of the Medical Department, who instructed the recruits in advance of their appearance before the examiners how to stand, how to breathe, and how to cough. The attention of the examiners was directed solely to the auscultation of the lungs for the presence of rales after expiration and 180 COMMUNICABLE AND OTHER DISEASES cough, cases which showed moist sounds being referred for more careful exami- nation. That an objective condition was revealed with remarkable regularity by this method is shown by the fact that when the number of men examined was large the cases rejected always amounted to between 0.5 and 0.6 per cent of the men examined.11 As stated above, with the increment of the draft called on March 26, 1918, primary examinations were first undertaken by the tuberculosis examiners. The total number of men rejected for pulmonary tuberculosis on primary examination in the second draft was 12,629 out of 2,040,051 examinations, or 6,174 per million. The grand total of examinations, including both reex- aminations and primary examinations of recently recruited soldiers and of incoming drafted men, by special tuberculosis examiners was 3,288,669, the total number of men rejected by these boards being 22,596 or 6,871 per million.11 In addition, the boards discovered 1,461 cases of pulmonary tuberculosis which were held to limited or special service in this country, 108 cases of sus- pected tuberculosis, and 613 cases of tuberculosis in organs other than the lungs. The total number of cases discovered by special examiners amounts to 26,173. From November, 1918, the examining boards were chiefly engaged in examinations previous to demobilization, 2,500,662 men having been examined up to June 30, 1919, of whom 1,356 were found to be tuberculous, or 542 per million.11 This gratifyingly small ratio of tuberculosis cases undoubtedly would have been still further reduced if all of the men demobilized had been submitted to earlier thorough examination for tuberculosis. Records are available from Camp Lewis, Wash., from which it appears that 63,575 men were examined there for demobilization.14 Of these, 8,500 who had not previously been examined by any board yielded 57 cases of tuberculosis, or 0.67 per cent; i. e., 6,700 per million; while among 55,075 men who had been examined at Camp Lewis, but 9 cases of tuberculosis were discovered: A percentage of 0.016, or 163 per million. It was pointed out further that at United States General Hospital No. 21, which received the tuberculous patients from organizations belonging to the Pacific coast and the neighboring inland Northwestern States, there were 183 cases of pulmonary tuberculosis from the region referred to, of which 170 were not mustered at Camp Lewis.14 Nine came from Camp Lewis but were not examined there, since they belonged to a group of 3,626 men of the first draft who were sent away before they could be examined. Four had been examined one of whom had been recommended by the board for discharge, but not discharged, leaving but 3 out of 13 cases for which responsibility could be fairly attached to the Camp Lewis board. Cases of pulmonary tuberculosis from the above mentioned States would naturally, in great part, be sent to United States General Hospital No. 21. Such data go far to prove that, given a sufficiently thorough and efficient examination, tuberculosis could be prac- tically eliminated from an army. The cases that break down under the stress of military service are largely those entering with lesions capable of detection by experts.14 Over 600 physicians acted as tuberculosis examiners, but the number of examiners available was never sufficient for the needs of the service- so as a rule, it was necessary to confine their activities to the larger camps, with special TUBERCULOSIS 181 reference to the examination of troops who were to go abroad. Unfortunately, the work of reexamination could not be organized in time to examine many of the troops who were sent overseas early. More than 40,000 soldiers were sent abroad, therefore, in the early months of the war of whom few could have been reexamined for tuberculosis.11 Some organizations likewise were embarked for Europe at a later time which escaped reexamination, as, for example, many of the hastily assembled stevedore regiments, the difficulty being partly due to the failure to learn in time of the existence or of the contemplated departure of the organizations, military operations and especially embarkations being shrouded in the utmost secrecy, and partly to the scarcity of examiners.11 How necessary reexamination of the colored enlisted men composing the stevedore regiments was, is shown by the fact that a special board at Newport News, Va., examined 8,734 men of colored stevedore regiments and reported 68 cases of tuberculosis, or 0.812 per cent.11 In addition to the work of examination of organizations, tuberculosis experts were detailed as specialists of divisions and of base and general hospitals, as officers of tuberculosis hospitals, and as instructors. When the need of examiners was greatest, physicians were employed temporarily as contract surgeons in order to assist in the examinations. As the qualifications of these contract surgeons were not always known, it was soon found advisable to give them a course in physical diagnosis of the chest, the primary object being to observe their work and to classify them according to their proficiency. This course, however, met with unexpected success and be- came popular among the medical officers. Its benefits were so manifest that from the original school, at the Army Medical School, Washington, instructors were sent out who established like courses of instruction at the medical officers training camps at Fort Oglethorpe, Ga.; Fort Riley, Kans.; and Fort Benjamin Harrison, Ind.15 A school was instituted at a later time at General Hospital No. 16, New Haven, Conn., in which, in addition to courses in physical diagnosis, instruction was imparted in the treatment of tuberculosis and in hospital administration, with a view of training medical officers for service at tuberculosis hospitals. Courses in physical diagnosis also were given to the medical officers of various camps and hospitals by travelling instructors.16 Especial attention was paid in this course to the physical signs of the normal chest. At the beginning of their work the chief function of the special examiners was necessarily eliminative; they were to rid the Army of the tuberculous. But they also appreciated the fact that quite as important a duty was conservation. Of their own initiative many of the boards stamped the records of the soldier "Examined and passed by the tuberculosis board," with a view of preventing the later discharge of individuals presenting signs which the inexperienced might misinterpret. The inexperienced diagnostician finding signs which may be those of tuber- culous disease usually recommends discharge, giving himself the benefit of the doubt, in the fear that he will be thought to have overlooked what should have been found if at a later time the bearer of the signs in question should be diagnosticated as tuberculous. The specialist should strive to retain in the service men in whom he thinks tuberculosis is not active notwithstanding the 182 COMMUNICABLE AND OTHER DISEASES presence of signs or symptoms which some might misinterpret. The conser- vation to the service of men with blemishes which do not disqualify is one of the most important of his functions. His duty is not only to secure the rights of the individual; it is fully as much his duty to protect the Government, which should not unnecessarily be deprived of soldiers when every man is needed. He who in time of war excuses men for trifling or doubtful deviation from the normal does not properly conceive his duty toward his country. There is no reason why the possibly tuberculous alone should be excluded from risks. This view was emphasized in Circular No. 20 and was enforced as far as practicable. But it remained one of the chief difficulties that medical officers were reluctant to take a definite stand with regard to many cases, that in some camps, wards were filled with apparently healthy men kept under observation whose supposed deviations from the normal had been discovered only in routine examinations, as if the desideratum was to make a positive diagnosis of tuber- culosis at all costs. The chief reason for this course was the fact that some one had diagnosticated active tuberculosis in these cases. It was undoubtedly of great benefit that a standard had been provided in Circular No. 20, upon which the examiner could rely and which relieved him of some of the burden of his responsibilities in the diagnosis of disputed cases. A standard, though imperfect, is believed to be an indispensable adjunct in Army tuberculosis work not only to support the examiner but also to secure the necessary uniformity of practice in the matter of discharge for tuberculosis. OCCURRENCE IN CAMPS IN THE UNITED STATES When considered by camps of occurrence, during the World War, two camps only are found to be outstanding in this respect, namely, Camps Kearny, and MacArthur. Camp Kearny (situated near San Diego, Calif.) had the worst record for tuberculosis of all the large Army camps.17 In the reexamination of 19,827 men at this camp, 853 cases of tuberculosis were discovered, or 4.83 per cent. The admissions for tuberculosis at Camp Kearny in September, October, November, and December, 1917, were at the rate of 157.53 per 1,000 of strength, Camp MacArthur, Tex., the second worst camp in this respect, having the com- paratively small ratio of 25.45. Camp Kearny was primarily a National Guard camp. It received 6,944 men of the National Guard from Arizona, New Mexico, Colorado, Utah, and California in September and October, 1917, and 13,680 men from other camps in November, largely drafted men. During 1918, also, additions were received largely from other camps.18 Matson's remark with reference to Camp Lewis 14 that the material was largely from the Southwest and contained enormous numbers of health seekers whom the boards of the first draft sent, thinking that change of climate might benefit the manifestly tuberculous, undoubtedly applies with even greater force to the command at Camp Kearny. The operation of this tendency above referred to is still more clearly exem- plified at Fort MacArthur, Calif. Here in 501 men examined for tuberculosis, 103 cases were found, a rate of 20.55 per cent.11 On investigation it was found that the large majority of these men were drafted from Texas, 53 towns in that TUBERCULOSIS TUBERCULOSIS. BY CAMPS ADMISSIONS, WHITE ENLISTED MEN, U. S. APRIL. 1917-DEC. 1918 RATIOS PER 1000 10 1? 14 16 18 20 22 24 28 28 30 32 34 36 38 Chart XXV 1S4 COMMUNICABLE AND OTHER DISEASES State having contributed 92 of the tuberculous cases. In any case, of course, it by no means fairly represented the drafted men of the State. Indeed, there was collected in the five howitzer companies at Fort MacArthur what in all probability constituted the majority of the tuberculous cases of the part of Texas from which the men originally came. There could hardly be more startling proof of the inefficacy of the usual routine examinations and the need of revision. The evils of the absence of an efficient medical examination pre- vious to the transfer over long distances of large bodies of troops is also apparent enough. New Mexico had the undesirable preeminence of furnishing the greatest number of tuberculous men per 1,000 of native population of any of the States of the Union.18 Yet there are regions in New Mexico where the climate is prob- ably best adapted of any in the United States for the treatment of pulmonary tuberculosis, its reputation for the climatic treatment of the disease being shown by the fact that the only sanatoria which were operated by the Army and by the United States Public Health Service before the war for the treatment of the tuberculous were located with in its borders. Like the other border States of the Southwest, New Mexico is overrun by consumptives from other States, many of whom were imported originally as patients in the Army and Public Health Service sanatoria, though many others came in as civilians. This latter class contains, as a rule, cases of pulmonary tuberculosis of more than average severity, many patients who fail to improve in the North being sent to the Southwest as a place of last resort. Moreover the popularity of the South- west as a resort for the treatment of consumption is of comparatively recent origin. Consumptives have visited the region from the first days of its occupa- tion by the whites, but not in considerable numbers until within recent years. It is improbable, therefore, that a sufficient number of sons of military age have been born to the immigrating consumptives to affect materially the ratios of tuberculous cases to native population. But the numerous patients discharged from the Government sanatoria would naturally more readily find openings in civil life in a part of the country with which they have become familiar, and the climatic advantages of New Mexico would be expected to induce tuberculous civilians in general to make it their home in a larger percentage than would be the case in the hotter climate of Arizona and Texas. Such men, many of them familiar with Army life and fond of adventure, many of them, too, perhaps alive to the prospects of future benevolence of the Government to tuberculous soldiers, would naturally seek enlistment in the Army and would conceal as far as pos- sible the suspicious fact that they were originally from other States. Another factor which should be considered is the Mexican element of the native population of the State, which composed 15 per cent of the population of the southern tier of counties in the census of 1910, since which time many- thousands of Mexicans, fleeing the civil war in Mexico, have immigrated to New Mexico and to the adjacent portions of Texas and Arizona. Physicians connected with the Atchison, Topeka & Santa Fe Railway medical service have noted that when Mexicans from remote districts are employed as laborers along the railroad a certain proportion of them suffer from acute forms of tuberculosis.19 Here, according to well-known epidemiological TUBERCULOSIS 185 laws, we have an illustration of what befalls individuals not all of whom have received the more efficient immunization against tuberculosis afforded by life in a civilized community; the men fall sick from tuberculosis not because the environment from which they come has too much but because it has in a sense too little tuberculous infection! In other words, the tuberculosis is acute be- cause it attacks the nonimmunized or imperfectly immunized individual. About one-third of the population of the northwestern quarter of New Mexico is stated to be composed of Indians, and there are large reservations elsewhere in the State. The various tribes differ widely as to the prevalence of tuberculosis. No recent statistics of value are available, but it was reported some years ago with regard to the Zuni Indians that tuberculosis was rare among them, but that the mortality of the disease was 100 per cent.20 Such a group would figure more largely in the statistics of mortality from tuberculosis than in the percentages of rejection upon admission to the military service; but the Indian as well as the Mexican element of the population is in general likely to become suspicious in the statistics which relate to tuberculosis. Unfortunately, the statistics as collected by the Provost Marshal General do not permit the determination of the race of the soldier. We are left to conjecture, therefore, as to the relative importance of the Indian and the Mexican in causing the high percentage of incidence of tuberculosis in New Mexico. The problem is highly complex, and it would be manifestly misleading to institute comparisons between a population like that of New Mexico, with its large percentage of health seekers and its admixtures of semicivilized races, and the more or less homogeneous American population of other portions of the United States. IN THE AMERICAN EXPEDITIONARY FORCES The care exercised in the United States in the elimination of tuberculosis from our Army was abundantly rewarded by the absence of any extensive prevalence of the disease among the troops in France. Cabot reported from Base Hospital No. 6 at Bordeaux that of 21,738 patients received at that hos- pital between September, 1917, and November 22, 1918, there were 63 positive cases of tuberculosis, pulmonary and extra-pulmonary—a percentage of 0.289.21 Of these, 51 were recognized by the presence of tubercle bacilli in the sputum and 12 were found post mortem. One hundred other cases were diagnosed as probably or possibly pulmonary tuberculosis, no other diagnosis seeming more likely, though bacilli were not found in the sputum. None of the 163 were apparently incipient cases. The incidence of tuberculosis was greatest in the early months, he says, when presumably the "combing out" of tuberculous cases by special examinations in the training camps of the United States had not begun, or was not extended to all units. Stevedores, labor companies, and engineers were especially affected. In the first 7,000 cases treated at Base Hospital No. 6 there were found 35 out of the 51 positive tuberculous cases, while in the last 6,000 cases received only 1 case was proven tuberculous. Cabot's conclusions are:21 (1) Pulmonary tuberculosis was of rare occurrence among the sick treated at Base Hos- pital No. 6. (2) It occurred chiefly among soldiers who had not been specially examined in the training camps of the United States with reference to its presence. (3) An even three- 186 COMMUNICABLE AND OTHER DISEASES fifths of the 51 cases with tubercle bacilli in the sputa occurred in the cases between No. 1 and No. 7,000 of our series, while in the last 6,000 cases received only 1 case was proven tuberculous. (4) Few, if any, cases could have been considered as originating in line of duty. No incipient cases were recognized. These observations by an experienced diagnostician located at a hospital at a port of embarkation through which many patients were evacuated to the United States and where, consequently, tuberculous cases must have abounded if the disease had been of frequent occurrence, are the more valuable because tuberculosis, not being a problem of magnitude in the American Army abroad, officers of hospitals, overwhelmed as they were at times by patients with wounds or acute infectious diseases, have remarked but rarely as to its prevalence. After tuberculous patients began to return to this country it was soon reported that a considerable percentage (sometimes as high as 50 per cent) had no clini- cally recognizable tuberculosis. It being important from a military stand- point that the Army abroad should not be drained of its men unnecessarily, a tuberculosis expert was sent to France with a view of securing a better diagno- sis of tuberculous conditions. This visit culminated in an order being issued in the American Expeditionary Forces to the effect that only cases with tuber- cle bacilli in the sputum should receive the diagnosis "pulmonary tuberculosis," all other suspected cases to be classified as "tuberculosis observation." 22 Three centers (Base Hospitals Nos. 20, 3, and 8) were designated to which cases under observation should be sent.22 No men were to be sent home as tuberculous unless their sputa contained tubercle bacilli or they had been passed as tuberculous at one of these centers. These measures rapidly reduced almost to zero the percentage of returning patients who were found to be negative for clinical pulmonary tuberculosis after observation in this country. But after the signing of the armistice, when retention of every possible man was no longer necessary, the above mentioned precautions were discontinued and large numbers of men who were simply suspected of having tuberculosis returned with a positive diagnosis of that disease. In all, 8,717 cases of pul- monary tuberculosis were received from Europe at the tuberculosis hospitals of the United States up to December 3, 1919.23 In a total number of admissions to these hospitals amounting to 18,713 the diagnosis of pulmonary tubercu- losis was not confirmed in 4,305.23 What proportion of these negative cases came from Europe is not known. EPIDEMIOLOGY In the enrollment of millions of men in the United States and in the mobili- zation of the large European armies we have experiments on a grand scale in the epidemiology of tuberculosis which can not be too carefully studied. In our Army in France certain observations were made which led to the belief that our soldiers were in danger of primary infection with tuberculosis.24 Glom- sett remarked at the Red Cross Conference on Tuberculosis held in November, 1918, at Paris25 that it was a pleasant surprise to learn that tuberculosis had played such an insignificant role, only 2.5 per cent of deaths having been due to this cause. Tuberculous lesions were found by him in 16.6 per cent of bodies of soldiers examined. He found "primary foci" in 50 per cent of his autopsies and stated that such foci were more common in the bodies of those TUBERCULOSIS 187 who had died from other causes than in those who had died of tuberculosis, persumably meaning old foci. He found no evidence of tuberculosis in fully two-thirds of fibrous pleurisies. He had six autopsies of soldiers who had died of tuberculosis, four of which showed miliary tuberculosis. At the same conference Robertson 25 reported that he had worked during the first year of the war in Freiberg, where of 100 autopsies of German soldiers 70 per cent showed tuberculous deposits in lungs or tracheobronchial glands, while in autopsies on our soldiers he was able to detect tuberculosis in less than 25 per cent. Each pathologist, it appears, had his own standard, and the results of autopsy findings differed as widely as did the standards. The number of autopsies considered, moreover, is much too small to indicate the true status of soldiers as to tuberculosis. Caseation of lymph glands was referred to by some of the observers in support of their position without, however, giving a description of the exact condition of the glands. The behavior of the lymph glands in a given case is fundamental for the decision as to the nature of the tuberculosis that is present. It may be remarked here that the pathology of lymphadenoma is admittedly dubious as to etiology and especially as relates to the role of the tubercle bacillus in the production of suppurative processes. The presence of local lesions in the vicinity of the glands, carious teeth, and the like is very significant. It would seem that a mixed infection, one infective agent which is active in the production of an unusual type of lymphadenitis being unidentified, would best explain the facts. Why should tuberculosis, if uncomplicated, pursue so unusual a course? At all events there seems to be no good reason why it should be necessary to assume continued new infections from without, and much that speaks against that hypothesis. The fact that notwithstanding the supposedly frequent reinfections the disease remained localized and the patient was in good health is the best evidence of the persistence of an immunization. A primary infection or an infection which sprang from a serious diminution, if not an entire loss, of a former immunization would tend to become generalized and fatal. This is well illustrated by the course of tuberculosis among the colonial troops of the French Army, as reported by Borrel.26 This command, the average strength of which was 50,000 men in 1917-18, was composed of negroes from Madagascar and Senegal, of Annamites, and of Kanakas. The Malgaches or Madagascans had tuberculosis of a chronic type—tuberculosis is not a rare disease in Madagascar. The Annamites, among whom the disease has long prevailed, had but a small percentage of tuberculous cases. Tuberculosis was found in about 10 per cent of the Kanakas; the disease had a duration of months and often of years. Enlargement of the cervical glands of a scrofulous type and of a chronic course, which was apparently often not incompatible with good health, was common among them. But the Senegalese were the most severely affected with tuberculosis. This is a rare disease in Senegal outside of the towns where there is contact with Europeans. Borrel found only 4 to 5 per cent of positive reactions to the skin test among newly arrived recruits, but unfortunately used tuberculin diluted to one-tenth strength. Apical tuberculosis was found in not more than 5 per cent of the 188 COMMUNICABLE AND OTHER DISEASES Senegalese. Those who had the chronic type of tuberculosis came from the towns. They spoke French. While in the command considered as a whole 50 per cent of the cases of tuberculosis were of the chronic European type, among the Senegalese who came from country districts the type of tuberculosis was that of the European infant; that is, it was primary tuberculosis. In these patients there was generally a chain of enlarged lymph glands extending from the supraclavicular or the superior cervical glands to the hilus, the largest ones of about the size of a hen's egg, having a location corresponding to that of the primary lesion—which might be situated upon the tonsil, in the posterior pharynx, the larynx, or at the level of the main bronchi; but in 80 per cent of the autopsies the disease began in the tracheobronchial glands. More than 70 per cent of the deaths from tuberculosis among them were due to miliary tuber- culosis in which the lungs were not more involved than the other organs. There was sometimes a massive caseous pneumonia from direct rupture of an enlarged gland into bronchi and alveoli, the gland then often becoming the center of a great caseous mass. Or there might be primary pleurisies without caseous foci in the lungs, or more than one serous membrane might be involved simultane- ously, the peritoneum as well as the pleura. Clinically after what Borrel calls the initial glandular period, lasting one to three months, in which there is no fever, the period of generalization comes on with high and irregular fever and death in from 15 days to 1 month; rarely 2 months. Roubier's account of this disease confirms that of Borrel. He called atten- tion to the constant presence in miliary tuberculosis of caseous mediastinal glands, sometimes so voluminous as to give rise to symptoms of compression.27 The important contribution of Borrel gives in epitome the entire pathology of tuberculosis. We see chronic localized pulmonary tuberculosis in soldiers who had been long exposed to infection, the scrofulous type, still chronic, with chronically caseated lymph glands in the imperfectly immunized Kanaka, but in the virgin soil of the Senegalese acute and enormous enlargement of glands, rapid generalization of tuberculosis, and death. It has been known from animal experiment that if the infected animal survives the primary inocula- tion with tuberculosis the glands acquire a certain immunization, such that they do not swell mateiially or at least long remain swollen in subsequent inocula- tions, irrespective of the fact that the animal may in reality be slowly dying as the result of the fiist inoculation. The same is true of man except so far as the picture is confused by the chronic caseations and suppurations of the scrofulous type. If, then, there be not found a primary lesion with enlargement of the corresponding gland, as Borrel described it, the case is not one of primary tuber- culosis. Immunity is generally completely lost in the last stage of fatal human tuberculosis; miliary disseminations of tubercle shortly before death, through- out the internal organs, whether macroscopic in size or only to be determined by the microscope, are well-nigh the rule in uncomplicated cases. The glands do not swell in this secondary miliary tuberculosis, but they may be found, of course, chronically enlarged and caseated in the scrofulous type. Evidence of chronic tuberculous changes is found in some cases of pul- monary tuberculosis with acutely fatal termination. That they are not found in all such cases which occur in civilized man is largely accounted for by the TUBERCULOSIS 189 difficulties of the search. Even Nageli in his classical investigations which finally resulted in finding tuberculous changes present in 97 to 98 per cent of autopsies, at the beginning found only 40 per cent.28 Opie 29 showed the sur- prisingly large number of calcifications to be detected in the lungs by his method of radiography, most of which would have escaped detection by the ordinary methods of search. Since civilized adults are shown by tuberculin tests to be infected with tuberculosis in almost 100 per cent, it is more logical to assume that the few whose evidence of past infection is not discovered have really been infected than that they should have escaped entirely the ubiquitous tubercle bacillus. Acuity of course and of termination of tuberculous disease is encountered in many cases in which earlier infection with tuberculosis is demonstrable. They should not, therefore, be considered to indicate a primary infection though earlier tuberculous changes may not be detected, certainly not unless the case presents the characteristics of truly primary tuberculosis. The experience of the British Army in France with Africans was some- what similar. Thus Cummins 30 stated that there were 165 deaths among British troops in 2,881 cases, which gives a case mortality of 5.7 per cent, while in the South African labor corps units consisting of "Cape boys" and Kaffirs there were 183 deaths in 372 cases of tuberculosis, a case mortality of 56 per cent. According to the same writer, the Indian divisions in France in 1916 had a tuberculosis incidence of 27.4 per 1,000, that of the British troops being 1.1 per 1,000. In comparing the mortality rates from tuberculosis, allowance must be made for the probability that in the British Army all but the most acute cases would be repatriated and that deaths which occurred after dis- charge, and perhaps after the individual had been returned to Great Britain though still in the service, would not appear in the mortality statistics in France, while the tuberculous negro would probably not be sent to his home. The relatively high death rate of the Africans, however, shows clearly enough that the negroes of South Africa are but imperfectly immunized against tuberculosis. The result of such imperfect tuberculization in these troops, including the Indian contingent, was a higher relative mortality from tuberculosis, though they had the same food, clothing and shelter as the white troops. If the Amer- ican troops had been imperfectly tuberculized, instead of a surprisingly low death rate from tuberculosis, the mortality would have been high. The acute forms of fatal tuberculosis among our soldiers were, then, really quite excep- tional. To account for such exceptions on the hypothesis of entire absence of previous opportunity is much more difficult in the case of men who do not appear to have been a peculiar class as respects their origin, mode of life, etc., than by the more natural supposition that they differed from other tuberculosis cases only in the fact that the course of their disease was more rapid; perhaps, as some German writers suggest, the fatigues and hardships of war had some- thing to do with this outcome. From the epidemiological standpoint the cutaneous tuberculin test is a valuable and harmless method of obtaining an approximate notion as to the degree of tuberculization of a group of individuals. It was employed for this purpose in our Army in two instances. At Coblenz 159 American soldiers between the ages of 18 and 30 years, with no family history of tuberculosis and 190 COMMUNICABLE AND OTHER DISEASES for the most part men of athletic build, were tested with undiluted "old" tuber- culin.31 Of these, 122 (76.7 per cent) reacted postively to the first inoculation, 26 to the second (giving a percentage of 93 positive in either the first or second test), and 3 to a third inoculation; which results in a total positive percentage of 94.9, 8 of the soldiers remaining negative. The distinction was made in this group between country dwellers, city dwellers, and (small) towm dwellers, but such slight difference as existed between these subgroups showed that the men from the country were infected with tuberculosis in a very slightly larger percentage than the men who came from towns and cities, the positive per- centage in the first, second and third tests combined being 96.9, 90, and 96.2, respectively, for the subgroups in the order given above. Unfortunately, the regiment to which these men belonged, being on the eve of return to this coun- try, it was impracticable to test further those who had failed to react.31 A similar test was made at General Hospital No. 21, Denver, Colo.32 One hun- dred soldiers between 21 and 30 years of age belonging to the Medical Depart- ment detachment of the hospital, but employed in outdoor occupations which did not bring them into contact with the patients (this institution being a hos- pital for the treatment of tuberculosis), were tested in the same way as in the preceding experiment. In the first cutaneous test 71 were positive, 29 negative. The negative cases received a second inoculation after five days, 24 becoming positive and 5 remaining negative. This gives a positive percentage of 95 for the two inoculations. One of the 5 negative cases was discharged at this time; the remaining 4 were further tested by subcutaneous injections of old tuber- culin. All were negative to 1 mg. and likewise failed to react to 5 mg. To the injection of 10 mg. 3 reacted positively. A fourth injection of 20 mg. was given to the man who remained negative. Though there was no rise of tem- perature after the injection, it was considered to have resulted positively on account of the "depot" reaction. Thus by following up the cases negative to the skin test with the subcutaneous injection, 100 per cent of positive reactions to tuberculin was obtained in 99 men.32 The above observations correspond closely with the results obtained by Freund,33 95.1 per cent of Austrian soldiers positive for the cutaneous test, and to those reported by Hamburger, 98 per cent of Austrian soldiers positive to the "stitch" reaction.34 The importance of recording such tests as those described lies in the light which they throw upon the claim that our soldiers are to a considerable extent unprotected by a precedent tuberculization against primary infection with acute and fatal forms of tuberculosis.32 DIAGNOSIS In the view of many who belong to what we will call the school of ultra- refined diagnosis, pulmonary tuberculosis begins in the apex of the adult lung, as a rule. Incipient tuberculosis of the apex can be recognized at a very early stage, before the occurrence of rales, by slight changes in breath sounds and percussion note, even by certain symptoms before physical signs are present. Others hold that tuberculosis of the lungs begins at the hilus, usually in childhood, and in favorable cases advances at first as a tuberculous lymphangitis along the blood vessels and bronchi. Tuberculosis of the apex is not incipient but advanced tuberculosis. The signs relied upon for the diagnosis of incipient TUBERCULOSIS 191 tuberculosis are not evidences of a new infection, but, so far as they are not normal for the part, are signs of old, perhaps obsolete, affections of the apex which are exceedingly common, and, unless they extend widely beyond the apex or have resulted in cavity, do not necessarily demand the exclusion of the individual from the military service. The only signs of true activity of the tuberculous process are moist rales. It should be possible to ascertain within a few years what has happened to the men who have been discharged for supposed incipient tuberculosis. If that diagnosis was correct the incipient cases should in part at least have gone on to develop manifest tuberculosis of the lungs. If such men are not discharged on account of their incipient tuberculosis and if tuberculosis is readily trans- missible from one adult to another, each one who remains in service would form a center of infection for his healthy comrades, who, moreover, are likewise endangered through contact with the seriously infected civil population in billets and the like. Hence pulmonary tuberculosis is likely to grow worse in the Army the longer active service continues. If the opposing view is correct, however, the elimination of the tuber- culous individual from the Army would result in freeing the Army from tuber- culosis in direct proportion to the perfection of such elimination. Such cases of active tuberculosis among soldiers as have escaped notice will break down under the conditions of military service if the disease is extensive and be suc- cessively eliminated so that active chronic pulmonary tuberculosis will become more and more rare. The evil of the ultrarefined diagnosis of pulmonary tuberculosis is most conspicuously exhibited in the now celebrated 86,000 soldiers of Landouzy,2 who, it was generally believed, had become infected with tuberculosis in the military service, a fact that not unnaturally excited considerable apprehension in the United States lest a similar evil befall American forces. But, according to Lereboullet,35 M. Godert reported to the Senate from the War Office that from August 2, 1914, to October 31, 1917, 80,551 men were discharged for disability from tuberculosis not incident to the military service (reformes No. 2) and 8,879 men for disability in line of duty (reformes No. 1) from the same cause. The evil is infinitely less severe, M. Godert remarked, than the figures seem to show without explanation, for 65,000 were determined to be tuberculous in the first year of the war and were eliminated without having been incorporated into, and therefore without having contracted their disease in, the army. From January to October, 1917, 4,839 men were discharged from the army for tuberculosis without pension and 6,863 were pensioned. This relieved the French Army of much of its bad reputation as creator of tuber- culous infection, but it remained to consider the diagnosis in this large group of over 80,000 men. Late in 1917 a cablegram was received in Washington from the French War Office which stated that at that time it was believed that less than 50 per cent of this group were really tuberculous. These figures, however, are most conservative, for Rist,2 an undoubted authority, states that when clearing stations were established for the purpose of securing a better diagnosis of tuberculosis, of the first 1,000 cases examined at one of them only 193 men were found to have active tuberculosis. He thinks that we are justified 192 COMMUNICABLE AND OTHER DISEASES in believing that out of the 86,000 soldiers discharged from the French Army during the first year of the war less than 20 per cent were really tuberculous, and adds "my personal impression is, much less than 20 per cent." Many of these men no doubt had other diseases, but in all probability it would not be an exaggeration to say that several divisions of soldiers (assuming 10,000 men for a division) might have been added to the French Army by a more correct diagnosis of tuberculous conditions at a time when France was most sorely beset. Between August, 1914, and December, 1918, 111,038 French soldiers were dis- charged for tuberculosis, of whom 25,000 were pensioned and S5,438 were granted no pension. There were 12,220 deaths from this disease in the French Army. France mobilized 8,410,000 men during the war.36 Conditions were nearly as bad in Germany. Fraenkel,37 one of the most distinguished of German internists, writing in 1916, said that in the endeavor to recognize tuberculosis as early as possible we have arrived at an overesti- mation of various relatively insignificant phenomena. Of those diagnosticated as tuberculous, only 40 per cent were really so; 40 per cent had other diseases; 20 per cent had no disease at all. Bliimel reports that of officers and men who had been declared temporarily or permanently incapacitated for military service on account of pulmonary tuberculosis, about 80 per cent of those whom he examined proved not to be tuberculous.38 Nevertheless the tuberculosis situation in the Army of Germany seems to have become highly satisfactory, for the errors of diagnosis complained of consisted in diagnosticating tuber- culosis too readily rather than in failure to find the disease when it was present in a manifest form. Goldscheider 39 stated expressly that the overlooking of slight manifest conditions seemed to have rarely occurred. Experience in our Army has long shown that pulmonary tuberculosis is discovered in the majority of cases in the early months of military service. But men with small and chronic tuberculous lesions (and occasionally with surprisingly large lesions) are often unconscious of their disease. In connection with diagnosis, and particularly as regards tuberculosis as a cause of rejection for military service, Circular No. 20, quoted above, was written from the standpoint of what may be called the regular school. Since it was designed especially for use in connection with the examinations for entrance into the Army, it does not take up the more acute forms of tubercu- losis, but notwithstanding this omission it was used in the instruction of medical officers. No change of importance was made in its test, and the chief point upon which experience showed that more light was needed was the size of the obsolete lesion which would justify rejection. The efforts of medical officers to commit the Surgeon General's Office to the definition of such a lesion by extent as measured by inches or by ribs and vertebra were resisted for the reason that not only the extension of a lesion but also the severity of the tuber- culous process which gave rise to it (determined by the density of fibrous tissue, existence of cavity, and the like) was of importance. The most radical posi- tion taken was the insistence upon moist rales as the only physical sign which justifies the diagnosis of activity. There the writer was supported not only by his own clinical experience but also by the opinions of Piery 40 of France, Goldscheider 41 of Germany, and many others. TUBERCULOSIS 193 The diagnosis of tuberculosis became more than ordinarily difficult during the war on account, first, of the prevalence of bronchopneumonia due to strep- tococcus infection which, with the exception of a sputum positive for the tubercle bacillus, sometimes gave all the classical signs of pulmonary tuber- culosis, including hemoptysis. At a later period many unresolved pneumonias following influenza still further complicated a difficult situation. At some camps so many men were discharged without warrant for tuberculosis during these epidemics that it became necessary to issue the order that no one should be discharged with that diagnosis unless the sputum was found to contain tuber- cle bacilli.42 This course met with many remonstrances at first but was finally approved by all as the only possible means of averting what promised to become a great evil. And, it may be pointed out, the requirement of a positive sputum was the more warranted because the tuberculosis imitated by other diseases was not the obscure and doubtful forms of the disease, but a frank and extensive tuberculosis which would almost without doubt be attended by sputum containing many tubercle bacilli. At a later time, in order to provide for cases still occasionally encountered, the order was modified to permit the report of old and extensive cases of fibrosis, though the sputum be negative, with a view to their discharge, the decision as to each case remaining, however, in the hands of the Surgeon General.43 Such a limitation was proved to be necessary in practice because some medical officers (not specialists) appeared to be of the opinion that the denomination of cases as those of fibrosis was simply a device to get rid of any and all cases of supposed tuberculosis irre- spective of the absence of any evidence of the existence of a large and old lesion. Considerable pressure was exercised during the first months after the United States entered the war by a number of prominent physicians and radiologists to induce the Surgeon General to make the radiograph the decisive factor in the diagnosis of pulmonary tuberculosis. The claim was that the work could be done with great rapidity and accuracy, that the negatives were easily stored in a comparatively small space and would form a permanent and more or less infallible record which would not only be of great scientific value but would also decide better than the results of physical examination as to the necessity of rejection, 90 per cent approximately of the men being accepted on their radiographs without further examination of the lungs, leaving the remaining 10 per cent for further study. Even granting that all of the above claims were well founded, it was evident that the practical difficulties in the way of the adoption of this plan were insuperable. Not to mention the enor- mous cost of photographing the entire new Army and the impossibility of obtaining a sufficient number of plates within a reasonable time, the lack of trained radiologists had to be considered. How serious this objection was is shown by the fact that several X-ray schools were kept in operation for many months in order to train technicians who after the brief course of training could still hardly be regarded as experts in the determination of tuberculous lesions from the radiograph. A technical service of the magnitude required could evidently not be made ready to function efficiently until long after the time when the decisions of which it was claimed to be the most trustworthy 56706—28----13 194 COMMUNICABLE AND OTHER DISEASES arbiter had perforce been made and the subjects for the most part dispatched overseas. A subcommittee of the general medical board of the Council of National Defense undertook a test to determine practically the merits of the proposed scheme. All of the members of certain companies of the 69th New York Regiment, National Guard (later renumbered the 165 Regiment of United States Infantry), were photographed by the X ray. Certain men diagnosed as tuberculous by this means were examined subsequently by an examining board composed of experts in physical diagnosis from New l ork City. For various reasons the total number of those who could be obtained for reexamination was only 25. Of these, 21 were found to have no abnormal physical signs, 1 had distinct signs of apical involvement with rales in both apices but no symptoms, and 3 had only slight or equivocal signs, of whom but 1 gave pulmonary symptoms. The last 4 men were rejected, 1 of them, however, not on account of physical findings, but because of suspicious history and radiograph. The board was disposed, as will be noted, to be most liberal in its concessions, but its findings can hardly be said to make out a good case for the method which in this instance was put into effect by skilled radiologists How the method would have worked out at Army camps on a large scale is best shown by the experience at Camp Lewis, Wash.—a camp the medical records of which are more than usually accurate and detailed—with men of the second draft; that is, at a time when the X-ray services had become well organized:" Of 570 men rejected for clinically evident tuberculosis, the Roentgenologists recognized 54 per cent as tuberculous. In another group of 343 men, who, the Roentgenologists stated, were unqualifiedly tuberculous and should be rejected on X-ray findings alone, irrespective of physical findings, only 315 were rejected after physical examination. The remaining 28 were considered either to be nontuberculous or to have obsolete lesions and were accepted for service. We have been able to follow these men through their military career and none has developed tuberculosis. Among another group of 1,500 men whom the Roentgenologists diagnosed as very suspicious of tuberculosis, physical examination revealed only 128 cases of tuberculosis which were rejected. No cases of tuberculosis developed among the remaining 1,372 accepted for service. The position taken in the Surgeon General's Office with regard to the X ray in the diagnosis of pulmonary tuberculosis was that while the radiograph is a very valuable, indeed, indispensable adjunct in the diagnosis, it can not be relied upon exclusively for that purpose because it not only fails sometimes to reveal early tuberculous changes but it also does not always indicate whether the lesions shown are active or obsolete. Circular No. 20 forbids the general use of tuberculin for purposes of diag- nosis in the individual case in Army examinations, the reasons for which hardly need to be set forth here. It may be remarked, however, that in giving the indications for the use of tuberculin in general an absolutely exact diagnosis of the condition of the lungs is always tacitly assumed as a preliminary to its administration. This assumption, however, can not be safely made with reference to the average medical officer any more than to the average practi- tioner in civil life. Tuberculin given blindly or with an incorrect appreciation of the degree of activity of the tuberculous process which may be present in the given case is a dangerous substance. TUBERCULOSIS 195 MANAGEMENT AND TREATMENT The treatment of tuberculosis as a disease does not differ, of course, in military practice from the well-recognized rules that govern in civil life. Certain difficulties, however, are met in Army hospital management to which it may be well to refer briefly. Tuberculosis being the "social disease," every layman feels competent to hold opinions on the subject of its treatment, especially its climatic treatment, and the population readily divides itself into groups which hold differing views with regard to two questions. First, shall or shall not the tuberculous patient be discharged promptly; second, shall he be treated near his home or shall he be sent far away to climates reputed to be most curative for his disease? The officers of charitable institutions and associations hold strongly to the view that the tuberculous individual shall be retained indefinitely in the Army. To many others it seems almost self-evident that he should be discharged as soon as the diagnosis is established. The anxious mothers, especially, who, in view of much unopposed criticism of the Army and of Army methods, not unnaturally are disposed to believe anything that is bad and are quite unprepared to believe anything good of Army hospitals, generally insist that their boys shall come home at once or at least be cared for in institutions near at hand. The treat- ment of the tuberculous near their homes has had many advocates, while, on the other hand, there are those who demand that they shall be given the advan- tages of the best possible climate. With such difference of views the demands of the opposing parties to a certain extent neutralize one another. It adds greatly, however, to the labor of administration that so many feel justified in seeking to impose their views as to the proper procedure in a given case upon the Army authorities. The desire of the Surgeon General was to retain the tuberculous in the Army for a considerable period, long enough for them to attain the maximum degree of improvement of which they were capable.45 In a certain class of patients, those possessed of considerable wealth, the objection was raised that they were able to procure for themselves the best of sanatorium care and of medical treatment. With this class in view, an order was issued that patients might be discharged if they satisfied their commanding officers that they were able to provide and would provide for themselves care and treatment as good as that which they sought to relinquish. This provision was inevitably supposed to be a mere device for circumventing the regulations of the Army, and many illiterate affidavits from presumably poor persons as to plans for care and treatment were submitted in support of requests for discharge. These difficulties were largely met by a campaign of education. In case of persistent application for the discharge of soldiers the aid of the nearest American Red Cross organization or tuberculosis association was solicited, which sent their workers to instruct the family as to the nature of the tuber- culosis hospitals, the excellence of their medical officers, the aims of the Surgeon General, etc. Likewise the commanding officers of tuberculosis hospitals prepared circular letters which set forth the facts as to their hospitals in a similar way. In case some public man was insistent upon a particular soldier's discharge, he was asked if he was prepared to guarantee, personally, that treat- 196 COMMUNICABLE AND OTHER DISEASES ment and care equal to that furnished by Army hospitals would be provided for the man whose discharge he sought, and when discharged the Red Cross or other agencies were notified and sent in a report as to what had actually been done for the individual in question. By thus bringing home responsiblity for courses recommended and by educating the families which had been making trouble, much good was effected. The trouble making was found to be largely due to pure ignorance and baseless assumptions which a little well-directed effort served to dissipate. Early in the war a circular inquiry as to the best size of tuberculosis institu- tions brought forth the unanimous opinion of the civilian experts that small sanatoria were better than large. Nevertheless, the scarcity of competent medical personnel and the greater difficulties in the way of building, organizing, and properly inspecting a large number of small hospitals led to the decision to depend, ultimately at least, upon a smaller number of large hospitals. The chief objection raised as to the large tuberculosis institution is the loss of that close personal contact of the physician with his patient which is possible in the small groups. This would be a real objection if the care of the expert were necessarily exercised over a much larger number of patients in the large institutions. It is assumed by those who object that the chief alone will be competent to exercise the proper influence over his patients. But if the staff were composed of medical officers who were all equally competent, this objection would cease to have force. This is an ideal condition which, it must be admitted, is rarely attained anywhere. However, the method adopted in the Army to meet the above objections is worthy of consideration. In a large tuberculosis hospital the patients are divided into sections by wards or other groupings. The commanding officer, if a tuberculosis expert— if not, the chief of service—selects the best assistants to be placed in charge of the individual sections. He is responsible for the selection of those in charge of sections, and should exercise the closest supervision over them, inspecting their work frequently, visiting also the individual patients at random from time to time to learn their views as to their treatment and what they have been taught as to their own cases, the reasons why they are treated as they are, etc. He should be accessible as to purely medical matters by all of his staff, who should look up to him as their chief counsellor and fellow worker. The medical officers in charge of sections exercise equal care in the supervision of their assistants. The endeavor is to enforce in every way a treatment, consisting largely in regimen, which can only be carried on with success if the patients understand what is aimed at and how they should cooperate with their physi- cians, and if they are made to see that their physicians are competent and are interested personally in their welfare. Such a treatment must necessarily be standardized in the sense that there shall not be a change of diagnosis and of treatment when physicians are changed or transfers of patients elsewhere effected; otherwise there is chaos. The endeavor was made to put into effect such a program, which presupposes a high degree of enthusiasm and much hard work. A good beginning was made toward its realization by the senior medical officers of our hospitals, but unfortunately the sudden cessation of the war interrupted, to a considerable extent, the development of the method to the TUBERCULOSIS 197 attainment of the best results, since there was a desire for discharge on the part of many medical officers, and a relaxation of the professional enthusiasm and of the energetic work which had been so gratifying during the war. The management of a large tuberculosis hospital demands a staff of the highest quality. With such a staff there seems to be no reason why the large tuber- culosis hospitals shall not be conducted with success.46 But the writer ventures to express, in this connection, an opinion in which he differs from many officers of our Army, which is that the commanding officer of such a hospital should himself be a tuberculosis expert, not a mere administrator. Either that, or he should be required to efface himself, so far as medical questions are concerned, in favor of the chief of the medical service. But the commanding officer, in the writer's judgment, is, by virtue of his official position, the officer who can best coordinate the activities of his subordinates. Before the World War, Fort Bayard, N. Mex., was the only institution in the Army devoted exclusively to the treatment of tuberculosis. It had capacity of some 400 beds. Early in the war the William Wirt Winchester Hospital, at New Haven, Conn.—a hospital built in the most substantial man- ner expressly for the treatment of tuberculosis—was leased for the duration of the war. By the erection of temporary wooden buildings its capacity was increased to a total of 500 beds. A sanatorium at Markleton, Pa., and a hotel at Waynesville, N. C, were also leased for temporary occupancy and increased to the capacity of 270 and 500 beds, respectively, by the use of tents and the addition of wooden buildings. Permission having been granted early in the war to use land at Otisville, N. Y., belonging to the New York City Municipal Sanatorium, it was hoped that a hospital with a capacity of 650 to 1,000 beds might be well advanced in construction before the onset of winter in 1917;4T but owing to various vexatious and unnecessary delays, chiefly due to the fact that the details of construction, of purchasing, and the like were required to be passed upon by many different departments, building operations were not begun until midwinter and the buildings were not ready for use until the summer of 1918. The capacity of the hospital was 650 beds. In the meantime a hos- pital with a 1,500-bed capacity was built at Azalea, near Asheville, N. C, and a permanent hospital was constructed at Denver, Colo., with foundations of concrete and walls of hollow tile, and with a capacity of 1,500 beds. The post of Whipple Barracks, near Prescott, Ariz., was also turned over to the Medical Department of the Army and its permanent buildings were supplemented at first by ward tents, at a later time by the construction of semipermanent hollow- tile structures, until the capacity of 500 beds was reached. Fort Bayard also was enlarged to a capacity of 1,000 beds by the erection of wards built of wood. At the time when tuberculous patients were being most rapidly returned from Europe, use was made temporarily of the base hospital at Cam]) Wadsworth, Spartanburg, S. C, as a tuberculosis hospital, with a capacity of 1,000 beds. The total maximum capacity of 6,650 beds, not including the hospitals at Markleton and Waynesville, was attained by these means.48 In making such provisions the greatest difficulty of course was the impos- sibility of providing properly and at the same time not excessively for the needs of an army the maximum strength of which could not be foreseen. The best 198 COMMUNICABLE AND OTHER DISEASES approach to a solution of such a problem is the choice of land and the preparation of plans in such a way that in case of need the hospitals can be enlarged without becoming cumbrous. Fortunately, since many tuberculous patients are bene- fited by an outdoor life, the use of tentage and of easily built shacks may avert temporarily the overcrowding of permanent buildings without causing serious inconvenience. MORTALITY Deaths from tuberculosis (primary admissions) during the fiscal year ending June 30, 1918, among officers and enlisted men in the United States numbered 422 (ratio per 1,000 average annual strength, 0.35) and in Europe 3S9, the ratio per 1,000 average annual strength being 0.39. (In all the mortality statistics of the Surgeon General's Office deaths occurring in men who had developed tuberculosis in Europe are charged to Europe, wherever the deaths may have actually taken place.) Deaths from pulmonary tuberculosis in 1919, officers and enlisted men, were, in the United States, 613; in Europe, 617. Of the deaths among enlisted men from pulmonary tuberculosis, 355 (a ratio of 1.27) occurred among white troops in the United States and 326 in Europe (ratio 0.67). Among the colored troops the deaths from pulmonary tuberculosis in the United States were 243 (ratio 4.15). In addition, 42 deaths occurred from pulmonary tuber- culosis in Europe, in cases in which the color is not stated. The incidence of tuber- culosis among the colored soldiers and their death rates from the disease are much higher than among white soldiers of the Army in the United States and Europe as a whole, but neither admissions nor deaths of colored troops differ materially from those of the white troops from the Southern States, from which part of the country the majority of the colored troops came.49 In 1919, 674 deaths occurred from all tuberculosis, officers and men, in the United States, and 781 in Europe.50 The type of disease in fatal cases of tuberculosis appeared to be more severe and acute in the later part of the war and after than in the early part. The total number of deaths from pulmonary tuberculosis in the Army from the beginning of the war up to January 1, 1920, was 2,240. DETERMINATION OF LINE OF DUTY Prior to the World War, when a case came up for discharge on account of physical disability, medical officers of the Army were expected to express their opinion as to whether or not the disability in question had been incurred in the line of duty; that is, whether it was or was not incident to the military service. This was to assist in determining whether or not the individual was entitled to a pension. The tendency of those who had to do with such matters was always to give the soldier the benefit of any reasonable doubt, it being under- stood, however, that if the medical officer was in possession of facts, such as the admission by the patient that the disease had existed prior to enlistment, or satisfactory proof submitted by reputable individuals to the same effect, the disability was not to be regarded as incurred in line of duty. But when the personal history was negative and the affection was of a chronic nature, particularly when it was chronic pulmonary tuberculosis, if the term of service before the disease was determined to be present was brief and there was a man- TUBERCULOSIS 199 ifest disproportion between the nature of the lesions (fibrous changes and the like) and the time within which they must have developed if first contracted after the patient had entered the military service, the disability was usually classed as not contracted in the line of duty. But even in such cases, if there was evidence of unusual exposure or of intercurrent disease which might reason- ably be expected to have aggravated materially positively existing pulmonary disease, the disability was considered as incurred in the line of duty. Thus, a soldier was so classed, though of brief service and presenting evidence of extensive chronic pulmonary tuberculosis, who had been compelled to stand immersed deeply in sea water for 24 hours at the time of the Galveston flood, it being held that the excessive exposure to cold and the deprivation of food and drink for so long a period might be expected to materially aggravate his lung affection and therefore entitled the soldier to a pension. Infringement upon the rights of the individual in such matters was therefore always carefully guarded against; in fact there can be no doubt that many a man was granted a pension when there were good grounds for the belief that the disability in his case was of much longer standing than his military experience could account for. Two views were held with regard to this matter. One was that, the soldier having submitted to the required physical examination and having been passed by the examiner, the Government was responsible for the character of the physical examinations and could not rightfully impugn the competence of its agent in claiming that he had erred, but was bound to abide by his decision that the individual at the time of his examination was free of disqualifying defects, so that any disability found at a later time was without question to be regarded as incident to the military service.51 The other view was that, as the courts are understood to have ruled, the Government can not be made to suffer on account of the error of its agents; specifically in the present instance it might be put that it is unjust that the people should be taxed to pay a pension which was not deserved. The Government had the right, therefore, to investigate each case and decide on the evidence of whether or not the disability was pensionable. This latter view was the one generally adopted. Circular No. 24, Surgeon General's Office dated September 11, 1917, was designed to furnish a standard for disability boards. It provided that, if in pulmonary tuberculosis the disability is detected in less than three months after the entrance of a man into the service, it will be regarded as not in line of duty unless of an acute type or unless the man had been subjected to extraordinary exposure or had had an aggravating intermittent disease. This circular, con- flicting as it inevitably would, with the wishes of many individuals, encountered so much opposition that it was finally revoked and in the summer of 1918 a change was made in the Manual for the Medical Department to the effect that any soldier who shall have been accepted on his first physical examination after arrival at a military station as fit for service shall be considered to have con- tracted any subsequently determined physical disability in the line of duty unless such disability can be shown to be the result of his own carelessness, misconduct, or vicious habits, or unless the history of the case shows unmistak- ably that the disability existed before entrance of the soldier into the service. 200 COMMUNICABLE AND OTHER DISEASES By some medical officers "history" was understood to include the course of former pathological processes (particularly the evidence of fibrotic changes) as determined by the physical signs. It was held with regard to this point that while without doubt in many cases it can be assumed with practical certainty that the disease has existed for many years, at the same time it is not safe to give general permission to depend upon physical signs for the determination of the age of lesions, and the word "history" in the preceding paragraph should be considered to mean solely the personal recollection and such other data (recollections of relatives, of comrades, and the like) as may constitute the medical record of the past life of the individual in question. But though so much was conceded to the soldier by these orders, it was not enough, for several acts of Congress defined with increasing liberality the position of the Govern- ment toward the tuberculous individual, until at last it became the law that every commissioned officer, or enlisted man, or any other member of the military service who suffers a disability from disease contracted in line of duty shall be entitled to compensation, provided that the disease has not been caused by his own willful misconduct; that for the purpose of compensation all such persons shall be held to have been in sound condition when examined, accepted, and enrolled for service; and that these provisions shall be deemed to become effec- tive as of April 6, 1917.52 The following data concern discharges for tuberculosis of enlisted men in the United States in 1917: In line of duty, 349; not in line of duty, 3,327.53 That is, in the opinion of the medical officers most conversant with the facts, the number of soldiers who had incurred manifest tuberculous disease as the result of military service was to the number of those who had brought the dis- ease with them into the Army approximately as 1 to 10. In reality it is probably considerably less than 1 in 10. It is out of place to comment upon this ratio here further than to call attention to the fact that the figures as to tuberculosis in our Army do not represent the incidence of the disease under the conditions of military service. Similarly a marked rise in the number of admissions for tuberculosis at a given camp is not to be interpreted as a sudden breaking down of large numbers of men under the conditions of military service nor as an acute epidemic of tuberculosis from recent infections but, rather, as due to the activities of an examining board which detected during its routine examinations the presence of tuberculous lesions in men who before the examination had for the most part been doing full military duty and in all probablity had not sus- pected that they were ill, such men being admitted to sick report for the better determination of their cases and as a preliminary to discharge. In some instances, however, local variations in individual commands or in special sections of the country present a more complicated problem. REFERENCES (1) Telegram from the Surgeon General, U. S. Army, to division surgeons (of six different camps), dated September 17, 1917. Subject: Ordering special reexamination. On file, Record Room, S. G. O., 172229 (Old Files). (2) Rist, Edouard, Maj., M. C, French Army: The Problem of Pulmonary Tuberculosis. The Military Surgeon, Washington, 1917, xli, No. 6, 659. TUBERCULOSIS 201 (3) S. O. No. 120, W. D., May 24, 1917, paragraph 38; S. O. No. 143, W. D., June 21, 1917, paragraph 50; also, letter from Col. George E. Bushnell, M. C, to Col. Charles Lynch, M. C, May 4, 1921. On file, Historical Division, S. G. O. (4) Biggs, H. M.: A War Tuberculosis Program for the Nation. American Review of Tuberculosis, Baltimore, 1917, i, No. 5, 257. (5) Examination of Soldiers for Tuberculosis, June 27, 1917. On file, Record Room, S. G. O., 181927 (Old Files). (6) Letter from the Surgeon General, U. S. Army, to The Adjutant General of the Army, June 26, 1917. Subject: Detail of officers in Medical Reserve camps for duties as specialists in Army camps. On file, Record Room, S. G. O., 089101 (Old Files). (7) Circular, War Department, July 16, 1917. Subject: Examinations of commands at camps for tuberculosis by board of medical officers. On file, Record Room, S. G. O., 189101 (Old Files). (8) Bushnell, G. E., Col., U. S. A.: How the United States is Meeting the Tuberculosis War Problem. The Military Surgeon, Washington, 1918, xliii, No. 2, 127. (9) G. O. No. 90, W. D., July 12, 1917. (10) War Department Annual Reports, 1918, Vol. I, 1103. (11) Reports, Tuberculosis Boards. On file, Record Room, S. G. O., 730. (12) Annual Report of the Surgeon General, U. S. Army, 1918, 343. (13) Telegram from the Surgeon General, to all camp surgeons and other senior surgeons of commands, April 29, 1918. Subject: Single examination. On file, Record Room, S. G. O., Correspondence File, 327.2 (Examinations). (14) Matson, R. C, Maj., M. C. U. S. Army: The Elimination of Tuberculosis from the Army. American Review of Tuberculosis, Baltimore, 1920, iv, No. 5, 398. (15) Instructors of School of Tuberculosis Examiners. On file, Record Room, S. G. O., 176001-144 (Old Files). (16) Annual Report of the Surgeon General, U. S. Army, 1918, 344. (17) Ibid, 119. (18) Ibid, 219. (19) Personal communications to the author. (20) Brewer, Isaac W.: Tuberculosis Among the Indians of Arizona and New Mexico. New York Medical Journal, 1906, lxxxiv, No. 20, 981. (21) Cabot, Richard C: In Conference on Tuberculosis of the Lungs. War Medicine, Paris, 1919, ii, No. 6, 978. (22) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1070. (23) Letter from the Surgeon General, U. S. Army, to Dr. Edouard Rist, Geneva, Switzerland, January 28, 1920. Subject: Occurrence of tuberculosis in the Army. On file, Record Room, S. G. O., 702-5. 24) Webb, Gerald B.: Some Lessons of the War in Pulmonary Tuberculosis. Transac- tions of the American Climatological and Clinical Association, Lancaster, Pa., 1919, xxxv, 114. (25) Glomsett, D. J., Maj.: What Can We Learn Regarding Pulmonary Tuberculosis from the Opportunity Afforded by the General Postmortem? War Medicine, Paris, 1919, ii, No. 6, 993. (26) Borrel, A.: Pneumonie et tuberculose chez les troupes noires. Annales de VInstitut Pasteur, Paris, 1920, xxxiv, No. 3, 105. (27) Roubier, Ch.: Sur la Tuberculose chez les troupes noires. Paris me'dical, 1919, xxxiii. No. 37, 207. (28) Nageli, Otto: Ueber Haufigkeit, Localisation und Ausheilung der Tuberkulose. Virchow's Archiv fur pathologische Anatomie und Psysiologie undfiir klinische Medicin, Berlin, 1900, clx, No. 2, 426. (29) Opie, Eugene L.: The Focal Pulmonary Tuberculosis of Children and Adults. Journal of Experimental Medicine, New York, 1917, xxv, No. 6, 855; and xxvi, No. 2, 263; also: First Infection with Tuberculosis by Way of the Lungs. American Review of Tuberculosis, Baltimore, 1920, iv, No. 9, 629. (30) Cummins, S. Lyle: Tuberculosis in Primitive Tribes and Its Bearing on the Tubercu- losis of Civilized Communities. International Journal of Public Health, Geneva, 1920, i, No. 2, 137. 202 COMMUNICABLE AND OTHER DISEASES (31) Bruns, Earl H., Lieut. Col., M. C: The Tuberculosis Situation in the American Expe- ditionary Forces. Unpublished Report to the Surgeon General, U. S. Army. On file, Record Room, S. G. O. (32) Bushnell, George E., Col., M. C, U. S. Army: A Study in the Epidemiology of Tuber- culosis. William Wood and Company, New York, 1920, 97. (33) Freund, Heinrich: Ueber cutane und conjunctival Tuberkulinreaktion bei Gesunden und Kranken. Wiener medizinische Wochenschrift, Wien, 1908, lviii, 1242; 1302. (34) Hamburger, F.: Die Ueberlegenheit der Stichreaktion uber die Kutanreaktion. Miin- chener medizinische Wochenschrift, Munchen, 1919, lxvi, part 1, No. 4, 100. (35) Lereboullet, P.: Les questions actuelles de tuberculose. Paris medical, 191S, xxvii, No. 1, 1. (36) Gallagher, Joseph F., First Lieut., M. C: Statistical Resume of the French Medical Service. The Military Surgeon, Washington, 1920, xlvi, No. 5, 579. (37) Fraenkel, A.: Ueber Lungentuberkulose vom militaraztlichen Standpunkie aus. Mun- chener medizinische Wochenschrift, Munchen, 1916, lxiii, part 2, No. 31, 1109. (38) Bliimel: Die Fehldiagnose Lungentuberkulose bei Beurteilung der Felddienstfahigkeit. Medizinische Klinik, Berlin und Wien, 1915, xi, August 8, 884. (39) Goldscheider : Aufgaben und Probleme der inneren Medizin im Kriege. Zeitschrift fiir Tuberukulose, Leipzig, 1915-16, xxv, No. 1, 36. (40) Piery: Le Poumon de guerre. Revue generate de pathologie de guerre, Paris, 1916, i, 509. (41) Goldscheider: Diagnose und Prognose der Lungentuberkulose vom Standpunkt des Praktikers. Berliner klinische Wochenschrift, Berlin, 1917, liv, No. 53, 1266. (42) Letter from the Surgeon General to commanding officers of all base and general hospitals, April 15, 1918. Subject: Discharge of tuberculosis patients. On file, Historical Division, S. G. O. (43) Letter from the Surgeon General, U. S. Army, to The Adjutant General of the Army, July 2, 1918. Subject: Discharge on account of pulmonary tuberculosis. On file, Record Room, S. G. O., 220.8, G. H. No. 18 (k). (44) Matson, R. C, Maj., M. C, U. S. Army: The Value of Chest Fluoroscopy. The Journal of the American Medical Association, Chicago, 1919, lxxii, No. 26, 1887. (45) Hospitals designated for reconstruction of disabled American soldiers and policy to be pursued outlined by the Surgeon General. Official Bulletin, published daily under order of the President of the United States, by Committee on Public Informa- tion, Washington, D. C, April 2, 1918, ii, No. 273, 8. (46) Hoagland, H. W.: The Treatment of Tuberculosis in the Army Hospitals. Transac- tions of the American Climatological and Clinical Association, Lancaster Pa 1919 xxxv, 21. (47) Annual Report of the Surgeon General U. S. Armv, 1918, 344. (48) Ibid., 1919, ii, 1072. (49) Ibid., 1919, i, 51. (50) Ibid., 1920, 178. (51) Memorandum on the question of line of duty, November 7, 1914. On file Record Room S. G. O., 153517 (Old Files). (52) War risk insurance act, with amendments prior to July 1, 1918. In special Regulations No. 72, Washington, Government Printing Office, 1919, 90, and amendments to war risk insurance act in Bulletin 7, War Department, April 17, 1923, 26. (53) Annual Report of the Surgeon General, U. S. Army, 1918, 158. CHAPTER IV CEREBROSPINAL MENINGITIS a Cerebrospinal meningitis was of serious importance in the United States Army during the World War, not because of its incidence, which was compara- tively low—in fact this disease ranked seventy-sixth as a cause for admission to hospital—but because of its high case mortality. Approximately 39 per cent of the cases died, thus causing meningitis to rank sixth as a cause of death. Furthermore, its appearance in a command usually caused a definite feeling of apprehension or alarm, and as a consequence few diseases were the cause of more concern to, or were given more active attention by, medical officers. Many sporadic outbreaks and small epidemics have been reported through- out the world since 1805, when the disease was recognized clinically by Vieusseau. However, an accurate bacteriological diagnosis was not possible before 1887 when Weichselbaum1 showed the meningococcus (Diplococcus intracellularis meningitidis) to be the specific cause of cerebrospinal meningitis. This infection has, no doubt, occurred in our Army during all previous wars. Interesting clinical reports of outbreaks are recorded in histories of the War of 1812, the Mexican War, and Civil War; while it is evident from these reports that meningitis was present, the incidence is not known since there was considerable confusion in the nomenclature and differential diagnosis and, of course, bacteriological diagnostic methods were unknown. In spite of the fact that the meningococcus had been recognized as the specific cause of cerebrospinal meningitis for 10 years previous to the Spanish-American War, very few of the cases which occurred during that period were diagnosed by accurate laboratory methods, and clinically the disease was confused to some extent with typhoid, typhus, and other fevers. It is obviously impossible, therefore, to make a com- parison of the meningitis rates of our Army for the World War with the rates for any previous war. Such a comparison not only would be worthless, but also misleading. Since the Spanish-American AVar the diagnosis of cerebrospinal meningitis in the Army has been more exact, and the records have included only cases in which the clinical diagnosis was confirmed by bacteriological examination. During this time, as indicated graphically in Chart XXVI, the annual admission rate per 1,000 strength has been almost negligible, except during the mobiliza- tion of unseasoned troops; for example, the rate increased noticeably in 1907 at the time of the Cuban occupation, in 1913 during the mobilization on the Mexican border, and again in 1917 when the United States entered the World War. It is noteworthy that the concentration of Regular Army troops on the Mexican border in 1911 was not attended by any remarkable increase in the meningitis admission rate. " Unless otherwise stated, all figures for the World War period are derived from sick and wounded reports sent to the Surzeon General.—-?-. 204 COMMUNICABLE AND OTHER DISEASES Cerebrospinal meningitis has for some time been known as a disease of soldiers, or a "barracks disease," because of its tendency to become more prev- alent during the mobilization of recruits. These terms were justified by the increased incidence in the Army during the World AVar. The rapid mobiliza- tion of enormous numbers of untrained, unseasoned men, from all sections of the country, and their subsequent, intimate contact in large camps, provided ideal conditions for the dissemination of meningococci, and as a consequence meningitis was far more prevalent than in normal peace times. o < i—«* o r«_— 1 a < Q 0 — — -- \-m o a uJ a rA >NM SSIC >NS /. / / \ \ 1 1 / / / / I / \ \ \ > t \ I ^ / i / s 1-------< C\, / / // // // '/ \ I \ \ ! -< N. \ ' _-< J- r >--.< h. i DE£ TH5 \ \ 1900 1901 1902 190} 1904 1905 1906 1907 1908 1909 1910 I9H I9U 191. 1914 1915 19l6 1917 1918 1919 1920 Chart XXVI.—Admissions and deaths for cerebrospinal meningitis, United States Army, 1900 to 1920. Ratios per 1,000 strength / STATISTICAL CONSIDERATIONS The total mean annual strength of the Army for the period April 1, 1917, to December 31, 1919, was 4,128,479. As indicated in Table 28, 4,831 cases of cerebrospinal meningitis were reported as "primary admissions" during this period, giving an annual admission rate of 1.17 per 1,000 of strength, or 117 cases among every 100,000 men. Death occurred in 1,836 cases, or 38 per cent, giving an annual mortality rate of 0.44 per 1,000, or 44 deaths in 100,000 men. CEREBROSPINAL MENINGITIS 205 Table 28.—Cerebrospinal meningitis. Primary admissions and deaths shown by countries of occurrence for officers and enlisted men, United States Army, with ratios per 1,000 strength, April, 1917, to December 31, 1919 Total mean annual strengths Admissions De aths Period, April, 1917, to December, 1919 Absolute numbers Ratios per 1,000 strength Absolute numbers Ratios per 1,000 strength 4,128,479 4,092,457 206,382 4,831 4,826 120 1.17 1.18 .58 1,836 1,833 56 0.44 .45 .27 Total enlisted American troops: White__________________________............._______________ 3, 599, 527 286, 548 3,928 526 252 1.09 1.84 1,387 239 151 .39 .83 Total ___________ ...........______________....._______ 3, 886, 075 36,022 4,706 5 1.21 .14 1,777 3 .46 Total native troops (enlisted)___......___........__________..... .08 Total Army in the United States (including Alaska): Officers....._______________________________________________ 124.266 69 .56 28 .23 1.965, 297 145, 826 2.466 343 1.25 2.35 825 133 .42 .91 2, 111, 123 2,809 1.33 958 .45 2, 235, 389 2,878 1.29 986 .44 U. S. Army in Europe (excluding Russia): 73, 728 45 .61 23 .31 1,469, 656 122,412 1,384 169 250 .94 1.38 534 96 149 .36 .78 1, 592,068 1,803 1.13 779 .49 1, 665, 796 19,480 19,688 8,388 14.232 1.848 3 5 6 22 51 13 1.11 .15 .25 .72 1.55 802 1 1 5 7 .48 .05 .05 .60 .49 Transports: 97,498 10, 535 .52 1.23 22 9 .23 .85 108,033 64 .59 31 .29 Natives troops enlisted: 18, 576 5,615 11, 831 1 2 2 .05 .36 .17 1 .05 2 .17 1 Only cases admitted to hospital primarily for cerebrospinal meningitis are considered in the figures given above or in the statistical tables used in this chapter. However, during this same period 1,008 additional cases and 443 deaths were reported as "concurrent diseases," having been admitted to hospital for other conditions. Therefore the total number of cerebrospinal meningitis cases was 5,839, an annual admission rate of 1.41 per 1,000 strength; while the total number of deaths was 2,279. 206 COMMUNICABLE AND OTHER DISEASES DISTRIBUTION BV GRADES The incidence and mortality rates for enlisted men were greater than un- commissioned officers. The annual admission rate among enlisted men with a total mean annual strength of 3,886,075 was 1.21 per 1,000, compared with a rate of 0.58 for officers, whose total mean annual strength was 206,3N2. The annual death rates per 1,000 were: Enlisted, 0.46; officers, 0.27. The lower incidence and mortality rates among officers were no doubt due to several factors. As a rule the officers were older than the enlisted men and possibly less susceptible to the infection. They also had certain advan- tages, such as less crowded living quarters, less exposure to hardship and fatigue, and because of their training they were better able to understand and apply the principles of personal hygiene and sanitation. RACIAL DISTRIBUTION Meningitis was more common among colored than among white enlisted men. The annual admission rates per 1,000 strength were: Colored, 1.84; white, 1.09. The mortality rates were: Colored, 0.83; white, 0.39. The case fatality for colored troops was 42.7 per cent and for white troops, 35.3 per cent. A comparison of the rates in the United States is shown in Chart XXVII. It has long been known that the incidence is usually higher among colored persons. This apparent racial susceptibility may be due mainly to insanitary habits, ignorance, and carelessness in matters of elementary personal hygiene which, together with the necessarily crowded conditions of camp life, facilitate the spread of meningococci. One case occurred among Philippine Scouts, 2 cases in Hawaiians, and 2 in Porto Ricans. GEOGRAPHICAL DISTRIBUTION In order of importance the geographical incidence was: The United States, Europe, Panama, Hawaii, Porto Rico, and the Philippine Islands. The slight difference between the rates for the United States and Europe probably has no significance, though it is possible that the lower incidence in Europe was influenced by the fact that overseas troops had become more hardened and resistant to infection because of their training, and a large percentage of meningococcus carriers were eliminated before the troops left the United States. The slight importance of meningitis in the Tropics is emphasized by these figures. IN THE UNITED STATES During the World War, meningitis occurred most frequently in troops stationed in the United States. There were 2,878 primary admissions among American enlisted men in this country, an annual admission rate of 1.29 per 1,000 strength; death occurred in 986, or 34.1 per cent of the cases. The annual death rate was 0.44 per cent 1,000 strength; 131 patients were dis- charged for disability, a rate of 0.06 per 1,000. A total of 150,386 days were lost because of the disease. The admission and death rates for colored troops were higher than for white, as shown in Chart XXVII. CEREBROSPINAL MENINGITIS 207 CEREBROSPINAL MENINGITIS. COMP. RATES WHITE & COLORED ENL. MEN-UNITED STATES APRIL. 1917- DEC. 1919 .0 .5 1.0 - ADMISSIONS RATIOS PER 1000 2.0 2.5 3.0 3.5 4.0 4.S 5.0 1.25 2.35 DEATHS .0 .5 1.0 1.5 RATIOS PER 1000 2.0 2.5 3.0 3.5 4.0 4.5 5.0 .42 .91 0 5 10 CASE FATALITY PERCENTAGE RATES 20 25 30 35 40 45 50 33.41 38.78 NONEFFECTIVE RATIOS PER 1000 .4 .5 -6 .7 .8 .9 .10 .18 .28 DAYS LOST AVERAGE FOR EACH CASE 40 50 60 70 80 90 100 53.70 i 44.20 DISCHARGES FOR DISADILITY RATIOS PER 1000 .1 .2 .3 .4 WHITEl .5 .6 .7 .8 .9 .10 COLORED| Chart XXVII .06 .05 208 COMMUNICABLE AND OTHER DISEASES Table 2\). —Cerebrospinal meningitis. Primary admissions and deaths, by months, with annual ratios per 1,000 strength; white and colored enlisted men, United States Army in the United States and Europe, April, 1917, to December, 1919 White enlisted men United States Month and year 1917 April_______ May_______ June........... July........... August........ September___ October........ November___ December___ 1918 January......___...... 1,096, 434 February____________ 1,095,039 March.._...........___! 1,129,223 Mean strength 183,758 245,454 309,205 458,817 562, 714 776, 466 1,032,244 1,061, 422 1,129,065 April. May______ June......... July......... August____ September... October...... November... December... January. February. _ March..... April....... May....... June....... July......_ August___ September. October___ November. December. 1919 Month not stated. Total......._____ 1,965,297 1,168, 558 1,197, 757 1,303,746 1, 328,513 1,284,247 1, 321, 440 1,343,933 1,255.195 941,219 672,937 471,815 406,839 339, 836 291,810 246,903 215,104 156, 791 149, 360 139, 877 132, 403 135, 441 Admissions Deaths Europe Absolute numbers Ratios per 1,000 18 35 22 22 15 10 93 273 371 409 222 142 122 83 74 61 30 41 136 70 63 2,466 1.18 1.71 .85 .58 .32 . 15 1.08 3.09 3.94 4.48 2.43 1.51 1.25 .83 .68 .55 .28 .37 1.21 .67 .80 .66 ..50 .74 .70 .44 .39 .38 .17 .09 Absolute numbers 1.25 19 102 149 131 68 39 43 17 15 10 7 20 51 22 27 825 Ratios per 1,000 0. .w . 98 .35 .21 . 15 .08 .22 1.15 1.58 .20 .31 .15 .2) .16 .05 .17 . 15 Admissions Mean strength Deaths Absolute numbers 626 12, 794 28,821 50,882 70, 266 92, 139 123,429 160,178 193, 264 223,130 283,268 388, 048 587,240 796,427 1,063,192 1,266, 592 1, 527, 793 1, 635,321 1, 682, 836 1,591,962 1, 488, 683 1, 310,083 1,115, 693 853, 425 569, 842 271, 633 111,634 48,006 30, 315 21,055 18,920 18, 379 1, 469, 656 54 25 40 31 33 42 21 35 78 197 141 180 122 108 81 63 23 10 10 5 4 Ratios per 1,000 0.89 2.08 .47 .68 .26 1.36 2. C2 3.35 1.34 1.69 .96 .67 .63 .24 .33 .61 1.45 1.01 1.36 .87 .89 .48 .44 1.07 1.25 1.58 5.13 .63 1,384 Absolute numbers 534 .36 CEREBROSPINAL MENINGITIS 209 Table 29.—Cerebrospinal meningitis. Primary admissions and deaths, by months, with annual ratios per 1,000 strength; white and colored enlisted men, United States Army in the United States and Europe, April, 1917, to December, 1919—Continued Colored enlisted men United States Europe Month and year Mean strength Admissions Deaths Mean strength Admissions Deaths Absolute numbers Ratios per 1,000 Absolute R£H°S numbers -j** Absolute numbers Ratios per 1,000 Absolute numbers Ratios per 1,000 1917 4,870 5,826 5,171 6,675 8,519 9,409 21,795 39,225 36,851 50,705 49,955 54,814 59,015 87, 650 89, 305 124,976 168, 422 164,846 182, 705 150, 587 104,140 68, 337 66,104 44,634 29,824 20, 780 18, 562 20, 058 18, 013 11, 322 9,084 8,792 8,935 July____......_______ August______......... September___________ October___.....______ 935 2.392 5,346 8,673 9,664 11,541 12, 667 28,279 33,208 47,171 78, 734 91, 270 138,827 148, 697 148,372 140, 396 131,219 123,152 119,801 108, 650 64,166 12, 508 1,741 1,287 185 83 November________ 16 38 30 11 22 21 51 •24 17 8 15 39 19 10 3 11 7 1 4.89 12.37 7.10 2.64 4.82 4.27 6.98 3.23 1.63 .57 1.10 2.56 1.51 1.15 .53 2.00 1.88 .40 6 1.84 15 4.88 1 2 5 2 3 5.03 4.48 6.92 2. 4S 1 1 1 5.03 2.24 1.38 December........ 1918 January............... February........._____ 3 9 12 17 6 6 6 3 10 8 8 1 7 3 1 .72 1.97 2.44 2.33 .81 .58 .43 .22 .66 .64 .92 .18 1.27 .81 .40 March_____............ 3.12 1 1.04 May___........ 4 2 2 8 14 25 20 20 16 11 9 10 7 6 1 1.70 .72 4 1.70 June________________ July________________ .51 August____. .61 .92 1.38 1.05 .90 September____ 1.84 7 2. 16 16 1.61 13 1.62 11 1.37 7 1.01 ! 6 .88 4 1.00 9 .77 4 1.12 5 .96 1 October..... November___ 1919 January_______........ February____________ 55 March............ 39 April....._________ 90 May_______.......___ .44 June______.....______ .94 July____ .96 August____. _______ September........_____ November____ t December____________ j 1 1 1. 3S Total___________ 145,826 343 2.35 133 .91 122,412 169 96 .78 56706—28- -14 210 COMMUNICABLE AND OTHER DISEASES Cerebrospinal meningitis, as indicated by the weekly reports of the I nited States Public Health Service and the United States mortality statistics, had been prevalent and widely distributed throughout the civilian population of the United States for several years before we entered the World War. The rapid mobilization of over a million men from all sections of the country between April and October, 1917, naturally brought the disease into every cantonment, and the monthly admission rates increased to a peak of over 4 per 1,000 in January, 1918. From this point the rate fell to about 0. 3 in August, and again rose to a second peak of less than 2 per 1,000 in October, 1918. Then, instead of rising during the winter of 1918, the rates decreased after the armistice began, until a low point of .09 was reached in October, November, and December, 1919, as shown in Table 29 and graphically by absolute numbers in Chart XXVIII. Evidently the incidence was affected not so much by temperature or season as by mobilization. CEREBROSPINAL MENINGITIS 8 MOBILIZATION ADMISSIONS & NO. OF ENL MEN MOBILIZED. U. S. COMPARATIVE TREND BY M0.. APRIL.1917-DEC. 1919 Since a majority of the men were collected in 39 large camps located in various sections of the country, the occurrence of meningitis in these camps, shown in Table 30 and Chart XXIX, is of interest, CEREBROSPINAL MENINGITIS 211 The highest primary admission rates for white and colored enlisted men combined occurred in Camps Jackson, S. C. (6.76 per 1,000), Beauregard, La. (6.40), and Funston, Kans. (2.72); and the numbers of cases in these camps were, respectively, 284, 132, and 153, or one-fifth the total number for the whole Table 30 Cerebrospinal meningitis. By camps of occurrence, showing primary admissions and deaths, irith annual ratios per 1,000 strength, white and colored enlisted men, United States Army: also case fatality rates, April, 1917, to December, 1919 Camps Beauregard, La Bowie, Tex____ Cody, N. Mex.. Custer, Mich. _. Devens, Mass__. Dix, N.J______ Dodge, Iowa___ Doniphan, Okla Eustis, Va_____ Fremont, Calif Funston, Kans Gordon, Ga___ Grant, 111____ Greene, N. C Greenleaf, Ga Hancock, Ga Humphreys, Va. Jackson, S. C Johnston, Fla Kearny, Calif Lee, Va_____ Lewis, Wash Logan, Tex MacArthur, Tex McClellan, Ala Meade, Md Mills, N. Y Pike, Ark Sevier, S. C Shelby, Miss Sheridan, Ala Sherman, Ohio Taylor, Ky Travis, Tex Upton, Long Island, N. V Wadsworth, S .C Wheeler, Ga Others Total Total enlisted men Admissions Deaths ■r. ^ t_ E i 8 2.81 .65 .22 .21 .34 .22 .49 .79 43.9 31.4 26.3 36.3 33.3 39.2 31.1 31.8 .69 .65 .28 .74 .17 .32 .39 1.99 . 15 .27 .28 .42 .30 25. 4 38.1 42.4 30.9 33.3 27.1 35.7 29.5 14.2 19.4 28.07 29.85 40.0 . 32 ! 23! 2 .46 .33 .83 .79 .45 .20 .17 .64 .52 .37 .25 .95 35. 3 19.5 41.8 32. 3 27.6 38.4 16.2 40.0 41.07 62.9 40.0 51.06 country. It is obvious that the increased prevalence was not due entirely to the size of these camps, since other large camps such as Camp Dix, N. J., had much lower admission rates; furthermore, it can not be ascribed to climate or other similar local conditions, since the rates for different camps in a single State, or for different States in a given section of the country, varied consider- ably. For example, in South Carolina the primary admission rates per 1,000 were 6.76 for Cam]) Jackson, 2.45 for Camp Sevier, and only 0.63 for Camp 212 COMMr.NICARLE AND OTHER DISEASES CEREBROSPINAL MENINGITIS, BY CAMPS ADMISSIONS, WHITE ENLISTED MEN, U. S. APRIL, 1917-DEC, 1919 RATIOS PER 1000 A A t2 1.6 242T*2T>a23764!04T*4:-5T257 7.2 7.6 M T: Chart XXIX CEREBROSPINAL MENINGITIS 213 Wadsworth. A study of the mobilization charts indicates that the disease was most common in the camps which were made up mainly of men from the rural sections of the Southeastern States and from Kansas and Missouri, and that it was relatively infrequent in camps composed of troops drawn from States which had large urban populations. Sporadic cases occurred in all of the other camps except Camp Forrest in Georgia, and Camp Syracuse in New York, which were relatively small camps, organized late in 1918. The relatively high incidence of meningitis in certain of our camps was no doubt due mainly to the fact that large numbers of susceptible men from rural sections, under the strain and fatigue incident to intensive military training, were, for the first time, brought into close contact with meningococcus carriers and cases. Camp Jackson, S. C. This National Army cantonment which had 284 cases of meningitis and an admission rate of 6.76 per 1,000, drew a large percentage of its men from the rural sections of North Carolina, South Carolina, and Florida.2 Meningitis occurred in practically epidemic form during November and December, 1917, and was prevalent from that time on. Camp Wadsworth, S. C. Although located in South Carolina, only 20 cases occurred in this camp, and the admission rate was 0.63 per 1,000 strength. However, Camp Wads- worth was made up largely of troops from New York City and other thickly populated localities.3 Camp Beauregard, La. There were 132 cases, an annual primary admission rate of 6.40 per 1,000 in this camp, which drew troops mainly from Louisiana, Arkansas, and Mis- sissippi,4 all of which States have a large rural population. Camp Funston, Kans. Including all troops in the State, 153 cases, or an admission rate of 2.72 per 1,000, were reported for Camp Funston. The men in this camp came mainly from Missouri and Kansas.5 IN EUROPE Meningitis in the American Expeditionary Forces occurred sporadically rather than in extensive epidemics. A large percentage of the cases originated either in the base ports or on shipboard, and, as a rule, the incidence was high- est in organizations from training camps with high rates in the United States. There were 1,848 primary admissions reported between June 1, 1917, and December 31, 1919, an annual admission rate of 1.11 per 1,000 strength, or 111 cases in every 100,000 men. Of these, 802 died, a case fatality of 43.3 per cent; the annual death rate was 0.48 per 1,000 strength. The first case was reported in June, 1917, and more cases occurred as the strength of the Army increased during the following months, until a peak was reached in January, 1918, with-59 cases and a rate of over 4 per 1,000. These cases were mainly due to outbreaks in organizations which had brought the infection with them from their training camps in the United States. 214 COMMUNICABLE AND OTHER DISEASES In October, 191S, when the strength was over a million and a half men, 222 cases occurred, or a rate of less than 2 per 1,000. This.increase occurred just after the highest incidence of influenza, which possibly contributed, along with hardships, fatigue, and overcrowding of troops, to lowering the resistance of soldiers to meningitis. During demobilization the monthly number of cases decreased rapidly until there were only 9 in October, 1 in November, and none in December, 1919. The high admission rate of 5 per 1,000 in October, 1919, is not considered significant, as it is based on only 9 cases. ETIOLOGY While the experience during the World War added nothing entirely new to our know ledge of the etiology of cerebrospinal meningitis, it emphasized the relative importance of certain contributing factors. As stated above, since 1887 it has been known that the disease is a specific infection caused by the meningococcus. In 1909 Dopter6 differentiated two types of meningococci which he designated "normal" and "para." Gordon7 divided meningococci isolated from cases of meningitis, which occurred in British troops during the World War, into four serological types, which he called I, II, III, and IV. His types I and II corresponded with Dopter's "para" and "normal" types, while III and IV were irregular or intermediate in their serological reactions. The relative frequency of these types in the British Army is indicated by the following table:8 Type. Specimens _ Percentage. I II 218 44.05 III IV 195 37.66 69 11.38 36 6.94 In 1917, Flexner 9 investigated the subject and agreed with Dopter by dividing the meningococci into normal, para, and intermediate types. In the United States Army the typing of meningococci was not a routine procedure; however, it was done in a great many instances. The information obtained sometimes aided in the selection of therapeutic serum for individual cases or in tracing the relationship between cases or carriers. The reports from certain organizations indicate that the normal type (II) predominated; that the para type (I) was about half as frequent, and that a relatively small percentage of the intermediate types (III and IV) were found. It is now generally believed that the normal habitat of the meningococcus is the posterior nasopharynx of man. In susceptible individuals the organism may invade the body and produce meningitis, while in resistant or immune persons infection does not occur. These latter, apparently normal "carriers," may harbor meningococci in their throats for long periods of time and spread them to their associates. While it has been estimated that about 1 to 3 per cent of the population are carriers, fortunately relatively few persons are susceptible to the infection. Conditions which increase the contact between carriers and susceptible individuals favor the spread of meningitis. The tend- ency of the disease to greater prevalence in the winter and early spring is, no doubt, due to the fact that people live indoors and are therefore closer together CEREBROSPINAL MENINGITIS 215 during the cold months. The higher incidence among recruits, especially those from rural localities, in mobilization camps points to the importance of contact between these relatively susceptible persons and carriers. Other infections, fatigue, and hardship may also help to lower the resistance of soldiers. DIAGNOSIS The specific diagnosis of cerebrospinal meningitis depends upon the iso- lation and identification of the meningococcus from the cerebrospinal fluid. During the World War, spinal punctures usually were performed on all patients with symptoms of meningeal irritation or inflammation; and the diagnosis was based entirely on the bacteriological examination of the spinal fluid. Wege- forth and Latham,10 however, warned against the indiscriminate use of spinal puncture as a diagnostic procedure in human septicemia, stating that the re- lease of spinal fluid was an important factor in the development of meningitis. This observation was preceded by the investigations of Weed, Wegeforth, Ayer, and Felton,11 who showed that in animals suffering with an experimentally produced bacteriemia, spinal puncture was invariably followed by meningitis. It was therefore recommended that careful consideration be given to the bac- teriological study of the blood before attempting puncture of the spinal canal. However, in spite of the fact that cases were observed in which the spinal fluid obtained at the first puncture was sterile and from later punctures in- fected, this was usually considered only an indication of the normal progress of the infection; and it was quite generally believed that diagnostic spinal puncture in meningitis was not attended by any serious results. The observations of previous workers that meningococci may invade the blood stream were confirmed during the World War by Herrick.12 He reported that in a comparatively large percentage of the cases at Camp Jackson, S. C, the organism was isolated in cultures made of the blood before the appearance of meningeal symptoms; and, as a consequence, he advocated the more general use of blood cultures as an aid to early diagnosis, and proposed that the term "meningococcus sepsis" be used. In most cases it is possible to isolate the meningococcus from the upper respiratory tract, and nasopharyngeal cultures may be helpful, when menin- gococci in a turbid spinal fluid escape detection. During the World War nasopharyngeal cultures were used mainly in the detection of carriers, but occasionally as an aid in the diagnosis of cases. The symptomatology of cerebrospinal meningitis observed during the World War did not differ materially from that already recognized as charac- teristic of the disease. Naturally, differences occurred in the percentage of severe and mild cases in the various camps, resulting in variations in the pre- dominant clinical signs and symptoms. TREATMENT Polyvalent antimeningococcic serum was used routinely for treatment. The gross case fatality for primary admissions in the whole Army was about 38 per cent. In the American Expeditionary Forces about 43 per cent of the cases died, while in the United States the percentage was about 34. Also the 216 COMMUNICABLE AND OTHER DISEASES case fatality in different camps in this country varied from 8 to 43.9 per cent, as shown in Table 30. These differences no doubt were influenced to some extent by differences in the severity of the disease in various localities, but the most important factor was probably the duration of the disease before serum therapy was begun. According to Flexner 9 and others, specific serum treatment reduced the mortality due to meningitis from a percentage of 60 to 90 to a gross case mor- tality of 23 to 50 per cent, and even to a much smaller percentage when the serum was administered in the first three days of the disease. Flexner Number of cases_________.............__________ l, 294 Treatment begun— Per cent Before third day....................____............. 18.1 From fourth to seventh day____________......_____ 27.2 After seventh day...........____........__________' 36.5 Netter 100 Per cent 7.1 11.1 23.5 Dopter 402 Per cent 8.2 14.4 24.1 Christo- manos 186 Per cent 13.0 25.9 47.0 Levy 165 Per cent 13.2 20.4 28.6 Flack Per cent 9.09 50. The polyvalent immune serum used in the Army was supplied principally by the Rockefeller Institute, the New York City Board of Health, and three commercial laboratories.13 As a rule, from 30 to 80 strains of meningococci, representing different proportions of the various types, were employed in its preparation. In France, additional serum was obtained from the Pasteur Institute.14 In individual cases, considerable differences were observed in the therapeutic results obtained with different sera, and occasionally cases which were not im- proved by one serum were promptly benefited by another. In some of these instances the first serum used may have been generally lacking in antibody content, but usually the therapeutic failure occurred because the serum had been prepared with a large proportion of meningococcus strains which were different from the type causing the disease. In the treatment of 13 cases at Camp MacArthur, Tex., by Medalia 15 it was concluded from the therapeutic results and agglutination tests that one serum which they used was more effective than another because it contained specific antibodies for the particular strains of meningococci causing their infections. Robison and Gerstley 16 reported that they found an American serum to be practically useless in the treatment of meningitis in Coblenz, Germany, while almost 100 per cent of the cases treated with French serum recovered. They thought that possibly the American serum failed because strains of meningococci, similar to those encountered in Germany, were not used in its manufacture. Because of these differences, sera from several sources were usually kept available for use in the large hospitals. Since the value of serum is greatest when given early in the disease, every effort was made to avoid delay in its administration. Usually doses of from 30 to 60 c. c. were injected intraspinally immediately following diagnostic lumbar puncture and drainage of the spinal fluid. If bacteriological examination showed meningococci in the fluid, the dose was repeated in 12 hours, and then daily, depending upon the condition of the patient. In the more severe cases usually 6 to 10 injections were given. The therapeutic results obtained bv CEREBROSPINAL MENINGITIS 217 this method in different camps varied considerably, as is indicated by the case- fatality percentages. This was no doubt due to a number of factors; such as differences in the severity of infections, differences in the types of infecting meningococci, and variations in the time and methods of treatment. While as a general rule serum was administered by the intraspinal route alone, in certain camps, including Camp Jackson, Camp Funston, and Camp Beauregard, intravenous injections were used in addition to the intraspinal therapy in a number of the cases. A comparison of the results obtained by the intraspinal method and the combined intraspinal and intravenous method of treatment at Camp Jackson was reported by Herrick,12 as follows: Entire epidemic Number of cases. Cases treated by intraspinal route 137 Number Percent" Number Percent Deaths. Mild cases.......... Early diagnosis. Late diagnosis.. Severe cases_______ Early diagnosis. Late diagnosis.. 168 46 122 24.8 3.0 3.3 2.5 37.4 34.7 38.5 Cases treated by intraspinal and in- travenous routes Number Per cent 5.5 8.3 »Percentages are mortality rates. At Camp Beauregard, where the gross case mortality was 43.9 per cent, Landry and Hamley 17 reported that whereas the mortality was 54.2 per cent in 86 cases given only intraspinal injections, and was 55.5 per cent in 9 cases given intraspinal injections followed late in the disease by intravenous injections, in 34 cases treated on admission by the combined method the mortality was 32.3 per cent. Again, the mortality among 191 Camp Funston cases, treated intraspinally, was 28.8 per cent; Stone and Truitt 18 reported a mortality of 28.1 per cent in 32 cases treated by the combined intraspinal and intravenous method. Bigelow 19 reported that 70 per cent of 10 cases treated intraspinally at a hospital center in France died; while the mortality was 62.5 per cent in 8 cases given the combined treatment. The usual nonspecific symptomatic treatment was used, of course, in all cases. Cases of recurrent meningitis were treated, as a rule, in the same way as were primary infections. Serum sickness occasionally followed the serum treatment in meningitis, but no cases of anaphylaxis occurred. COMPLICATIONS, SEQUELS, AND CONCURRENT DISEASES Complications or sequelae of various kinds occurred in more than one-third of the 4,831 cases admitted to hospital primarily for cerebrospinal meningitis; however, the case fatality was only 32.3 per cent among these complicated cases, while the fatality among the uncomplicated cases was 41.1 per cent. 218 COMMUNICABLE AND OTHER DISEASES Some of the more important complications and sequelae which wore re- ported are shown in the following table: Disease Arthritis_________________ Ankylosis________________ Apoplexy. _......--------- Bronchitis_______________ Cardiac dilatation....... Cystitis__________________ Conjunctivitis___________ Choroiditis______________ Endocarditis, acute_______ Erysipelas_______________ Epididymitis (nonvenereal) Neuroses, functional______ Hemorrhage......._______ Hearing, defective________ Iritis_______...........____ Laryngitis________________ Myocardial insufficiency.-- Cases Deaths 79 6 7 0 5 2 62 27 3 3 8 4 fi 0 4 1 13 5 17 7 9 0 1 1 1 29 0 3 0 2 2 15 3 Case mortal- ity Per cent 7.6 0 40 43.5 100 50 0 25 :«. 4 41.1 0 37 100 0 0 100 20 Disease Mastoiditis_______ Nephritis: Acute_________ Chronic_______ Neuritis__________ Neuralgia_________ Otitis media....... Pericarditis_______ Pleurisy: Suppurative... Serofibrinous-. Paralysis: Facial____..... No cause stated Paraplegia________ Pneumonia: Lobar......___ Bronchial_____ Cases Deaths 39 27 14 7 14 5 28 U 4 n 100 42 13 4 12 8 6 5 4 0 50 2 6 0 120 92 144 117 Case nortal ity 'er cent 69.2 50 35.7 0 n 42 30.7 66.6 83.3 0 4 0 76.6 81.2 It will be noted that the mortality of meningitis, complicated by pneumonia, was especially high. The records of the Surgeon General's Office show that in the Army during the World War the following concurrent diseases occurred in cases of cere- brospinal meningitis: Disease i Case Cases | Deaths mor- | tality Acute articular rheumatism_____ 12 | 5 Diphtheria____________________ 9> 1 Influenza______________________ 67 24 Per cent 41.6 ! Measles____ 11.1 : Mumps___ 35. 8 \ Scarlet fever Cases Case Deaths mor- tality Percent 32 17 53.1 68 10.2 8 1 12.5 The same records show also the occurrence of cerebrospinal meningitis as a concurrent disease in patients already suffering with the following diseases: Disease Cases Measles__________________ 93 Influenza_________________ 542 Mumps__________________ 35 Otitis media_______________ 23 Case Deaths mor- tality Per cent 37 39.7 256 47.2 10 28.5 14 60.8 i Disease Bronchitis... Pneumonia: Lobar___ Bronchial Cases j Cast- Deaths j mor- tality P(r cent 4 16.6 73.3 47.6 PREVENTION The measures employed to prevent meningitis in the Army during the World War can not be considered as altogether successful. In spite of the great care exercised in the isolation of cases, wholesale examinations made to detect and eliminate carriers of meningococci, and the various other methods employed to limit the spread of the disease, the incidence of meningitis in troops was much greater than in the civilian population. These experiences, however, were of value, as they helped to crystallize scientific opinion concern- ing the relative practical value of the different preventive methods tried. CEREBROSPINAL MENINGITIS 219 Since the meningococcus, a delicate organism which dies quickly outside the body, is probably disseminated only by human cases or carriers, most of the methods used for controlling meningitis aimed at the prevention of contact between persons harboring the organism and normal individuals. All meningitis patients were given specific and general treatment and were carefully isolated until disposed of, or until their secretions became free of meningococci, thus minimizing the danger of secondary contact infections during the course of the disease and eliminating the menace of "convalescent carriers." The special precautions observed varied; in some instances patients were isolated in separate rooms, but usually they were kept in isolation wards in which the beds were separated by sheets arranged to form cubicles. As a rule gowns were worn by the attendants and often gauze face masks were used by attendants, patients, or both. Antiseptic solutions of various kinds were used extensively for the disinfection of the hands and the upper respira- tory secretions, and occasionally were employed as gargles or nasal sprays by attendants and patients. The experience in the Army and in civil communities indicates that healthy individuals rarely contracted meningitis from patients having the disease. Usually, it was very difficult to trace the infection from any patient to a pre- ceding one. This was no doubt largely due to the great care with which patients were isolated during treatment. Whenever a case of meningitis occurred, all persons who had been closely associated with the patient were isolated, and nasopharyngeal cultures were made and examined for meningococci. Usually several individuals known as " contact carriers " were found who, although they showed no evidence of menin- gitis, harbored meningococci in the mucous membranes of the nose or throat. The percentage of carriers among contacts was greater than among noncontacts, and in the former group the percentage was highest among those most inti- mately associated with the patient. Contact carriers were isolated until their nasopharyngeal cultures indicated that they were free from meningococci. Various antiseptics and antimeningo- coccus sera were used locally, and vaccines were administered subcutaneously in attempts to eradicate meningococci from the upper respiratory tract. The results of such treatment were not of obvious value, but fortunately the carrier state in contacts was usually temporary and even without treatment over two- thirds of them cleared up in a short time. Many observers thought that, except in carriers with diseased tonsils, sinuses, or pharynx where surgical removal of the focus was indicated, it was best to rely chiefly on exercise, fresh air, and sunlight for treatment of the carrier state. Incubationary carriers or persons in the incubation stage of meningitis were rarely identified by nasopharyngeal cultures before clinical signs of the disease became manifest. When detected, they were isolated, of course, and given the usual specific and general treatment. Extensive carrier surveys made in many of the camps showed that from ] to 3 per cent of apparently normal individuals, who presumably had not been associated with meningitis cases, harbored meningococci in the upper respiratory tract. These persons were called "casual" or "noncontact carriers." 220 COMMUNICABLE AND OTHER DISEASES In some of the camps where meningitis was especially prevalent meningo- coccus carriers were reported as follows: At Camp Funston, Shorer20 found 3.22 per cent in 102,179 nasopharyngeal cultures; while Stone and Truittls reported 2.1 per cent in 196,000 cultures; and according to Baeslock,21 2.6 per cent carriers were identified in 19,178 cultures at Camp Jackson. An unusually large proportion of carriers, 9.1 per cent, was reported by Robey22 in 10,076 cultures at Camp McClellan, where meningitis occurred relatively infrequently. Lamb23 found 1.28 per cent in 20,208 cultures at Camp Cody, while at Camp Lewis 1.4 per cent carriers were reported in 18,998 cultures. The isolation and treatment of these large numbers of meningococcus carriers proved to be a very difficult problem. They were kept in special wards, hospitals, or in segregation camps. Many antiseptics, including dichloromine- T, tincture of iodine, silver nitrate solution, and others were used locally in the nose and throat. The injection of meningococcus vaccines or local applica- tions of serum apparently had no specific effect upon meningococci in the respira- tory passages. Although some observers claimed that certain antiseptics were effective, it can be stated that no generally satisfactory specific cure for the carrier state was found. Apparently, outdoor exercise and exposure to sunshine was about as effective as the use of drugs in the treatment of meningococcus carriers. The results of attempts to immunize normal individuals against menin- gococcus infections by means of specific vaccines were inconclusive. Theoretically, it should be possible to prevent the occurrence of meningitis by the isolation of all cases and carriers, but the experience of the World War demonstrated the futility of such a course in large, active military organizations. As a result, during the latter part of the war it was considered advisable to limit isolation and treatment to actual cases of meningitis and contact carriers and to attempt to keep down infection by paying particular attention to the improvement of the general living conditions. REFERENCES (1) Weichselbaum, A.: Ueber die Aetiologie der akuten Meningitis cerebro-spinalis. Fortschritte der Medicin. Berlin, 1887, v, No. 18, 573; Ibid., No. 19, 620. (2) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. I, 350. (3) Ibid., 592. (4) Ibid., 127. (5) Ibid., 264. (6) Dopter, Ch.: Etude de quelques germes isoles du rhino-pharynx, voisins du m<§ningo- coque (parameningocoques). Comptes Rendus Hebdomadaires des Seances et Mi- moires de la Societe de Biologic Paris, 1909, lxvii, Tome ii, 74. (7) Gordon, M. H.: Cerebrospinal Fever. Special Report Series No. 50. British Medi- cal Research Council, His Majesty's Stationery Office, London, 1920, 17. (8) Official History of the War (British). Medical Services, Diseases of the War. His Majesty's Stationery Office, London, Vol. I, 147. (9) Flexner, Simon: Control of Meningitis. The Journal of the American Medical Association, Chicago, 1918, lxxi, No. 8, 638. (10) Wegeforth, Paul, and Latham, Joseph R.: Lumber Puncture as a Factor in the Causa- tion of Meningitis. The American Journal of the Medical Sciences. Philadelphia 1919, clviii, No. 2, 183. CEREBROSPINAL MENINGITIS 221 (11) Weed, L. H.,; Wegeforth, Paul; Ayer, J. B.; and Felton, L. D. : The Production of Meningitis by Release of Cerebrospinal Fluid. The Journal of the American Medical Association, Chicago, 1919, lxxii, No. 3. 190. (12) Herrick, W. W.: Early Diagnosis and the Intravenous Serum Treatment of Epidemic Cerebrospinal Meningitis. The Journal of the American Medical Association, Chicago, 1918, lxxi, No. 8, 612. (13) Biological Files, S. G. O. (Old Supply Files). (14j Overseas finance and supply records. On File, S. G. O. (Old Supply Files). (15) MedaUa, Leon S.: Epidemic Meningitis Situation at Camp MacArthur. The Military Surgeon, Washington, 1919, xliv, No. 3, 258. (16) Robison, J. S., and Gerstley, J. R.: An Experience with Epidemic Meningitis. The Journal of the American Medical Association, Chicago, 1919, lxxiii, No. 15, 1134. (17) Landry, Adrian A., and Hamley, Wm. H.: Epidemic Cerebrospinal Meningitis at Camp Beauregard, La. The American Journal of the Medical Sciences, Philadelphia, 1919, clvii, No. 2, 210. (18) Stone, Willard J., and Truitt, Ralph C. P.: A Clinical Study of Meningitis Based on Two Hundred Fifteen Cases. Archives of Internal Medicine, Chicago, 1919, xxiii, No. 3, 282. (19) Bigelow, Geo. H.: Nonepidemic "Epidemic" Meningitis. Archives of Internal Medi- cine, Chicago, 1919, xxiii, No. 6, 723. (20) Schorer, E. H.: Epidemic Meningitis and Detection of Meningococcus Carriers. The Journal of the American Medical Association, Chicago, 1919, lxxii, No. 9, 645. (21) Baeslack, Fred W.: Epidemic Cerebrospinal Meningitis at Camp Jackson, S. C. The Journal of the Michigan State Medical Society, Grand Rapids, 1919, xviii, No. 11, 561. (22) Robey, Wm. H., jr.; Saylor, H. L.; Meleney, H. E.; Ray, H.; and Landmann, G. A.: Clinical and Epidemiological Studies on Epidemic Meningitis. The Journal of Infectious Diseases, Chicago, 1918, xxiii, July 26, 317. (23) Lamb, Frederick H.: Epidemic Cerebrospinal Meningitis at Camp Cody. The Journal of Laboratory and Clinical Medicine, St. Louis, 1919, iv, No. 7, 387. CHAPTER V ANTHRAX0 STATISTICAL CONSIDERATIONS Table 31 shows 149 primary admissions for the total Army during the World War, giving an admission ratio of 0.04 per 1,000 strength. Officers and en- listed men, American troops, contributed 148 of these primary admissions, 2 of which were among officers, 123 among white enlisted men, and 6 among colored enlisted men. One case was reported among native troops. There were reported 22 deaths for the total Army among the primary admissions. All of these deaths were among American troops, 19 among white enlisted, 1 among colored enlisted, and 2 among enlisted men whose color was not stated. The case mortality was 14.8 per cent. Anthrax was more common in the Army serving in the United States than in Europe. There were 94 primary adjnissions among white troops and 6 among colored troops serving in the United States. There were 14 deaths among the former and 1 among the latter. About one-sixth of the total number of primary admissions for anthrax in the United States Army occurred among white enlisted men serving in Europe. There were 26 such admissions. (Table 31.) The admissions ratio per 1,000 strength was 0.02. There were no cases reported among colored enlisted men serving in Europe. The records show 15 cases in the American Expeditionary Forces from March to August, 1918. Of these, all but 2 occurred in men who had just arrived on transports, or who had developed the disease during the voyage.1 Of the other two, one developed malignant pustule at the site of an incision caused by shaving. In several lots of shaving brushes collected from among arriving troops, the Bacillus anthrocis was found by bacteriologists in England and in France. Table 31.—Anthrax. Admissions and deaths, by countries, officers and enlisted men, United States Army, April 1, 1917, to December 31, 1919 Total officers and enlisted men, including native troops. Total officers and enlisted men, American troops------ Total officers______________________________________ American troops, total enlisted men. White________________________ Colored________ Color not stated. Total native troops______________________________________ U. S. Army in United States, including Alaska, enlisted men. White_______........._______________________________ Colored--------------------------------........ U. S. Army in Europe, excluding Russia, enlisted men. White________________________________________ Color not stated______________........---------- Admissions Deaths, Absolute numbers Ratios per 1,000 absolute numbers 149 148 2 0.04 .04 .01 22 22 146 .04 22 123 6 17 .03 .02 19 21 1 .03 100 .05 15 94 6 .05 .04 14 1 43 .03 6 26 17 .02 4 2 » Unless otherwise stated, all figures for the World War period are derived from sick and wounded reports sent to the Surgeon General.—Ed. 223 224 COMMUNICABLE AND OTHER DISEASES The distribution of primary admissions for anthrax by camps in the United States is given in Table 32. The disease was uncommon among the troops and occurred sporadically over practically the entire United States. The largest number of primary admissions for any one camp was for Camp Taylor, Ky., where nine cases were reported. Camp Mills, Long Island, N. Y., ranked second, with eight cases. Table 32.—Anthrax. Admissions and deaths, by specified camps of occurrence, enlisted men, United States Army, April 1, 1917, to December 31, 1919 Camps of occurrence Bowie, Tex..... Devens, Mass.. Dix, N.J_____ Dodge, Iowa___ Doniphan, Okla. Fremont, Calif- Gordon, Ga___ Grant, 111_____ Greene, N. C._ Hancock, Ga__ Jackson, S. C... Lewis, Wash___ ■ White troops only; one death was reported among colored troops at Camp Dodge. ETIOLOGY The exciting cause of anthrax was well understood before the World War, and its occurrence in man was well known. It was known that anthrax in man was an industrial disease and occurred commonly among persons working in tanneries on hides, or in factories where hair and wool had been obtained from animals dead of anthrax. In England, in 1917, Coutts 2 reported the finding of anthrax bacilli and anthrax spores in shaving brushes made of imitation badger hair. He was able to trace the source of infection to the use of Chinese horsehair that had been imported as goat's-hair. With the outbreak of anthrax among the American soldiers and its most common site located on the face, the shaving brush was suspected as being the source of infection. Accordingly an investi- gation of the shaving-brush industry, with special reference to anthrax, was made by the United States Public Health Service.3 It was shown that prior to the entry of the United States into the war all, or nearly all of the horsehair and pig bristles used in the United States came from Russia, China, or Japan, after having been submitted to cleaning and disinfecting processes in France or Germany. When the war began in 1914, the materials came direct to the United States by way of the Pacific coast. Through ignorance of the danger, or through an unwarranted confidence in certificates of disinfection that accom- panied the importations, some American brush manufacturers took no pains to insure the safety of the material going into their products.3 Horsehair, which is the most frequent source of shaving-brush anthrax infection, is of both foreign and domestic source. The largest part of that used in the manufacture of shaving brushes in the United States comes from oriental sources, with China and Siberia furnishing by far the greater portion. With the investigation of establishments in the United States which manufacture Admissions Deaths white ° White Colored 4 1 1 4 4 1 1 0 1 5 0 0 2 0 1 0 1 1 • 0 2 2 0 3 2 Admissions Camps of occurrence White Colored Logan, Tex____________ MacArthur, Tex________ Mills, Long Island, N. Y. Pike, Ark................. Shelby, Miss.....______ Sherman, Ohio___....... Taylor, Ky___......____ Travis, Tex..........____ Upton, Long Island, N. Y Wheeler, Ga___________ Total_______...... Deaths white a ----- ------- -- 1 1 7 1 2 1 8 1 4 1 i 0 ......-- 0 l\ — 0 0 0 '■ 1 0 2 1 0 54 5 10 ANTHRAX 225 shaving brushes, a great variance was found in their method of disinfection. Some were deemed safe, while others were deemed totally unsafe. The methods of disinfection employed were, briefly, boiling for periods varying from one- half hour to 9 or 10 hours; steaming in streaming steam for from 1 to 8 hours; treatment in the autoclave for from 15 minutes to 3 hours, subjection to dry heat for varying periods up to a total of 24 hours. It was found that the dis- infection process used on light-colored hair was less thorough than that used on the dark hair. Shaving brushes were secured in the open market and subjected to bacteriological examination. Some were found to be anthrax-infected.3 Coutts 2 reported that the horsehair from China and Siberia seemed to be particularly involved, especially gray or yellow hair imitating badger hair. The anthrax organisms were found not only on the free portions of the bristles, but also on the ends set in the handles. Anthrax was recovered from a new shaving brush at Camp Jackson in November, 1918. The hair was supposed to be badger's hair.3 It is believed that anthrax infection of the skin can occur only when there is an abrasion. In shaving, these abrasions are not infrequently made, and with the use of infected shaving brushes the explanation of the common site of the malignant pustule on the face is readily seen. Among tannery workers, butchers etc., direct inoculation takes place through abrasions from the handling of infected materials. The mode of infection in intestinal anthrax is through the mouth, eitheri n the form of infected, uncooked meat, or by means of the hands carrying infection to the mouth. Workers in infected wool, through inhalation, occasion- ally contract a pulmonary form of anthrax, which is known as "wool sorters' dis- ease." It is very probable that anthrax is not conveyed directly from man to man. PATHOLOGY The malignant pustule shows a circumscribed area with a black depressed necrotic center (carbon, of the French). It is raised and surrounded by an inflamed, edematous, indurated area. Vesiculation occurs in the early stages and surrounds the eschar. The lymph glands located on the chain of lymphatics from the malignant pustule show enlargement and acute inflammation. The spleen is enlarged and shows the presence of anthrax bacilli. In the so-called "wool-sorters' disease" the lungs show a pneumonic process. Occasionally the meninges are involved, showing meningitis. The cerebrospinal fluid in such cases is slightly increased and hemorrhagic, contains the Bacillus anthracis, and shows some increase in the cell count. The following autopsy report and microscopical examination of tissues is that of a fatal case of anthrax, Fort Sam Houston, Tex.: Fort Sam Houston, Tex., May 1, 1918. Autopsy Report No. 61, Pvt. A ------C------C-----•. The body is that of a somewhat slenderly built man, about 167 cm. long. There is slight rigor mortis. There is only moderate livor mortis. The pupils are dilated and equal. The right half of the neck is swollen and slightly indurated. There is a small wound measuring 1 by Y s lost Total mean an-nual strengths Abso-lute num-bers Ratios per 1,000 strength Abso-lute num-bers Ratios per 1,000 strength Abso-lute num-bers Ratios per 1,000 strength Abso-lute num-bers 3,563 Non-effective ratios per 1,000 strength U. S. Army in Europe, excluding Russia: 73,72* 137 1.86 3 .04 .04 .01 1 .01 13 3, 921 74 72S 2.67 1 61 .60 1 1,469,656 122, 412 22 .01 143,552 1,923 19,062 Colored enlisted.............___ 04 Color not stated......__________ 11 1,592, Otis 4. 723 2.97 73 .05 22 .01 164, 537 Total officers and men_______ 1, 665, 796 4,860 2.92 76 .05 23 .01 168,100 . 2S Officers, other countries___________ 8,388 16, 995 21,451 16,161 19,688 5 3 3 .60 .18 . 14 90 82 82 47 206 03 U. S. Army in Philippine Islands: White enlisted............. Total enlisted_________________ .01 U. S. Army in Hawaii, white en-listed___________________________ .01 .03 U. S. Army in Panama, white en-listed......._________........___ 19 .97 1 1 U. S. Army in other countries not stated: White enlisted ___......... 26 1 2 919 6 183 Colored enlisted__________..... I Color not stated___ ____....... --...|---- Total *_________.............. 14, 232 97, 498 10, 535 29 2.04 2 .14 1,108 .21 Transports: White enlisted_____. _______ 104 3 1.07 .28 3 .03 4 .04 2,905 33 Colored enlisted........ _______ .01 Total_______.....______..... Native troops enlisted: Philippine Scouts......._____ 108,033 i 107 .99 18,576 1 .05 5,615 , 1 .18 3 .03 4 .04 2,938 15 12 •07 .00 .01 Hawaiians__________________ ' * Separate strength of white>nd colored not available. DIPHTHERIA 235 Table 34 shows the number of admissions and deaths, together with the annual rates, by months, of white and colored enlisted men, United States Army, for both the United States and Europe. Table 34.—Diphtheria. Admissions and deaths, by months, white and colored enlisted men, United States Army, United States and Europe, April 1, 1917, to December 31, 1919. Absolute numbers and annual ratios per 1,000 strength Mouth and year April...... May_____ June_____ July_____ August___ September. October___ November. December. Total. January-.. February.. March___ April____ May_____ June_____ July_____ August___ September. October___ November. December. January... February.- March___ April____ May_____ June_____ July......_ August___ September. October___ November- December . Total_____ Month not stated Total for period.. White enlisted men United States Europe Mean strength 183,758 245, 454 309,205 458, 817 562, 714 776, 466 1,032,244 1,061,422 1,129,065 479, 929 1,096,434 1,095,039 1,129,223 1,168, 558 1,197, 757 1,303,746 1,328,513 1, 284,247 1, 321,440 1,343,933 1, 255,195 941,219 Admissions Abso- lute num- bers Ratios per 1,000 strength loss 152 213 300 401 349 1, 205, 442 672, 937 471, 815 406, 839 339, 836 291, 810 246,903 215,104 156, 791 149,360 139, 877 132, 403 135, 441 279,926 1,965, 297 424 434 531 607 356 160 111 101 111 79 122 122 3,158 Deaths Admissions Deaths Abso- lute num- bers Ratios per 1,000 strength Mean strength Abso- Ratios ! Abso- Ratios lute per i lute per num- 1,000 | num- j 1,000 bers strength bers Istrengtta 0.98 1.81 2.60 2.82 3.24 3.29 3.49 4.53 3.71 3.42 0.10 .08 .05 .02 .01 .02 .09 626 12,794 28, 821 50, 882 70, 266 92, 139 123,429 160,178 44, 928 1 0.89 13 5.41 7 1. 65 10 8 15 18 1.71 1.04 _______ 1.46 _______ 1.35 ---- 72 1 1.60 _______ 4.64 4.76 5.64 6.23 3.57 1.47 1.00 .94 1.01 .71 1.17 1.56 2.62 .18 .15 .10 .06 .04 .02 .01 .01 .03 172 147 166 130 73 27 16 5,577 3.07 3.74 4.90 4.59 3.00 1.31 .72 .86 .73 .12 .13 .07 193, 264 223,130 283, 268 388,048 587,240 796, 427 1,063,192 1, 266, 592 1, 527, 793 1,635,321 1, 682,836 1, 591,962 43 62 323 209 338 321 237 182 180 248 282 288 936, 589 I 2, 713 1, 488, 683 1,310,083 1,115,693 853, 425 569, 842 271,633 111,634 48,006 30,315 21,055 18, 920 18,379 270 248 187 142 101 77 29 16 4 15 14 22 2.78 .06 488,139 1,125 11 2.84 .05 1,469,656 j 3,921 2.67 3.33 13.68 6.46 6.91 4.84 2.67 1.72 1.41 1.82 2.01 2.17 2.90 2.18 2.27 2.01 2.00 2.13 3.40 3.12 4.00 1.58 8.55 8.88 14.36 2.30 2.67 0.22 .42 .03 .08 .08 .05 .01 .02 .03 .02 .04 .02 .05 .02 .04 .02 .04 2'M\ COMMUNICABLE AND OTHER DISEASES Table 34.—Diphtheria. Admissions and deaths, by months, white and colored enlisted men. United States Army, United States and Europe, April _, 1917, to December 81, 1919. Absolute numbers and annual ratios per 1,000 strength -Continued Colored enlisted men United States Europe Month and year Mean strength 4,870 5,826 5,171 6,675 8,519 9,409 21, 795 39, 225 36, 851 Admissions Deaths Mean strength Adm Abso-lute num-bers ssions Deaths 1917 April_______________ May________________ Abso-lute num-bers .. 2 fi 8 Ratios per 1,000 strength Abso- Ratios lute per num- 1,000 bers strength Ratios per 1,000 strength Abso-lute num-bers Ratios per 1,000 strength July August______________ September_____ _ ___ ......... 2.55 1.10 1.84 2.61 1 935 2,392 5,346 3 6.73 Total 11,529 18 1.56 723 3 4.15 1918 January_____________ February_________ ... 50, 705 49, 955 54, 814 59, 015 87, 650 89,305 124,976 168, 422 164,846 182, 705 150, 587 104,140 3 8 6 13 14 4 4 8 2 5 8 6 .71 1.92 1.31 2.64 1.92 .54 .38 .57 .15 .33 .64 .69 1 0.24 8,673 9, 664 11.541 12,667 28. 279 33, 208 47,171 78, 734 91,270 138,827 148,679 148,372 2 2 3 1 2 1 3 6 K 16 2.08 1.89 1.27 ---- .36 .51 .15 .39 .52 .65 1.29 July 1 .10 September___________ 1 .07 1 0.08 Total__________ 107, 260 81 .76 3 .03 63,090 44 .70 1 .02 1919 68,337 66,104 44,634 29, 824 20, 780 18, 562 20,058 18,013 11,322 9,084 8,792 8,935 7 10 5 2 1.23 1.82 1.34 .81 140,396 131,219 123,152 119,801 108,650 64,166 12, 508 1,741 1,287 185 83 13 7 2 3 1.11 .64 .19 .30 May________________ 1 1 .19 .96 July________________ 2 1.20 August______________ October.....__________ 1 1 1.32 1.36 November.. _ ._____ Total......______ 27,037 28 1.04 58, 599 27 .46 Total for period... 145, 826 127 .87 3 .02 122, 412 74 .60 1 .01 The following summary from Table 34 shows the annual admission rates by location, years, and race: For white troops 1917______ 1918 in United St; ite S ! 3. 2. 2. 1. 2. 2 42 fi? 1919______ 78 For white troops tionary Forces 1917______ in American E: _pedi- fin 1918______ 90 1919______ 30 For colored troops in United States: 1917____________________________ 1918_______________________•____ 1919____________________________ For colored troops in American Expedi- tionary Forces: 1917___________________________*_ 1918____________________________ 1919_______________________ 1. 56 . 76 1.04 4. 15 . 70 . 46 DIPHTHERIA 237 A study of these figures shows that white troops had a much higher rate in the United States during 1917 and 1919 than did those in the American r-xpcditionary Forces; while the latter, during 1918, the period of greatest activ- ity overseas, had the higher rate. Seasonal variation was not significant, except that in 1917 the prevalence at home remained consistently high through- out the year; while in 1918 and 1919 it was high during late winter and spring, and low during the summer. In the American Expeditionary Forces the incidence rate was excessively high in July, 1917; it then dropped to a low point and remained low until late winter, when it climbed rapidly, reaching the peal- in March and remaining fairly high until midsummer. During 1919 in the American Expeditionary Forces the rise came in June and, except during Sep- tember, remained high to the end of the year, reaching the high point of the war (14.36 per 1,000) in December. There seems very little correlation throughout the period between the rate of prevalence at home and abroad. One might expect to find a lag in the American Expeditionary Forces curve, showing a summer rise, produced by an influx of carriers from the spring peak in the United States; there is some indication of such a condition in the early part of 1918. Considering the whole period, white troops in the United States had an annual admission rate of 2.84 per 1,000, while those in Europe had 2.67. Among the colored troops the rate at home was 0.87 and in Europe 0.60. There is nothing significant in the difference shown between troops at home and abroad, and comparison is hardly justified. All troops numbered as in the American Expeditionary Forces were also counted at some period among home troops, and it is reasonable to presume that unknown passive carriers were sources both at home and in Europe. Table 33 indicates that for the whole period, April 1, 1917, to December 31, 1919, the admission rate for the Army in the American Expeditionary Forces was 2.92 per 1,000; while that of the Army at home was 2.63. This difference of 29 cases per 100,000 men is not significant, and was undoubtedly influenced, particularly in the early part of the period, by imported cases. For example, in December, 1917, the strength of colored troops was 5,346 (Table 34), or 3 per cent of the entire strength, yet they furnished 3 cases, or 15 per cent of the total (21) for that month. It is quite probable that the cases in question origi- nated in the United States. OCCIRREXCE IN THE UNITED STATES Figures for the Army in the United States (Table 33) show a total of 5,SS46 cases in an aggregate strength of 2,235,389, or an annual incidence rate of 2.63 per 1,000. The deaths totaled 96, making an annual rate of 0.04 per 1,000 and a case fatality rate of 1.6 per cent, or 16 deaths per 1,000 cases. As noted previously and shown graphically in Chart XXX, there was a noticeable difference between white and colored troops in resistance to diph- theria. As conditions of exposure wrere practically the same for both, the varia- tion in prevalence is best accounted for by the hypothesis of crediting the colored soldiers with higher resistance or less susceptibility. However, when the appar- *> This figure represents primary admissions. 238 COMMUNICABLE AND OTHER DISEASES ent higher immunity in the latter race is broken down by invasion, there is less resistance to the toxic effect of the microorganism, and the case fatality is much higher than among the whites; 23 per 1,000 as against 16 per 1,000. The days lost for each case (Chart XXX) are practically the same for white and colored, and the noneffective rate correlating with the admission rate, is, of course, much higher for the white troops. Officers in the United States (Table 33) show an aggregate strength of 124,266 and 180 cases, or an annual rate of 1.45 per 1,000; among these there were 4 deaths, giving a case fatality of 2.22 per cent, or 22 deaths per 1,000 cases, which is considerably higher than that for the enlisted men (16 per 1,000). It is interesting to note (Table 33) that the officer strength, 124,266 is approxi- mately within 20,000 of the colored strength, and the case fatality rates are fairly close, the difference being 1 death per 1,000 cases. The lower incidence rate among officers is probably due to their more advanced age, as we know that immunity to diphtheria increases with each year beyond childhood. The higher fatality rate among cases may be assigned to the same hypothesis applied to colored troops. It is well known in all chil- dren's diseases attacking adults that the case fatality is high. Presumably, the adult victims are a small percentage who have built up little or no immunity, and the virus finds a favorable soil for development. BY CAMPS A study of Chart XXXI and Table 35 shows at once that camps in the central area had a decided influence on the general admission rate. Camp Doniphan, Okla.; Camp Pike, Ark.; Camp Funston, Kans.; Camp Grant, 111.; and Camp Dodge, Iowa, furnished 17 per cent of the aggregate strength and 50 per cent of the diphtheria. These camps were populated from the agricultural area of the United States, and possibly a large proportion of the men had never been subjected to the exposure incident to density of population and industrial conditions of the East, and hence had acquired less immunity. Chart XXXII shows graphi- cally the decided susceptibility of men from the agricultural States. It is quite true that many of our southern camps drew men from agricultural regions also, but a large percentage of their strength was colored, which, as already shown, had a decidedly racial resistance. The northwest area had a rate just below the average for the United States, but this position was characteristic of the men from this section, for all causes of admission. DIPHTHERIA 239 DIPHTHERIA. COMPARATIVE RATES WHITE & COLORED ENL. MEN-UNITED STATES APRIL. 1917-DEC. 1919 5 1.0 ,--- ADMISSIONS RATIOS PER 1000 1.5 2.0 2.5 3.0 3.5 wmk. 4.0 4.5 5.0 2.84 .87 .0 .05 .10 .15 DEATHS RATIOS PER 1000 .20 .25' .30 .35 .40 .45 .50 .05 .02 CASE FATALITY PERCENTAGE RATES 4 5 6 7 8 9 10 1.60 2.36 .0 .1 .2 NONEFFECTIVE RATIOS PER 1000 .3 .4 .5 .6 .7 .8 .9 .10 .19 .05 0 5 10 DAYS LOST AVERAGE FOR EACH CASE 20 25 30 35 40 45 50 24.60 22.80 DISCHARGES FOR DISABILITY .0 .01 .02 .03 RATIOS PER 1000 .04 .03 .06 .07 P"":"1?* __1 .08 .09 .10 .03 .01 WHITE! COLORED| Chart XXX 240 COMMUNICABLE AND OTHER DISEASES Table 3.5.—Diphtheria. Admissions and deaths, by camps of occurrence, white and colored enlisted men, United States Army, April 1, 1917, to December 31, 1919, inclusive. Abso- lute numbers and annual ratios per 1,000 strength ! Total mean strength White enlisted men Colored enlisted men Total Admissions enlisted men Deaths Admi ssions If 6 ~j C3 0.30 1.51 3.58 1.90 .92 1.42 5.21 21.57 Deaths Admi; g S ° a o si sions Deaths Camps a 3 a 3.C 1 6 38 81 69 42 64 173 577 a 3.5 c o o o aa a W _ O -W 3 3 "si eg .2 K 8 3 a "c o o _ s~ 1^ a a 3-Q o 2 3 3 2 -i a 3 a o >-3£ O s o o b_ c ~ a. Beauregard, La_ ______ Bowie, Tex____________ 20, 625 26,193 22, 636 37, 631 47, 921 49, 7X6 39, 032 26, 747 6, 7X0 8,980 15,414 56,222 44,871 49,256 29, 710 11,959 37,994 12,836 42,011 22,267 25, 472 57, 635 47, 792 27, 734 25,271 28,664 50,033 24,197 49, 587 27, 786 30, 432 26, 507 42,750 3,367 46, 962 44,264 44, 871 31, 809 25, 726 339 """"_ | 6. 09"" 2 .06 2 .04 1 2.37 7.35 45 81 69 43 67 180 577 0.34 1.72 3.58 1.83 .90 1.35 4.61 21.57 2 2 2 0.09 .05 .04 2.47 2.90 1 3 7 .45 .62 1.21 4.65 Dix N J 3 1 .09 7 .26 3 .08 .26 1.67 Doniphan, Okla ___..... 1.21 l 17 345 20 216 126 3 38 4 19 18 47 22 98 86 106 16 84 203 226 8 17 52 114 1 47 19 43 64 13 1.10 6.89 .53 5.10 4.81 .25 1.04 .41 .52 .91 1.85 .43 2.07 3.23 4.36 .60 2.00 8.85 5.53 .31 .59 2.03 3.08 .30 1.10 .5i 1.07 2.12 .54 1 1 .06 5 .10 17 361 22 227 126 3 38 4 22 18 47 27 98 88 106 17 88 206 228 8 17 54 122 1 47 22 48 65 13 2 1.10 6.42 .49 4.61 4.24 1.00 .31 .52 .81 1.85 .47 2.05 3.17 4.19 .59 1.76 8.51 4.59 .29 .56 2.04 2.85 .30 1.00 .50 1.07 2.04 .51 5.90 1 5 .06 .09 5.89 16 2 11 2.59 .29 1.59 1.39 Grant, 111 4 1 .09 1 .04 4 2 .OX .07 1.76 * 0.28 1.59 , 1 | .10 1 .OX .00 3 .59 1 1 .04 1 .04 2.13 5 .75 1 , .02 1 i .04 1 .04 1 1 1 .02 .04 .04 1.02 2 1.87 1.14 .C4 McClellan. Ala 1 } 2 .47 .50 Meade, Md l .02 1 .04 8 .20 1 1 s .02 .04 .16 1. 14 Mills, N. Y____________ Pike, Ark 2.39 .23 --- -- .49 3.51 Shelby, Miss ____ i 2 8 2.26 1.38 2 .05 1 .17 3 .07 2.46 Taylor, Ky____________ 1 3 5 1 .46 1.07 .60 Upton, Long Island, N. Y. Wadsworth, S. C_______ 2 5.90 _____ Total - ______ 1,270,069 3,122 2.69 44 .04 89 .80 2 .02 3,211 2.53 46 .04 1.43 Among the camps in the Central United States which had high admission rates, the following case fatalities are found (calculated from cases and deaths, Table 35): Camp Pike, Ark.: Cases_______________________ 226 Deaths______________________ 8 Case fatality (percent)________ 3.54 Camp Grant, 111.: Cases_______________________ 216 Deaths______________________ 4 Case fatality (per cent)________ 1. 85 Camp Dodge, Iowa: Cases_______________________ 173 Deaths______________________ 3 Case fatality (per cent)________ 1. 73 Camp Funston, Kans.: Cases_______________________ 345 Deaths______________________ 5 Case fatality (per cent)_________ 1. 45 Camp Doniphan, Okla.: Cases_______________________ 577 Deaths______________________ 7 Case fatality (per cent)_________ 1.21 DIPHTHERIA 241 DIPHTHERIA. BY CAMPS ADMISSIONS. WHITE ENLISTED MEN. U.S. APRIL. 1917-DEC. 1919 RATIOS PER 1000 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Chart XXXI 56706—28- -16 242 COMMUNICABLE AND OTHER DISEASES Chart XXXI indicates very clearly that Camp Doniphan, Okla., led all stations in the United States as a diphtheria center. Reefer, Friedberg, and Aronson l show that sporadic cases were present through the period October, 1917, to February, 1918, when the admissions increased rapidly; there was a slight fall during the first week of March and then a secondary rise, reaching the highest point during the week ending April 7. The outbreak studied by these authors covered the period October 7, 1917, to May 31, 1918, and included 461 of the 577 cases occurring between April 15, 1917, and December 31, 1919. The undue prevalence was rather sharply limited to February and March. A careful study was made of carriers and, as might be expected, the carrier rate paralleled the morbidity. As indicated above, the case fatality was low, pointing to low infectivity of the microorganism. A study of occurrence by organizations showed decided DIPHTHERIA, BY NATIVE STATES WHITE ENL MEN, U.S. & EUROPE, U.S. ARMY APRIL, 1917-DEC, 1919 RATIOS PER 1000 Chart XXXII resistance on the part of those coming from urban centers, except among hos- pital personnel, where continued exposure to presumably heavy infection broke down the resistance of urban as well as rural dweller. In all other camps diphtheria was present, but did not show any alarming increase other than an occasional slight rise in admission rates, with seasonal changes, and the addition of carriers coming with augmented population. OCCURRENCE IN THE AMERICAN EXPEDITIONARY FORCES Table 33 shows a total mean annual strength of 1,665,796 in the American Expeditionary Forces, with 4,860 admissions, or an annual rate of 2.92. There were 76 deaths, giving a case fatality of 1.56 per cent, or 15 deaths per 1,000 cases. While the annual admission rate (2.92 per 1,000) is higher than that for troops in the United States (2.63), the period of higher incidence is practi- cally limited to the spring of 1918 and the fall of 1919. The latter period was one of markedly reduced strength, with concentration of troops in the occupied area in Germany, and increased contact with civilian carriers in younger age groups. The rate of incidence was not significant; for example, in December 1919, there were only 22 cases. Since the strength now had fallen to 18,379, the resultant annual rate for the month (14.36 per 1,000) is high. DIPHTHERIA 243 Considering diphtheria as a divisional problem, which it properly became in the American Expeditionary Forces, there were only 2 divisions of the total 42 in which the disease became at all alarming. The history of diphtheria in each unit was traced by Neal and Sutton.2 Both these divisions came from camps in the United States where there was undue prevalence, namely, Camp MacArthur, Tex., and Camp Doniphan, Okla. It is quite reasonable to pre- sume, then, that each division brought its own sources of infection in carriers, and the necessary crowding in trains, transports, and billeting provided increased means of spread. The two divisions affected were the 32d, which came from Camp Mac- Arthur, Tex., and the 35th, from Camp Doniphan, Okla. The 32d Division had a constant source of known infection from the time it left camp until it reached its area in France; that is, cases developed in Camp MacArthur just before departure of the division (February 4, 1918); others ap- peared en route to Camp Merritt, and while in this camp awaiting embarkation. Various units of the division were separated for transportation to Europe. It was well along in April, 1918, before the division was concentrated in its area in France, but the incidence of diphtheria in certain units as they arrived was sufficiently high to demand immediate investigation. Surveys revealed a con- siderable number of carriers as well as clinical cases. Several units of this divi- sion had practically no cases, while among others it reached epidemic proportions. The division moved into the Alsace sector on May 14, and continued having sporadic cases until about July 18, when the epidemic virtually subsided. The effect of this division's diphtheria is shown in the admission rate for the Amer- ican Expeditionary Forces during the spring of 1918. (See Table 34.) The 35th Division had a similar experience to that of the 32d, but less alarming. There were, however, a sufficient number of scattered cases con- stantly present to demand attention from June to September, 1918. The divi- sion left Camp Doniphan about the time the epidemic, previously mentioned, was subsiding. Its subsequent diphtheria indicates, as might be expected, that carriers were present throughout the organization. The disease was quite prev- alent during the ocean voyage, and while in England 27 scattered cases were reported for the week ending May 29. The division moved shortly after this date, and on June 5 entrained in France for the American area. Forty-eight hours of close contact followed, and a week later there was a sharp rise in diph- theria admissions. The division finally reached its sector in the Vosges Moun- tains, and troops were distributed in billets and dugouts. There was less opportunity in this situation for contact and spread, and the morbidity rate declined. During this same period a field laboratory was assigned to the division, and all contacts were cultured and the Schick test was made on them. The resultant weeding out of carriers, active and passive, was undoubtedly the deciding factor in preventing an epidemic in the organization. The concentration of American forces for the St. Mihiel and the Meuse- Argonne operations found diphtheria well controlled and no longer a cause for alarm, but now the hospital centers were beginning to feel its presence.2 244 COMMUNICABLE AND OTHER DISEASES IX HOSPITAL CENTERS The first hospital center to report an undue prevalence was that at Mesves. One of its units, Base Hospital No. 54, found during the month of October, 191N, that 1 per cent of its admissions was due to diphtheria, and several cases appeared among the hospital personnel. During the first two weeks of Novem- ber, 1918, 34 cases appeared in the center personnel and 50 per cent were among those on duty at Base Hospital No. 54. The diphtheria prevalence occurred during the last three months of the year, when hospitals were badly over- crowded, the center under discussion averaging 18,000 patients. In the other centers, the disease was much less prevalent than at Mesves, though quite a number of cases occurred among patients and personnel. Base Hospitals Nos. 25, 26, and 49, Allerey center, reported a number of nurses and orderlies as carriers who had been diagnosed carriers in the United States. PATHOLOGY In the vast majority of instances during the World War the character- istic lesion, the false membrane, was located on the fauces. Its extension into the larynx, trachea, and bronchi occurred, although not frequently. Other changes occurred due to the absorption of diphtheria toxin or mixed infection. An analysis of 20 protocols on file in the Army Medical Museum, Washington, D. C, obtained from diphtheria cases autopsied during the World War, show the following pathological processes: Pleurisy, 5; laryngeal diph- theria or ulceration, 14; tracheal diphtheria, 9; extension into the bronchi, 5; pneumonia, 15; endocarditis, 2; myocarditis, 9; pericarditis, 5; nephritis, 6; hydro thorax, 1; fatty degeneration of the heart muscle, 3; basilar edema, 1; meningitis, 1; gangrene of the tonsils, 1; edema of the glottis, 2; acute splenitis, 7; pneumothorax, 1; bullous emphysema, 2; cloudy swelling of the liver, 8, of the kidney 7, and of the heart, 5; petechial hemorrhage, 4; evi- dences of gassing, 3; septicemia, 6; urticaria, 1. The blood was examined for diphtheria bacilli four times, all of which were negative. Duration of the disease after admission to hospital varied from 1 to 19 days, with an average of 5. 3 days. The cases of longer duration, generally speaking, showed heart involvement. Among 4, 500 autopsy reports after pneumonia, the diphtheria bacillus was recovered in five instances, once from the bronchus and four times from the consolidated lung. Among 13,246 autopsies in the American Expedi- tionary Forces, 26 were on bodies of diphtheritic cases. A study of these protocols showed that 12 cases died during the acute stage of the disease. Of the others, 11 died from later complications or contributory causes. SYMPTOMS Types of the disease by location of the membrane are: Faucial, nasal laryngeal, bronchial, and wound diphtheria. The records of the War Depart- ment do not permit of analysis for the total Army by such types; however the vast majority of the cases were faucial; for example, at Camp Custer' Mich.,3 among 55 cases the membrane was situated as follows: Pharynx 4' DIPHTHERIA 245 tonsils, 41; tonsils and pharynx, 10; pharynx and larynx, 1; nose, 1. That cases of laryngeal diphtheria, and extension of the process into the trachea, bronchi, and even into the lung tissue itself, occurred is shown by reports of tracheotomy and autopsy protocols; however, the exact number of such cases in the Army is not known. In the severely gassed, pseudo membranes often occurred in the bronchi and trachea which masked the diagnosis of diphtheria. Depending upon the severity of the disease, diphtheria is arbitrarily divided into the following types: Mild, moderately severe, severe, and malignant. This classification was used by the Army during the World War as a basis upon which to determine the antitoxin dosage. Figures, by types, are not available, but numerous reports, at home and abroad, indicate that the disease in epidemic form was relatively mild, and that though the more severe types occurred, they were in the minority. COMPLICATIONS, SEQUEL_E, AND CONCURRENT DISEASES Complications and sequelae constitute important phases in the clinical course of diphtheria. Among the total 10,909 primary admissions, 2,439 com- plications were reported, with 107 deaths. The total number of deaths credited to diphtheria among primary admissions is 177. No explanation, other than diphtheria, is found for the cause of death among the remaining 70 cases. The case mortality for the total Army was 1.62 per cent. The most important early complication was pneumonia. This compli- cation is a frequent cause of death, more especially in the laryngeal form of diphtheria. Usually, it is due to a secondary infection by the pneumococcus or pus organisms. In 162 cases pneumonia was reported as a complication of diphtheria, as follows: Bronchopneumonia, 61; lobar pneumonia, 101. The death rate, however, was far greater among the former. There were 10 deaths, or 9.9 per cent, among the lobar cases and 27, or 44.2 per cent, among the bronchopneumonia cases. Perhaps the next most important complications were those involving the heart. Of 21 clinical histories of diphtheria on file in the Surgeon General's Office, the cause of death in 4 cases was attributed to pericarditis, in 2, to myo- carditis, and in 1 to heart block. The average time in hospital before death was 7 days for cases with pericarditis, 6 days for those with myocarditis, and 6 days for those with heart block. Neal and Sutton,2 studying diphtheria in the American Expeditionary Forces, attributed the myocarditis, cardiac paralysis, post-diphtheritic optic paralysis, laryngeal paralysis, and other nerve affections, as well as prolonged convalescence, to inadequate methods of treatment. The clinical histories of 21 men discharged from the service on account of disability following diphtheria show disability to have been due to mitral disease in 2 cases and myocarditis in 1. Tachycardia was noted in 25 of the primary admissions and neurocirculatory asthenia among 14. Among cases in which diphtheria was a concurrent disease, pericarditis was noted in 1, aortic insufficiency in 2, mitral insufficiency in 7, mitral stenosis in 3, myocarditis in 7, tachycardia in 2, and neurocirculatory asthenia in 6. 246 COMMUNICABLE AND OTHER DISEASES Among 47 protocols of fatal cases of diphtheria in the Army during the World War, laryngeal paralysis was a cause of death in 5. Of 21 cases dis- charged from the service on account of disability following diphtheria, there were 11 instances with paralysis of the upper extremity and 12 of the lower. Optic neuritis was a cause of discharge for disability in 9 cases. The cases with paralysis of the extremities also had laryngeal paralysis in 3 instances. One case was discharged from the service on account of facial paralysis and one each for the following conditions: Otitis interna, myocarditis, psychasthenia, and paralysis of deglutition. Among the 2,439 complications of the cases of diph- theria in the Army, paraplegia was present in 3, and other paralyses in 14 cases. Neuritis (without location) was present in 14 instances. No cases of hemi- plegia were reported. Nephritis was an uncommon complication. It was reported in 20 cases, 8 of which were acute and 12 chronic nephritis; that is, 0.81 per cent of the total complications. Among the nephritides there were 4 deaths, 3 of which fol- lowed the acute form. Meningitis is a rare complication. During the war, five cases of meningitis were reported among primary admissions for diphtheria, 2 of which were of the epidemic type. The Klebs-Loeffler bacillus was not recovered from the cere- brospinal system in any of these cases. Occurrence of diphtheria with the exanthemata is well known and at times offers difficult differentiation, particularly in some cases of scarlet fever. Occur- rence with the most important exanthematous diseases during the war was as follows: Disease Measles_______ Scarlet fever___ Chicken pox___ German measles Mumps______ Total___ DIAGNOSIS The diagnosis of a typical faucial case is not difficult. The presence of a membrane in the throat of a patient acutely sick should immediately suggest diphtheria, and the case should be observed and dealt with accordingly until this tentative diagnosis has been confirmed by clinical and laboratory means. The onset of diphtheria is acute; locally there is usually a membrane, and the patient is suffering from an acute toxemia. However, other organisms are capable of producing false membranes—pneumococcus, streptococcus, bacillus of Friedlander, and Bacillus pyocyaneus. Rarely in diphtheria no membrane is formed. In practice the diagnosis of diphtheria is justifiable, provided the patient is acutely sick, suffering from a membranous sore throat, the micro- scopical examination of which reveals the presence of an organism morpho- Primary admis- Complicating diphtheria sions Cases Deaths 98,225 11,675 1,757 17,378 230,356 23 64 5 4 90 0 1 0 1 1 359, 391 186 3 DIPHTHERIA 247 logically similar to the Klebs-Loeffler bacillus. If the patient has no consti- tutional symptoms, although diphtheria bacilli are found in the exudates, he is a carrier of a virulent or an avirulent strain, and clinically the case is not one of diphtheria. Theoretically, in order to establish a diagnosis of diphtheria, the patient must have local and general signs of the disease, the diphtheria bacillus must have been isolated from the local lesion in pure culture, it must have been proved to be virulent, and the case must have responded to antitoxin. In practice, virulence tests are reserved for carriers, and antitoxin is used for therapeutic or prophylactic and not for diagnostic purposes on man. Although the diphtheria bacillus is abundantly present in the local lesion, carelessly taken smears may fail to reveal them; therefore, cultures should be taken with care and from the most suspicious area. Dependence can not be placed upon one negative culture. Early diagnosis is of the greatest importance, not only for treatment, but in prevention as well. Too much emphasis can not be placed on this, since it was noted during the war, especially in the American Expeditionary Forces, that battalion and regimental surgeons occasionally were reluctant to make a clinical diagnosis of diphtheria;2 furthermore, some cases occurred on transports returning to the United States where late diagnosis was made and the cases terminated fatally on the day of, or the day after, debarkation in the United States. Differential diagnosis between diphtheria and follicular tonsillitis, Vincent's angina, scarlet fever, streptococcic sore throat, peritonsillar abscess, and syph- ilitic ulceration of the mouth is important. In addition to these, cases of retropharyngeal abscess, phlegmon of the glottis, and severe gassing must be carefully examined in order to differentiate from laryngeal diphtheria. Diag- nosis based upon careful physical examination and bacteriological examination is possible. In the above-mentioned conditions clinical examination alone may not furnish sufficient data for differential purposes. The fact must also be borne in mind that diphtheria may be engrafted upon one or the other of these conditions, or the case may be in reality a diphtheria carrier and clinically suffering from some other condition. Therefore, a correct diagnosis can be made only by a careful analysis of the physical findings in conjunction with the laboratory report. During the war, severely gassed cases in whom laryngeal fibrino-purulent membranes were formed strongly resembled diphtheria. Medical officers serving overseas often remarked on the difficulty in differential diagnosis from diphtheria. The membrane in gassed cases, according to Barron and Bigelow,4 covered the lining of the larynx and trachea and extended from the epiglottis down into the bronchi and bronchioles. The tissues of the ventricles and vocal cords were at times markedly edematous, producing voice changes and mechan- ical obstructive breathing. This membrane rarely extended up into the larynx or over the tonsils; but nearly all of the serious cases of diphtheria had severe laryngeal manifestations, so that even at autopsy it necessitated close scrutiny to differentiate between laryngeal diphtheria and laryngitis and tracheitis following gassing. Besides, diphtheria was occasionally superimposed upon laryngitis following gassing. 24S COMMUNICABLE AND OTHER DISEASES CONTROL AND PREVENTIVE MEASURES The most important measures for control and prevention of diphtheria are early recognition of cases and carriers and their proper isolation. Frequent inspections of men with sore throat, and culturing them will detect the cases. Not infrequently, cases occur where the symptoms are mild and the throat presents a beefy red appearance with but little membrane. Upon careful examination, pinhead-sized patches may be seen. Such cases usually have an elevated temperature, and are important in the spread of the disease. The wholesale culturing and administration of antitoxin to all those in mediate or immediate contact is a thing of the past in dealing with masses of soldiers. The control of diphtheria is principally the detection and control of diptheria carriers. Nichols 5 makes the statement that in theory the detection and management of carriers have been carried almost to perfection, but in practice the system breaks down because the number of men exposed and the number susceptible are large. Since laboratory and clinical facilities are usually limited, only a certain number of cultures can be examined daily, and a much smaller number of virulence tests made. Furthermore, a limited number of Schick tests can be made daily and several days of observation are needed, while only a few persons can be quarantined and held under observation. The result is, the bacteriological plan of attack fails and common sense must govern. Clinical cases are to be considered first, and as much carrier work done as is feasible.5 The Surgeon General, on January 1, 1918, outlined the procedure to be followed in the case of diphtheria.6 These instructions were briefly as follows: Strict isolation was to be instituted. Male attendants were to be segregated and not allowed to eat or sleep with other members of the medical detachment. Nurses were to be provided with special quarters and messing facilities. When on duty in the wards, all female nurses, male attendants, and medical officers were to wear operating gowns, caps, and gauze masks over the nose and mouth; the hands were to be thoroughly washed and disinfected after coming off duty and before leaving the ward. Cultures were to be taken every fourth day from the personnel on duty in diphtheria wards, and no nurse, officer, or enlisted man was to be assigned to other duty until negative cultures were obtained. The bedding, clothing, etc., of patients and the gowns and caps of attendants were to be thoroughly disinfected by steam or chemicals before going to the laundry; nasal and oral discharges of patients were to be disinfected or burned; dishes, etc., were to be sterilized before being returned to the general kitchen. Diph- theria convalescents and carriers were not to be returned to duty until three consecutive negative cultures, taken at intervals of from three to six days, were obtained. Diphtheria carriers were not to be segregated in the same room with men sick with diphtheria, but in a suitable segregation ward, camp, or barrack. In addition the Schick test was to be applied to nurses and male attendants and those not immune were to be immunized. Diphtheria patients were invariably hospitalized; also some of the carriers. When in hospital, they were assigned to special wards where cubicles and masks were used. Weaver7 claimed that, coincident with the use of the mask there was an absence of diphtheria and diphtheria carriers among the physicians and nurses of his hospital and only a limited amount of throat infection. At Camp DIPHTHERIA 249 Sherman, Ohio, before the days of universal masking, it was difficult to obtain a sufficient number of negative cultures of both diphtheria and meningitis patients to permit their release from hospital.8 At Camp Grant, 111., experi- ments were conducted with the mask in contagious wards, and it was concluded that this was a valuable agent in preventing cross infection.9 Haller and Col- well 10 conducted extensive experiments with varying layers of gauze possessing different-sized fibers and mesh, and showed that about six layers of ordinary gauze should be used. Barron and Bigelow,4 stated that it was impracticable, of course, to mask all of the 16,000 individuals in the hospital center where they worked, though one hospital of the center tried masking its entire personnel. Cubicles were recommended by them to supplement the masks of the patients, since few could sleep with the mask in place. The original mask had two layers of gauze with a mesh of 14 to 16. It was recommended by them that two such masks be worn, since two thicknesses were insufficient. The personal cooperation of the patients was held to be absolutely essential to individual quarantine. The following thorough procedure was adopted at Camp Sherman, Ohio, in the control and prevention of diphtheria there:8 (a) Procedures adopted in line organizations after diagnosis of a case: Detection of one or two carriers does not call for quarantine. All contacts of the company are segregated (intimate contacts). All contacts are Schicked, cultured (nose and throat), and masked. Transfer all carriers to hospital for observation and treatment and immunize all those showing positive Schick tests. (b) Procedure in wards where diphtheria appears: Where the patient is able to be transferred— Transfer the patient to the diphtheria ward and do not institute quarantine. Examine all close contacts by culture and Schick testing. Mask all personnel and patients of the ward. No patients will be transferred to other wards until the culture is negative. If a case develops among the carriers, then reculture the entire ward. Give prophylactic serum to all with positive skin tests. If the patient is too ill to be transferred— Quarantine the entire ward and place the patient in a single room of the ward. Culture and Schick test the entire ward and mask all patients and personnel. Transfer all detected carriers to the carrier ward, if possible; if not, place them in cubicles. Repeat the culturing at two-day intervals. When the patient's condition permits, transfer him to the diphtheria ward. Quarantine is lifted when two negative cultures are received. Procedure among suspects sent to hospital— Mask them on entering the ambulance and hold under observation in an observation ward until a diagnosis is made and then make the transfer. (c) Procedure in diphtheria and diphtheria-carrier wards: At all times quarantined, cubicle the patients and mask the personnel. Keep patients, convalescents, contacts, and carriers segregated by groups. Several hospitals found it advisable to culture patients on admission, notably the hospitals at the port of embarkation, Hoboken, N. J.11 Although toxin-antitoxin mixtures were thought of during the war as a prophylactic measure, this means of conferring immunity was used to a very limited extent. It was not considered a practical war measure on account of the time required for administration and to establish immunity. 250 COMMUNICABLE AND OTHER DISEASES TREATMENT Laryngeal diphtheria, cases seen late for the first time in treatment, and those occurring as a complication of an exanthem, should be regarded as severe and treated accordingly. In severe cases, suspected of being diphtheritic, it is better to give antitoxin and not await the results of laboratory reports, as valuable time may be lost. Cases of death due to anaphylactic shock are so rare that possible death from this cause does not justify withholding antitoxin, even intravenously, where the severity of the disease warrants its administra- tion. However, in cases known to be sensitive to horse serum, desensitization may be attempted. The favorite dose of antitoxin used in the Army was 20,000 units, injected, as one dose, into the buttock. There is no record of desensitization having been used before giving serum during the war. If hypersensitiveness to serum is feared, an hypodermic of adrenalin should be available for immediate injection. This precaution was taken by many medical officers. A study of many World War protocols shows that antitoxin was often repeated; for example, in one case, in which death occurred 2 days after admis- sion to hospital, 4 injections of 20,000 units each were given, 2 subcutaneously and 2 intravenously. In another, wdiere tracheotomy was performed immedi- ately on admission to hospital, 30,000 units were given intravenously. As stated above, several cases were transferred from transports, upon arrival in the United States, and died soon after debarkation from laryngeal diphtheria. In some of these cases 50,000 units or more were given. Tracheotomy was not an uncommon form of treatment in laryngeal diphthe- ria in the Army. The low operation was the one of preference. However, so far as the available data show, all cases died; these cases were seen late and irrep- arable damage was done before treatment was commenced. The O'Dwyer intubation sets were freely distributed during the war, but there is no record of intubation having been performed. As regards the treatment of serum sickness in diphtheria, this differs in no way from that occurring in any other disease. It usually appears a week or 10 days after serum administration and responds immediately to hypodermic use of adrenalin. Since this response is of short duration, however, the intense itching is relieved only temporarily; therefore a saline purgative should be given, which usually reduces the intensity of symptoms. This condition is of short duration and commonly borne by soldiers without treatment. There is no dis- coverable record of sudden death occurring in the Army during the war follow- ing the use of serum in any form. DIPHTHERIA 251 Table 36.—Diphtheria carriers. Admissions, discharges for disability, and days lost, by coun- tries of occurrence, officers and enlisted men, United States Army, April 1, 1917, to Decem- ber 31, 1919, inclusive, absolute numbers and annual ratios per 1,000 Total mean annual strengths Admissions Discharges for disability Days lost Absolute numbers Ratios per 1,000 strength Absolute numbers Ratios per 1,000 strength Absolute numbers Noneffec-tive ratios per 1,000 strength Total officers and enlisted men, including 4,128, 479 4,092,457 206,382 5,043 5,041 112 1.22 1.23 .54 9 9 0 0 98, 579 98, 383 1,163 0.07 Total officers and enlisted men, American .07 .02 Total American troops: White........____________......_____ 3, 599, 527 286, 548 4,634 99 196 1.29 .35 8 0 91,147 2,127 4,126 .07 .02 1 Total............_____......_____ 3,886,075 4,929 1.27 9 0 97,400 .07 36,022 2 .06 16 .00 Total Army in the United States (including Alaska): 124,266 80 .64 665 .01 1,965,297 145,826 2,957 76 1.50 .52 8 0 49,235 1,264 .07 .02 2, 111, 123 3,033 1.44 8 0 50,499 .07 2,235,389 3,113 1.39 8 0 51,164 .06 V. S. Army in Europe, excluding Russia: 73, 728 32 .43 498 .02 1,469,656 122,412 1,661 22 195 1.13 .18 41,624 848 4,116 .08 .02 1 1, 592,068 1,878 1.18 1 0 46, 588 .08 1, 665, 796 1,910 1.15 1 0 47,086 .08 U. S. Army in Philippines Islands: 16,995 4,456 1 .06 8 14 .00 .01 21,451 1 .05 22 .00 U. S. Army in other countries: 10 1 170 10 14, 232 11 .77 180 .03 Transports: 97,498 10, 535 5 1 .05 .09 110 1 .00 .00 108, 033 6 .06 111 .00 Native troops enlisted: Philippine Scouts--- 18, 576 2 .11 16 .00 » Separate strength of white and colored not available. 2")2 COMMUNICABLE AND OTHER DISEASES CARRIERS Only carriers who were admitted to hospital were reported to the Y\ ar Department; therefore no record was made of those kept in quarantine areas except when under hospital jurisdiction. This being so, it is impossible^ to estimate the number of carriers detected in the Army during the World War, since various camps used their own methods of control. Table 36 shows the number of primary admissions to hospital for diphtheria carriers. There were 5,043 such admissions for the total Army, the total mean annual strength being 4,128,479 men. The ratio per 1,000 per annum was 1.22. Officers contributed 112 primary admissions, a ratio of 0.54, and enlisted men the remaining 4,929, which gave an annual admission ratio per 1,000 strength of 1.27 for the latter. The carrier state was not common among colored troops; only 99 primary admis- sions were reported for colored troops against 4,634 for white troops. The ratios per 1,000 were 0.35 and 1.29, respectively. The number of carriers among native enlisted troops was negligible, there being but two reported. In the United States there were 3,113 primary admissions for the Army, with a ratio of 1.39 per 1,000 per annum; in the American Expeditionary Forces there were 1,910, with a ratio of 1.15. Despite these figures, it is not believed that there were more carriers among the troops in the United States than in Europe. Culturing was as extensively carried out abroad as in the United States, but the difference essentially is, more carriers were admitted to hospital at home than abroad. This was primarily due to the fact that relatively more bed space was available in the hospitals in the United States than in the Ameri- can Expeditionary Forces. Carriers, not being sick, could be cared for as well in isolation camps as in hospital. This method was used extensively abroad. Carriers undoubtedly existed on transports, but it was neither practicable nor advisable to undertake any extended search for their detection. There were but six primary admissions on transports for carrier state. As would be expected, there were no deaths from this cause. Nine cases were discharged from the service for disability on account of a chronic carrier state, eight of which were among white enlisted men and one color not stated. Noneffectiveness caused by carriers was of considerable importance. For primary admissions to hospitals, Table 36 shows a loss of 98,579 days from duty, giving a noneffective ratio per 1,000 per annum of 0.07. Of the total number of days lost, white enlisted men where responsible for 91,147 days and colored 2,127. The remaining days were among soldiers where color was not stated. Time lost in the United States amounted to 51,164 days and in Europe to 47,086 days. The noneffective ratio in the United States was 0.06 and in Europe 0.08. In other words, cases admitted to hospital in the American Expeditionary Forces remained absent from duty over a longer period than for the primary admissions in the United States. The average number of days of hospitaliza- tion per case in the United States was 16.43 and in Europe 24.64. Table 37 shows primary admissions for white and colored troops, respec- tively, in the United States and Europe, by months of occurrence; also the ratios per 1,000 per annum. As before stated, it is seen from this table that the num- ber of cases reported was greater in the United States than in Europe; however, during the latter half of 1918, and for a like period in 1919, the conditions were reversed. This is accounted for by the increase in the diphtheria rate for the army of occupation on the Rhine. DIPHTHERIA 253 Table 37.—Diphtheria carriers. Admissions, by months, white and colored enlisted men, tinted States and Europe, April 1, 1917, to December 31, 1919, absolute numbers and annual ratios per 1,000 April_____ May_____ June....... July______ August___ September- October___ November. December. 1917 Total, 1917. January... February. _ March..... April_____ May_____ June_____ July....... August___ September. October___ November. December. 1918 Total, 1918. January... February.. March____ April_____ May_____ June_____ July______ August___ September. October___ November. December . Total, 1919____ Month not stated___ Total for period. White enlisted men United States Europe 183, 758 245,454 309, 205 458,817 562,714 776,466 1,032,244 1,061,422 1,129,065 479,929 1,096,434 1,095,039 1,129, 223 1,168,558 1,197, 757 1,303,746 1,328,513 1,284,247 1,321,440 1,343,933 1, 255,195 941, 219 1,205,442 672,937 471,815 406,839 339,836 291,810 246,903 215,104 156, 791 149,360 139, 877 132,403 135,441 279,926 1,965, 297 o G "s: ® _. o> bo 3JO o 2w «> « 626 12,794 28,821 50,882 70,266 92,139 123,429 160,178 232 351 341 250 166 104 64 91 64 3 49 239 2,957 .53, 44,928 2.54 3.85 3.62 2.57 1.66 .96 .58 .85 .58 .33 .47 3.05 1.65 1.91 2.87 4.04 5.47 3.66 2.38 .61 .46 1.21 1.89 .45 .71 193, 264 223,130 283, 268 388,048 587,240 796,427 1,063,192 1,266, 592 1, 527,793 1,635,321 1, 682,836 1, 591,962 2.08 .71 .34 10 .22 936, 589 15 181 80 77 79 110 152 74 77 143 138 1,126 .81 7.67 2.47 1.57 1.19 1.24 1.44 .58 .57 1.02 1.04 Colored enlisted men United States 870 826 171 675 519 409, 795 . 225, 851 1 0.31 14 4.56 50,705 49,955 54,814 59,015 87,650 89,305 124,976 168,422 164,846 182, 705 150,587 104,140 1.20 107,260 .47 1.44 .44 .81 .41 .54 .10 .14 .44 .07 .40 .92 .41 1,488, 1,310,083 1,115,693 853,425 569,842 271,633 111,634 48,006 30,315 21,055 18,920 18, 379 2. 56 j 488,139 1.50, 1,469,656 1,661 .69 .91 1.05 .59 .84 1.33 1.83 2.25 .40 1.71 41.85i 13.05 68,337 66,104 44, 634 29, 824 20, 780 18, 562 20, 058 18,013 11,322 9,084 8, 792 8, 935 .53 .18 2.42 1 .58 1 .65 I 1.06 1 1.32 Europe 935 2,392 5,346 8,673 9,664 11,541 12,667 28, 279 33,208 47,171 78,734 91,270 138,827 148, 679 148, 372 63,090 19 0.42 1.08 .25 .13 .09 .16 .81 .30 140,396 131,219| 123, 152 . 119,80c 108,6501. 64,1661. 12,508: 1,741 . 1,287 . 185 83 . .09 . 18 1.051 27,037 V, . 63 58, 599 1.13 145,826 76 .52| 122,412 i I The number of carriers reported by months shows a distinct seasonal occurrence, which reached its height during the colder months of the year. This is not true in so far as colored troops were concerned, among whom the cases reported were only sporadic. The trend is better brought out by the re- ports of primary admissions of carriers in the United States. In addition to the 5,043 primary admissions, the carrier state was reported 2,359 times as a concurrent condition. This makes a total of 7,402 carriers reported as patients. It is not believed, however, that 2,359 represents the total number of carriers detected among patients during extensive outbreaks of diphtheria in our large hospital centers oversea; numerous carriers were detected, the rush of work preventing recording all such cases. 254 COMMUNICABLE AND OTHER DISEASES At Camp Custer, Mich., Blanton and Burhans3 found 14S carriers among 8,236 soldiers examined, or 1.8 per cent. McCord, Friedlander, and Walker* found 89 contact carriers among 3,215 soldiers at Camp Sherman, Ohio, or 2.76 per cent. Keefer, Friedberg, and Aronson1 reported 686 carriers among about 30,000 men cultured at Camp Doniphan. The most extensive report on the detection of carriers is that of Schorer and Ruddock11 from the embar- kation and debarkation hospitals, New York City. There, on account of the ex- tensive occurrence of diphtheria, routine culturing of all patients admitted to hospital was deemed necessary. Table 38 shows the results of some 50,000 admissions of soldier patients arriving on transports at this port. Table 38.—Results of cultures for the detection of diphtheria bacilli among soldiers arriving- at the port of Hoboken on transports, December, 1918, to May, 1919 Debarkation Hospi- tal No. 3 Month December. January... February.. March___ April_____ May....... Patients 4,482 2, 958 3, 198 5, 651 8, 520 2, 378 Posi- tive Per cent Total. .76 1.22 1.59 1.23 .95 27, 187 1.07 Debarkation Hospi- tal No. 5 Patients 810 1,442 2,958 5,473 4,047 14, 730 Posi- tive Per cent 1.73 1.32 1.52 1.11 .79 Debarkation Hospi- tal No. 2 Embarkation Hospi- tal No. 4 Patients 2,261 2,033 1,128 1, 10S Posi- tive 6,530 Per cent 2.65 2.41 1.51 .45 Patients 384 278 425 294 438 229 Posi- Per tive cent 2.16 2,048 0.52 .72: .24 .34 .23 .44 .39 Grand total: Patients, 50,495; positive, 612; per cent, 1.21. Table 38 shows that the percentage of positive cultures varied from 0.39 to 2.16. Debarkation Hospital No. 2 served largely as a contagious hospital, Embarkation Hospital No. 4 for officers and nurses, while Debarkation Hospitals Nos. 3 and 5 were used for general enlisted men's debarkation hospitals. The percentage for December, 1918, and January, February, and March, 1919, was higher than during the following April and May. While 1.2 per cent of positive cultures is not high, yet the actual number, 612, is large when the short period of time and the actual number of exposures are considered. Table 39 shows the relationship between carriers and clinical cases in Debarkation Hospital No. 3. Table 39.—Diphtheria carriers and clinical cases of diphtheria, relative occurrence, at Debar- kation Hospital No. 8, New York, December, 1918, to May, 1919 Month Admissions (total) Carriers Clinical cases 1918: December___ 4,482 2,958 3,198 5,651 8,520 2,378 34 37 51 70 81 19 2 13. 1919: January______ February_______ March______ 20 April____ 30 May 1-15 - 15 In the American Expeditionary Forces, as well as in the United States, the diphtheria carrier was a serious problem in preventive medicine; however DIPHTHERIA 255 routine culturing of line organizations was not considered practical or neces- sary. Upon the appearance of diphtheria, contacts were examined for the detection of carriers. Messmates, soldiers of the same sleeping quarters (more especially those whose beds were adjacent), and members of drill squads were considered contacts for quarantine and culture purposes. The search for car- riers in hospitals was usually confined to patients and personnel of the ward where cases occurred; but in some instances the disease was so widespread that it necessitated examination of many wards. Reappearance of cases necessi- tated a second, or further, culturing for carriers. In Base Hospitals Nos. 25, 26, and 45 of the Allerey hospital center, several nurses and enlisted men of the Medical Department were detected as carriers who were known to be carriers in the United States before departure for overseas, but had been released upon the report of three negative cultures.2 In Base Hospital No. 25, 75 carriers were found, 333^ per cent of whom gave histories of having been gassed. Since the incubator space was limited to 2,000 cultures per day, entire hospital centers were not cultured. It was remarked that it would require about eight days to culture the population of the Allerey hospital center, which approximated 16,000 persons.2 Such delay would have resulted in the loss of much of the ben- efit of extensive control measures. Some 13,000 cultures were made on selected cases. Carriers in the Savenay hospital center offered the same problem of control.2 Direct or indirect contact with one harboring the organism is necessary for the development of a carrier. If the strain with which the individual becomes infected is an avirulent one, or if virulent and the individual is immune, a car- rier state results. Enlarged or diseased tonsils have been shown to harbor the germs with great tenacity. The presence of excessive lymphoid tissue in the nasopharynx, atrophic rhinitis, hypertrophied turbinates, deflected nasal sep- tum, or any chronic condition that interferes with nasal ventilation predisposes the individual. Empyema of the accessory nasal sinuses and open suppurating wounds of all kinds, at times, show the presence of virulent or avirulent diph- theria bacilli. Like the disease itself, diphtheria carriers are more common dur- ing the colder months when respiratory diseases are most prevalent. Judging from our experience during the World War, carriers are much more common among white persons of the soldier age than among colored. Weaver and Mur- chie 12 cultured the hands of internes and nurses, also door knobs of the hospital, for the purpose of showing what part they played in the spread of diphtheria. Hemolytic streptococci were also looked for during these examinations. The technique was that commonly used in isolating these organisms; virulence and antitoxic immunization tests were also used. Of the persons examined, who came in contact with diphtheria patients, a total of 268 examinations were made by taking smears from under the fingernails and from the palmar surface of the right index finger. Of these 9.3 per cent showed the Streptococcus hemolyticus and 3 per cent the diphtheria bacillus. Of 45 nurses, 35.6 per cent showed the streptococcus and 13.3 per cent the diphtheria bacillus. Among 51 cultures made from graduate nurses, specially trained in the care of diphtheria patients and actually engaged in this work, 2 per cent showed the Streptococcus hemolyti- cus and none the diphtheria bacillus. Of 45 cultures made from 3 internes, 250 COMMUNICABLE AND OTHER DISEASES 15.6 per cent yielded the Streptococcus hcmolyticus and 6.7 per cent the diph- theria bacillus. Each of the three internes showed the diphtheria bacillus on one occasion after ordinary washing. It was recovered after autopsy on a diph- theria case where no rubber gloves were worn. Cultures were also made from the door knobs in 137 instances. The Streptococcus hemolyticus was found in 5.8 per cent and the diphtheria bacillus in 4.4 per cent. All of the above exam- inations were made after ordinary washing with soap and water. Barron and Bigelow 4 made 522 cultures from the hands of patients, and from fomites in wards containing diphtheria as well as in wards where no diphtheria was reported. This was done for the purpose of showing the value and danger of the face mask in the spread of diphtheria bacilli. The following is a summary of this work: Exposed wards: Typical B. diphtheria—- Per cent On "masked" hands_______ 6.3 On "masked" fomites______ 8. 1 Typical B. diphtherise— On "unmasked" hands_____ 16. 1 On "unmasked" fomites____ 4.9 Atypical B. diphtherix—- On "masked" hands_______ 6.3 On "masked" fomites___ __ 11.7 Exposed wards—Continued. Atypical B. diphtheria"— Per cent On "unmasked" hands_____ 14. 9 On "unmasked" fomites---- 7. 4 Unexposed wards: Atypical B. diphtherise—- On "unmasked" hands_____ 5. 9 On "unmasked" fomites____ 5.0 "Exposed wards" were wards in which clinical cases of diphtheria or carriers were treated; "unexposed wards" were wards in which no cases of diphtheria or carriers had been found. The term "masked" means that the patient whose hands or fomites were cultured wore a mask, while " unmasked" means, conversely, that he wore no mask. Typical diphtheria bacilli were found nearly three times as often upon the hands of those not wearing masks as upon those wearing them. TECHNIQUE OF EXAMINATION FOR CARRIERS The detection of carriers bacteriologically requires the same technique as in the search for cases; however, the taking of specimens differs. In the former, there is usually no acute pathological process as a guide to the most probable site where the organisms may be found and found in great preponderance. In routine culturing for carriers a sterile swab is pressed and passed firmly over the faucial surfaces, particular attention being paid to the tonsils. The swab is then stroked over the surface of a blood serum slant which is incubated and later examined as in the detection of cases. Additional swabs, made from the nasal passages, increase the percentage of positive cultures. Both faucial and nasal smears may be made on the same slant. This method was used in some instances, especially at Camp Doniphan, Okla.,1 although it may be said that most medical officers were content with the faucial specimen, except in selected carriers where the carrier state became chronic and the focus of infection was sought for. It was emphasized by medical officers repeatedly during the war that single cultures, irrespective of the technique used, would reveal only a portion of the carriers. The percentage varies between wide limits. Among healthy DIPHTHERIA 257 persons of various ages, single cultures show from 1 to 30 per cent to be carriers, with an average of 3 to 4 per cent, and probably reveal less than one-half of the persons infected. As regards the pathology of chronic carriers, Nichols5 states that among incubationary carriers the bacilli are found in large numbers at the site of the common lesion; in contact carriers nothing specific is found, and among chronic convalescent carriers the tonsil is by far the most common focus of infection. Occasionally, however, the organisms are found in sinuses or in adenoid tissue. There is no local inflammatory reaction with an outpouring of exudate into the tonsillar crypts; therefore the organisms are not easily detected. Keefer, Friedberg, and Aronson,1 reporting 294 patients at Camp Doniphan, Okla., where the tonsils were removed to relieve the carrier state, found 57 per cent positive and 43 per cent negative in cultures made from the tonsil immedi- ately preceding the operation. Cultures of the tonsils made after tonsillectomy gave positive results in 77.2 per cent. They concluded that 22.8 per cent of the cultures were negative and emphasize the importance of not relying upon a single examination. Blood cultures were made by them from 43 contact throat carriers, 9 convalescent throat carriers, 3 wound carriers, and 2 wound cases. All were sterile except 1 and that may have been a skin contamination. Urine cultures were made from centrifugalized specimens of 26 carriers and all were negative. The feces were negative in all of 21 carriers examined. Simmons, Wearn, and Williams13 examined the blood of 25 carriers for isohemagglutinins, according to the Moss classification, with the following results: Group 1, 4 per cent; group 2, 24 per cent; group 3, 12 per cent, and group 4, 60 per cent. Virulence is the most important factor as a guide to subsequent manage- ment. If the carrier is an early convalescent or a contact one, no virulence test is necessary, as most of these strains are virulent; but if the carrier state is a long or doubtful one, then virulence tests are indicated. As to retesting for virulence, this is not necessary, since avirulent strains never acquire virulence and virulent strains retain their virulence with great tenacity. Although about 10 per cent of chronic carriers are found to harbor virulent organisms, those who have not been in contact with cases do not seem to be of importance. At camp Custer, Mich., among 148 carriers found, 24 strains were recovered and tested for virulence on guinea pigs.3 Of these 88 per cent were avirulent. Simmons, Wearn, and Williams,13 reporting on the virulence of 52 strains among throat and wound carriers, state that the percentage among contact throat carriers was 48.1 per cent, and from canvalescent throat carriers 84.6 per cent. Blanton and Burhans3 expressed the opinion that too much reliance is probably placed on the so-called "virulence tests." Duration of the carrier state is either short or prolonged, lasting from a few days to months or years. The average period of hospitalization for car- riers, previously admitted to hospital for this condition, was 19.54 days. In the United States the average was 16.43 and in the American Expeditionary Forces, 26.04 days. When analyzed more in detail, it is seen that the duration varied between wide limits. At Camp Custer, Mich., the average number of days in hospital among 148 carriers was 11.7 days.3 At Camp Doniphan, 56706—28---17 25N COMMUNICABLE AND OTHER DISEASES Okla., it was arbitrarily assumed that the carrier state, among patients conva- lescing from diphtheria, commenced at the end of the third week of the disease, since the average case becomes bacteria free at that time.1 It was found that 91.3 per cent of convalescent carriers became baccillus free at the end of the second week following tonsillectomy, among 294 carriers operated upon. The length of time required for the carrier state to end in the debarkation and embar- kation hospitals, New York City,11 is shown in Table 40. Table 40.—Diphtheria carriers. Duration of carrier state, embarkation and debarkation hospitals, New York. Absolute numbers and average periods of hospitalization by 10-day groupings Hospital Ship O'Reilly_____ Debarkation Hospital No. 1. Debarkation Hospital No. 3. Debarkation Hospital No. 5. Embarkation Hospital No. 4 Number of car- riers 65 100 276 36 Period of hospitalization Less than 10 days 10 to 20 days Num- Per ber cent 46.1 42.0 64.2 Average N number ! Yl" of days j Der 5.1 7.0 S.4 Per cent 36.9 35.0 26.7 8.5 10.5 Average number of days 12.9 13.7 12.7 15.3 11.8 20 days or longer Num ber Per cent 18.3 2.3 5.4 2.3 Average number of days 22.7 28.7 24.4 22.0 Grand average in days 12.2 10.94 8.0 8.1 This table includes 543 carriers tabulated by hospital and subdivided into 3 classes as follows: Less than 10 days; 10 to 20 days; and 30 days or longer. It is seen that the averages varied from 8.0 to 12.2 days. There were some chronic carriers in all of these hospitals, but officers and nurses cleared up quickly. The majority were only temporary carriers. On the hospital ship O'Reilly only 12 per cent cleared up in 12 days or less as compared with the results of Embarkation Hospital No. 2, where, among 270 carriers, but 9 had to remain in isolation for more than 3 days. As to the handling of diphtheria carriers, during the earlier months of the war practically all such carriers in the United States were hospitalized, their presence being looked upon with grave apprehension. As time went on, how- ever, and space in hospitals became less available, it became the practice to isolate carriers (except incubationary and convalescent) in barracks or tent areas especially set aside for the purpose. Incubationary and convalescent carriers continued to be cared for in hospital. As soon as practicable after being quarantined, each carrier was given the Schick test. Contact and chronic carriers showing positive skin tests were immunized, generally with 1,000 units of antitoxin. In rare instances a toxin-antitoxin mixture was used. Pseudocar- riers were released as soon as detected. If a carrier state was a prolonged one, it was often shortened by transfer to hospital for tonsillectomy or virulence testing. In hospitals, carriers were assigned to wards where cubicles and masks were used; in barracks, improvised cubicles were used. The quarantine of contacts was considerably shortened by the use of throat cultures and the Schick test. It was considered safe to release carriers 24 hours after all suscep- tibles had been immunized. DIPHTHERIA 259 TREATMENT OF CARRIERS Various chemicals were used locally to clear up carriers. Tincture of iodine seems to have been the favorite. Diphtheria antitoxin was used locally and by injection without success. The only local measure that seems to have met with general favor was tonsillectomy. At Camp Sherman, Ohio, tonsil- lectomy was performed on a number of cases with prompt results.8 Of the 294 carriers treated by tonsillectomy, reported by Keefer, Friedberg, and Aronson, 32 per cent had no further positive cultures, while 46.4 per cent were negative at the end of one week, and 91.3 per cent negative at the end of the second week. Striking results were seen after tonsillectomy at Camp Custer.3 The consensus of opinion of medical officers seems to have been that in chronic car- riers where diphtheria bacilli were located in the tonsils, by far the best form of treatment is tonsillectomy. This method of treatment could not be expected to produce favorable results if there were foci of diphtheria bacillus infection elsewhere. Other than this, it may be said that local treatment was, in general, ineffective in relieving the carrier state. Briefly, it may be said that carriers of avirulent organisms are harmless and attemps were made to isolate only carriers of virulent bacilli. Appropriate treatment, depending upon the kind of carrier, was given. For release from quarantine, three consecutive negative cultures, without treatment, at daily intervals, or on alternate days, were required. A long protracted isolation was not looked upon with favor unless the organism was a virulent one. WOUND DIPHTHERIA Diphtheria bacilli are capable of producing a false membrane in wounds. These organisms may exist alone or associated, and it appears that no variety of wound is immune. Wound diphtheria has been reported as complicating empyema wounds, chronic suppurating wounds in general, especially such as amputations, burns, bites, blisters, contusions following gunshot injuries, com- pound fractures. Though there is usually a false membrane, diphtheria infec- tion has been found where no membrane was present. This, however, is the exception. There is usually a fetid, offensive odor, which, too, may be absent. All authors reporting on this subject apparently agree that the diagnosis of wound diphtheria can not be made with certainty upon clinical grounds alone; nevertheless, any unusual appearance in a surgical wound should lead to a bacteriological examination of the discharge; and if an organism is found that resembles diphtheria morphologically or culturally, virulence tests are called for. By this method it can be determined whether the wound infection is really of a diphtheritic nature or not. In the diagnosis of suspicious wounds, where cul- tures made from surface smears are negative, curettement should be done and smears taken from a deeper layer. Hartsell and Morris14 reported upon 60 cases of wound diphtheria in the Army during the World War. In none of these wounds were there any systemic symptoms referable to diphtheria toxin. The clinical appearance of the wound varied; that is to say, 12 per cent showed the grayish membrane typical of diphtheria; one-half showed only a faint grayish discoloration of the granu- lating surfaces; about 6 per cent looked absolutely healthy and ready for 260 COMMUNICABLE AND OTHER DISEASES secondary closure. So far as could be observed, the presence of diphtheria bacilli in the wound had no effect upon healing. The Schick test was performed on 43 patients, 6 being positive. The response to treatment varied. In some cases the diphtheria bacilli disappeared 2 days after treatment, while in others they were very resistant, ranging to 49 days. By far the most efficient treat- ment was tincture of iodine. With this treatment, 15 cases cleared up under 48 hours, and only 11 cases remained positive longer than a week. Antitoxin, in 4 doses of 20,000 units each, was given in 4 cases, but had no effect on ridding the wound of the bacillus. Antitoxin as a wet dressing was also used in two cases without effect. Acetic acid, cauterization, and Carrel-Dakin solution were used without effect. Keefer, Friedberg, and Aronson, reported an epidemic of wound diphtheria in two wards of the base hospital at Camp Doniphan, Okla., where rib resections had been made on account of empyema. Between March and May, 1918, 40 cases occurred. In 33 eases the diphtheria bacillus was found in the wound, while in 12 it occurred both in the throat and wound of the same individual. Simmons, Wearn, and Williams13 reported diphtheria infections with particular reference to carriers, and wound infection with diphtheria bacilli at the Walter Reed General Hospital, Washington. They reported that 42 per cent of the strains from wound carriers were very virulent, while 80 per cent of those from wound cases were very virulent. Neither morphology, fermentation reactions, nor cultural characteristics gave any indication of the degree of virulence of the organism studied. Simmons and Bigelow,14 reporting on diphtheria bacilli in postoperative empyema wounds from the laboratory of the Southern Department at Fort Sam Houston, Tex., found an organism morphologically like the diphtheria bacillus in 60 healing cases. Of the organisms isolated, 17.8 per cent were virulent for guinea pigs, and all of these strains failed to produce acid when grown on saccharose broth for eight days. However, the degree of virulence of sugar negative strains was variable. The morphologic characteristics of virulent and avirulent strains were the same and all cultures contained a mixture of West- brook's types A, C and D with subtypes. They found no evidence of the development of specific agglutinins, precipitins, or complement fixation sub- stances for diphtheria bacilli in the serum of infected individuals. Apparently, there is no invasion of the blood stream by the diphtheria bacillus in wound cases. All methods of treatment proved unsatisfactory, due probably to the growth of the bacilli deep in the granulations. The extent of wound diphtheria in the American Expeditionary Forces is not known. Barron and Bigelow 4 reported its presence at the Allerey hospital center, but the number of cases was not given by them. As a primary admission, wound diphtheria was not tabulated on the Army's list of diagnoses; therefore, the total number of cases can not be determined. The specific treatment of wound diphtheria is that of faucial diphtheria. The treatment of wound carriers is as unsatisfactory as that of throat carriers. Antitoxin, both local and by injection, has been used without satisfactory results for carriers. The unsatisfactory results obtained from local treatment are probably explained by the deep situation of the bacilli. In the work of Simmons, Wearn, and Williams,13 all methods of treatment proved to be unsatisfactory, and, as a rule, the carrier state continued until complete healing of the wound had taken place. DIPHTHERIA 261 REFERENCES (1) Keefer, F. R.; Friedberg, S. A.; and Aronson, J. D. : A Study of Diphtheria Carriers in a Military camp. The Journal of the American Medical Association, Chicago, 1918, lxxi, No. 15, 1206. (2) Neal, M. P., and Sutton, A. C: Diphtheria in the A. E. F. The Military Surgeon, Washington, 1919, xlv, No. 5, 521. (3) Blanton, W. B. and Burhans, Chas. W.: A Report of Diphtheria at Camp Custer, Mich., from September, 1917, to March, 1919. The Journal of the American Medical Asso- ciation, Chicago, lxxii, No. 19, 1355. (4) Barron, Moses, and Bigelow, Geo. H.: Diphtheria at a Hospital Center. The Journal of Infectious Diseases, Chicago, 1919, xxv, 58. (5) Nichols, H. J.: Carriers in Infectious Diseases. Williams and Wilkens Co., Baltimore, 1922, 72. (6) Circular Letter, S. G. O., January 1, 1918. (7) Weaver, Geo. H.: The Value of the Face Mask and other Measures in Prevention of Diphtheria, Meningitis, Pneumonia, etc. The Journal of the American Medical Association, Chicago, 1918, lxx, No. 2, 76. (8) McCord, C. P.; Friedlander, A.; and Walker, R. C: Diphtheria and Diphtheria Car- riers in Army Camps. The Journal of the American Medical Association, Chicago, 1918, lxxi, No. 4, 275. (9) Capps, J. A.: A New Adaptation of the Face Mask in Control Contagious Disease. The Journal of the American Medical Association, Chicago, 1918, lxx, No. 13, 910. (10) Haller, D. A., and Colwell, M. C: The Protective Qualities of the Gauze Face Mask. The Journal of the American Medical Association, Chicago, 1918, lxxi, No. 15, 1213. (11) Schorer, E. H., and Ruddock, A. S.: Detection of Carriers and Missed Cases of Diph- theria in Embarkation and Debarkation of Troops. The Military Surgeon, Wash- ington, 1919, xlv, No. 3, 319. (12) Weaver, Geo. H., and Murchie, J. T.: Contamination of the Hands and Other Objects in the Spread of Diphtheria. Observations on Secondary Infections in Hospitals for Contagious Diseases. The Journal of the American Medical Association, Chicago, 1919, lxxiii, No. 26, 1921. (13) Simmons, J. S., Wearn, J. T., Williams, O. B.: Diphtheria Infections, with Particular Reference to Carriers and to Wound Infections with B. diphtherix. The Journal of Infectious Diseases, Chicago, 1921, xxviii, 327. (14) Hartsell, J. A., and Morris, M. L.: A Report of Sixty Cases of Wound Diphtheria. The Journal of the American Medical Association, Chicago, 1919, lxxii, No. 19, 1351. (15) Simmons, J. S., and Bigelow, G. H.: Diphtheria Bacilli from Postoperative Empyema Wounds. The Journal of Infectious Diseases, Chicago, 1919, xxv, 219. CHAPTER VII THE VENEREAL DISEASES0 STATISTICAL CONSIDERATIONS That venereal diseases were responsible for great noneffectiveness and economic waste to the Army during the World War is shown by the fact that, of the total primary admissions to sick report on account of diseases only, num- bering 3,500,000, venereal diseases were the direct causes in 357,969 admissions, or 10.2 per cent of the whole. If to this number be added cases reported as concurrent with other diseases, the total reported venereal incidence would be 383,706. For admission to hospital, solely on account of venereal disease, there was a loss of 6,804,818 days from duty. Loss to the service is not entirely repre- sented in the above figure, principally due to the fact that it was the practice to return men to their organizations and to a duty status as soon as their phys- ical conditions would permit, further treatment being carried on in the organi- zation while the soldier was on duty status. Inevitably time was lost for treatment, but was not officially charged as such; and in the case of salvarsan treatment for syphilis, carried out during convalescence, more especially in the United States, men were returned to the hospital or dispensary at regular intervals as out-patients, treated and sent back to their organizations, usually with a loss of about one-half day per case. Venereal diseases, as a class, stood second among the most common diseases as a cause of admission to sick report for the Army as a whole, and exceeded the total number of men killed and wounded in action by approximately 100,000. As a cause of loss of time from duty, disregarding the additional time unac- counted for, as explained above, the venereal diseases stood second only to influenza, the greatest scourge of the war. As a cause of permanent disability, requiring discharge from the service, venereal diseases ranked fourth among the most common diseases, being exceeded in this respect by, first, tuberculosis, (5.52), second, valvular heart dis- ease (2.59), third, mental deficiency (2.58). For venereal diseases (2.53), the discharge rate was 49.4 per 1,000 strength for total diseases. There was a marked difference in the discharge rates for white and colored enlisted men, as shown in Table 41. The former had a rate of 1.41 and the latter 18.36 per 1,000 per annum. The highest rate for any troops in the entire Army and serving in any country was 35.57 for colored enlisted men servmg in the United States. The highest admission rate for American enlisted men was among the 21,000 stationed in the Philippine Islands. The rate was 192.12 per 1,000 strength. The second highest admission rate for enlisted men was in the United States (134.33) and the lowest in Europe (34.64). » Unless otherwise stated, all figures for the World War period are derived from sick and wounded reports sent to the Surgeon General.—Ed. 264 COMMUNICABLE AND OTHER DISEASES The admission rate for the total Army during the war period was S6.71, based upon total primary admissions. Venereal diseases were approximately five times more common among colored than among white enlisted men. Among the former there were 95,026 primary admissions (331.02), as compared with 250,597 (69.62) among the latter. Table 41.—Venereal diseases (all). Primary admissions, deaths, discharges for disability, and noneffectiveness, officers and enlisted men, United States Army, by countries of occurrence, April 1 1917, to December 31, 1919. Absolute numbers and ratios per 1,000 Total mean annual strengths Admissions Deaths Discharge for disability Noneffectiveness Abso-lute numbers Ratios per 1,000 strength Abso-lute num-bers Ratios per 1,000 strength Abso-lute num-bers Ratios per 1,000 strength Days lost Ratios per 1,000 strength Officers and enlisted men includ- 4,128,479 4,092,457 206,382 357,969 356,151 3,300 86.71 87.02 15.99 173 170 0.04 .04 10,450 10,422 43 2.53 2.55 .21 6,804,818 6,761,087 105,957 4.52 Total officers and enlisted men, 4.53 Total officers_________________ 5 .02 1.41 Total enlisted men, American troops: White _____......._______ 3,599, 527 286,548 250,597 95,026 7,228 69.62 331.62 106 .03 5,085 5,261 33 1.41 18.36 5, 208,880 1, 323,424 122,826 3.96 56 3 .20 12.65 Total....................... 3,886,075 352,851 36,022 1,818 90.79 50.46 165 3 .04 .08 10,379 28 2.67 .78 6,655,130 43,731 4.69 Total native troops____________ 3.33 Total Army in United States in-cluding Alaska: Officers..........___________ 124,266 1,148 9.24 2 .02 34 .27 42,701 .94 1,965,297 145,826 198,727 84,867 101.12 581. 94 66 36 .03 .25 4,879 5,187 2.48 35.57 3,619,990 1,082,759 5.05 Colored enlisted......______ 20.34 Total enlisted......______ 2, 111, 123 283, 594 134. 33 102 .05 10,066 4.77 4,702,749 6.10 Total officers and men____ U. S. Army in Europe, excluding Russia: Officers______............... 2,235,389 284, 742 1 73, 728 | 2,043 127.37 27.71 104 2 .05 .03 10,100 6 4.52 .08 4, 745,450 60,083 5.82 2.23 1,469,656 122,412 41,011 7,032 7,109 27.91 57.45 35 18 3 .02 .15 161 68 18 .11 .56 1,359, 297 207,661 121,026 2.53 4.65 Total enlisted____________ 1,592,068 55,152 34.64 56 .04 247 .16 1,687,984 2.90 Total officers and men____ 1,665,796 8,388 57,195 109 34.33 12.99 58 1 .03 .12 253 3 .15 .36 1, 748,067 3,173 2.88 1.04 TJ. S. Army in Philippine Islands: 16,995 4,456 3,062 1,059 180.14 237.66 2 1 .12 .22 6 1 .35 .22 77,195 24,385 12.45 Colored enlisted___.......... 14.99 Total enlisted.............. 21,451 4,121 192.12 3 .14 7 .33 101, 580 1 12.98 U. S. Army in Hawaii: 16,161 3,319 813 193 50.30 58.15 7 .43 25,156 4,690 -4.26 3.87 19,480 1,006 51.64 7 .36 29,846 4.20 U. S. Army in Panama: White 19,688 1.748 88.78 1 .05 6 .31 30,870 4.26 U. S. Army in other countries not stated: 3,211 1,448 107 1 17 5 15 73,215 916 Colored enlisted_______ 1,710 i 14 fid Total____.....___........ 14,232 4,766 334.89 1 .07 37 2.60 75. 841 Transports: 97,498 1 2,025 10,535 427 20.77 40.53 1 1 .01 .09 9 .09 23, 157 65 Colored enlisted___ 3,013 1 78 Color not stated___________ _________ 12 90 _______ Total...........__________ 108,033 , 2,464 22.81 2 .02 9 .08 26,260 67 Native troops: Philippine Scouts.. ._..... 18, 576 5,615 11, 831 680 314 824 36.61 55.92 69.64 3 5 20 .16 .89 1.69 17,468 5,788 20,475 2 58 Hawaiian.. _ _____ . ___ 2 82 3 1 .25 i THE VENEREAL DISEASES 265 Venereal diseases, at least during their acute stages, are not among the common killing diseases. Therefore the number of deaths attributed to these causes in the Army during the World War is relatively small. The duration of the war and the length of service were too short for the most fatal type, syphilis, to show its effects. Table 41 shows that 173 deaths were attributed to venereal diseases in the total Army during the war. Among these, 5 were officers, 106 white enlisted men, and 56 colored enlisted men. Three cases were charged to native troops, and 3 to enlisted men whose color was not stated. For a number of years prior to the World War, venereal diseases constituted a cause for the rejection of applicants for enlistment in the Army. Since this cause for rejection obviously could not obtain, in so far as the World War Army was concerned, from the first practically all cases of venereal diseases were deemed acceptable.1 The number of cases discovered among the inducted men on their physical examination after their arrival at Army camps gives a very excellent measuring stick as to the incidence of these diseases among the young adult male population of the United States. From the beginning of hostilities, in 1917, until May 1,1918, about 1,000,000 men were inducted into the Army.2 This is spoken of as the first million and is referred to in Table 42 as Pi. The physical examination blanks used at the time that these men were being inducted provided but one space for the nota- tion of defects and only the major defects were noted; therefore, other defects, including venereal diseases, if not considered the major defect, were not listed. During the same period, organization was taking place with the draft boards and within the camps. Under these circumstances, it is to be supposed that the records do not show the occurrence of venereal disease as fully as was the case subsequently. The second million men, referred to as P2 was called between May 1, 1918, and November 11, 1918. On the physical examination blanks used for the second million men, two spaces were provided for major defects. Local boards and camp examining boards were well organized and running smoothly. The records, therefore, are more complete. This second million was in reality 1,780,000 men, and, as notations shown on the original table2 are based upon 1,000,000 men only, figures used in Table 42 are raised by multi- plying those in the original table by 1.8, in order to estimate the total number of cases. Table 42.—Defects found in drafted men—Venereal disease (all)" >> Group A Group B Group C Group D and Vg Venereal diseases Pi P2 Pi and 2 Pi P2 Pi and 2 Pi P2 P. p and 2 i ' P2 2, 745 198 4,333 Pi and 2 Cl.Vg Total Total Syphilis____ Chancroid.. Gonorrhea.. 2,927 952 22, 812 15,130 2,353 72, 058 18.057 3. 305 94,870 .... 5 2 23 5 2 24 12 ~2_" 279 54 1, 458 291 1,501 54 1 35 1,482 490 4,246 233 4,823 4,541 120 1,135 8,787 353 5,958 27,140 3,714 102,334 Total.. 26,691 89,541 116, 232 1 30 31 | 36 1,791 1,827 2, 026 7,276 9,302 5,796 15,098 133,188 "Source of information: Defects Found in Drafted Men. War Department, 1920, 424. * A—Men selected for full military service. B—Accepted for remediable treatment. C—Accepted for special or limited service. D—Rejected at camps. Vg—Rejected by local boards. Pi—First million men. P2—second million men and others. 266 COMMUNICABLE AND OTHER DISEASES Since venereal disease was not a disqualifying defect, very probably it was not carefully searched for; furthermore, the recorded cases, 133,188, were detected upon a quick routine physical examination without clinical his- tory or full laboratory facilities. With the less complete system of recording, 28,754 instances of venereal disease were reported among the first million drafted men. With the more complete system, as applied in the examination of the second million men, VENEREAL DIS.(ALL) AND MOBILIZATION ADMISSIONS & NO. OF ENL. MEN MOBILIZED. U. S. COMPARATIVE TREND BY MO.. APRIL. 1917-DEC. 1919 ABSOLUTE NUMBERS WMtM0 I..00,000 800.000 I---f LOGARITHMIC SCALE I»I7 VENEREAL US. (ALL) •(SCALE TO LEFT) Chart XXXIII : u j S K o -* Ii. M < I»I9 MOBILIZATION— (SCALE TO RKSHTJ 54,843 cases of venereal disease were recorded by the camp examining boards alone. Taking the second million as an index of occurrence, the grand total of venereal diseases was shown to be 56.69 per 1,000, or 5.67 per cent. Among the 133,188 men with venereal disease reported in the second million, 15,098 were rejected. Venereal diseases accounted for nearly 5.8 per cent of all'de- fects and were the third most important cause of defects found in camps" THE VENEREAL DISEASES 267 If to the cases detected as outlined above we add cases which could be de- tected only by thorough physical examination, including the microscope for gonorrhea, and the dark-field and complement fixation for syphilis, the aggre- gate would be greatly increased. If mcoming men brought venereal disease into the Army, a study by draft increments should show this. Chart XXXIII is designed to show the relation between the total venereal diseases by months (lower line) and the draft increments (upper line). VENEREAL DIS. (ALL) 8 ENLISTED STRENGTH WHITE AND COLORED TROOPS, U. S. AND EUROPE COMPARATIVE TREND BY MO., APRIM917-DEC..1919 .o.ooo.ooo^|AR,THM'c SCALE 8.000.000 6.000.000 S.000.000 4.000.000 3.000.000 2.000.000 1.000.000 800.000 600.000------1 —y- 500.000------—/*- — 400,000------V — } 300.000---y'~-----~ 200,000;,' — 1.000 ABSOLUTE NUMBERS SO. I- Hl CI n i_ a < a -» •» t u> o 1*19 VENEREAL DIS. (ALL) — >x_Sii<_**>oi B.o_co- 1917 1919 STRENGTH: WHITE-------.: COLORED Chart XXXIV Much has been said relative to the high incidence rate of venereal dis- eases among colored men. Where the number of inducted colored men was greater than the number of inducted white men, the incidence rate was also greater. Chart XXXIV shows the strength trend of white and colored enlisted men in comj_arison with the trend for venereal diseases. If this be consid- 268 COMMUNICABLE AND OTHER DISEASES ered in conjunction with Chart XXXIII, it becomes apparent that the pro- portion of venereal admissions increased as the proportion of colored strength to the white strength increased. To assist further in this visualization Chart XXXV has been prepared. This chart shows the actual monthly strengths for white troops, but the monthly strengths for colored troops were raised VENEREAL DIS. (ALL) 6 ENLISTED STRENGTH ACTUAL FOR WHITE TROOPS BUT BOTH RAISED FOR COLORED TROOPS. U. S. & EUROPE COMPARATIVE TREND BY MO.. APRIL. 1917-DEC. 1919 ^LOGARITHMIC SCALE ABSOLUTE NUMBERS 1917 1918 STRENGTH: WHITE--------; COLORED 1919 VENEREAL DIS. (ALL)' Chart XXXV to what they would have been if the mean annual strength for the two races, for the war period, had been the same. The mean annual strength for the white troops for the war was to that of the colored troops as 12.805 is to 1. The actual monthly strengths for colored troops were, therefore, multiplied by the factor 12.805 to obtain the raised strength. In the same manner the THE VENEREAL DISEASES 269 number of admissions for colored troops in the United States and Europe were multiplied by this factor to obtain the corrected number of cases for each month, which was then added to the true monthly admission figures for the whites. These figures were used as a basis for the heavy line. Chart XXXV, considered in conjunction with Charts XXXIII and XXXIV should enable one to visualize the comparative effects of the white and colored population upon the absolute number of cases of venereal disease reported. It shows how closely the increase in venereal diseases followed the rise in the colored enlisted strength and how nearly the line of cases of venereal diseases paralleled the line for colored enlisted strength until the last peak of mobili- zation was passed in July. Chart XXXV also shows that colored enlisted men were inducted later and demobilized earlier than the white enlisted men; in other words, the average colored soldier was in the military service during a shorter period of time than was the white soldier. OCCURRENCE IN THE ARMY IN THE UNITED STATES Since the larger proportion of cases of venereal disease was imported into the service at the time of the draft, and since active steps were taken in the latter part of the summer of 1917 to prevent men with venereal disease from embark- ing for service abroad,3 it is clear why the majority of cases should have been reported in the United States. Table 41 shows that of the total admissions for venereal diseases in the Army during the war, numbering 357,969, troops serving in the United States contributed 284,742, or 79.6 per cent. Whereas the admission rate per 1,000 per annum was 86.71 for the entire Army, the rate at home was 127.37. The admission rate was high for both white and colored enlisted men, being 101.12 and 581.94, respectively; but was low for officers (9.24). Although the admission rate for white enlisted men was less than one-fifth that for colored enlisted men, it was about one and one-half times the mean ratio of the total Army. OCCURRENCE IN THE AMERICAN EXPEDITIONARY FORCES In considering the incidence of venereal diseases in the American Expedi- tionary Forces, particularly when in comparison with the incidence in the Army in the United States, it is necessary to have in mind the fact that every effort was made both in the mobilization camps and at the ports of embarkation to detect all cases of venereal disease among men destined for overseas prior to their departure from the places mentioned.3 Table 41 shows for the Army in Europe, throughout the World War period, 57,195 primary admissions for venereal disease; the admission rate being 34.33 per 1,000 per annum as compared with 127.37 for the Army in the United States. Among enlisted men there were approximately five times as many admissions in the United States as in the American Expeditionary Forces, with an admis- sion rate of approximately fifteen times greater at home. White enlisted men abroad contributed the bulk of the cases, approximately 41,000, and the admis- sion rate was equal to that of the officers and one-half the rate of colored enlisted troops. The noneffective rate for white enlisted in Europe (2.53) was approximately that of officers (2.23) and about one-half the rate at home (5.05). The non- 270 COMMUNICABLE AND OTHER DISEASES effective rate for colored enlisted men, American Expeditionary Forces (4.65), was about one-fourth that of colored enlisted men in the United States (20.34). These differences are perhaps better shown by comparing the average num- ber of days lost per case. Officers in the United States lost on an average of 36 days per case, against 33 days in the American Expeditionary Forces. The average for white enlisted at home was 18 days and abroad 33 days; while for colored enlisted at home the average was 12 days, against 29 days in the Amer- ican Expeditionary Forces. The average for the Army at home was 16 days, against 31 days abroad. For white troops serving in Europe—disregarding the abnormally high rates reported in the latter part of 1919 for the American Forces in Germany— the peak of admissions occurred in October, 1917. A marked drop occurred in June, 1918, with low rates subsequent to that time, due at least in part to the new system of reporting, by which only hospital cases were recorded on the sick and wounded reports. This same drop was apparent for colored enlisted men, the rate declining from 228.83 in April to 145.96 in May and to 88.54 in June. This lowered incidence rate was not entirely due to the system of record- ing, but was very materially influenced by the prophylactic system used in the American Expeditionary Forces. OCCURRENCE IN OTHER COUNTRIES The highest admission rate for enlisted American troops during the World War was not in the United States, as might have been presupposed, due to mobilization influences, but was in the Philippine Department, where very high venereal incidences have been recorded since the year 1898.4 The Philippine rate for American troops during the war was 192.12 per 1,000 strength; the United States rate (134.33) held second place. Again, the incidence among colored enlisted men (237.66) was a material factor in causing this high rate; the incidence among white enlisted men in the Philippine Department was 180.14. The venereal disease rate among American troops in the Hawaiian Department was low (51.64) for both white (50.30) and colored (58.15) men. Native troops serving in their own country showed the lowest venereal incidence (50.46), with 1,818 cases among a mean strength of 36,022 men. FACTORS INFLUENCING INFECTION At the outbreak of the World War, the exciting causes of the venereal diseases were well known and accepted; therefore nothing is to be added herein along these lines. However, regarding the factors influencing infection, there has been much discussion, and the literature is rich in this material, the purpose of which was to remove these influences, as far as possible, in order that the venereal diseases might be held at lowest ebb. From the Army point of view, there were certain influencing factors which are worthy of special consideration. The most important of these are the incidence of venereal diseases among the civil population, the influence of age, race, length of service, prostitution, and alcoholism. With the exception of the influence on the Army rate of infection in recruits (to include newly drafted men), these factors are interwoven one with the other. That the source of infection for the Army lies outside of the service requires no proof, as the opportunity for infection solely within the service is slight, in THE VENEREAL DISEASES 271 fact so slight that it need scarcely be mentioned. It is true that very occasion- ally venereal infections have occurred and have been reported as being in line of duty, where, for example, an attendant became infected during the care of a patient; but the sum total of these cases is indeed small, and others arising within the service were of about the same rarity. That race was an important element in the cause of venereal disease in the Army is shown by reviewing the records from any angle, as these diseases were far more prevalent among the colored troops. It is not intended to imply that colored men are more susceptible, or that the white soldiers possess a higher degree of immunity to venereal infection; but from the Army standpoint the greater the proportion of colored troops the higher the venereal rate. Age, in like manner, is an important factor, as venereal disease is more common among the ages represented by the soldier age group seen during the World War. In this connection a study by length of service shows that the larger number of cases occurred among men with least service, and vice versa the smallest number of cases among those with longer service. It is a matter of history that prostitution follows in the wake of armies. The soldier does not bring about this condition of lowered morality, but mobili- zation attracts women of both clandestine and professional types, and experi- ence has shown that a very large percentage of such females are venereally infected. Prostitution, in its relation to armies, was one of the most extensively studied of the health problems during the war. The calling of whole nations to service altered the conditions that obtained in former wars in which there were relatively small fighting forces, preyed upon by the professional prostitute. The World War greatly enlarged the field for venereal infection. The dangers resulting from alcoholism were immediately appreciated when the United States entered the World War, and Congress empowered the Presi- dent with authority to safeguard the troops against them.5 The following table shows admissions, absolute numbers, and ratios per 1,000 strength for alcoholism and venereal diseases (all) by years from 1917 to 1919, for total American troops in the World War: Alcoholism and venereal disease (all). Primary admissions among total American troops during the World War. Absolute numbers and ratios per 1,000 per annum Year Alcoholism Venereal disease Cases Rate Cases Rate 1917 1,835 2,183 1,734 2.73 .87 1.75 82,299 226,875 61,182 122.62 1918 ________________________________________ 89.72 61.65 GONOCOCCUS INFECTION Table 43 shows that the total incidence of primary admissions for gono- coccus infection during the World War was 251,899. If to this figure cases reported as concurrent diseases (8,403) be added, the total occurrence for the American Army was 260,302, among a total mean annual strength of 4,128,479 officers and men. The strength from which the concurrent cases were reported can not be determined, therefore these cases are not included in further dis- cussions on the occurrence of gonococcus infection unless specifically mentioned. 272 COMMUNICABLE AND OTHER DISEASES Table 43.—Gonococcus infection. Primary admissions, deaths, discharges for disability, and noneffectiveness, officers and enlisted men, United States Army, by countries of occur- rence, April 1, 1917, to December 31, 1919. Absolute numbers and ratios per 1,000. Admissions Deaths Discharges for disability Non-effectiveness Total mean annual strengths Abso-lute num-bers Ratios per 1,000 strength Asbo-lute num-bers Ratios per 1,000 strength 0.01 .01 .01 Abso-lute num-bers 7,027 7,021 9 Ratios per 1,000 strength 1.70 1.72 .04 Days lost Non-effective ratio per 1,000 strength Officers and enlisted men, includ- 4,128,479 4,092,457 206,382 251,899 250, 874 2, 027 61.02 61.30 9.82 24 24 2 3,903, 303 3, 879,174 60,922 2.59 Total otfeers and men, American 2.60 .81 Total enlisted men, American troops: White"__________________ 3, 599, 527 280, 548 178,322 66, 466 4,059 49.54 231. 95 20 2 .01 .01 2,941 4,067 4 .82 14.19 3,179, 595 568, 860 69,797 2.42 5.44 Total _____.......-- 3, 886, 075 248.847 64.03 22 .01 7,012 1.80 3,818,252 2.69 36,022 124, 266 1,025 664 28.45 5.34 6 7 .17 .06 24,129 20, 907 1.84 Total Army in United States, inciuding Alaska: .46 1,965, 297 145,826 149, 073 61,901 75.84 424. 49 7 1 .00 .01 2,863 4,037 1.46 27.68 2,353, 700 492,884 3.28 9.26 2, 111, 123 210,974 99.93 8 8 .00 6,900 3.27 2,846, 584 2, 867,491 3.70 Total officers and men____ 2, 235, 389 211, 638 94.67 .00 6,907 3.09 3.51 U. S. Army in Europe, excluding Russia: 73, 728 1,469,656 122,412 1,301 23,437 2,481 3,980 17.65 15.95 20.27 2 10 .03 2 .03 38, 442 1.43 .01 62 27 4 .04 .22 724,938 59,130 68, 982 1.35 1.32 1,592, 068 29,898 18.78 10 .01 93 .06 853,050 1.47 Total officers and men____ 1, (i()5, 7911 8. 388 16,995 4,456 31,199 62 18.73 7.39 12 .01 95 .06 891,492 1,573 1.47 .51 U. S. Army in Philippine Islands:6 White enlisted____________ 1,359 457 79.97 102. 56 1 .06 37,035 12,139 5 97 Total enlisted.......... . 21,451 1,816 84.67 36.39 37.36 1 .05 49,174 6 28 U. S. Army in Hawaii: 16,161 3,319 588 124 3 .19 17, 461 2,278 2.96 19,480 712 36.55 3 .15 19, 739 2.78 U. S. Army in Panama: White enlisted_____----- - ----- 19, 688 857 43.53 1 .05 12,835 1.78 U. S. Army in other countries and not stated: White enlisted <___________ 1,547 1,196 72 1 .07 9 3 20,119 587 773 Colored enlisted '----....... Color not stated___________ Total__________________ 14,232 97,498 10, 535 2,815 1,461 307 7 197. 80 1 .07 12 .84 21,479 4.14 Transports: 14.98 29.14 1 1 .01 .09 3 .03 13, 507 1,842 42 .38 .48 Colored enlisted__________ Color not stated___________ Total__________________ 108,033 1,775 16.43 2 .02 3 .03 15,391 .39 Native .troops: Philippine Scouts__________ 18, 576 5,615 11,831 378 276 371 20.35 49.16 31.36 10,206 4,614 9,309 1.51 2.25 2.16 Hawaiian______.........___ 1 5 .18 .42 » Includes total strength for "other countries and not stated." b Includes troops in China. ' Separate strength for white and colored not available. THE VENEREAL DISEASES 273 The ratio per 1,000 per annum for primary admissions was 61.02 for the total Army. Officers and enlisted men, American troops, contributed 250,874 cases (61.30), of which 2,027 (9.82) were officers. The remaining cases, 1,025, were among native troops (28.45). The rate of occurrence among enlisted men was 64.03 and about five times more common among colored troops (231.95) than among the whites (49.54). Deaths, as would be expected, were very few, a total of 24 being reported 20 among white enlisted and 2 each among officers and colored enlisted men. There were 7,027 officers and men discharged from the service on certificates of disability on account of gonorrhea, with a discharge rate of 1.70 per 1,000 strength. These were cases with complications that unfitted the individual for the performance of his duties. There were nine officers (0.04), 2,941 white enlisted men (0.82), and 4,067 (14.19) colored enlisted men so separated from the service. It is to be noted that the discharge rate among the colored enlisted men was about fifteen times greater than among the white enlisted men. The more important influence of gonorrhea on the fighting strength of the Army is shown in the number of days lost from duty, which was 3,903,303, a noneffective rate of 2.59 per 1,000. This disease ranked third among the 30 most common diseases in the Army, from a standpoint of noneffectiveness. Officers lost 60,922 days (0.81) and American enlisted men 3,818,252 (2.69) days. The noneffective rate among white troops (2.42) was approximately one-half (5.44) that of the negro troops. Gonorrhea among the native troops was consistently less in its various aspects than among American troops. The admission rate for the former was 28.45 and no deaths were reported. OCCURRENCE BY MONTHS Season, per se, as is well recognized, had no influence on the prevalence of gonococcus infection; however, a review of the incidence by years and months shows a marked variation. The annual rates, for example, for the three years of the war were, respectively, 93.66, 113.30, and 99.93 per 1000 strength for enlisted men in the United States as compared with the annual rate of 54.84 for 1916, the year preceding the entering of the United States into the war. Great variations are revealed in a study by months of occurrence. For white enlisted men in the United States during the first month of the war, April, 1917, the rate was 61.52, and rose to its peak for this year, in September, to 136.25, concomitant with the mobilization of a large number of drafted men. In January, 1918, the rate for white enlisted men had fallen to 48.29, with a report of 4,412 cases during that month. The mean enlisted strength was about 1,100,000 men. By July, which was the peak for 1918, the rate had increased to 133.81, and the mean strength to 1,300,000. There was a pro- gressive decrease in the ratios until the summer and fall of 1919, when a gradual increase brought the trend to 72.32; the end of 1919 found the rate among white troops 56.27 per 1,000 per annum, with an average for the period of 75.84. Fluctuations were much greater among the colored enlisted men, and the occurrence among them determined the monthly and annual ratios for gonococcus infections for the Army as a whole. The beginning of the war 5«>706—2S----1S 274 COMMUNICABLE AND OTHER DISEASES found the admission rate for colored enlisted men at 49.26. This ratio rapidly increased to 408.04 in October, 1917, with the rapid increase in the number of colored drafted men, an increase from 4,870 in April to 21,795 in October. January, 1918, had a rate of 230.30 per 1,000 and a mean strength of 50,705. The rate increased rapidly throughout the spring and summer, reaching 988.38 in August. There was, relatively speaking, a gradual decrease during the following year and in August, 1919, it was 217.85. At the end of 1919 the admission rate for colored enlisted men decreased to 22.82, these troops being principally of the Regular Army type. The rate for colored enlisted men in the United States throughout the war was 424.49 as compared with 75.84 for the white enlisted men. COMPLICATIONS, SEQUELS, AND CONCURRENT DISEASES For the total Army there were among 251,899 primary admissions for gono- coccus infection a total of 59,896 recorded complications, sequelae, and con- current diseases. Among the more important were arthritis, epididymitis, prostatitis, lymphadenitis, and associations with other types of venereal disease. Among the enlisted men, there were 14,777 cases of epididymitis, or 5.9 per cent of the total primary admissions were so complicated. Epididymitis con- stituted 24.7 per cent of the total complications and associated conditions. Arthritis was recorded as a complication in 7,895 cases, or 3.1 of the total pri- mary admissions and 13.2 per cent of the total complications and concurrent conditions. Table 44.—Complications, sequelse, and concurrent diseases, among primary admissions for gonococcus infections in the United States Army April 1, 1917, to December 31, 1919 Disease Syphilis (all)________ Chancroidal infection Arthritis___.....___ Lymphadenitis..... Prostate, diseases of.. Epididymitis......... Cases Per cent 4,467 1.8 4,272 1.7 7,895 3.1 3,203 1.2 5,850 2.3 14,777 5.9 Per cent of compli- cations and con- current diseases 7.5 7.1 13.2 5.3 9.8 24.7 Among concurrent conditions, syphilis and chancroidal infection were the most important. Of enlisted men admitted to sick report for gonorrhea, there were 4,467 cases in which syphilis was recorded as an additional diagnosis. That is, 1.8 per cent of the total primary admissions for gonococcus infec- tion were associated with syphilis, and contributed 7.5 per cent of the compli- cations and concurrent diseases. Chancroidal infections were reported in about the same proportions. There were 4,272 such cases, or 1.7 per cent of the total admissions to gonococcus infection. Chancroidal infections constituted 7.1 per cent of the total complications and concurrent diseases. DIAGNOSIS The diagnosis of gonorrhea in the Army during the war involved physical examination and microscopic examination of stained urethral smears and of cultures. While the majority of men having a purulent urethral discharge are THE VENEREAL DISEASES 275 suffering from gonorrhea, one should not forget that organisms, other than gonococci, cause urethritis. The possibility of a nonspecific infection in the acute stage should always be borne in mind. It is important that the pre- sumptive diagnosis made on physical examination alone be confirmed by micro- scopic means, since in the Army the line of duty status is dependent upon it. During the war there were 3,444 primary admissions for nonvenereal urethritis, or 0.83 per 1,000 strength. It was more common than hydrocele, acute or chronic nephritis, and about as common as cystitis. In proportion to gonorrheal urethritis, it occurred in the ratios of 1 nonspecific to 73 cases of gonorrheal urethritis. In general, the practice was to look for urethral discharge during the regular semimonthly physical examinations and on special occasions. Cases showing discharge were sent to hospital for admission, further examination and treatment, unless for some particular reason such patients were admitted to a venereal ward or other place of treatment with the presumptive diagnosis of gonorrheal urethritis. At the first examination, a note was to be made of the amount of discharge and of the condition of the glans and prepuce, the presence or absence of chancre and chancroid, and the testicles were to be examined for a beginning epididy- mitis. Then the two-glass test was to be given for the purpose of determining, first, if the posterior urethra was affected and, second, the amount of pus passed. The following description is of the two-glass test and microscopic exami- nation of the pus as extensively used during the war in permanent hospitals, segregation camps, and venereal clinics:6 The urine passed during gonorrhea appears turbid from admixture with pus, and in it are little clumps or masses of desquamated epithelium. After standing, the pus settles to the bottom of the glass and a cloud of mucus appears floating above it. As the patient goes on toward recovery, the pus disappears, but the hypersecretion of mucus continues and occasions a cloudiness of the urine, giving it a mucilaginous appearance. After the mucus disappears, the "clap-shreds" persist for months, because isolated portions of mucous mem- brane are not covered with epithelium and are still secreting pus. In the two-glass test, if the anterior urethra alone is affected, the first glass of urine will be cloudy and the second glass clear; but if the posterior urethra is involved both glasses null be turbid from the presence of pus. This is accounted for by the action of the "cut-off " muscle which forms a barrier between the anterior and post3rior urethra. It prevents pus in the anterior urethra from flowing back into the bladder; so that in anterior urethritis alone the pus in front of the cut-off muscle is washed out in the first flow of urine, while the last of the urine will flow over a clean surface and remain clear; that is, the first glass will be turbid, the second clear. On the other hand, in posterior urethritis, the cut-off muscle holds back the pus, as it does the urine in the bladder, and the pus flows back into the bladder and renders all the urine turbid. When the urine in posterior urethritis is passed into two glasses, the second glass is turbid as well as the first. If it is desired to determine the con- dition of the anterior urethra in posterior urethritis, it can readily be done by irrigating the anterior urethra with saline solution and collecting the washings in a glass for inspection. Microscopic examination of pus.—-Microscopic examinations of pus are indispensable, not merely for the establishment of the diagnosis, but also for the observation of the progress and stage of the disease, for the selection of the appropriate treatment for the different stages, and finally for the purpose of determining whether the gonococci have been eliminated and the patient cured. 276 COMMUNICABLE AND OTHER DISEASES The gonococcus.—The gonococcus is coffee bean or kidney shaped, and usually found in diplococcus form, the flat or slightly indented side of the organisms facing each other. In pus from acute gonorrhea organisms are found both within and without the cells, crowded in masses in the leukocytes. The intracellular location of the organisms is of diagnostic importance, but is not so characteristically seen in pus from chronic cases. The gonococcus is easily stained with methylene blue or with most of the other anilin dyes. It is a Gram-negative organism, and for the purpose of differentiation from other diplococci a Gram stain is necessary. It is quickly decolorized by Gram's method and can then be counterstained with safranin or other stain. The Gram stain does not furnish an absolutely characteristic differentiation of the gonococcus from all similar cocci, but in pus from the urethra or vagina, or from the eye in cases of acute conjunctivitis, it may be accepted as a reliable test. For the absolute differentiation of the gonococcus, cultural methods are necessary. In the prodromal stage when the discharge from the meatus is thin and scanty, micro- scopic examination of smears shows quantities of desquamated cylindric epithelial cells and a moderate number of pus cells containing clumps of intracellular gonococci. In the ascending stage a large number of pus cells, many of them containing gonococci, and a number of free gonococci are to be seen. The stage of decline is indicated by the appearance of squamous epithelial cells, showing that the erosions have begun to cicatrize and have become covered with newly formed epithelium. Clumps of gonococci are also present, adhering to the epithelium. The pus cells have diminished in numbers and a smaller number of them con- tain gonococci. As the disease continues to improve, pus cells and gonococci disappear, and finally the discharge from the meatus is found to be composed only of squamous epithel- ium, mucus, and an occasional pus cell, without gonococci. The diagnosis of gonorrheal arthritis was made upon the following symp- toms and signs: The presence of, or a very recent history of, gonorrhea, pain and swelling (effusion) of a joint, commonly unilateral and a large joint of a lower extremity; fever; chronicity, and poor response to treatment. Para- centesis of the joint was used, but the extent can not be stated. Gonorrheal ophthalmia had as its basis for diagnosis an acute purulent conjunctivitis in which the gonococcus was demonstrated; and in the few clinical records available for examination these patients also had acute gonorrheal urethritis. Nothing new was developed during the war in the diagnosis of gonorrheal prostatitis, seminal vesiculitis, cowperitis, epididymitis, and other common complications of gonorrhea. Complement fixation in the diagnosis of gonococcus infections was per- formed sparingly in the laboratories of the base hospitals, general hospitals, and other permanent or semipermanent institutions. It was not a routine procedure, but was considered of value when positive results were obtained. In like manner, cultural methods were reserved for special cases. While neces- sary for the absolute differentiation of the gonococcus, these methods are slow, time consuming, and were considered not necessary in the usual case of purulent urethritis, especially when a Gram-negative intracellular coccus had been demonstrated. PROGNOSIS The gonococcus is not a great destroyer of life. From the Army's point of view, prognosis is measured by deaths and discharges of men from the service and by the days lost from duty for men temporarily incapacitated. Among 251,899 admissions for gonococcus infection there were but 24 deaths A more THE VENEREAL DISEASES 277 detailed study of these deaths shows such concurrent diseases as pneumonia, and epidemic meningitis, which in all probability were the actual causes of death. It was the policy not to discharge emergency men, who were venereal patients, from the Army in the United States during demobilization.7 However, due to many urgent claims for release from military service after the armistice began, especially in 1919, and due to the chronicity of many cases, some of which had been under treatment for a long period, it became necessary to make exceptions to this rule. Table 43 shows 7,027 men discharged from the Army during the war for disability incident to gonococcus infection. This number constitutes 2.8 per cent of the total primary admissions for gonorrhea. They were discharged on account of complications and may or may not have been cured of the gonococcus infection. On the whole, the duration of American participation in the World AVar was too brief to reveal the outcome of cases of gonococcus infection. Virulence of the gonococcus differs in different cases. It is at times noted that when a person has chronic gonorrhea, the gonococci, when transplanted into the tissues of another person, are not capable of producing such virulent inflammatory symptoms as when taken from a fresh case. This attenuated virulence explains the fact that in such cases the period of incubation is com- paratively long, the purulent discharge is scanty, the cases often become chronic, and result in prostatitis and stricture. Another factor which influences the prognosis of gonorrhea is the state of the patient's general health. Gonorrhea acquired by persons affected with phthisis, or who are debilitated from any cause, is apt to run a subacute, but exceedingly protracted, course. Other causes which retard recovery may be grouped as follows: Posterior urethritis, prostatitis, etc.; reinfection from an urethral gland, seminal vesicle, prostate, etc.; lack of rest; alcoholic indulgence; too vigorous treatment, especially injections which are too strong or too fre- quently repeated; coitus. As stated above, the ultimate effects of gonococcus infection can not be measured by experience in the Army. Though more than 97 per cent of the cases were returned to duty, one can not state how many cases suffered from relapse or acute exacerbations among men discharged from the service as cured, or what eventually happened to men with venereal disease discharged for dis- ability. Analysis of the average days lost, for officers and enlisted men, and by countries, shows a great difference when compared one country with another. This may have been due, in part, to a difference in virulence of the organism or difference in resistance on the part of the patient; but it is believed the principal difference was in the system of management. The average number of days lost from duty per case was 15.4 for the total Army. It was 15.6 for American officers and men and 23.5 for native troops. The average among white enlisted was 17.8, and colored enlisted, 8.5. The average for total officers was 30 days. This difference is probably explained by the prac- tice of holding an officer on sick report, once taken up for gonorrhea, until apparently cured, while an enlisted man was generally released from hospi- 278 COMMUNICABLE AND OTHER DISEASES tal or sick report as soon as the acute stage or symptoms had subsided and he was physically able to do duty. The soldier was restricted to the military garrison, assigned to a convalescent camp, development battalion, or venereal detachment with his organization. In either case his name was removed from the sick list. As to the difference in race, there was a much larger percentage of col- ored drafted men with gonorrhea on entrance into the service than of white, and in both incidences the vast majority of cases had passed the very acute stage of the disease; furthermore, the colored soldier was often very anxious to be discharged from hospital especially when he was forfeiting his pay while confined there. These two factors are believed to account for the shorter period of hospitalization for gonorrhea among colored soldiers. In the United States the average for white and colored enlisted men was 15.8 and 7.9 days, respectively; in Europe the average for white enlisted men was 30.9, and colored, 23.8 days. The longer period in Europe, as compared with the United States, is accounted for, as above stated, by the fact that cases with complications were the ones usually admitted to sick report, while others were retained with their organizations. TREATMENT » ACUTE GONORRHEA In order to aid the natural process of repair, the first essential is rest. No other measure contributes so much to a prompt and uncomplicated recovery as rest in bed during the acute stage of gonorrhea. The patient, therefore, should be put to bed and kept there during the ascending stage of from one to two weeks, or until the discharge becomes mucopurulent and the burning on urination has disappeared. In order to keep the urine bland and unirritating and to promote frequent urination, so as to clear the urethra from the products of inflammation and to expel free organisms that may reinoculate new areas, the patient in bed should receive from the wardmaster and drink one glass of water every hour. The diet should be bland and of a low nitrogen content; highly seasoned and rich foods should be strictly excluded; cereals, fruit juices, toast and cream with a moderate amount of milk should make the bulk of the meals. Alkalis and alkaline mineral waters should not be prescribed, because of their effect on the reaction of the urine. An acid reaction of the urine is the best safeguard against a cystitis from bacteria that find their way into the blad- der. The acidity of the urine will be reduced sufficiently by the free use of milk and the abstinence from meat. The bowels should be kept open with aperients, and during the very acute stage a saline cathartic should be admin- istered every other morning. Dressings for the purpose of catching the urethral discharge to keep it from soiling the clothing always should be worn. Several varieties may be used: (a) For patients with a long foreskin, the familiar gauze butterfly; (6) for patients unable to hold the butterfly, a 4-inch gauze bandage bag with a " Based upon "A Manual of Treatment of the Venereal Diseases, for the Use of Medical Officers of the Army". Prepared under the direction of the Surgeon General, 1917. THE VENEREAL DISEASES 279 little gauze in the bottom, made fresh daily or oftener, or (c) a loose bag, made by cutting off the foot of a stocking, into the bottom of which gauze can be placed to catch the pus. The bags are to be suspended from a waist band. The loose bags permit and encourage a free flow of pus from the urethra, while they prevent retention. Constriction of the penis by dressings wrapped around it should carefully be avoided so as to insure no interference with the return circulation. A suspensory bandage should be worn when the patient is allowed to get up in order to relieve the sensation of dragging on the sper- matic cord and to lessen perhaps the danger of epididymitis. Oil of sandalwood is soothing and curative to the mucous membrane; it may be given during the acute stages, but will have little effect owing to dilution from the drinking of large quantities of water. Sandalwood oil should be administered in capsules in doses of from 0.5 to 1 c.c. three times a day after food. It sometimes disagrees with the digestion, or it may cause an intense pain in the back; when such symptoms occur, it should be discontinued. No copaiba or cubebs should be given in acute gonorrhea; they are serviceable only in the declining stages. SEVERE ACUTE URETHRITIS In very severe urethritis with intense reaction, profuse discharge, and great swelling and edema, it is good judgment to wait for some subsidence of the symptoms before beginning injections. In the meantime the parts should be kept clean; the penis held in hot water for 15 minutes at a time every few hours, and hot sitz baths given every three or four hours to relieve distress. If sitz baths are unobtainable, hot fomentations may be substituted. If pain on urination is very distressing, it may be relieved by an injection, five minutes before urination, of 1 c.c. of 1 per cent solution of cocain hydrochlorate or procain. Sandalwood oil diminishes the pain on urination in most cases, so that the use of a local anesthetic is not often necessary. Local treatment.—In the ascending stage of acute urethritis and in other acute cases, which do not reach the intensity suggested in the preceding para- graphs, local treatment by injection may begin at once. In selecting the drug used for injection, it is necessary to bear in mind the indications for its use, which may be thus formulated: 1. To destroy the gono- cocci in all foci within reach as early and completely as possible. 2. In doing so, to avoid irritation of the mucous membranes, any exacerbation of the exist- ing inflammation, and everything that has a caustic action on the tissues and all unnecessary pain. These indications are very well met by the silver protein compounds of the argyrol and protargol type. The syringe should be all glass, of 5 c.c. capacity, with a smooth acorn tip. For injection, solutions in water are used of the following strengths: Argyrol, from 3 to 5 per cent; protargol, from 0.25 to 1 per cent. Before injecting, the urine should be passed so as to wash out the pus accumulated in the urethral canal. In making injections the tip of the syringe should be firmly pressed into the meatus, and the penis should be held under moderate tension. The solution should be injected with the utmost gentleness. It should be held in the urethra for at least five minutes. If 280 COMMUNICABLE AND OTHER DISEASES injections produce distress, their strength should be reduced. Injections should not be given frequently enough nor sufficiently concentrated to cause any irritation of the mucous membrane; an injection which is too often repeated or is too concentrated prolongs the course of the case. In practice it is found that once in two hours is sufficiently often to destroy the gonococci without damaging the inflamed mucous membrane, provided the injection is carefully given and the solution is not too strong. SUBACUTE ANTERIOR URETHRITIS After from 10 days to 3 weeks in those cases that run a favorable course under the treatment with silver proteinates, the acute symptoms disappear. The discharge becomes watery and scant; microscopic examination reveals many newly formed desquamated epithelial cells and few or no gonococci; the urine in the first glass becomes clear or slightly turbid, although it contains many long mucous filaments. If treatment is now discontinued, relapse with extensive reinfection is certain to occur in from two to three weeks from the few gon- ococci left in the tissues. When the gonorrhea has reached this subacute stage, the task remains of curing the existing postgonorrheal lesions, which consist of a catarrhal inflammation of the mucous membrane, erosions, periglandular infiltrations, and infiltrations of the submucous tissues. Since the silver pro- teinates only destroy the gonococci and have little effect on the inflammatory processes, it is necessary at this time to treat the existing catarrh of the mucous membrane with astringent remedies. At this point in the progress of the disease it is highly desirable to substitute copious irrigations of the urethra for the hand injections. Irrigations.—The solution best adapted for the double purpose of destroying the few remaining gonococci and of acting as an astringent to cure the super- ficial postgonorrheal lesions of the mucous membrane is silver nitrate in strengths of from 1:3,000 to 1:5,000 of distilled water. Irrigation with silver nitrate solution acts particularly well in the presence of a clear urine containing shreds of pus or mucous. It may be used every day or every other day. Potassium permanganate in water solution of the strengths of from 1: 3,000 to 1: 5,000 is also useful for irrigations. It is especially called for when there is a free purulent discharge containing no organisms. A purulent discharge that arises from the presence of a nongonococcic bacterial urethritis yields to irrigation with mercuric oxycyanide in solution in water in strengths of from 1: 3,000 to 1: 5,000. This should never be used if the patient is taking iodide or iodine in any form. The irrigations should be given at temperatures of from 110° to 115° F.—as hot as can comfortably be borne—and may be repeated as often as four times in 24 hours. Technique.—The patient should sit well forward on the chair, resting his shoulders against its back, or he may stand. He should hold a small basin to catch the overflow of the irrigation. The irrigator tip is pressed against the meatus and the anterior urethra distended with fluid. Then by a short release of pressure of the tip a return flow is allowed. This is repeated until thorough irrigation of the anterior urethra has been obtained. If it is desired to irrigate the posterior urethra, the anterior urethra should first be wrashed out. Then THE VENEREAL DISEASES 281 the tip should be firmly pressed against the meatus and the anterior urethra dilated with fluid. The patient is then instructed to take a long breath and to try to urinate; this releases the cut-off muscle and the irrigating fluid flows into the bladder. The bladder is allowed to fill with fluid, but should not be distended beyond the point of comfort. After the bladder is filled, the patient empties it by urination. Should difficulty be experienced in irrigating the posterior urethra from the meatus, a soft rubber catheter may be introduced through the cut-off muscle into the posterior urethra and the bladder filled through the catheter. The patient then urinates after the catheter is removed. Under the irrigation treatment the urethral discharge ceases, and the shreds disappear from the urine, but before the patient is declared cured the condition of the prostate and vesicles must be investigated and the urethra must be found to be free from stricture. It should be borne in mind that it is possible to treat a gonorrhea too long, and to cause the discharge to persist by the simple irritation of injections. In such cases, there will be a secretion free from gonococci which on squeezing will appear at the meatus as a small, transparent, glycerin-like drop, and which will cause sticking together of the meatus in the morning. In cases manifesting this condition, it is advisable to stop treament and to allow the irritation to sub- side. In consequence, the mucous discharge will often disappear spontaneously. ACUTE POSTERIOR URETHRITIS Severe posterior urethritis demands complete rest in bed and measures directed to the relief of the distressing symptoms. All local treatment of the urethra should be suspended. The nearer the diet approaches to a liquid or milk diet, the better. Abundant water should be taken, but diuretics should not be used, because they cause the too frequent evacuation of an already over- taxed bladder. Saline cathartics should be given every other day to reduce congestion in the pelvis. For the relief of tenesmus and pain, hot sitz baths of half an hour's duration, repeated several times a day, are useful. Alkalies, which favor the growth of bacteria in the bladder by rendering the urine alkaline, are contraindicated, as they are in acute urethritis. Sandalwood oil is not only curative, but soothing and gives relief in many cases. In the severe cases morphine should be given to relieve tenesmus and desire to urinate. It is best to give it in these cases in rectal suppositories. As a rule, the acute stage of posterior urethritis disappears promptly, and the cases pass into the condition of mild posterior urethritis, and then should be treated as such. SUBACUTE POSTERIOR URETHRITIS In subacute posterior urethritis, treatment is given on principles similar to those applicable to subacute anterior urethritis. Solutions are applied to the surface, either by the injection of small quantities of concentrated solutions or by irrigations of copious quantities of dilute solutions. In the first method, a small soft rubber catheter is introduced just beyond the cut-off muscle, and by means of a small urethral syringe about 10 drops of 1:500 to 1:100 solution of silver nitrate are introduced into the posterior 282 COMMUNICABLE AND OTHER DISEASES urethra. This is to be repeated at intervals of one or two days according to the tolerance of the case. In order to prevent immediate precipitation of the silver by the urine, the injection should be made with the bladder empty. Urethrovesical irrigations by the gravity method are particularly applicable to the treatment of posterior urethritis. They are given through a gravity irrigator elevated 5 to 6 feet above the penis, according to the technique already described for irrigation. For posterior irrigations, protargol or similar silver protein preparation in the strength of from 1:1,000 to 1:250, or silver nitrate from 1:10,000 to 1:4,000, are used. Less effective, but still useful in some cases, is potassium permanganate, 1:3,000. As a rule, posterior urethritis extends to the prostate and seminal vesicles, and persistence depends on reinfection from these structures. In every case these structures should be examined and, if necessary, treated. COMPLICATIONS OF ACUTE GONORRHEA FOLLICULITIS The treatment of folliculitis consists in opening the abscess freely as soon as fluctuation is noticed, evacuating the pus, and allowing it to heal by granulation. It should be opened through a urethroscope from within the urethra, when this is practicable. If incision is done promptly, the occurrence of a persistent urethral fistula is prevented. CHORDEE The patient subject to chordee should empty his bladder just before going to bed; should sleep in a cool place, lightly covered; and, to avoid sleeping on his back, should tie a towel around his waist with a knot at the back. Before going to bed the penis should be given a prolonged immersion in hot water. When the patient wakes with chordee, he should get out of bed and immerse penis and testicles in cold or hot water, and before going back to bed should empty the bladder. He should be warned of the danger of "breaking" a chordee. In severe cases sedatives are necessary; potassium bromide, 2.0 gm., or camphor monobromate, 0.3 gm., in the afternoon and before going to bed, are useful; in extreme cases a morphine rectal suppository may be necessary. EPIDIDYMITIS Immediately on the development of epididymitis all injections or instru- mentation of the urethra must be stopped, the patient be confined to bed, and put on a light diet. The testicles should be elevated by a bandage going under them and over the thighs, and hot applications should be made. Hot sitz baths for half an hour three times daily are soothing and hasten recovery. If the symptoms are severe, epididymotomy may be performed. This immedi- ately relieves pain and hastens recovery. In a few days the acute stage passes. The urethral discharge is then likely to recur, but local treatment of the urethra must be resumed only after a con- siderable period of rest and with the greatest caution. A suspensory bandage should be worn until the patient is entirely well. There is in many of these cases a chronic inflammatory exudate in the epididymis, which in time often disappears. Massage of it may hasten its absorption. THE VENEREAL DISEASES 283 ACUTE PROSTATITIS In acute prostatitis the indications are (1) to lessen the severity of the posterior urethritis; (2) to prevent suppuration of the prostate; (3) if pus forms, to evacuate it promptly by incision. The patient should be put to bed, sandalwood oil administered, and, if necessary, the pain and tenesmus controlled by opium suppositories. Locally either ice bags or hot poultices are applied to the perineum, a safe guide for the choice between hot and cold applications being the amount of comfort which is given to the patient. Hot sitz baths of from one-half hour to an hour's duration two or three times daily are always indicated. Irrigation of the rectum with hot water for half an hour at a time may be used instead. A rectal prostatic irrigator, or, in its absence, a return flow catheter, is introduced into the rectum, and a continuous flow of water as hot as can be borne, is passed through it. If retention of urine should occur, it may be necessary to introduce a catheter, but this should be done only when absolutely necessary. Before catheterizing, the urethra should be well irrigated to free it from pus. One c. c. of 2 per cent cocaine solution may be injected into the urethra to relieve pain and facilitate catheterization. Prostatic abscess.—W nen a very limited area of suppuration of the prostate is present, involving perhaps two or three of the prostatic tubules, the temper- ature is only slightly elevated, and the local symptoms are not marked. After two or three days the temperature becomes normal and the tenesmus and frequent urination disappear. In such cases an incision into the prostate is not required, for the minute abscess generally ruptures into the urethra and the sinus fills in by granulation. If, on the contrary, the symptoms do not improve within the first week, but the fever continues and chills occur, the local symptoms grow worse, and rectal examination shows an increase in the size of the inflamed prostate, it is evidence that an abscess is forming. These symptoms constitute an urgent indication to evacuate the pus; for if the pus is allowed to break through the capsule of the prostate, it will burrow through the tissues and may cause urinary infiltration and pyemia, or, at least, a fistula which will not heal without opera- tion. In these cases immediate surgical measures are indicated. Two opera- tions may be used to evacuate the pus: 1. The prostate may be exposed by a transverse incision in the perineum, and the collection of pus evacuated with- out opening the urethra. 2. An incision may be made in the perineal urethra, the mucous membrane of the prostatic urethra broken through with the finger, and the pus collection evacuated through the opening thus made. ACUTE SEMINAL VESICULITIS The general treatment of acute vesiculitis is the same as that for acute prostatitis, with which it is usually associated. Injections into the interior urethra, of course, are contraindicated; but above all things, any attempt at massaging or stripping the vesicles should be avoided. 284 COMMUNICABLE AND OTHER DISEASES CHRONIC GONORRHEA CHRONIC AXTERIOR URETHRITIS Based on the pathologic changes in the tissues, the indications for treat- ment are: (a) To rid the tissues of gonococci; (6) to cure the catarrhal inflam- mation in the mucous membrane and promote the formation of squamous epithelium to cover the erosions; (c) to cause absorption of the submucous infiltration; (d) to restore to normal the intraglandular and periglandular inflamed and infiltrated tissues. These indications can be met by irrigations with antiseptic and astringent solutions and by dilatations of the urethra with sounds and soft bougies. When general catarrh of the mucous membrane is present and turbidity of glass 1 exists, free irrigation of the urethra and bladder by the gravity method, daily or every second day, using silver nitrate or potassium permanganate, soon clears up the diffuse inflammation in the mucous membrane, un- til the process is no longer general, but is reduced to isolated spots. This condition is denoted by glass 1 being no longer turbid; it does, however, still contain the shreds derived from isolated erosions which are not covered by epi- thelial cells and are still secreting pus, or from the prostatic ducts and Mor- gagni's crypts. Comma-shaped shreds which are often present are formed by the secretion from the open mouths of the prostate ducts and Morgagni's crypts. Gonorrheal shreds floating in clear urine continue until the submucous infiltra- tions resolve and the pathologic secretion of the prostate and crypts disappears. In order to promote the absorption of the submucous infiltration it is neces- sary to pass steel sounds large enough to distend the urethra fully and put the ring of infiltration on the stretch. Meatotomy may be necessary in order to pass sounds of sufficient size. The therapeutic effects of the sound can be materially increased by massag- ing the urethra over it with the fingers. The contents of Morgagni's crypts can in this way be expressed, and more favorable influence is exerted on the ring of infiltration in the submucous tissues. Sounds may be passed too frequently. In cases of soft and recent infiltra- tion, the intervals should be from four to seven days, always waiting until the reaction following has subsided. In cases of hard, organized infiltration the intervals should be a week. If the urethra is acutely inflamed and freely secret- ing pus, instrumentation is, of course, out of the question. Dilatations should not be started until the urine is clear and contains only shreds. It makes no difference, as far as treatment is concerned, whether the sub- mucous round cell infiltration is soft and recent or whether it has been trans- formed into scar tissue; the indications in either case are to promote its absorp- tion by dilatation and pressure. Cases in which a considerable surface of mucous membrane is involved are unsuitable for dilatation until the catarrh has been checked by irrigations and the superficial process has been localized in a few spots in the urethra, as denoted by shreds floating in clear urine. GLANDULAR URETHRITIS Many intractable cases of gonorrhea lasting for years in spite of constant treatment are caused by a chronic inflammation of Morgagni's crypts. Such cases show few symptoms, the morning drop at the meatus being the most THE VENEREAL DISEASES 285 constant. But they are characterized by exacerbations of the discharge after slight provocation, with a free discharge of pus containing gonococci, which leads the patient to believe that he has acquired a fresh infection. Urethro- scopic examination shows the mouths of a few of the crypts to be open and pouting, with red and slightly elevated edges. In other cases the mouths of the crypts are occluded by a growth of epithelium. When the crypts are affected the gonococci may remain in them for years and the case remain infectious. These cases should be treated by dilatations with full-sized sounds fol- lowed by irrigations. When the mouths of the glands are occluded by the growth of epithelium, dilatation of the urethra opens them and forces out the purulent secretion. The irrigating fluid enters the cavities and acts on the chronic inflammatory processes within the glands. In that form of inflamma- tion in which the mouths of the glands are held open and the entire crypt is stiffened and inelastic from the periglandular infiltration, dilatations cause the absorption of the infiltrate around the glands and promote a return to normal condition. When, after sufficient treatment by dilatations and irrigations, it is found by urethroscopic examination that a few glands still remain chronically inflamed and suppurating, and are thus foci of infection, these should be destroyed. This can be accomplished by bringing them into view with the urethroscope, and introducing a galvanocaustic needle. The cauterization must be very superficial and rapid; otherwise there will be danger of stricture formation. Not more than three or four crypts may be destroyed at a sitting. It is possible by destroying the glands harboring the gonococci to cure in this way a chronic gonorrhea of years' standing which has resisted all the other usual forms of treatment. CHRONIC POSTERIOR URETHRITIS In the presence of free pus formation urethrovesical irrigations by the grav- ity method with a solution of silver nitrate from 1:10,000 to 1:4,000 or potassium permanganate, 1:3,000, is the best method of rapidly reducing the purulent dis- charge. After the urethra becomes clear, the prostrate and vesicles should be examined, and if found to be diseased must be massaged in connection with the irrigation. When the urethroscope shows the infiltrated changes localized to the colliculus, direct applications of from 10 to 20 per cent silver nitrate solu- tion should be made once a week through the endoscope. Granulations in the posterior urethra should be treated by cauterizing with strong silver nitrate solution. Small polypi, or granulations on the colliculus may be removed by scissors, forceps, or a galvanocaustic point. If the utricle is infected it should be injected with silver nitrate solution with a small syringe. Chronic prostatitis.—In almost every case of chronic gonorrheal urethritis the prostate is involved. Chronic prostatitis usually originates in an attack of acute prostatitis, but it may result from a slow, insidious extension through the prostatic ducts of an infection from the posterior urethra. Aside from its frequency, chronic prostatitis is perhaps the most important complication of gonorrhea, for the reason that the gonococcus, with all its infectious qualities unimpaired, may be retained for years in the diseased tubular glands of the prostate without its presence being suspected. Probably most of the cases in 286 COMMUNICABLE AND OTHER DISEASES which wives are infected with gonorrhea by their husbands come from uncured prostatitis. Chronic prostatitis is also important on account of the profound disturbance of the nervous system and the impairment of the sexual function, which it occasionally produces. The first indication in the treatment of chronic prostatitis is to improve the general condition of the patient by a proper regimen. Constipation is generally a prominent symptom, which is best treated with saline cathartics, because they have some effect in relieving pelvic congestion. All sorts of erotic excite- ment should be interdicted on account of their effect in inducing congestion of the prostate. Coitus should not be permitted, both because of its ill effect on the diseased prostate and because of the certainty of spreading the infection. The most effective local measure is the emptying of the prostatic tubules of their retained and thickened contents by rectal massage two or three times weekly. In this procedure both lobes should be massaged from above downward and the manipulation should not be very vigorous, the object being to force out the prostatic contents by moderate pressure. Massage of the prostate is not well borne by all patients; and, if it produces irritating symptoms, it should not be persisted in. In order to lessen the danger of epididymitis from prostatic massage, it is advisable to irrigate the urethra and fill the bladder before massage with a solution of silver nitrate from 1:10,000 to 1:4,000 or potassium perman- ganate 1:3,000. Treatment by massage and irrigation should be persisted in for from six to eight weeks, or until a microscopic examination of the expressed prostatic secretion shows only a small number of pus cells in the field. Many cases will be found to improve under massage up to a certain point and then remain sta- tionary. In such instances it is advisable to stop treatment for a month. If after this intermission the remaining evidences of prostatitis have not disap- peared, another course of massage may be given. Such treatment should be repeated until the pus cells in the expressed prostatic secretion are found on microscopic examination to be only from four to six in a field, and lecithin bodies are abundant. While treating chronic prostatitis, it is important not to overlook the chronic posterior urethritis which nearly always accompanies it. This should be treated by irrigation, dilatation, and other measures, as already described. Chronic seminal vesiculitis.—The treatment consists in massaging and expressing the contents of the vesicles twice a week. Massaging empties the vesicles of their inspissated contents, without forcing the muscular fibers to contract; and, by the relief of distention and the rest thus afforded them, the muscles recover their tone. Contraindications to massaging are: (a) The existence of acute vesiculitis; (b) blood in the expressed material, or (c) excessive tenderness. With these conditions present, there is always danger of setting up an epididymitis. In chronic vesiculitis the posterior urethra should not be overlooked but should receive treatment, with irrigations or instillations or by applications made through the urethroscope as outlined under chronic posterior urethritis. It is desirable not to apply local treatment to the posterior urethra and massage the vesicles at the same sitting, but rather to allow a couple of days to intervene THE VENEREAL DISEASES 287 The duration of treatment must be protracted, for it requires from 2 to 12 months to effect a cure. In obstinate cases characterized by marked sexual neurasthenia or intractable gonorrheal rheumatism, free incision into and drainage of the seminal vesicles may be demanded. This is a procedure requir- ing expert skill. CHANCROIDAL INFECTION Chancroidal infection, more than gonorrhea or syphilis, is a disease of the careless and uncleanly, relatively uncommon among clean people, and read- ily prevented.6 It was the least common of the venereal diseases in the Army during the war, contributing about 11 per cent. Being an acute disease and without any known carrier state or common chronic complications, chancroid infection played a comparatively unimportant role among men entering the service; there were 3,714 cases among the first and second million drafted men examined. (See Table 42.) Of these, 120 were discharged as physically unfit for service by the local examining boards, and 233 by the camp examining boards.8 Therefore, and in contradistinction to syphilis and gonorrhea, the great majority of cases were acquired by men while in the service. The ratio of chancroid to syphilis and gonococcus infection was 1 to 2 to 6. There were 39,044 primary admissions for chancroid, with an admission rate of 9.46 per 1,000 per annum. Of these cases, 105 were discharged from the service on account of disability; loss of time from duty amounted to 973,614 days, with a noneffective rate of 0.65 per 1,000 strength. As might be presumed, chancroid was relatively uncommon among officers, more common among white enlisted men, and with greatest frequency among native and colored enlisted men. There were 374 primary admissions for officers (1.81), 26,819 among white enlisted (7.45), 271 for native (7.52) and 9,937 among colored enlisted men, with the very high rate of 34.68 per 1,000 strength. More than 60 per cent of the discharges following chancroidal infection in the total Army were among colored enlisted men. Although not as disabling to the fighting strength of the Army as either syphilis or gonorrhea, chancroidal infection caused considerable noneffectiveness. The ratio per 1,000 strength was 0.65 and the average number of days lost from duty per case was 24.9 as compared with 28.7 for syphilis and 15.4 for gonorrhea. The difference in time lost per case was approximately the same between officers (24.5), white (25.7) and colored (25.3) enlisted men. The average number of days lost among native troops was 23.4. Although the average number of days lost among the enlisted men, white and colored, was about the same, the noneffective rate was about five times greater for colored enlisted men. DIAGNOSIS The practical diagnosis of chancroidal infection is based upon the period of incubation and the clinical appearance of the ulcer. Autoinoculation, and cultural and microscopic examinations for the Ducrey bacillus, have been used but without encouraging results for routine practice. These methods were known before the war and nothing new and of special value developed during that time. In view of the vital importance of differential diagnosis between 288 COMMUNICABLE AND OTHER DISEASES chancroid and syphilis, and the great importance of diagnosing syphilis as coexisting with chancroid, much stress during the war was placed on the early and thorough examination of all venereal ulcers to determine whether or not syphilis was present.7 Where sores were concealed it was recommended that the necessary inci- sion, either dorsal or bilateral be made, in order that the lesion might be exposed for diagnostic and therapeutic purposes. Moore9 made a special report on the diagnosis of chancroid, and the effect of prophylaxis upon its incidence in the American Expeditionary Forces. During the 12 months ending March, 1919, there was afforded opportunity to see over 4,000 venereal cases, among which more than 800 were venereal ulcers. In a selected 10-month period, ending in February, 693 venereal ulcers were encountered. The original diagnosis, based on the clinical appearance of the sore and dark-field examination, was chancroid in 379 instances, or 54.5 per cent, and primary syphilis in 314, or 45.5 per cent. In order to obviate the possibility of unrecognized syphilis, an effort was made to follow each chancroid case for at least eight weeks, but, owing to military exigencies, this was possible in only 135 cases. Every sore was suspected as being syphilis until proven otherwise, and it was an unalterable rule that dark-field examination should be carried out on every sore for three consecutive days before search for the spirochete was abandoned. Moore de- clared that while it had been conclusively demonstrated that the bacillus of Ducrey is the cause of chancroid, it is exceedingly hard to find. In 81 cases, clinically chancroid, in which smears were made, the Ducrey bacillus was dem- onstrated 20 times; while in 61 cases the smears were negative. Cultures on serum blood agar were made 55 times and were positive in only 5 instances, proving that these methods of microscopic and cultural diagnosis are not to be relied upon. A Wassermann test was made when the patient was first seen, once a week thereafter for the first 8 weeks, and at the middle and end of the third month. All of the 135 cases were followed for more than 8 weeks, 97 of them for more than 12 weeks. Autoinoculation proved to be of very little value for two reasons, according to Moore:9 First, because of the difficulty of controlling ambulatory patients, who frequently developed large spreading ulcers at the site of inoculation, which were very difficult to heal, and, second, because so-called positive reac- tions (positive in 24 to 48 hours) can be obtained from secondarily infected ulcers in which the spirochete can be demonstrated. A few experiments were conducted by Moore in Paris. Five men were selected with clinically typical chancroid, and from the sores three inoculations, about 2 inches apart, were made on the left arm. The top inoculation was left as a control; the middle one was treated at various intervals after inoculation, ranging from 10 minutes to 2 hours, with calomel ointment well rubbed in for exactly five minutes. The bottom inoculation was treated with tincture of green soap and warm water at the same intervals and with thorough use for five minutes. In all cases, the controls were positive, as was the inoculation treated with calomel ointment, while the lesion treated with soap and water was uniformly negative. Therefore, it may be stated that the history of incubation, clinical appearance of the sore, and examinations to determine the presence of the Ducrey bacillus THE VENEREAL DISEASES 289 are no more than suggestive in ruling out primary syphilis. All venereal ulcers should be repeatedly examined by dark-field illumination before local applica- tion of antiseptics or the cautery; all patients with chancroid infections should be subjected to frequently repeated Wassermann tests for several months, to prove the presence or absence of syphilis. COMPLICATIONS, SEQUEUE, AND CONCURRENT DISEASES There were 39,044 primary admissions for chancroidal infection and 7,679 cases reported as concurrent with other diseases, making a total of 46,723 cases for the total Army during the war. The most common and more important concurrent diseases were syphilis and gonorrhea. Chancroid was associated with syphilis in 3,687 cases, or 8.8 per cent. Gonorrhea was more commonly so associated; there were 5,221 cases in which gonorrhea and chancroid coex- isted, or 11.11 per cent. PROGNOSIS The prognosis of chancroidal infection in the Army, as to recovery, was good. Among 39,044 cases of chancroid, 105 were discharged from the service on account of permanent disability, though it is very probable that causes other than chancroid were contributory in many of these. Among the primary admissions there were 4,811 complications and concurrent diseases, with one death; therefore it can be said that chancroidal infection did not increase the liability to death. Recovery was complete in all cases, with the possible exception of scars at the site of infection or operation. As to duration of the illness, but few diseases showed such a consistent general average among officers and enlisted men. TREATMENT0 GENERAL TREATMENT In order to hasten recovery, the patient with chancroid should be put to bed, kept clean, and given a nourishing diet. Rest not only makes for a prompt healing of the chancroid, but greatly reduces the danger of bubo. Destructive chancroids are seen in the dirty and debilitated. If patients with chancroids are kept clean and well nourished, healing is usually prompt, and extensive ulceration very rarely seen. LOCAL TREATMENT Abortive treatment.—In a certain proportion of cases of chancroid, abortive treatment is successful. The principle of all methods of abortive treatment is to convert the infected ulcer into a sterile one by the use of some destructive agent. This may be either the actual cautery, or one of several strong chemical caustics. The thermocautery is doubtless the best agent for this treatment Its application is as follows: The ulcer is thoroughly cleaned and well dried; then the entire area of it is seared with a cherry red cautery. Every particle of dis- eased tissue must be destroyed. It should be done under a general anesthetic, preferably gas. <• Based upon A Manual of Treatment of the Venereal Diseases, for the Use of Medical Officers of the Army. Pre- pared under the direction of the Surgeon General, 1917. 56706—2S-----19 290 COMMUNICABLE AND OTHER DISEASES Chemical cauterization is done as follows: The ulcer is well cleaned, being first irrigated and then dried. Then a pledget of cotton wet with 5 to 10 per cent solution of cocain hydrochlorate or procain is applied to it. After anes- thesia is produced the ulcer is dried as thoroughly as possible, preferably with blotting paper, in order to prevent the running of the chemicals subsequently to be applied. After it has been thoroughly dried, the entire surface of the ulcer, both edges and base, is touched with pure liquid phenol (carbolic acid) applied on a small cotton swab, care being taken to let no infected point escape. Then the excess of phenol on the surface is taken up, and nitric acid is applied lightly in the same way. The ulcer should be flushed immediately with sterile water to stop the action of the acid. Instead of nitric acid a saturated solution of zinc chloride can be used. This is as active a caustic as nitric acid, and its action should be stopped as quickly after application by flushing with water. After cauterization in any of these ways the wound should be dressed with cold compresses of boric-acid solution or similar bland solution. There results an acute inflammatory reaction, the slough is thrown off, and in success- ful cases a healthy granulating surface is left. The advantage of these methods of treatment is that, in successful cases, healing takes place quickly and the danger of bubo is almost eliminated. Their success depends on thoroughness in destroying the infected area. If the pro- cedure fails to do this completely, harm results, because it produces a larger ulcer, which becomes infected from the focus of disease that has been left. Attempts at abortive treatment with superficial caustics, such as silver nitrate, are always failures. Attempts at abortive treatment should not be made un- less the prospects of complete destruction of the diseased tissue are good. Abortive treatment is contraindicated under the following conditions: (1) When the diseased area or areas are so extensive or so situated that the destruction produced by this treatment would result in considerable deformity. The chief situation in which it is contraindicated is in chancroid at the meatus. (2) When the inflammatory reaction is already intense and there is much edema. These would be increased by cauterization. (3) Wlien there is inguinal adenitis. This would be aggravated by cauterization. (4) In healing chancroids. Here the infection is already under control and nothing would be gained by cauterization. Abortive treatment will, of course, interfere with any further search for spirochetes. For this reason it should never be undertaken until every reason- able effort to find the spirochetes has been made. The early diagnosis of syphilis is so much more important than the prompt healing of a chancroid that efforts to heal the chancroid should be given no consideration until the ques- tion of diagnosis is settled as far as possible. And after successful abortive treatment there should be no relaxation in the weekly Wassermann tests or in the clinical observations until syphilis can be finally ruled out. In all cases, except those favorable for abortive treatment, reliance is placed on cleanliness, the use of antiseptics, and measures to promote healing. The first principle in treating chancroids is to keep them as free as possible from pus, both to promote healing of the ulcer and to prevent infection of the THE VENEREAL DISEASES 291 lymphatics. In all cases, for the effect of the heat as much as for cleaning effect, the patient should hold the penis in hot water for half an hour several times daily. Then the lesion should be given a copious warm irrigation with boric acid solution or mercuric chloride, 1:10,000, or potassium per- manganate, 1:3,000, or some other nonirritating antiseptic solution. Then the ulcer should be dusted with an antiseptic, such as iodoform (the preferable antiseptic), thymol iodide, calomel, or argyrol. After this there should be applied a moist dressing of one of the solutions which are used for irrigating the ulcer. In very acute cases a good dressing is one wet with aluminum acetate solution, 1 part of the 8 per cent solution of aluminum acetate to 7 or 15 of water. The dressings must be kept continually moist and changed frequently enough to prevent accumulation of pus on the ulcer. When for any reason it is impracticable to keep a wet dressing constantly applied, the next best course to pursue is to dust the ulcer after irrigation with argyrol crystals or iodoform and then cover it with gauzes spread with petro- latum. Dry powders alone are not good applications for chancroids. They cake into crusts, under which the pus accumulates, and this materially increases the risks of infection of the lymphatics and the occurrence of bubo. Occasionally in the course of healing of chancroids, the granulations become sluggish; in such cases, stimulation by the application of balsam of Peru works well, or the granulations may be touched occasionally with silver nitrate. If there is an overgrowth of the unhealthy granulations, they should be trimmed off with a knife or razor or seared with a cautery, and then dressed with iodoform and a wet compress. In chancroids under a greatly swollen or long, tight prepuce, wet dress- ings can not be used. In these cases prolonged soakings in hot water several times daily are particularly serviceable. After each soaking the preputial sac should be cleaned by inserting into it a catheter or a long flat syringe nozzle and thoroughly irrigating with hot antiseptic solution. After the irrigation there should be injected into the preputial sac from 2 to 4 c. c. of a suspension of antiseptic powder in oil or glycerine, such as 20 per cent calomel, 10 per cent thymol iodide, or 10 per cent iodoform in oil or glycerine. Of these, 10 per cent iodoform in glycerine is best. In patients with a long prepuce it is best not to make a dorsal slit, if prog- ress can be made without so doing for if a dorsal slit is made, the whole surface at once becomes chancroidal. Not infrequently in cases with intense reaction and great swelling no headway can be made while the prepuce is intact; in other cases the reaction becomes so exaggerated that, unless relief of tension is given, sloughing of the prepuce will occur. Under these conditions a linear slit along the dorsum of the prepuce should be made, and the case then treated as an open chancroid. A complete circumcision should never be attempted until the infec- tion has entirely disappeared. SUPPURATIVE INGUINAL ADENITIS Under the usual conditions of treatment of chancroids, when patients are not in bed, suppurative inguinal adenitis occurs in from 30 to 50 per cent of the cases. But the factors that predispose to bubo are muscular activity and 292 COMMUNICABLE AND OTHER DISEASES accumulation of pus on the chancroid; so that with patients in bed and with their chancroids kept free from pus, bubo is a relatively infrequent complication. When bubo threatens, extra care should be used to see that there is no absorption of pus from the chancroid; the patient should have complete rest, and hot applications should be applied. If fluctuation develops, the hot appli- cations are continued until the gland has full}7 broken down. W hen it is soft throughout and full of pus, a small incision with a double-edge knife should be made and the pus evacuated. Iodoform glycerin, 10 per cent, is then injected into the cavity. The emulsion should be injected three times at the first sitting. The first two injections run out and the last one remains in. The wound is then bandaged with gauze, moistened with solution of aluminum acetate, 1 part in 7 of water, or boric-acid solution, or some other antiseptic solution. On the following day the wound is emptied by squeezing, and iodoform emulsion injected once and left in. The bandage is then applied, and in five or six days the wound is closed and healed. If after a week the wound is not closed, it should be injected again; this will usually result in healing in five or six days. The method of injecting the wound with silver-nitrate solution has been abandoned on account of the pain that it causes and because it is no better than the injection with iodoform. The plan of encouraging suppuration and evacuating the pus through a small incision is satisfactory in most cases when the glands break down rapidly. But sometimes suppuration goes on very slowly; and in these cases it is better to make a free incision, evacuate the pus, and dissect or curette out the partially broken-down remains of the glands. Then the wound is packed with gauze and allowed to heal by granulation. It is better to avoid this course if possible, as the subsequent healing takes six or eight weeks and requires daily dressing. It was the practice a few years prior to the World War to endeavor to prevent suppuration in the glands by dissecting them out and trying to get a clean wound, which was closed by suture. This practice has now been aban- doned because it was found that a solid edema, or elephantiasis, of the penis and scrotum and inguinal region often followed, in consequence of the obliter- ation of the lymphatic vessels in the area of the wound. Another objection was that, when patients came to operation, suppuration had nearly always begun in the center of the gland, even though no fluctuation was evident; the wound was not aseptic and could not be closed, but had to be left open for the slow process of healing by granulation. SYPHILIS Table 45 shows the occurrence of syphilis in the Army during the World War by countries of occurrence for officers and enlisted men. In addition to the 67,026 primary admissions, all forms, 9,665 cases were reported as con- current with other diseases, making a total of 76,691; that is, with a total mean strength of 4,128,479 men, 1.85 per cent were admitted to sick report on account of syphilis. THE VENEREAL DISEASES 293 Table 45.—Syphilis. Primary admissions, deaths, discharges for disability, and noneffective- ness, officers and enlisted men, United States Army, by countries of occurrence, April 1, 1917, to December 31, 1919. Absolute numbers and ratios per 1,000 Total of mean annual strengths 4,128,479 4, 092,457 206, 382 Admi ssions Ratios per 1,000 strength 16.24 16.25 4.36 Deaths Discharges for disability NonefTect Days lost iveness Abso-lute num-bers 67,026 66, 504 899 Abso-lute num-bers 143 140 3 Ratios per 1,000 strength 0.03 .03 .01 Abso-lute num-bers Ratios per 1,000 strength Nonef-fective ratio per 1.000 strength Officers and enlisted men, including native troops______......_____ 3,318 3,297 33 0.80 .81 . 16 1,927,901 1,914,653 35, 835 1 28 Total officers and men, American 1 28 Total officers.....___________ 48 Total enlisted men, American troops: White .. 3, 599, 527 286, 548 45,456 18, 623 1,526 12.63 64.99 82 53 2 .02 . IS 2,104 1,131 29 .58 3.95 1, 338, 950 502,437 37,431 1 02 4 80 Color not stated........ _____ Total___________________ 3, 886,075 65,605 16.88 137 .04 3,264 .84 1,878,818 1..2 36,022 522 14.49 3 .08 21 .58 13, 248 1.01 Total Army in United States, in-cluding Alaska: 124, 266 1,965, 297 145,826 413 34, 915 16,200 3.32 17.76 111.09 2 56 35 .02 .03 .24 27 1,984 1,089 .22 1.01 7.47 19,445 919,290 407,226 .43 White enlisted.. .. . . ___ 1.28 7. 65 2, 111, 123 51,115 24.21 91 .04 3,073 1.46 1,326, 516 1.72 Total officers and men_____ 2, 235,389 51, 528 23.05 93 .04 3,100 1.39 1,345,961 1.65 U. S. Army in Europe, excluding Russia: 73, 728 1, 469, 656 122,412 454 8,672 2,039 1,515 6.16 5.90 16.66 4 96 41 14 .05 .07 .33 15, 293 368, 875 90, 646 36, 843 .57 24 17 2 .02 .14 .68 Colored enlisted.....-------- 2.03 1, 592,068 12, 226 7.68 43 .03 151 .09 496, 364 .85 Total officers and men. ___ 1, 665, 796 8,388 12, 680 32 7.61 3.81 43 1 .03 .12 155 2 .09 .24 511,657 1,097 .84 .36 U. S. Army in Philippine Islands: 16, 995 4, 456 609 143 35.84 32.09 1 1 .06 .22 5 .29 15,098 1,842 2.43 1.13 21,451 752 35.06 2 .09 5 .23 16, 940 2.16 U. S. Army in Hawaii: 16,161 3,319 19, 4S0 19,688 122 47 169 277 7.55 14.16 8. 08 14.07 4 .25 4,210 1,842 .71 1.52 4 2 .21 .10 6,052 7,446 .85 U. S. Army in Panama: White 1 .05 1.04 U.S. Army in other countries and not stated: 610 141 9 8 1 15 is, 010 184 540 18,764 Total 14, 232 760 53.40 24 1.69 3.61 Transports: 97,498 10, 535 251 53 2 2.57 5.03 5 .05 5,991 697 48 .17 .18 Total......______________ 108, 033 306 2.83 5 .05 6, 736 .17 Native troops: Philippine Scouts---------- Hawaiian----------------- 18, 576 5,615 11.N31 195 23 304 10. 50 4.10 25. 69 2 4 15 .11 .71 1.27 4, 278 989 7,981 .63 .48 3 .25 1.85 294 COMMUNICABLE AND OTHER DISEASES The primary admission rate per 1,000 strength was 16.24 for the total Army and the total days lost from duty was 1,927,901. One hundred and forty-three deaths were charged to syphilis. Since the duration of the war was short, the above number of deaths obviously does not represent the toll that was claimed by syphilis among soldiers. The above figures are not intended to represent total syphilis in the Army, but only those cases with manifest lesions. Doubtless there were many cases that were never recognized. Levin10 made more than 10,000 blood tests on troops at Camp Funston, Kans., and at Fort Riley. These tests were made on men from all walks of life. He found the percentage of syphilis among officers to be low, with one double-plus reaction in 59 cases examined. The following table shows the results of this survey, among white and colored enlisted men: Comparison of figures obtained in surveys of white and colored men Troops Number examined Known syphilitics Wasser-mann Undoubted syphilitics Wasser-mann Estimated probable syphilitics 1 White........___________________ 1,577 Colored_______ ... . 1 1,422 Per cent 3.44 1.08 Per cent 4.77 21.80 Per cent 8.21 22.88 Per cent 7.87 13.11 Per cent 16.08 36.00 For the total Army during the war there were 67,026 primary admissions for syphilis, of which 899 were officers. White enlisted men furnished 45,456, and colored enlisted 18,623 cases. The admission rate for officers was 4.36; for white enlisted men, 12.63; and for colored enlisted men, 64.99 per 1,000 strength. Of the deaths recorded, 3 were among officers and 137 among enlisted men. White enlisted men contributed 82 and colored enlisted men 53 of these deaths, with ratios of 0.02 and 0.18, respectively. This same higher incidence among the colored enlisted men is also shown by discharges for dis- ability and days lost from duty. The discharge rate for the white was 0.58 and for the colored enlisted men 3.95. White enlisted men lost 1,338, 950 days from duty and colored enlisted men 502,437. The noneffective rates were, respectively, 1.02 and 4.80. The disease was relatively less common among native than among American troops. For the former there were 522 cases (14.49), with 3 deaths (0.08), 21 discharges for disability (0.58), and a loss of 13,248 days (1.01) from duty. OCCURRENCE IN THE ARMY IN THE UNITED STATES The vast majority of syphilis cases in the Army were reported in the United States. There were 51,528 primary admissions, with the high rate of 23.05 per 1,000 per annum. This disease was more common among white enlisted men in the United States (17.76) than in the Army at large (12.63); however, only about one-seventh as common as among the colored enlisted men. Among the latter there were 16,200 primary admissions, with the high rate of 111.09 per 1,000 strength. The majority of deaths, and practically all the discharges for disability, were recorded for troops serving in the United States. The death rate among white enlisted men was one-eighth (0.03) that of colored enlisted men (0.24), and the discharge rate was almost in the same proportion. THE VENEREAL DISEASES 295 Time lost from duty amounted to approximately 900,000 days for white enlisted and 400,000 days for colored enlisted, with noneffective ratios of 1.28 and 7.65 per 1,000, respectively. The average enlisted rate at home was 1.72. OCCURRENCE IN THE AMERICAN EXPEDITIONARY FORCES As shown in Table 45, syphilis was not as commonly reported in the Ameri- can Expeditionary Forces as in the Army in the United States. There were 12,680 primary admissions in the former against 51,528 in the latter. The admission rate in the American Expeditionary Forces was 7.61 per 1,000 and 23.05 in the Army in the United States. Syphilis was about twice as common among officers abroad as it was at home, the admission ratios being 6.16 and 3.32 per 1,000 strength, respectively. It was about one-third as common among enlisted men overseas (7.68) as in the United States (24.21); and at home it was more common among colored (111.09) than among the white enlisted men (17.76). Among colored enlisted men abroad there were 2,039 primary admissions, and among white enlisted men 8,672, with admission ratios of 16.66 and 5.90 per 1,000 per annum, respectively. OCCURRENCE IN OTHER COUNTRIES Syphilis has been a common disease among American troops in the Philip- pines since the first occupation of these islands in 1898. During the World War there were 752 primary admissions among the enlisted man, white and colored, with admission ratios of 35.84 and 32.09, respectively; in this instance the rate was higher among white troops than among the colored. It is of interest to note that the rate was twice as high as that of the Army at large (16.24). In Hawaii, syphilis was relatively uncommon. There were 169 pri- mary admissions' among approximately 20,000 enlisted men; the rate was 8.68 per 1,000 strength. Syphilis was more prevalent among white troops in Pan- ama than in Hawaii; in the former there were 277 cases, with the admission rate of 14.07. The highest rate for enlisted men (53.40) was in a miscel- laneous group of stations that included China, Siberia, Russia, etc. The high- est rate among the native troops was for the Porto Ricans (25.69). Among Philippine Scouts, numbering approximately 19,000, there were 195 cases (10.50). The Hawaiian rate was the lowest (4.10) recorded for any troops during the war. DIAGNOSIS The diagnosis of syphilis in the Army during the war was conducted along conventional lines and but little new was developed. However, never before were examinations carried out on such a large scale, nor has it been possible before to study data in such masses. The outstanding feature in diagnosis was the attempt at the recognition of syphilis as soon as possible after infection. This explains the relatively high occurrence of primary syphilis. Briefly, the methods used were physical examination, examination of the ulcer for the Spirochxta pallida, and serological methods. The luetin test was used scarcely at all. The colloidal-gold test and the cell count were used in selected spinal fluids. The Rontgen ray was used as an auxiliary in cases of suspected visceral syphilis. 296 COMMUNICABLE AND OTHER DISEASES The importance of early diagnosis was frequently emphasized and, in this regard medical officers were advised by the Surgeon General as follows: The matter of prime importance in handling syphilis is to get it at the beginning of the infection. The earlier it is treated the better are the prospects of cure, and the quicker the soldier can be made noncontagious and gotten back to duty. It should be the constant effort to discover syphilis at the earliest possible time, if possible before the development of a possible Wassermann reaction. To this end, every sore, whether on the genitals or elsewhere, that is open to any sus- picion of being a chancre should be repeatedly examined for spirochetes. No determining weight should be given to the so-called specific clinical characteristics of any lesion that might by any possibility be a chancre. Experience has shown that the typical clinical char- acteristics of the chancre, aside from indolence—and this may be masked by another infec- tion—are often lacking. Any excoriations, papule, nodule, crack, herpetic or other erosion no matter how small, may be an initial lesion of syphilis; and such lesions, as well as ulcers about the genitals—and elsewhere, if there is any reason to suspect them or if they are indo- lent and not readily to be accounted for—should be searched for spirochetes. Chancroids in particular should never be accepted as uncomplicated by syphilitic infection. They are likely to have a double infection, and should always be zealously exam- ined for Spirochseta pallida. Sometimes, in spite of the most careful search, the spirochetes escape detection in chancroids. For that reason, one can never be sure that a chancroid does not hide a chancre; patients with chancroid, therefore, require watching for the possi- bility of syphilis, and, when the spirochetes can not be found, should always have weekly Wassermann tests for three or four weeks until the question of syphilis can be decided. Antiseptics, especially mercurials, render the finding of Spirochseta pallida difficult or impossible, and, because of this, it should be routine practice to apply no mercurial dressings, or, better, no antiseptic dressings, to suspicious lesions until the necessary examinations to exclude Spirochseta pallida have been made. If any such application has been made to a suspected lesion, the lesion should be thoroughly irrigated with physiologic sodium chloride solution, and a wet dressing of this solution applied for 12 hours or more before examining for spirochetes. In order to aid in discovering the initial lesion at the earliest moment soldiers who have been exposed should be inspected at intervals of a few days for at least three weeks, and also instructed to be themselves on the watch for suspicious lesions. Examination for Spirochseta pallida and diagnosis.—To obtain the Spirochsetse pallidas for examination two procedures are of value. In obtaining them directly from the lesion the surface should be wiped with gauze wet with physiologic sodium chloride solution to remove saprophytic organisms, especially the Spirochseta refringens. The rubbing should leave a clean oozing surface, not bleeding. Light curettement may be necessary in some cases. Moderate squeezing of the lesion will then cause an exudation of lymph from the deeper portions of the tissues. A drop of this lymph is then touched to a cover glass and placed on a slide, or the fluid may be collected in a capillary pipette. It may be preserved for a few hours by sealing the pipette, or the specimen on the slide may be ringed with paraffin or petro- latum and kept on ice for variable periods up to 12 hours or longer. Delay impairs the validity of the findings, however, and multiplies uncertainties, so that examination should be made at once. A valuable method, which relieves the observer of much of the responsibility for differ- ential diagnosis of the organism, is glandular aspiration. This can be done on prominent nodes in the satellite adenopathy accompanying the primary lesion. It can also be performed on the indurated base of a suspected chancre. A sterile glass syringe, of 1 c. c. capacity, fitted with an ordinary stout hypodermic syringe needle, an inch or so in length, is sufficient! The skin over the gland is painted with iodine and the gland palpated and fixed between the thumb and forefinger of the left hand. The needle is plunged through the skin into the gland, the penetration of the capsule being indicated by the moving of the gland under the finger when the position of the syringe is changed. The gland is then held firmly while the needle is manipulated enough to macerate the tissue immediately around the point, Aspi- THE VENEREAL DISEASES 297 ration will draw a drop or two of tissue juice into the needle and barrel. The fluid thus ob- tained is often rich in Spirochseta pallida. The method is not especially painful, and is easily borne by the average patient. The Spirochseta pallida, as obtained for study by these methods, has a morphology usually easily recognized by the experienced observer. It is a regular spiral organism, oi from 6 to 15 microns in length, with from 3 to 26 turns. The average length is about twice that of a red blood cell, and the usual number of turns is from 10 to 20. It is rather slow moving, which is a distinctive characteristic. A movement in the direction of the long axis and a rotating movement are most commonly observed. The organism retains its clear-cut, regular spiral turns exceptionally well, even at rest—another distinctive characteristic. Long forms bent in the middle are occasionally seen. From Spirochseta refringens, if this is not eliminated by proper cleansing, the Spirochseta pallida is distinguished by the fact that Spirochseta refringens is obviously coarser and the turns are fewer and less regular. Spirochseta refringens does not keep its corkscrew shape so well as Spirochseta pallida when at rest, and when in motion moves much more rapidly than the Spirochseta pallida. Spirochseta dentium, seen in mouth preparations, is much more minute than the Spirochseta pallida. Fibrin spirals have been mistaken for syphilitic spirochetes by inexperienced observers. In general it may be said that while the recognition of the organism of syphilis is not an affair for the tyro, a moderate amount of experience on the part of the examiner, coupled with the presence of numerous organisms of the above-described type in a given preparation made under favorable conditions, is sufficient for a diagnosis of syphilis and the institution of appropriate treatment. Failure to find them, however, is no evidence that the lesion is not syphilis. In all suspected cases Wassermann tests should be made. It should be made a general rule that the first finding of a positive Wassermann reaction should immediately be confirmed by a second, but it is not necessary to delay beginning treatment until the second report is received. For the first 10 days after the appearance of the chancre the Wassermann reaction is usually negative. It is at this critical period that the establishment of the diagnosis of syphilis by demonstration of the specific spirochetes is of such importance, because it enables us to begin treatment while the infection is still relatively localized and can usually be aborted by thorough treatment. In suspected chancres in which spirochetes can not be found Wassermann tests should be made at intervals of a week, for a month, before it is decided finally that the case is not syphilis. In cases in which the spirochetes are found a Wasser- mann test should be made at the outset, and if it is not positive should be repeated at weekly intervals for the first few weeks to see if, in spite of treatment, it becomes positive. Further Wassermann tests should be made at about monthly intervals. In no cases should specific treatment be started until a positive diagnosis of syphilis has been made. Though the Surgeon General's Office recommended certain laboratory methods, much latitude was allowed the officers in charge; therefore, methods used by all laboratories were not identical. Particularly was this true of lab- oratories in the United States. In the American Expeditionary Forces the instructions11 were that a man with a suspicious sore should be sent to the labo- ratory of the division, where preparation for staining and dark-field examina- tions were to be made by the pathologist, a consultation obtained with the urol- ogist, if feasible, and the man returned at once to his unit with an immediate report of findings. Local application of mercurial preparations or cauterization of the sore was forbidden before smears for microscopic diagnosis were taken, nnd failure of the microscopic examination to demonstrate Spirochseta pallida was not to be regarded as final until several additional smears had been made. Twenty-eight and four-tenths per cent of the admissions for syphilis were diagnosed in the primary stage. This was accomplished by examination of the sore for the Spirochseta pallida; 50.4 per cent were diagnosed in the secondary 298 COMMUNICABLE AND OTHER DISEASES stage, accomplished by means of physical examination, confirmation by the results of the Wassermann complement fixation test or some modification thereof. Xo test was considered positive unless there was complete inhibition of hemolysis, except in the early primary cases when less inhibition was consid- ered positive in a few cases. Four degrees of reaction are noted in reports from the Army laboratories. A positive reaction is reported as double-plus (+ +), and means that there is absolute inhibition of hemolysis. A doubtful reaction is reported as plus (+) or plus-minus (+ -), the former term indicat- ing that there wTas over 50 per cent inhibition of hemolysis, the latter that there was less than 50 per cent inhibition of hemolysis. A negative reaction is reported as minus (—). In most civilian laboratories the results of the Wassermann test are reported as four plus (+ + + +), three plus (+ + +), two plus (++), plus ( + ), plus-minus (+—), and negative (—). The four- plus reaction corresponds to the Army double plus, the three plus and twc plus to the Army plus, the plus and plus-minus to the Army plus-minus. Although, as generally performed, the Wassermann test is not a true specific reaction, the work of Noguchi12 and Craig and Nichols13 had proved that, with antigens prepared from pure cultures of Spirochseta pallida, complement fixa- tion can be obtained with syphilitic sera, and that in such instances the reaction is really a specific one, due to antibodies in the patient's blood serum against the spirochete. Examination of the cerebrospinal fluid, not only in cases presenting neuro- logical signs and symptoms, but also as an indicator of cure of the syphilitic infection, was the practice in the Army. Negative findings in the fluid is a requisite of cure in the Army standard index. The vast majority of chancres were genital; however, extragenital chancres occurred, and were of special interest to the military service in determining the status of the individual officer or soldier as to whether or not the illness was in line of duty. The number of such cases was exceedingly small; they were found more commonly among the medical personnel as the result of infection by patients. Lambie14 made a survey of approximately 30,000 Army syphilitic registers and found 139 cases of extragenital infection. COMPLICATIONS, SEQUELAE, AND CONCURRENT DISEASES Since practically no tissue of the human body is immune to the syphilitic virus, the number of possible complications is large. Complications and sequelae, however, develop relatively slowly and since the average length of service per man in the Army during the war was approximately a year,15 and the average period of time in hospital for syphilis was 28.7 days, it is apparent that the Army's World War statistics are of little interest in this connection. As pre- viously stated, complicated syphilis, when detected, was a cause of rejection from military service; however, many uncomplicated cases were accepted for service. Such complications as cardiovascular syphilis and syphilis of the nerv- ous system were but seldom reported. THE VENEREAL DISEASES 299 Table 46.—Primary admissions, complications, sequela;, and concurrent diseases reported with 12,843 cases of syphilis in the United States Army, April 1, 1917, to December 31, 1919 Diseases (primary and secondary) Acute articular rheumatism... Chancroidal infection_______ Gonococcus infection________ Arthritis__________________ Leukemia_________________ Hodgkin's disease__________ Anemia, chlorosis__________ Alcoholism, acute or chronic.. Drug addiction............... Fracture, faulty union of____ Locomotor ataxia......_____ Multiple sclerosis__________ Apoplexy....._____________ Facial paralysis____________ Paraplegia........__________ Paralysis, others___________ Epilepsy__________________ Neurasthenia______________ Neuritis____________....... General paralysis of the insane Duodenal ulcer____________ C irrhosis of the liver________ Nephritis: Acute_________________ Chronic_______________ Number of cases 126 ,687 ,498 653 2 3 5 29 27 17 62 5 71 15 8 44 66 57 68 79 8 13 32 65 Diseases (primary and secondary) Mental deficiency___________________ Dementia praecox____________________ Chorioiditis_________________________ Iritis___________________________________ Keratitis_______________________________ Retinitis_______________________________ Pericarditis____________________________ Endocarditis___________________________ Aortic insufficiency____________________ Aortic stenosis_____________......_______ Mitral insufficiency____________________ Mitral stenosis________.....____________ Myocarditis and myocardial insufficiency Angina pectoris________________________ Aneurism______________________________ Aortitis_______......___________________ Tachycardia....._______.....__________ Ulcer of the stomach____________________ Bones, other diseases of_________________ Total______________........______ Number of cases 95 45 56 307 84 34 6 13 36 9 122 32 95 5 12 42 41 14 165 12, 843 PROGNOSIS For reasons above stated, the World War statistics are of but little or no value in determining the prognosis of syphilis. For the total Army during the World War there were recorded 51,119 deaths from disease. For syphilis, both among primary admissions and concurrent diseases, there were 317 deaths; that is, 0.54 per cent. Syphilis ranked twenty-first on the list of the most common causes of death among primary admissions for disease and if all cases, both primary and concurrent, be included, it ranked fifteenth. From the military point of view, the prognosis of syphilis was better than, for example, scarlet fever, in that, although there were about one-sixth as many cases of scarlet fever there were approximately twice as many deaths, while time lost from duty was about twice as great per case. As a rule, syphilitics were ad- mitted to hospital and held there during the contagious stage and while physi- cally disqualified for duty. They were then returned to their organizations for prolonged treatment, and but rarely were readmitted to sick report. And as shown under treatment in this chapter, since the course of treatment was a long one, the total interference with duty can not be determined. From previous experience, especially since 1911, when the Army syphilitic register was inaugurated, the Surgeon General prescribed a standard cure for syphilis:16 One year of observation must elapse after all treatment has been stopped. During this year there must be no clinical evidences of syphilis, several negative Wassermann reactions and no positive ones. At the end of the year a complete physical and laboratory examination, including that of the spinal fluid and a provocative blood Wassermann reaction must be negative. If all these requirements have been fullfilled, the case can be closed as "cured" and the register sent in. Among enlisted men, white and colored, during the war there were treated 19,024 cases of primary, 34,787 cases of secondary, and 10,984 cases of tertiary syphilis, but it can not be stated how many were cured. It is difficult to say 300 COMMUNICABLE AND OTHER DISEASES positivelv that a patient is cured of syphilis. This may require years of obser- vation, including careful scrutiny at the necropsy table by a competent path- ologist. However, from the military viewpoint it may be said that the prognosis of syphilis in the Armv during the war, and based upon the records only, was good, as there were but 143 deaths and 3,318 discharges for disability among approximately 67,000 cases of syphilis, with an average period of hospital treatment amounting to 28.7 days. TREATMENT a TREATMENT OF THE CHANCRE Excision of the chancre is a procedure which theoretically should be useful, on the ground that it removes the important focus of infection. And when the location of the chancre is such that its excision will not cause deformity, sur- gical excision may be done; but excision of the chancre does not abort syphilis. The excised chancre should be preserved and sent for laboratory examination. Until the search for spirochetes is ended, the chancre should be treated only by cleansing with saline solution and covering with a compress wet with the same solution. As soon as spirochetes are demonstrated, if the chancre is not excised, it should receive an inunction of 33 per cent calomel ointment twice daily for a week; it should be kept clean and protected by a calomel ointment or some bland protecting dressing. SYSTEMIC TREATMENT In the presence of early syphilis, treatment should be immediately started and vigorously pushed. It should be with both arsphenamine " and mercury. Before beginning there should be a preliminary survey of the patient's physical condition. Patients with acute febrile diseases or with diseases of the liver, kidney, or vascular system—when they are nonsyphilitic in origin—should be given arsphenamine with caution. Arsphenamine b There is agreement among syphilographers that the most effective time for producing radical results with arsphenamine is in the first few weeks of syphilis—best before the Wassermann test becomes positive—and that arsphe- namine should be pushed at this time. The normal dose should be on the basis of 1 decigram of arsphenamine for each 30 pounds of body weight, i. e., from 4 to 6 decigrams for patients of ordi- nary weight. The first dose should be one-half the normal dose. Administer at intervals of from five to seven days. Six doses constitute a course. It is possible that in cases seen before the Wassermann test has become positive, one such course of arsphenamine combined with mercury may cure. But this is not safe to assume, and, in the light of our past knowledge of syphilis, it is advised even in these cases to repeat the course of arsphenamine and mer- cuiy treatment at least once after a rest period of from six to eight weeks. ° Based upon A Manual of Treatment of the Venereal Diseases for the Use of Medical Officers of the Army. Pre- pared under the direction of the Surgeon General, 1917. b Arsphenamine is the official name now applied to the drug formerly called salvarsan. THE VENEREAL DISEASES 301 Such patients should be subsequently watched for a year with monthly Wasser- mann tests and treated should any evidence of syphilis be discovered. In all cases seen after the W^assermann test has become positive the first course of treatment should be followed by a second after four to six weeks' rest. And it is safest to give at least a third similar course after an interval of two months even in the most promising of cases. In all those cases in which a positive Wassermann test or any other evi- dence of syphilis remains, further courses of arsphenamine and mercury should be given at intervals similar to the foregoing, the persistence in treatment to be determined by the findings in the individual case. In place of arsphenamine, neoarsphenamine can be used in 50 per cent larger doses. It may be somewhat less effective, but the difference is not suffi- cient to allow of dogmatic statements on this point. It may be repeated that the use of arsphenamine is to be combined with that of mercury in the attempt at cure of syphilis; and that reliance is not to be placed on arsphenamine alone. Preparation and Care of Patient The urine should be examined before each injection of arsphenamine. Arsphenamine should be given with the patient's stomach empty, or nearly so. The treatments are best given at noon or in the early afternoon, the patient omitting lunch. He should remain quiet for the rest of the day—best in bed— and should take no food until the next morning. Reactions from Arsphenamine As a rule the administration of arsphenamine is followed by no symptoms whatever. Occasionally, however, reactions occur from it; these vary in sever- ity from slight, evanescent distress to symptoms of the gravest poisoning. To some extent, perhaps, these reactions are due to individual hyper- sensitiveness to the drug. There is good reason to believe, however, that the severe reactions are chiefly produced by impurities in the drug, due to faults in manufacture, or sometimes to oxidation produced by carelessness in technique of administration. The reactions may be divided for consideration into early and late; the early reactions occurring from the very time of injection to 6 or 8 hours after- ward, and the late occurring from 1 to 4 or 5 days, and, occasionally, even longer afterward. The early reactions have the symptoms of acute poisonings; the late, symptoms of organic disturbances that have resulted from the slower action of a poison. Early Reactions Xausea.—The commonest reaction after arsphenamine is a feeling of malaise with some nausea from five to seven hours afterward. Not infrequently this amounts to a chill, followed by slight fever and more or less severe vomiting. These symptoms disappear in a few hours. They do not constitute a contraindication to the further use of the drug, but they should suggest that more care than usual be exercised to see that, 302 COMMUNICABLE AND OTHER DISEASES before administration, the bowels have been cleaned out and the stomach is empty and that, afterward, the patient rests without food until the next morning. Febrile reaction.—Rarely these reactions are more severe. The temperature may go to from 101° to 104° F. with headache and general pains, especially of the legs and back, diarrhea as well as nausea and vomiting, and an eruption of urticaria or toxic erythema. The treatment is rest in bed and a liquid diet until symptoms have subsided. The pain may be controlled by a few doses of salicylates. Xo more arsphenamine should be given in these cases until several days after all symptoms have disappeared, and any further administration of the drug should be in relatively small doses and at intervals of not less than a week. Temporary albuminuria.—It is not uncommon to find a trace of albumin and a few casts in the next morning's urine after an injection of arsphenamine. This is not a contraindication to the further use of the drug unless the albumin is present in considerable quantity and there are more than half a dozen casts to the slide. Immediate acute reaction.—The early reaction which in rare cases accom- panies or immediately follows the administration of arsphenamine is that of an acute poisoning, characterized by intense congestion from vasomotor dis- turbances; this is the so-called anaphylactoid reaction of arsphenamine. It is probably due to impurities in the drug. In these cases the patient suddenly— perhaps before the injection is finished— manifests symptoms of distress. He may first notice a taste of garlic or ether, or of a metallic substance. An erythema appears on the neck and spreads thence over the face, and the jugular pulse is exaggerated and rapid. He complains of faintness; the pulse becomes weak and the respiration labored. The face is puffed and congested; the pupils dilate; there is a feeling of constriction in the throat; and there may be edema of the glottis, which fortunately is very rarely fatal. There is tightness in the chest, and especially precordial distress. The pulse may become imperceptible, the patient cyanotic, and syncope may occur. Altogether the picture is ex- tremely alarming in the severe cases, but fortunately the symptoms as a rule quickly improve, and recovery nearly always takes place. These cases promptly respond to the injection of from 1 to 2 c. c. of 1:1,000 solution of adrenalin, which may be repeated at intervals of 20 or 30 minutes, if required, until the symptoms subside. In preparation for this emergency a sterile hypodermic syringe with 2 c. c. of adrenalin solution in it should always be at hand when arsphenamine is given. The occurrence of this reaction does not preclude the further use of arsphen- amine; but is suggests that careful control of the patient's preparation should be exercised, that the technique should be reviewed, and that the preparation of arsphenamine should be investigated. Late Reactions Lowering of general health.—Occasionally during a course of arsphenamine a patient's general health becomes lowered without other evidence of organic disturbance. There is lassitude and, perhaps, headache; the appetite is poor THE VENEREAL DISEASES 303 and the patient falls off in weight. Such symptoms—likely to be overlooked because of their insidiousness—should lead to careful consideration of the case. Patients who are doing well under specific treatment show it in an improvement in their general well-being. If this lowering of the health progresses under arsphenamine, it should be discontinued. The patient should be relieved from duty, placed on a liberal, perhaps forced, diet, given tonics, and his elimination stimulated by abundance of water and the use of laxatives or cathartics; also he should be carefully examined for other diseases. Erythema and dermatitis.—In rare cases, patches of scarlatiniform erythema develop from 12 to 24 hours after arsphenamine; these are usually accompanied by evidence of kidney irritation. The appearance of areas of scarlatiniform erythema is an indication that arsphenamine should be stopped until well after these symptoms have disappeared, and that its further use should be very guarded. These preliminary manifestations of intoxication usually disappear spon- taneously in a few days, although rarely they develop into the severe cases. If arsphenamine is continued in spite of these warnings, there is likely to develop a universal exfoliative dermatitis with nephritis. In extreme cases the nephritis is severe, accompanied by high fever, diarrhea and bronchopneumonia, and the result may be fatal. The same measures, to a greater degree, are indicated here as already suggested for lesser intoxication—complete rest, support of the patient's strength by an abundant diet, and stimulation of elimination. Nephritis.—Severe nephritis with its sequelae may occur without skin symptoms. For this reason the urine should always be carefully watched while arsphenamine is given. As stated above, a transient albuminuria with a few casts is common the next morning after an injection of arsphenamine. If this promptly disappears, it is not a contraindication to the continuance of the injections. Again, albuminuria due to syphilitic nephritis is not very rare. The evidence of the characters of such an albuminuria is that it is quickly benefited by arsphenamine as by other specific treatment. Persistent evidence of nephritis developing in the course of arsphenamine administration is another matter. It requires that the course be stopped and not resumed until the nephritis has disappeared; and then the further use of the drug must be with extreme caution. If these precautions are neglected the case is likely to develop into one of severe, permanently disabling, or fatal type. Jaundice.—In rare cases jaundice occurs in the course of the use of arsphen- amine. It is always a sign of serious intoxication and should cause immediate, careful attention to be given to the case. Such cases may go on to acute yellow atrophy of the liver with fatal termination. They require in the way of treat- ment measures for overcoming intoxication of the sort already outlined. The larger proportion of jaundice cases are said to follow neoarsphenamine. Hemorrhagic encephalitis.—This, fortunately, is one of the rarest, as it is one of the most serious, of arsphenamine accidents. The cases begin from two to four days after arsphenamine with severe headache, mental confusion, and dullness; then, usually, convulsions, coma, and death in a few days. 304 COMMUNICABLE AND OTHER DISEASES The pathology of cases succumbing from this type of arsenical intoxication shows as a rule the following features: There is characteristically an acute hemorrhagic encephalitis with softening of the cerebral tissue and with punctate hemorrhages, especially in the basal ganglia, pons, and medulla, but also involv- ing the cerebral lobes adjacent to the lateral ventricles and less frequently the cerebellar tissue. With this is associated an acute ependymitis, especially in the lateral ventricles, with hyperemia and punctate hemorrhages. There may be general cerebral congestion and edema. Acute nephritis may be present but is not constant. Degenerative lesions may develop in the liver, sometimes giving a picture resembling acute yellow atrophy. Treatment of these cases consists of vigorous elimination, which may include withdrawal of blood, and the intramuscular use of epinephrin in full doses. Herxheimer reaction.—In the presence of syphilitic lesions in vital structures, the administration of arsphenamine which, presumably from the liberation of spirochetal endotoxins, causes a temporary engorgement of the syphilitic lesion, may produce serious symptoms of pressure, of obstruction, or of other impair- ment of function. This reaction is most likely to occur with early cerebral lesions, producing pressure symptoms, which may cause paralysis, coma, and even death. As a rule, while the symptoms are alarming, recovery takes place. Similar reactions, producing symptoms of a character dependent on the location of the syphilitic focus, may occur with syphilitic lesions of the viscera, or of the circulatory system, particularly in myocarditic coronary arteritis and aortitis. To guard against these accidents, when there is reason to suspect lesions in any of these structures, particularly in the brain, mercury and iodide should be vigorously given for several days before arsphenamine is started, if the symptoms are not so urgent as to warrant taking the risk of a Herxheimer reaction, and then the use of arsphenamine should be cautiously begun, with small doses, and only after two or three injections should full doses be given. In these reactions treatment is symptomatic. In general, the careful man is likely to attach undue importance to minor symptoms arising in the course of arsphenamine administrations, and to be influenced too readily by them to give up its use in the particular case. On the other hand, a reasonable caution in the face of symptomatic warnings of arsphenamine intoxication demands care in its further use in such cases. Recurrences of Nerve Involvement It is an occasional experience to see, with patients who have had insufficient treatment with arsphenamine or mercury, a recurrence of syphilis in a nerve or the brain or cord, producing symptoms of impairment of function in the partic- ular structure involved. These recurrences are most likely to be observed in the auditory or optic nerves, producing more or less damage to hearing and vision. While these are mentioned here, they are not manifestations of arsphen- amine poisoning. They are due to syphilitic infiltrations and occur, as well, in patients who have had no arsphenamine. They require vigorous specific treatment with mercury, iodide, and arsphenamine—especially the latter in THE VENEREAL DISEASES 305 patients who have already had arsphenamine. Of course, when these recur- rences are cerebral as in the case of involvement of the optic nerve, due care must be exercised with arsphenamine to avoid a Herxheimer reaction Technique of Arsphenamine Administration The fundamental principle of administering any form of arsphenamine is a rigid asepsis, and only extreme conditions justify its administration wThen this is not obtainable. The apparatus should be boiled for 20 minutes. It is important that freshly distilled water be used for arsphenamine solution. Thirty c. c. of water per decigram of arsphenamine is a safe dilution. The ampule should be sterilized by immersion in a strong antiseptic solution, such as mercuric chloride, 1: 1,000, and then should be immersed in 95 per cent alcohol in order to be sure it is not cracked. If it has been immersed in mercuric chloride it must be carefully wiped dry before it is opened. It must never be sterilized by boiling. The drug is first dissolved in about 50 c.c. of water. The American prepara- tion, arsenobenzol, requires hot water for its solution, and is safely dissolved in hot water. The other preparations dissolve in water at room temperature and should not be heated, because of the danger of the formation by heat of highly toxic compounds. The direct solution of arsphenamine is a strongly acid solution, which must be neutralized and diluted before injection. Neutrali- zation is accomplished after all the arsphenamine is dissolved by a 15 per cent freshly prepared solution of sodium hydroxide, which should be added drop by drop. Arsphenamine is precipitated from the solution by the alkali, but redissolves as soon as the suspension becomes slightly alkaline. The point at which this occurs can be gauged with sufficient accuracy if the sodium hydroxide is added carefully and mixed after each drop or two. Since arsphenamine oxidizes easily, it should not be violently shaken in preparation. As soon as the arsphenamine has redissolved, yielding a clear yellow solution, it may be filtered through wet sterile cotton in a funnel directly into a graduated container; then warm or cold distilled water is added to the proper dilution and to approxi- mately body temperature. Care must be taken to fill the tube attached to the container with physiologic sodium chloride solution and to expel all air bubbles before the arsphenamine solution is filtered into the container. In the event that the arsphenamine precipitates somewhat on dilution, it may be redissolved by another drop or two of the sodium hydroxide. If the prep- aration has been made too strongly alkaline, a drop of dilute hydrochloric acid may be added and the neutralization repeated. The drug should be administered promptly after preparation, and no more than enough for use on the patients to be treated at the time should be prepared. The technique of injection of the solution is comparatively simple, and the older custom of making an incision to find the vein, with its resultant scarring, has been abandoned by skillful operators. A variety of needles has been pro- posed, but the Schreiber 18-gauge with thumb guard and a proper adapter, or even a plain needle, will answer all purposes. In difficult cases a finer needle may make it much easier to get in the vein. The skin over the field of opera- 56706—28----20 306 COMMUNICABLE AND OTHER DISEASES tion, preferably in the region of the large cubital veins, is sterilized as for a surgical procedure, but if tincture of iodine is employed it is desirable to remove it with alcohol in order that the vein may be more easily seen. The injection should be given with the patient lying down and the veins distended by encir- cling the arm with a tourniquet. In nervous patients, local anesthesia may be used to advantage. Ihe needle is pushed directlv through the skin over or to one side of the vein and then introduced into the vein. As soon as the blood returns freely through the needle, the adapter attached to the tube of the container is fitted to the shoulder of the needle, the tourniquet is released, and the injection begun by elevating the container about 2 feet. As a rule assistance is desirable, since the operator is occupied by keeping the needle in position in the vein. Failure to enter the vein is apparent by this method, before injection is begun, through the imper- fect flow of blood through the needle. The saline solution contained in the tube allows sufficient warning of the infiltration of the tissues before the arsphena- mine solution reaches the needle point. Various forms of apparatus which inject saline solution as a test before beginning the injection of the arsphenamine are not essential and are often complicated. A glass telltale in the rubber tube permits the operator to watch the progress of the injection. When the injection is completed, the lowering of the container below the level of the arm before the needle is withdrawn will aspirate a small amount of blood from the vein and prevent the escape of solution into the tissues. Recent investigations have shown that the danger from intoxication with arsphenamine is much greater when it is administered in concentrated solution or is injected rapidly. For this reason it should be used in weak dilution and slowly injected. Infiltrates, if they occur, are usually trivial, provided the operator has been on his guard. The escape of arsphenamine into the subcutaneous tissues is indicated by a burning sensation, which the patient should be warned to report. The reaction which ensues when arsphenamine is injected around the vein is inflammatory, with induration and infiltration, and may, if severe, progress to a slough. Arsphenamine infiltrates should be treated by wet dressings, ice bag, and, after inflammatory symptoms subside, by massage and passive movement. An alarming degree of involvement may subside with practically no damage after several weeks or months. Thrombosis of the vein is an infrequent com- plication if the drug has been properly diluted, and should be treated on general indications. Technique of Neoarsphenamine Administration The original administration of neoarsphenamine, in dilutions similar to those used with arsphenamine, has been greatly simplified by the injection of the dose in concentrated solution. In this procedure, the dose of neoarsphena- mine is dissolved in 10 c.c. of freshly distilled sterile water at room temperature— not hot water. The solution is drawn up into an all-glass syringe and adminis- tered as an intravenous injection after the usual preparations. The method is rapid and extremely convenient, and its applicability to difficult cases is apparent. THE VENEREAL DISEASES 307 The solution of neoarsphenamine, being already neutral, requires no ad- dition of sodium hydroxid. Care must be taken to avoid infiltrates with the concentrated solution, but in general infiltrates with neoarsphenamine are apt to be less serious than those with arsphenamine. The French preparation novarsenobenzol (Billon) was used almost exclu- sively with the American Expeditionary Forces. The results were satis- factory. It was given in concentrated solution, the ordinary dose in 2 c. c. of water, and the ease of administration of this small injection proved of great practical advantage in the field. MERCURY For the cure of syphilis, arsphenamine and mercury should be combined, and at the same time with each course of arsphenamine a vigorous course of mercury should be given. This should begin before or at the same time with or within a few days after the first dose of arsphenamine. A course of mercury should consist of 9 or 10 weekly injections of an insol- uble salt, of from 24 to 30 injections of a soluble salt at two-day intervals, or of from 40 to 50 daily inunctions of mercurial ointment. The administration of mercury either by inunction or by intramuscular injection is effective; and in the selection of either method one may be properly influenced by considerations of convenience and practicability. Inunctions If inunctions are used, it is necessary to see that they are properly per- formed. Patients can not be trusted to give themselves inunctions; but they can very readily do it for each other by sitting one behind another and having each man rub the back of the man in front of him. From 4 to 8 gm. of mercurial ointment may be used for a daily inunction. It is desirable before the inunction to wipe off the area to be rubbed with alcohol or to wash it lightly with soap and water and dry. The ointment should be rubbed in slowly and gently with the palmar surface for 20 or 30 minutes, or until the ointment is practically absorbed. Any excess should be allowed to remain on the skin. After six inunctions a day should be skipped and the patient allowed a bath. In giving inunctions, hairy surfaces and the thin skin of joints should be avoided, and the same area should not be used often enough to produce der- matitis. The two sides of the back furnish the most tolerant areas. The sides of the abdomen and of the chest, and the inner surfaces of the thighs, the arms, and the forearms may all be used. Injections For injections, the preferable insoluble preparations are mercuric salicylate or calomel in oil, or metallic mercury in the form of gray oil. Perhaps the best proportion for the salicylate or calomel suspension is 20 gm. (weight) in sterile olive oil or thin liquid petrolatum, enough to make 100 c. c. (volume). A good formula for mercurial oil (gray oil) is redistilled mercury, 20 gm.; chlorbutanol, 2 gm.; anhydrous lanolin, 30 c. c. and liquid petrolatum, enough to make 100 c. c. The intramuscular dose of calomel, salicylate, and metallic mercury are the same. These three preparations, being of the same strength, have the advantage of having the same dose. The average dose of either, for an adult man, is 0.06 30N COMMUNICABLE AND OTHER DISEASES gm. weekly; by graduations the dose may be increased to 0.12 gm. weekn , or with caution even higher. The curative action of the injection of soluble salts of mercury is perhaps less than that of the insoluble. However, they are free from the dangers of cumulative effect which are inherent in the insoluble salts; and in emergencies, when there is need to get prompt, certain, and vigorous effect of mercury, they are of great value. Mercuric chloride, mercuric succinimide, or mercuric benzoate are the most useful soluble salts for injections. Good preparations are 1 or 2 per cent mercuric chloride or 1 or 2 per cent mercuric succinimide with 1 per cent sodium chloride by weight in distilled water. The average dose is 0.015 gm. into the muscle of the buttock every second day. Mercuric benzoate is given in 2 per cent solution with 2.5 per cent sodium chloride, average dose 0.015 gm. every second day. The American Expeditionary Forces used as routine treatment intravenous injection of 1 per cent solution of mercuric cyanide. The average dose is 1 c. c., representing 0.01 gm. of mercuric cyanide, given daily. Technique of Injections For intramuscular injection, a syringe such as the all-glass Liier hypodermic syringe with a 11^-inch, 20 or 22 gauge needle is used. The needle should have a slip shoulder to permit of its easy detachment from the syringe. Steril- ization of the skin with tincture of iodine is sufficient; emulsions once sterilized will remain so with reasonable care in their handling. In military service the syringe and needle should be sterilized by boiling, or by liquid phenol, and the water or phenol removed by filling the syringe first with alcohol and then with ether. The site of the injections is usually in the upper outer quadrant of the but- tock, care being taken to avoid the region of the sciatic nerve or the structures about the hip joint. They can also be well given in the upper inner quadrant of the buttocks. Injections are made alternately into each buttock. The needle with the syringe empty should be introduced to its full length, and the syringe then detached and filled with the necessary dose. This intro- duction of any empty needle is a safeguard against making an injection into a vein. If the dry needle should be in a vein, on detaching the syringe, blood would well up through it; if the needle remains free from blood, as is nearly always the case, there is reasonable security against introduction into a vein. In general, in order to prevent leakage of the emulsion, it is desirable to introduce the needle on a slight slant in the tissue. This may be accomplished by drawing downward on the skin of the buttock, which permits a valve action as soon as the needle is withdrawn and the hand released. The injection if made slowly is practically painless. The development of infiltrates and nodules of any considerable size, or in any number, during a course of injections, is either a reflection on the operator's technique or shows the case to be unadapted to this form of treatment. When an insoluble salt has been used, each of these nodules represent encapsulated mercury, and materially increases the danger of cumulative action. Daily massage by the patient will usually reduce them in a short time. If their formation can not be prevented the patient should be given injections of a soluble salt. THE VENEREAL DISEASES 309 Care of Patient While Taking Mercury Mercury as well as arsphenamine throws a burden on the kidneys; and patients under intensive treatment with mercury and arsphenamine should have the renal functions carefully watched. An examination of the urine for albumin and casts should be made weekly, and the development of definite nephritis during a course of treatment is an indication to stop. Treatment may be undertaken again after the nephritis has disappeared, but must be less vigorous than before and must be carefully watched. Care of the mouth is a part of the general care which a syphilitic should have, Dental troubles should be looked after and the patient instructed in the care of the teeth. When a syphilitic patient is sent to the dentist, the dentist should without fail be notified that the patient has syphilis in order that he may safe- guard himself against infection. A dentifrice should be used, and it is a good plan to have the patients as a routine use an oxidizing mouth wash such as a one-half saturated potassium chorate solution, or a diluted solution of hydrogen peroxide. When the gums are soft or unhealthy, a good astringent application is tincture of myrrh to be painted on two or three times daily, after brushing the teeth. Salivation If salivation occurs, the mouth should be cleaned at short intervals by washing with hydrogen peroxide solution or half saturated potassium chlorate solution. Dobell's solution may also be used, and, while less effective, it has the advantage of being soothing. Pledgets of cotton or gauze moistened with boric acid solutions placed between cheeks and teeth give comfort and get rid of exudate. Atropine is useful, given to the point of reducing salivary secretion. If the patient has been using inunctions, he should, in order to get rid of mer- cury in the skin, be greased with an oil and then well washed with soap and water and put in fresh clothes. He should have a soft, nutritious diet, be pro- tected from exertions, and given the care for exhausting illness. In particular, he should be given an abundance of water. Estimating the Course of Cases During the early course of syphilis, a Wassermann test should be made at monthly intervals, and after it has apparently become permanently negative, it should still be repeated at intervals of two or three months for at least a year. It should be remembered that the Wassermann test is not likely to be positive for the first 10 days of the chancre. After it becomes positive, the obtaining of a single subsequent negative reaction means little; it must remain negative over a period of months to justify the conclusion that it is permanently negative. In estimating the effect of treatment on syphilis, not only the disappear- ance of specific clinical symptoms and of the positive Wassermann reaction should be considered, but the patient's general well-being as well. In zeal to sterilize a patient of spirochetes the effect of the treatment itself on the patient should not be overlooked, and treatment should not be pushed beyond the point at which the patient is able to tolerate it without distinct lowering of his general physical tone. A patient may be regarded as free from the necessity for further obser- vations or treatment who, under observation and with Wassermann tests at intervals of two months, has remained free from all evidence of syphilis for a year. 310 COMMUNICABLE AND OTHER DISEASES There is room for difference of opinion as to the advisability of spinal puncture or a provocative injection of salvarsan with a subsequent V\ asserniann test in every case before discharge. Conservative practice reserves the use of these diagnostic measures to cases in which there are special indications. LATE SYPHILIS The late manifestations of syphilis in the Army are less common than the early. Gummatous lesions in the skin or bones or elsewhere, which may be cured without leaving any serious damage to the body, do not constitute a difficult clinical problem. In old cases of this sort there is not the need for the intensive treatment administered in early cases. These patients should have mercury and potassium or sodium iodide until their lesions are cured. How much further treatment should be carried is a matter for judg- ment in the individual case. The deep lesions of late syphilis—syphilis of the viscera, of the vascular system, especially of the heart or aorta, and of the central nervous system—indicate such serious impairment of the body that these patients will not be able to endure the strain of military life in the field. If the lesions in such cases can be controlled, it may be practicable to find duties for which the patients are still fit; otherwise, they should be considered for discharge. REFERENCES (1) Form No. 11, Provost Marshal General's Office. (2) Provost Marshal General's Report. (3) Letter from The Adjutant General of the Army to all Department, National Guard, and National Army Division Commanders, November 15, 1917. Subject: Con- trol of venereal diseases. On file, Record Room, S. G. O., Correspondence File, 726.1 (Venereal) General. (4) Based on Annual Reports of the Surgeon General, U. S. Army, 1899-1920. (5) Bulletin No. 45, W. D., July 25, 1917. (6) Manual of Treatment of the Venereal Diseases, for the Use of Medical Officers of the Army. Prepared under the direction of the Surgeon General of the Army, 1917. (7) Circular No. 86, W. D., November 25, 1918. (8) Defects Found in Drafted Men. Washington, Government Printing Office, 1920, 424. (9) Moore, J. E.: The Diagnosis of Chancroid and the Effect of Prophylaxis upon Its Incidence in the American Expeditionary Forces. Journal of Urology, Baltimore, 1920, iv, No. 2, 169. (10) Levin, Wm.: The Incidence of Syphilis among White and Colored Troops as Indi- cated by an Analytical Study of the Wassermann Results in over Ten Thousand Tests. The Journal of Laboratory and Clinical Medicine, St. Louis, 1919-20 v No. 2, 93. (11) Manual of Military Urology. Masson et Cie., Paris, 1918, 75. (12) Noguchi, H.: Serum Diagnosis of Syphilis. J. B. Lippincott Company, Philadelphia 1913, 3d Ed., 59. (13) Craig, Charles F., and Nichols, Henry J.: A Study of Complement fixation in Syph- ilis with Spirochseta Culture Antigens. Journal of Experimental Medicine New York, 1912, xvi, No. 3, 336. (14) Lambie, John S.: The Prevention of Extragenital Chancres in the Army, Based on a Study of Syphilitic Registers on File at the Army Medical School. The Military Surgeon, Washington, 1922, li, No. 3, 261. (15) Love, Albert G.: A Brief Summary of the Vital Statistics of the U. S. Armv During the World War. The Military Surgeon, Washington, 1922, li, No. 2 139 (16) The Management of Syphilis in the Army. Medico-Military Review, S. G. O Wash- ington, July 15, 1921, ii. CHAPTER VIII THE DIARRHEAL GROUP OF DISEASES a The diseases which may be grouped together as inflammations of the intestinal tract, and which possess in common the symptom diarrhea, were of much less importance during the World War than during any previous major conflict of which we have record. It will be the main attempt of this chapter, therefore, to show not only the fact of the greatly decreased incidence of these diseases as compared to that of earlier wars, but to study the causes of this decrease and to deduce, if possible, from this study the lines along which further progress in their prevention may be made. In the comparison of the rates for the diarrheal diseases obtaining during the World War with those of earlier wars we are at once faced with a difficulty arising from differences in nomenclature. The last few decades have been so fruitful of discoveries in the pathology and etiology of disease and in advances in the exactness of clinical diagnosis that the significance of many a diagnostic term as understood to-day is widely different from that accepted only a short time ago. The modern conception of dysentery is that of a clinical entity or complex characterized by an increase in the number of stools, which contain pus, mucus, and blood, accompanied by abdominal pain and tenesmus. This symptom complex may be induced by several known specific agents, of which the most important are the dysentery bacilli and the Entamoeba histolytica. Of the dysentery bacilli there are several well recognized, more or less nearly related strains, and possibly other bacteria such as the paratyphoid group organisms may at times cause the same group of symptoms. Conditions per- mitting accurate diagnostic work, the Surgeon General accepts the diagnosis "dysentery" only when supported by evidence as to the specific causative organism. Under war conditions it usually proved impossible to carry out the laboratory studies necessary to such proof and hence by far the greater number of cases of dysentery reported during the war period were unclassified etiologi- cally. A minority, however, were reported as of bacillary or amebic origin. Headings are found in the war tabulations for balantidic dysentery and for dysentery due to other protozoal agents. In addition to the dysenteries properly so called, there were reported dur- ing the war a large number of cases under the headings "diarrhea," "enteritis," and "colitis," the two latter combined in the tabulations. It is self-evident on account of the clinical character of these conditions that a certain number of cases recorded as diarrhea or as enterocolitis actually may well have been dysentery, and, conversely, that some of the cases recorded as "dysentery, unclassified" might better have been called diarrhea or enterocolitis had a strict etiological classification been possible. That in general, however, the • Unless otherwise stated, all figures for the World War period are derived from sick and wounded reports sent to the Surgeon General.—Ed. 311 312 COMMUNICABLE AND OTHER DISEASES distinction between the dysenteries and the nonspecific diarrheal diseases is a valid one on clinical grounds there can be no doubt as will be shown later. In the earlier records of the United States Army little attempt seems to have been made to distinguish accurately the different types of "intestinal flux." Diarrhea, dysentery, enteritis, and colitis, as well as other now archaic diagnostic terms, were used evidently more or less interchangeably. In the Medical and Surgical History of the War of the Rebellion,1 the "fluxes" are divided into four groups: Acute and chronic diarrhea and acute and chronic dysentery. Modern diagnostic criteria were not sufficiently in use during the period of the Spanish-American War and the Philippine insurrection to make the statistics of that period much more valuable in the differentiation of the vari- ous types of intestinal disease than were those of earlier years. Indeed, in spite of increased diffusion of knowledge and of greatly increased laboratory facilities, experience during the World War has shown that under field condi- tions—and the greater number of these cases must be expected to occur during active campaigning—accurate differentiation is impossible. For this reason com- parisons between the incidence of diarrheal diseases in the World War, and that in earlier conflicts must necessarily be based on totals of the entire group. Nor is this necessarily an unscientific or illogical method of comparison for, so far as may be said at present, the methods of transmission of the diseases of this group, varying as they do clinically and etiologically, are essentially the same. We believe that they are all acquired by the ingestion of infected food or drink " and that consequently the underlying predisposing causes and the necessary preventive measures must be considered to be the same for all these diseases however different the specific etiology of individual cases. Returning to the question of the nomenclature of these diseases, it is evident that in spite of the probability of some confusion in recent statistics, and of the impossibility of separating from the statistics of the past any groups comparable to those of modern tables, there can be little doubt that in the statistics of the World War the diarrheal diseases can be divided into two clinically different groups, on the one hand those which were reported as dysentery on clinical grounds and on the other those cases which were perhaps more loosely classified as diarrhea, colitis, or enteritis. The distinction between these two groups originally made by the clinicians in the individual cases is emphasized and con- firmed by the study of the incidence of the two groups month by month, and by a comparison of the severity of the cases as shown by the average number of days lost from duty per case. Table 47 shows the monthly incidence rates of these diseases for the white enlisted men on duty in the United States for the period of the war. Inasmuch as these figures are not influenced by sharp vari- ations in sanitary conditions such as occurred during operations at the front in France, they furnish a better means of comparing the varying incidence of disease than would the figures for the entire Army. The rates under the heading "Dysentery (all)" include all specifically diagnosed cases of dysentery and all cases of "Dvsenterv, unclassified." b With the possible exception of diarrheas believed by some to be due to chilling of the abdomen. THE DIARRHEAL GROUP OF DISEASES 313 Table 47.—Diarrheal diseases. Primary admissions, white enlisted men in the United States, April, 1917, to December, 1919. Annual rates per 1,000 by months April....... May_____ June______ July______ August____ September. October___ November. December. January. February... March____ April_____ May....... June....._. July........ August..... September. October___ November. December.. 1918 Enter- itis and colitis Total 1.76 2.09 17.63 21.48 1.76 2.49 17.11 21.36 2.41 4.70 23.75 30.86 .63 5.44 26.88 32.95 .87 6.21 43.36 50.44 1.28 6.54 32.05 39.87 .72 4.86 17.75 23.33 .64 1.04 7.76 9.44 .34 .69 6.72 7.75 .36 1.20 6.75 8.31 .14 .94 6.77 7.85 .50 1.20 9.76 11.46 .49 3.98 13.04 17.51 .79 5.28 15.62 21.69 1.17 9.78 18.70 29.65 .91 11.34 19.94 32.19 .69 13.66 21.69 36.04 .82 8.63 11.74 21.19 .29 4.48 6.21 10.98 .36 4.67 5.47 10.50 .38 2.83 4.31 7.52 1919 January_______ February______ March..______ April__________ May_________ June_________ July_________ August_______ September____ October........ November____ December_____ Average, 1917... Average, 1918... Average, 1919... Average for war Dysen- tery (all) .52 .38 .38 .35 .74 .49 .28 .23 .56 .43 .54 .27 Diar- rhea Enter- itis and Total colitis 2.43 1.17 1.59 2.19 2.59 3.06 4.07 5.43 3.54 5.83 3.17 2.04 1.16 3.78 .58 5.67 .46 3.09 .64 4.89 4.32 4.10 4.45 3.85 4.98 8.85 10.88 14.85 9.40 6.52 7.52 8.95 21.45 11.74 7.39 12.92 7.27 5.65 6.42 6.39 8.31 12.40 15.23 20.51 13.50 12.78 11.23 11.26 26.39 17.97 10.94 IS. 45 April to December 191T 1918 1919 Chart XXXVI-The diarrheal group of diseases. Annual admission rates by months for dysentery (all), diarrhea, and enterocolitis, white enlisted men in the United States Study of the figures given in Table 47, and the graphic comparison of the rates shown in Chart XXXVI, which is drawn from the same figures on a logarithmic scale of ordinates, leads to the conclusion that while the rates for cases classed as "diarrhea" and those for "enterocolitis" rose and fell together in almost perfect correlation, the cases classed as "dysentery" varied independ- ently, showing not nearly so much seasonal variation, and the curve for dysen- 314 COMMUNICABLE AND OTHER DISEASES tery is quite independent of that for diarrhea or that for enterocolitis. V\ e are thus justified on statistical grounds in assuming that the distinction made by the reporting officers is an entirely valid one. We are further supported in this conclusion by the analysis of the severity of the average case as shown by the number of days lost from duty per case under each heading. Three thousand five hundred and forty-seven cases of dysentery in white enlisted men accounted for the loss of 99,561 days, or 28.3 days per case. There were 19,125 cases classed as "diarrhea," with 215,420 days lost, or 11.2 days per case. Enterocolitis resulted in the loss of 605,811 days among 56,865 cases, the average case losing 11.4 days from duty. It is seen that the two latter conditions were of equal severity, while the dysentery cases averaged much greater severity. It seems amply justifiable, therefore, to divide the consideration of these dis- eases into two groups, the dysenteries, on the one hand, and the cases reported as "diarrhea" and as "enterocolitis," on the other. Both groups are doubtless of mixed etiology. In the dysentery group we shall find some data for conclu- sions as to the relative importance of the recognized inciting agents in the period of the war. In the second group no specific statements as to bacterial or protozoal etiology are possible. Table 47 shows the further interesting fact that the rates for all classes of diarrheal diseases showed a marked tendency to decrease as time passed. The highest rates were shown during the first months of mobilization, during the period of-voluntary recruiting, and before the completion of the great training camps and cantonments which housed the National Army during the period of preparation. During the following year, 1918, although the camps were con- stantly filled with recruits as the older troops were sent to the front, the rates for these diseases showed a definite decline. This may probably be best explained by the improved environmental conditions possible in the completed camps and by the results of training in sanitary matters. However, the rates for 1919 showed a still further improvement. During this year the camps were the scene of the rapid demobilization of the Army. Men returned from abroad and passed rapidly to the camp selected for discharge. Conditions were not as favorable for maintaining a high sanitary standard as was the case in the previous year, though every effort was made to do so. It may be permissible to argue that the low rates during demobilization indicate that in the intestinal infections as in those of the respiratory tract the seasoned soldier shows a greater resistance than does the recruit. THE DIARRHEAL GROUP OF DISEASES 315 Table 48.— The diarrheal diseases (dysentery, acute and chronic, and diarrhea). Admissions and deaths, absolute numbers and ratios per 1,000 per annum, white enlisted men, United States Army, 1819 to 1919 Admissions Total mean annual strengths 8,942 5,746 5,211 5,949 5,779 5,719 5,809 5,722 5,529 6,169 5,951 5,869 C) C) C) C) C) C) 8,653 9,704 10,116 9,748 10,000 9,863 8,570 8, ,-)!)0 !), 0S3 tn O 9, 148 8, 97U 9,242 9,203 9,904 8,095 9,367 14, 434 12, 701 14, 510 15, 510 13, 531 19, 954 279, 371 614,325 619, 703 574, 022 99, 080 40,183 42, 861 31,376 Abso- lute num- bers 2,281 3,315 2,359 1,641 1,697 2,197 1,814 2,742 2,337 1,869 1,750 1,828 2,039 C) C) C) C) CO C) 6,499 2,650 4,807 6,699 5,759 3,358 2,260 3,046 6,351 C) (■0 7,905 4,828 4,047 4,337 3,892 3,381 5,452 8,655 5,754 6,052 4,619 3,707 13, 702 215, 058 521, 879 395, 720 393, 783 48, 984 22, 942 16, 795 9,320 Ratios per 1,000 strength Deaths 262. 54 370. 72 410. 55 314. 91 285. 26 380. 17 317.19 472. 03 408.42 338.04 283.68 307.18 347. 42 C) C) C) C) CO C) 751. 07 273. 08 475.19 687. 22 575. 90 340.46 263. 71 354. 60 699. 22 C) C) 864.12 538. 24 437. 89 471. 26 392. 97 417. 67 582.04 599. 62 453. 03 417. 09 297. 81 273. 96 686.68 769. 79 849. 52 638. 56 686.01 494. 40 570. 94 391. 85 297.04 Abso- lute num- bers C) C) CO C) C) C) 137 46 47 137 110 27 10 8 63 C) C) 180 64 60 53 47 23 33 74 20 22 12 18 16 • 1, 205 '10, 554 '10, 661 '13, 740 «1,630 172 75 33 Ratios per 1,000 strength 1.04 5.70 14.27 5.95 3.03 1.04 2. 10 3.61 3.15 2.71 1.13 1.18 1.02 C) C) C) C) C) C) 15.83 4.74 4.65 14.05 11.00 2.74 1.17 .93 6.94 C) C) 19.67 7.13 6.49 5.76 4.75 2.84 3.52 5.13 2.05 1.52 .77 1.33 .80 4.17 15.99 15.78 21.29 16.00 4.28 1.75 1.05 Year 1870. 1871. 1872. 1873. 1874. 1875. 1876. 1877. 1S7S. 1879. 1880. 1881. 1882. 1883. 1884. 1885. 1886. 1887. 1890-... 1891.... 1892.... 1893.... 1894.... 1895.... 1896.... 1897.... 1898 /». 1899 »__ 1900 A.. 1901 *.. 1902 *_. 1903.... 1904 •__. 1905.... 1906.... 1907___ 1909 /.. 1910-.- 1911... 1912.- 1913... 1914... 1915... 1916 i.. 1917 *. 1918 *______2 1919 *. Admissions Deaths Total mean annual Abso-lute Ratios Abso-lute Ratios strengths per 1,000 per 1,000 bers strength bers strength 29,021 9,355 322. 35 43 1.48 26,814 7,478 278. 88 30 1.12 24, 294 6,806 280.15 25 1.03 25, 272 6,678 264. 25 17 .67 24,371 5,856 240. 29 18 .74 21, 508 4,809 223. 59 10 .46 22,733 5,519 242. 77 12 .53 21,642 4,195 193. 84 9 .42 21, 542 4,814 223.47 13 .60 21,946 4,944 226. 31 8 .37 21,566 4,655 215. 85 9 .42 20,903 4,591 219. 63 6 .29 20,910 4,379 209.42 6 .29 21,064 4,374 207. 65 7 .33 21, 740 3,480 160. 07 2 .09 21, 944 3,433 156.44 6 .27 21, 430 2,962 138. 22 8 .37 21, 601 2,832 131. 11 5 .23 22, 310 2,448 109. 73 3 .13 22, 591 2,604 115.27 3 .13 21,910 2,517 114.88 20,909 2,148 102. 73 2 .10 21, 437 2,373 2,251 110. 70 100.36 22,429 1 .04 22,904 2,174 94.91 3 .13 23,195 1,948 93.98 1 .04 23, 014 1,833 1,693 79.64 72.80 23, 253 140, 395 56,192 400.24 202 1.44 98, 635 39,040 395. 79 222 2.25 92, 374 44, 608 4S2. 91 629 6.81 85, 357 24,846 291. 08 276 3.23 71, 679 20,370 284. 19 171 2.39 59, 671 9,625 161. 30 50 .84 55, 619 5,722 102. 89 15 .27 53, 573 4,218 78.74 12 .22 53, 249 4,719 88.62 5 .09 50, 705 2,613 51.54 2 .04 62, 263 3,063 49.20 6 .10 71,025 2,433 34.26 13 .18 68, 548 2,196 32.04 5 .07 69, 746 1,567 1,021 22.47 13.73 74, 366 2 .03 76,135 750 9.85 7 .09 81,750 668 8.17 4 .05 87,458 547 6.26 2 .02 159, 553 13,956 87.47 16 .10 594, 005 2,963 4.77 4 .01 2, 207, 631 17, 763 8.05 53 .02 843, 451 2,301 2.73 12 .01 • For years 1819-1848, inclusive, statistics are for the year ending Sept. 30, for the years 1849-1882, inclusive, year end- ing June 30; for the years 1883-1919, inclusive, year ending Dec. 31. 6 Cholera epidemic, Black Hawk War. c No strength records available for these years. ■* Covers period of Mexican War (1847-48). « Civil War period: Ratios per 1,000 per annum for deaths, based on following strengths: 1862, 288,919; 1863, 659,955; 1864, 675,412; 1865, 645,506; 1866, 101,897; 1867, 40,183. / Years 1898-1903, inclusive, covers period of Spanish-American War and Philippine insurrection; also covers period; of the China expedition. (1900-01). o These two years (1898-99) not tabulated separately; does not inclue enteritis. * Reported as "other diarrheal diseases," but does not include dysentery and enteritis. • Previous to this year, officers were included with white enlisted men; beginning 1904 they are excluded. ' 1916 includes enteritis. * Covers period of World War, through period of demobilization. 316 COMMUNICABLE AND OTHER DISEASES Table 48 and Chart XXXVII, drawn from the same figures on a loga- rithmic scale of ordinates, show the experience of the United States Army with diarrheal diseases for the 100-year period 1819-1919. Inasmuch as in the earlier years there were no colored enlisted men in the Army, the figures are for white enlisted men throughout. The rates are the total of dysentery, diarrhea, enteritis, and colitis, since for the reasons given no accurate differ- entiation of these diseases is possible during this period. While there are periods for which no figures are available it is evident that there has been a definite downward trend in the rates for admissions and deaths from these diseases broken only by wars and mobilizations. The figures for the Mexican War period are missing, but reports indicate that the rates for diarrhea and dysentery were excessively high at that time. The additional conclusion Chart XXXVII.—The diarrheal group of diseases. Admissions and deaths in the United States Army, 1819 to 1919. Annual rates per 1,000 strength from these figures is that during the century each war showed a decreasingly great increase in the incidence of the diarrheas over the preceding peace-time figures. This tendency culminated in the World War, during which the rates for the combined diarrheal diseases were actually lower than at any previous time in the history of our Army. Some details of this record will be considered later and further compar- isons made. Here it will suffice to point out that while in the record of the Civil War a large volume was required for the consideration of these diseases, here they occupy but insignificant space. In the Spanish-American War and Philippine insurrection, the dysenteries and diarrheas formed a formid- able proportion of the total illnesses afflicting the troops. It should be remem- bered in this connection, however, that these campaigns were conducted in tropical countries and the special liability to intestinal disease of troops serving THE DIARRHEAL GROUP OF DISEASES 317 in the Tropics has long been recognized. Doubtless some of the freedom from these diseases enjoyed by the Army in the World War was the result of the geographical location of the territory occupied, but making all allowance for this factor it becomes evident that the disparity in rates for diarrheal diseases between the World War and those preceding it must be mainly due to improved methods and practices of sanitation. Table 49. deaths Dysentery (all), diarrhea, and enterocolitis. Officers and enlisted men, United States Army, by countries of occurrence. Primary admissions. , discharges for disability, and noneffectiveness, absolute numbers and ratios per 1,000 per annum, April, 1917, to December, 1919 Total Prin admis Dysem ery (all) NonefTect Diarrhea lary sions Deaths Discharges for disability iveness Primarv norths Discharges for admissions ll'1 1 disability NonefTect iveness annual strengths AbsQ. lute num-bers 4,128, 479 , 4, 738 4, 092. 457 ! 4, 546 Ratios per 1,000 1.15 1.11 Abso-lute num-bers Ratios per 1,000 Abso-lute num-bers Ratios per 1,000 Days lost Nonef-fective ratios per 1,000 0.09 .08 . 12 Abso" Ratios ; AbS0" lute I K™os lute num- .H,nn num-bers 1,0C0 ! bers 22,433 5.43 21 Ratios per 1,000 0.01 Abso-lute num-bers Ratios per 1,000 Nonef-Davs fwtivr Y„a}s ratios l0ia per 1,000 Total officers and enlisted men, includ- 73 69 0.02 .02 86 85 3 0.02 128,223 13 245,748 : 0.16 Total officers and enlisted men, Amer- .02 .01 125,693 8,927 22,215 5.41 21 .01 13 244,784 .16 206, 382 254 I 1.23 1 19,125 __;__ ____ ____ -- Enlisted American troops: 3, 599. 527 286. 548 3,547 .99 220 | .77 525 !_______ 54 8 6 .02 .03 79 2 .02 .01 99, 561 6,248 10, 957 .08 .06 1 5.31 18 .01 12 1 215,420 .16 6,411 .06 16,593 _______ Colored___.......-........------ 1,550 |.....--. 3 Color not stated...........------- ........ Total________________________ 3, 886,075 36,022 4,292 1.10 68 4 .02 .11 82 1 .02 .03 116,766 2, 530 .08 .19 21,368 5.50 21 .01 13 238,424 .17 964 .07 2, 082 .05 Total native troops (enlisted)--------- 192 107 1,261 5.33 467 ' ____ ____ V. S. Army in the I'nited States, includ-ing Alaska: 124,266 .86 1 .01 3 .02 4,421 | .10 376 1 . White enlisted men------------- 1, 965, 297 145, 826 .64 14 6 .01 .04 70 1 .04 .01 31, 062 3,313 .04 .06 9,604 410 4.89 2.81 1 10 1 .01 .01 32,327 ! .05 2,380 : .04 Colored enlisted men------------ 131 . yu Total enlisted men------------ 2,111,123 1,392 | .66 20 .01 | 71 .03 34. 375 .04 10,014 4.74 1 !_----.-- 11 11 _______ 34,707 j .05 Total officers and men.....----- 2, 235, 389 1,499 .67 21 .01 | 74 .03 38, 796 .05 10,481 4.69 1 ______ --- 36,789 | .05 1 4,079 .15 j 17*. 942 .33 .1 3,916 | .09 IT. S. Army in Europe, excluding Rus-sia. 73, 728 133 1.80 4,245 .16 315 4.27 i White enlisted men------------- 1, 469, 556 122,412 1,975 69 482 1.34 .56 35 2 6 .02 .02 S .01 1 .01 1 ------ 61,146 2,196 10, 688 .11 .05 8,921 231 1,466 6.07 1.89 16 , .CI , 2 3____________ 1, 592,068 2,526 1.59 43 .03 10 .01 74,030 .13 10,618 1 6.67 1 19 | .01 I 2 .' 199,071 .34 Total enlisted men--------..... Total officers and men--------- 1,665,796 2,659 1.60 43 .03 | 10 .01 78,275 . 13 | 10, 933 6.56 | 19 | .01 | 2 _______ 203,150 | .33 ' ' ' U. S. Army in the Philippine Islands: White enlisted men................ Colored enlisted men......._____ Total...................--....... U. S. Army in Hawaii: White enlisted men_____________ Colored enlisted men______...... Total enlisted men-----........ V. S. Army in Panama: White enlisted men___________________________ Native troops, enlisted: Philippine. Scouts_______........ Hawaiians____________________ Porto Ricans____________......- 16,995 4,456 152 13 8.94 2.92 4 .24 1 .06 21,451 165 7.69 4 .19 1 .05 16,161 3,319 4 .25 19,480 4 .21 19,68* 18, 576 5,615 11,831 28 111 1 80 1.42 5.98 .18 6.76 3 .16 1 .08 1 .08 4,090 607 .66 .37 52 39 3.06 8.75 1 _____1_____ 231 8* .04 .05 ........1 4,697 .60 91 4.24 319 .04 112 .02 25 3 1.55 .90 1 .06 258 6 .04 112 .02 28 35 92 20 106 1.44 1 .05 264 178 465 146 353 .04 ----. __ - 719 1,857 8 665 .10 .27 .15 1.78 4.95 3.56 8.96 .02 ---- .07 .07 .08 CO Table !"• -Dysentery (all), diarrhea, and enterocolitis. Officers and enlisted men, United States Army, by countries of occurrence. Primary admissions, deaths, discharges for disability, and noneffectiveness, absolute numbers and ratios per 1,000 per annum, April, 1917, to December, 1919—Continued Total officers and enlisted men, including native t roops-----------------.....-----:------------ Total officers and enlisted men, American troops.-. Total officers------------------------------- Enlisted American troops: White__________ Colored--------- Color not stated----- Total_______________ Total native troops (enlisted). U S \rniv in the United States, including Alaska: Officers.... ___________________________ White enlisted men--- Colored enlisted men_. Total enlisted men--- Total officers and men. U S Armv in Europe, excluding Russia: Officers________ _______________ White enlisted men---------- Colored enlisted men--------- Enlisted men, color not stated... Total enlisted men--- Total officers and men V. S. \rniv in the Philippine Islands: \\ hire enlisted men____________ Colored enlisted men__________ Total. Enterocolitis iveness Nonef-fective ratios per 1,000 T otal Discharges for disability Abso- ' ., .. lute i Ratlos mini- * b!"s 1,000 243 0.05 242 .06 12 .05 NonefTect Davs lost 1,061,229 1,054,671 53,120 Primary admissions Deaths hut0" R»ir Discharges for disability Noneffec Days lost Prin admi. Abso-lute num-bers 92, 512 91,711 4,337 lary sions De? Abso-lute num-bers ths Ratios per 1,000 0.07 .07 .01 veness Abso-lute num-bers Ratios per 1,000 Abso-lute num-bers Ratios per 1,000 Ratios per 1,000 Nonef-fective ratios per 1,000 65,341 i 15.83 64,950 15.87 3,236 15.68 174 173 2 0.04 .04 .01 144 144 9 0.03 .04 .04 6S7, 258 684,194 37, 833 0.46 .46 .50 22.41 22.39 21.01 267 263 3 0.71 .70 .70 56, 865 2,534 2,315 15.80 8.84 150 12 9 .04 .04 130 4 1 .04 .01 605,811 24,309 16, 241 .46 .23 79, 537 3,447 4,390 22.10 12.03 222 20 18 .07 .07 221 7 2 .06 .02 920, 792 36,968 43, 791 .70 .35 61,714 15.88 391 10.85 171 1 .04 .03 135 .03 646,361 2,064 .46 . 16 87, 374 801 22.48 22.23 2C0 .07 .14 230 1 .05 .03 .08 .05 1,001,551 5, 558 16,973 202, :<02 12,966 .71 .42 .1 1,602 12. 88 1 .01 8 .06 10, 470 .23 2,176 17.50 2 .02 11 .3* 25, 383 889 12.92 6.09 21 3 .01 .02 101 4 .05 .03 138, 913 7,273 .19 .14 26, 248 1,430 18.45 9.80 36 9 .02 .06 181 6 .27 .24 26,272 12.44 24 .01 105 .05 146,186 .19 37, 678 17.84 45 .02 187 .08 215,268 .2* 27, 874 12.47 25 .01 113 .05 156, 656 .19 39, 854 17.83 47 .02 198 1 .08 232,241 . 29 1,550 21.02 1 .01 1 .01 26, 769 1.00 1,998 27.09 1 .01 .01 35,093 1.31 29, 345 1,439 2,276 19.97 11.76 127 9 9 .09 .07 27 .02 454, 240 15,508 16,830 .85 .35 40,241 1,739 4,224 27.38 14.21 178 11 18 .12 .09 37 1 2 .03 .01 694,328 21,620 42, 931 1.29 49 1 1 33,060 20.77 145 .09 28 .02 485, 778 .84 46,204 29.3 207 .13 40 1 .03 758, 879 j 1.31 34, 610 20.78 146 .09 29 .02 512, 547 .84 48, 202 28.94 208 .13 41 j .03 793,972 j 1.30 633 118 37.25 26. 48 4,420 583 .71 .36 837 170 49.25 38.15 4 .24 1 .06 8,741 1,278 1 41 1 .78 751 35.01 5,003 .64 1,007 46.94 4 .19 1 .05 10.01S — U. S. Army in Hawaii: White enlisted men-------------------- Colored enlisted men------------------ Total enlisted men------------------ .., C, S. Army in Panama: White enlisted men ~ Native troops, enlisted: ^J Philippine Scouts—...........-------- ~ Hawaiians____________________________ T Porto Ricans_________________________ 269 38 307 127 179 3 209 16. 64 11.45 15.76 6.45 9.64 .53 17.66 1,119 121 1,020 10 1,034 298 41 190 382 24 395 18.44 12.35 20.80 20.57 4.27 33.38 .05 1,489 127 3,342 164 2,052 .23 .21 .49 .07 .47 > Ed Ed W > F O Ed O n O >=_ CO 322 COMMUNICABLE AND OTHER DISEASES OCCURRENCE IN THE WORLD WAR A general view of the occurrence of the diarrheal group of diseases during the World War is given in Table 49. The figures are not only for the Army as a whole but also for those fractions stationed in the principal geographical loca- tions occupied by our troops. The cases are grouped under four headings, "Dysentery (all)," which includes the unclassified cases as well as those etiolog- ically diagnosed, "Diarrhea," and "Enterocolitis," the latter including cases reported as either enteritis or colitis. The fourth heading gives the total of the three named, thus representing for the World AVar period a close approxima- tion to the totals given for the preceding century in Table 48. The absolute numbers under each heading are for the period of the war. The corresponding rates per thousand are based on a strength aggregate obtained by the summa- tion of the mean strength for each year, the resulting rate being an annual rate per thousand strength. In the case of the noneffective rate the annual figure is further divided by 365 to give a rate directly comparable to the usual average noneffective rate of Army reports, which represents the number of men per thousand constantly excused from duty for any given cause. Of the total of 92,512 admissions only 4,738 were reported as dysentery cases, or 5.12 per cent of the group. It is probable, owing to the policy of the Surgeon General already referred to, of requiring an etiological diagnosis in reports of cases of dysentery whenever facilities for such work are available, that a certain prop6rtion of cases of dysentery were reported under the other headings as diarrhea, or more probably as enteritis or colitis. However, a most liberal esti- mate of such cases could not more than double the probable number of dysen- tery cases and that would mean that but 10 per cent of the diarrheal group of diseases were dysentery. In the Philippines and in Panama that proportion was exceeded, but there is no reason for extending the effect of tropical environ- ment to the mass of the Army. It would appear, then, that a striking fact in the figures before us is that the proportion of cases of the serious or fatal type, true dysentery, was small compared to the total of the group. That the total incidence, while impressive in absolute numbers of cases, was not of serious import in loss of man power, is shown by the annual admission rate of 22.41 per annum, which, distributed over a year, would mean a little less than two cases per month for each thousand men. As the greater number of these admissions were for the milder types of intestinal disturbance, the total number of days lost from duty on account of diseases of this group amounted to only 1,061,229, a figure that gives a noneffective rate for the period of 0 71 which means that on the average 1 man in a little over 1,400 was excused from duty on account of one of these conditions. The loss to the Army by deaths due to this group totaled 267 with an annual rate per thousand of 0.07, or 1 death per year in each 14 282 men An even smaller number of men were lost to the service by discharge for disability namely, 243, which gives a rate of 0.05 per thousand per annum or 1 each VP!r to 20,000 men. ' n year As a measure of the progress made in military sanitation in the last half cen tury it is instructive to compare the record given above with that of the Civil War. There were during that conflict 1,585,196 cases of diarrhea and dysentery THE DIARRHEAL GROUP OF DISEASES 323 in an average strength of 2,193,427 white troops.1 Had the same rate prevailed in the World War there would have been 2,601,915 cases among white troops. Had the incidence rate for colored troops in the Civil War obtained in the World War there would likewise have been 240,517 cases among our colored sol- diers, a total of 2,842, 432. As a matter of fact there were reported as diarrhea and dysentery during the World War but 27,171 cases, or less than 1 per cent of the number that would have obtained had Civil War conditions been repeated. If we include the enterocolitis cases reported during the World War the total, already given, is 92,512, or, roughly, 3 per cent of the cases to have been expected at Civil War rates. In the Civil War there were 37,794 deaths among white troops and 6,764 among colored troops charged to dysentery and diarrhea. At these rates there would have been 62,021 deaths among white soldiers and 10,427 among the colored in the recent war, a total of 72,448. The total deaths ascribed to this group of diseases in 1917-1919 was only 267, a saving of 72,181 lives. It is perhaps claiming too much to attribute this impressive difference entirely to advances in sanitation and therapeutics, as other factors such as differences in the geographical location of the campaigns, questions of the nomenclature and classification of disease, may have entered into the comparison; but however explained, the impressive fact remains that this enormous saving of life and disability has been accomplished not only in this group of diseases but in the related typhoid-paratyphoid group as well. Instead of being the most impor- tant cause of illness and death in the Army, the diarrheal group ranked seventh among diseases for admissions, tenth for deaths, and twelfth for days lost from duty. That, nevertheless, these diseases are an ever-present menace to armies, and that military concentrations, especially under active service conditions, still present dangers from intestinal infections is shown by Table 50, which compares the death rates obtaining in the Army during the World War with those of the comparable age and sex groups in the United States registration area for the same period. It is seen that the Army rate for dysentery is ten times that of the civilians, for diarrhea and enteritis seven times, and for the group as a whole a little more than seven times as great. Table 50.—Diarrheal group of diseases. Comparative mortality in the United States Army during the World War, and the United States registration area, males, age 20-34, 1917-1919. Annual death rates per 1,000 Registra- i ar< les, 34 tion area," TT Q A ,_,. males, 20- ^' S-Arm> Dysentery_________________________! 0.002 Diarrhea and enteritis______________ .007 0.02 .05 Total__________________________, .009 « Compiled from Mortality Statistics, Bureau of the Census, 1917-1919. >> Reports of sick and wounded, S. G. O. 1917-1919. Certain other facts are brought out by Table 49 which are worthy of more than passing notice. The admission rates for the group were approximately the same for officers and men whether stationed in the United States or in Europe. The same is true of the death rates for those stationed in the United States. 324 COMMUNICABLE AND OTHEK DISEASES In Europe, however, the death rate for the group is much higher for enlisted men than for officers. This fact will be referred to again in the discussion of dysentery. In general, the rates for admissions and deaths in this group are much higher in Europe than is the case with troops in the training camps at home. That this was due to the stress of battle conditions is evident from the monthly rates for the diseases in question, which show that great military activity was always accompanied by an increase in the incidence of diarrhea. The prevalence of diarrheal disease in our Army in Europe was undoubtedly greater than the figures of Table 49 would indicate. Many of the cases were of a mild type and as such were not made a matter of record. Moreover, early in the war only hospital admissions were recorded in Europe. The following quotation gives an idea of the general prevalence of the diarrheal diseases during the summer of 1918 in the American Expeditionary Forces.2 Epidemic diarrheas, with a considerable amount of dysentery and probably some unrecognized typhoid and paratyphoid fevers, developed in various parts of France late in June, appearing first in the more southern areas occupied by our troops, and wherever insani- tary disposal of human wastes, fly breeding, and insufficient precautions in the preparation and serving of food prevailed. Immediately after the Chateau Thierry operation the troops suffered quite generally from diarrheal diseases, probably as many as 70 per cent having been so affected. This was inevitable under the conditions of a hard-fought and prolonged battle which made even the elementary principles of sanitation impracticable of application. Inadequate and ill-prepared food, chilling of the body at night, polluted water sources, and the plague of flies, which bred and fed upon human excreta everywhere exposed and upon the dead bodies of men and draft animals upon the battle fields, combined to produced a widespread epidemic of diarrhea among which was a certain proportion of true dysentery and typhoid-paratyphoid infections. Most of the cases never reached a hospital or obtained medical treatment. Spontaneous recovery in a few days was the rule. The enthusiasm of the victorious forward movement of the troops carried many men out of reach of hospitaliza- tion, and a true measure of noneffectiveness from that epidemic can only be guessed. A small number of serious and persistent infections found their way through the evacuation hospitals to the base hospitals, and of these the great majority examined early in the course of their disease were found to be suffering from true dysentery caused by well-known strains of bacilli. Fortunately the type of the infection was mild and very few deaths resulted from the entire epidemic. The disease prevailed during the warm weather while the fly-breeding season continued. In a few favored places, where medical care was combined with adequate physical equipment to avoid fecal exposure and pollution of food and water, only an occa- sional case of diarrhea developed and entire organizations escaped infection, but in the main the disease prevailed throughout the American Expeditionary Forces from July to the middle of September. That these diseases continued through the fall of 1918, during the Meuse-Argonne operation and immediately thereafter, is shown in the following report of the surgeon of the Second Army.3 cm The movements of the 79th Division troops during October and November took th into the region formerly occupied by German troops around Etraye, Reville Crepion' Gibercy, and Damvillers, where the Germans had a hospital with considerable intestinal disease, some of their latrines being reserved for "intestinal cases." Previous to this tl troops, while in action in November, drank water from shell holes, springs, and wells Diar- rhea developed so that estimates of regimental medical officers ranged from 50 to 75 per t of the command. THE DIARRHEAL GROUP OF DISEASES 325 A mobile laboratory investigated the outbreak in the 79th Division and from the report it appears that there were cases reported as diarrhea which in reality were typhoid fever. The investigation also extended to the 7th Division, where a great many soldiers were examined for the typhoid carrier state. Of 100 kitchen personnel examined, 25 per cent gave a history of having had "bowel trouble." A report from Base Hospital No. 89 shows the difficulty of classifying the diseases generally listed as "diarrhea."4 The cases of infectious diarrhea, which come to the hospital by the score, were nearly always in soldiers who had been ill for many days. The stools of practically every case were examined bacteriologically, but we were never able to find amebae or the organisms of bacillary dysentery, although we all felt sure that the latter was the cause of the symptoms present. Numerous organisms resembling the bacillary types were isolated, but none of them aggluti- nated with known sera. Of the relatively small bodies of our troops stationed in various parts of the world other than the United States and Europe, some were in tropical countries and such generally suffered more severely from the diarrheal diseases, especially from true dysentery. By far the highest admission and death rates for the diarrheal group in white enlisted men in the Army was shown by the force of about 17,000 men stationed in the Philippine Islands. The admission rates in Panama were not notably above the average for the group, though there was a disproportionately large incidence of a nonfatal form of dysentery. The incidence in Hawaii was about the same as that in the United States. An interesting racial difference appears when the rates for white and colored troops are compared. Almost without exception admission rates in these diseases are definitely higher for the white soldier, sometimes several times as high. On the other hand, the greater fatality of the individual case in the negro brings his death rate up to or higher than that of the white. From the standpoint of noneffectiveness, the negro shows to excellent advantage, as his noneffective rate for the diarrheas is definitely less than that of the white. The native Porto Rican and native Filipino soldiers, also of races indige- nous to the Tropics, manifest no such advantage. After the whites in the Philippines, these groups showed the highest susceptibility to diarrheal diseases. It is perhaps possible that the colored American soldier benefited from the effects of discipline and sanitary training. The colored troops in the Tropics were in organizations of long service. There were considerable differences in the rates of different training camps in the United States. In general the camps showing higher rates were more apt to be located in the Southern States than were camps showing low rates. The camps showing the highest annual admission rates were Camp Hancock, Ga. (27.21); Camp Beauregard, La. (26.91); Camp MacArthur, Tex. (26.51); and Camp Doniphan, Okla. (27.70). The lowest rates for admissions were Camp Forrest, Ga. (4.34); Camp Eustis, Va. (6.93); and Camp Fremont, Calif., (4.48). 326 COMMUNICABLE AND OTHER DISEASES THE DYSENTERIES OCCURRENCE In the discussion of the prevalence of true dysentery during the World War it is not permissible to rely exclusively on the records. Statistical tables are not always to be regarded as complete in themselves, nor are the various figures of which they are composed to be regarded as conveying always entirely truthful impressions, unless they are interpreted with some knowledge of the sources of the information which entered into their compilation, and of the difficulties which beset those making the original reports. Several of the difficulties which serve to render the recorded figures for the dysenteries an understatement of the actual facts have been brought out in the previous pages. The clinical characters of mild dysentery are so similar to those of a nonspecific enterocolitis that some confusion is to be expected in the reports of these conditions. It has already been pointed out that the number of days lost per case in dysentery as reported was much greater than was the cases in the nonspecific diarrheas. One is justified, therefore, in assuming that, as a class, the cases reported as diarrhea and as enteritis or colitis were different from and milder than the cases of dysentery. That some cases of dysentery were included in the epidemics of intestinal disease experienced by the troops at the front during periods of great military activity has been indicated by several reports quoted above. Also that an undetermined but probably large number of these cases escaped hospitalization entirely and were probably never reported at all. Of those which did reach hospitals and were reported as cases of diarrhea or entero- colitis, it is probable that many were true dysentery, although Do specific diagnosis could be made. This was the opinion expressed in the report from Base Hospital No. 98 already quoted. If a considerable proportion of the more severe dysentery cases were included under the headings "diarrhea" and "enterocolitis" it would serve to increase the average severity of the latter cases and increase the number of days lost per case, and also the case fatality. Of the 9,604 cases of diarrhea reported in white enlisted men in the United States (Table 49), only one proved fatal, a fatality of slightly over one one-hundredth of one per cent. The average duration of these cases was three and three-tenths days. Of the 8,921 cases reported from Europe, 16 were fatal, 0.18 per cent, and the average of the days lost was 20. The corresponding figures for enterocolitis in the United States were, case fatality 0.082 per cent with 5.5 days lost per case, and in Europe, fatality 0.43 per cent and 14.7 days lost per case. It is evident that some element was present in the European cases which greatly increased the severity of the average. That this was the inclusion under these headings of a certain number of cases of true dysentery is probable for all of the reasons given. An exact estimate of the number of cases so included is manifestly impossible, but judging from the excess number of deaths per thousand cases in Europe over the corresponding figures from the United States, and applying to these deaths the case fatality of the reported dysentery cases, it seems possible that the true incidence of dysentery was not far from THE DIARRHEAL GROUP OF DISEASES 327 double that shown in the tables. This conclusion does not in any way vitiate the comparison already given between recent rates and those of the Civil War, as that comparison was based on totals of the entire group and not on dysenteries alone. ETIOLOGIC TYPES Here again in order to properly evaluate the figures given it is necessary to appreciate certain facts in regard to the difficulties in the specific diagnosis of a given case of dysentery. The isolation of the specific dysentery bacilli from the stool of a patient depends for its success upon a combination of cir- cumstances not easily attained under war conditions, indeed not always possible of attainment under most favorable surroundings. After the possession of adequate facilities the most important of these conditions are that the stool should have been recently passed, and that the patient should have been in the very early stages of his disease. The latter requirement is probably explained by the early development in the intestines of the bacteriophage of d'Herelle, which inhibits growth of the specific organism. Under war conditions, there- fore, when adequate laboratories were not always available, when stools were often necessarily delayed on the way to the laboratory, and when the majority of patients had been ill for several days before reaching a hospital at which bacteriological work could be initiated, it should be expected that many, probably a majority, of the cases of true bacillary dysentery should fail of bac- teriological confirmation. In a way the reverse is true of entamebic cases. It is coming to be more and more generally recognized that finding E. histolytica in the stool does not constitute valid grounds for the diagnosis of amebic dysentery. Of all indi- viduals who harbor the entameba in their intestines, only a small proportion, probably not over 3 per cent, ever develop dysenteric symptoms. The others remain healthy carriers as evidenced by the more or less constant evacuation of the cysts of the organism. When such a carrier becomes affected with any diarrheal disease, the trophozoites or active vegetative forms of the organism are carried down and evacuated, and their discovery may lead to a diagnosis of amebic dysentery not justified by the facts. As will be shown later, a con- siderable proportion of our troops returned from France carrying this organism in their intestines. It seems probable that a certain percentage of cases on record as amebic dysentery were probably of bacillary origin in carriers of the entameba. Two circumstances fortify this conclusion. First, the entameba is readily identified under the microscope, especially as compared with the diffi- cult and time-consuming process of isolation of the dysentery bacilli. Secondly, the cytologic methods by which it is now possible to distinguish with great accuracy between the two main types of dysentery had not at the time of the World War been perfected, but since, in the hands of Willmore and Shearman,5 Manson-Bahr,6 and Haughwout,7 have attained great reliability. All these considerations lead to the conviction that the number of cases of bacillary dysentery were understated in the records, that that of the amebic cases was overstated, and that the majority of the cases reported as dysentery unclassified were probably in reality of the bacillary type. This was un- doubtedly especially true in Europe where the dysentery cases occurred in 32S COMMUNICABLE AND OTHER DISEASES epidemic groups since, owing to the biological peculiarities of the organism, amebic dvsenterv is rarelv known to occur in epidemic outbreaks. Tables 51 and 52 show the incidence of the various types of dysentery in white enlisted men bv months in the United States and in Europe. In Europe bacillary and amebic dvsenterv and the unclassified group as well, varied in a closely correlated manner. This would hardly be expected in two conditions epidemiologically so different as bacillary and amebic dysentery. In the United States, where there were no epidemic outbreaks of the disease, but only the slower seasonal variations, it is possible to compare the curve of the unclassified April to December, 191T 1918 1919 Chart XXXVIII.—Dysentery, incidence by etiologic types by months, annual rates per 1,000, white enlisted men, United States Army, in the United States group with those of the bacillary and amebic cases in the attempt to see which pair are the more closely correlated. The curves are shown in Chart XXXVIII. That for bacillary dysentery ends with 1918, as but one case of this disease was reported during 1919. It is seen that the curve for bacillary dysentery more closely approximates that of the unclassified dysenteries than does the curve for amebic cases. The number of cases classified each month was so small that the comparison loses some of its value, but for as much as it is worth it bears out the conclusion already arrived at that the great majority of the cases reported in the tables as "dysentery unclassified" were in fact bacillary cases. THE DIARRHEAL GROUP OF DISEASES 329 Table 51.—■Dysentery. Incidence by types, and annual ratios per 1,000 by months, white enlisted men, United States Army, in the United States, April, 1917, to December, 1919 Strength Bacillary Balantidic Entan Abso-lute num-bers lcebic An-nual ratios per 1,000 0.91 .73 1.09 .29 .51 .29 .22 .32 .30 .18 .03 .12 .13 .30 .25 .32 .14 .25 .11 .14 .19 .20 .13 Other proto-zoal Ders 1,000 Unclassified Total Abso-lute num-bers An-nual ratios per 1,000 Abso-lute num-bers An-nual ratios per 1,000 Abso-lute num-bers An-nual ratios per 1,000 0.85 1.03 1.20 .31 .26 .80 .38 .15 .03 .16 .10 .31 .31 .39 .79 .51 .50 .52 .17 .20 .15 .32 .25 .24 .28 .45 .15 .08 .32 .26 .27 .09 Abso-lute num-bers An-nual ratios per 1,000 1917 April____........ 183,758 245,454 309,205 458, 817 562, 714 776,466 1,032,244 1,061,422 1,129,065 1,096,434 1,095,039 1,129, 223 1,168, 558 1,197,757 1,303, 746 1,328, 513 1,284,247 1,321,440 1,343,933 1,255,195 941,219 672,937 471,815 406,839 339,836 291,810 246,903 215,104 156, 791 149, 360 139,877 132,403 135,441 0 0 3 1 5 12 9 14 1 1 1 6 5 10 12 6 4 5 1 1 2 0 0 0 0 0 e 0 0 0 0 0 1 14 15 28 11 24 19 19 28 28 16 3 11 13 30 27 35 15 27 12 15 15 11 5 13 21 31 12 12 52 33 13 3 15 9 29 30 39 86 56 53 57 19 21 12 18 10 8 8 11 3 0 1 4 3 3 1 27 3(1 62 24 41 S3 62 57 32 33 13 47 48 79 127 101 74 90 33 38 30 29 15 13 10 18 10 5 3 7 5 6 3 1.76 1 1.76 June............. 0.12 .03 .11 .19 .10 .16 .01 .01 .01 .06 .05 .10 .11 .05 .04 .05 .01 .01 .03 i 2.41 July_______...... 1 .63 August___. _ .. 1 ............"" .87 September_____ . 1 1.28 October_____ i 1 2 0.01 .02 .72 November___ .64 December. _ ___ .34 1918 1 0.01 .36 .14 1 .01 .50 .49 .79 2 4 2 1 1 1 1 .02 .04 .02 .01 .01 .01 .01 1.17 July .91 .69 September_______ .82 .29 .36 .38 1919 .52 .38 5 2 7 7 5 2 3 2 .15 .07 .29 .34 .28 .38 .35 .74 .49 July .28 .15 .24 .17 .27 .23 September______ __ .56 .43 3 1 .54 .09 .09 .27 Total........ 1,965,297 100 .05 1 0 458 .23 16 .01 686 .35 1,261 .64 330 COMMUNICABLE AND OTHER DISEASES Table 5 :>.—Dysentery. Incidence In, types, and annual ratios per 1,000 by inonths, white enlisted men. United States Army, in Europe, April, 1917, to December, 1919 Strength Baci Abso-lute num-bers 1 2 llary Balantidic Entamcebic Other proto-zoal Uncla ssified An-nual ratios per 1,000 To Abso-lute num-bers tal An-nual ratios per 1,000 Abso-lute num-bers An-nual ratios per 1,000 Abso-lute num-bers An-nual ratios per 1,000 Abso-lute num-bers An-nual ratios per 1,000 Abso-lute num-bers An-nual ratios per 1,000 1917 April___________ May I 13,420 28,s21 50,882 70,266 92,139 123,429 160,178 193,264 223,130 283,268 388,048 587,240 796,427 1,063,192 1, 266, 592 1,527,793 1,635,321 1,682,836 1, 591,962 1,488,683 1,310,083 1,115,693 853,425 569,842 271,633 111,634 48,006 30,315 21,055 18,920 18, 379 0.89 .S3 1 4 1 2 2 7 9 5 2 3 5 5 7 53 275 314 493 239 91 26 22 2 3 0 5 4 6 1 0 0 0 3 0.89 1.67 .24 .34 .26 .68 .67 .31 .11 .13 .16 .10 .11 .60 2.61 2.47 3.64 1.70 .69 .21 .20 .02 .04 .22 .43 1.50 .40 2 7 1 3 5 10 12 9 3 8 6 9 10 121 366 375 546 261 103 35 28 3 8 0 5 9 22 3 2 0 0 3 1.79 June___________ July........_____ August_________ September______ 1 0.42 2.91 . 24 ,... l 3 3 2 1 0 3 .17 .39 .20 .15 .06 .51 i | .65 November______ j .97 i 1 0.07 .90 1918 3 1 2 0 1 1 55 67 34 38 9 5 3 1 0 0 0 0 4 15 0 1 0 0 .19 . 05 .OS .56 .16 .13 .34 1 0 0 2 2 2 4 ° .03 .02 .02 .02 .03 .01 .19 .02 .02 .62 3 2 8 21 25 11 13 6 6 5 1 5 0 0 1 1 2 1 0 0 .06 .02 .09 .20 .20 .OS .09 .05 .05 .05 .01 .07 .18 .15 July. ....... 3 0.03 .01 1.37 .63 1 3.47 .27 .28 .06 2. 95 4.01 1.86 .04 .02 .01 .78 1919 January........... .28 .26 .03 April .11 Mav .22 Julv. .43 3.75 .11 .25 .79 .57 .97 5.50 1.19 Oetober... . ___ .57 1.14 December Not stated______ __ Total______ 1,469,656 243 17 4 0 125 .09 1,590 1.08 1,975 1.34 Seventy per cent of the dysentery cases were reported without etiologic classi- fication (Table 53), 47 per cent in 1917,78 per cent in 1918, and 52 per cent in 1919. The proportion so reported varied greatly from month to month, usually highest when the absolute number of cases was greatest especially in the European cases. Of the classified cases, those reported as amebic consistently exceeded those called bacillary. During the World War (Table 53) there were reported 926 amebic cases to 460 demonstrated as bacillary, a proportion of nearly 2 to 1. Inasmuch as, combined, these two groups represented less than a third of the cases of dysentery, and as we have shown the probability that most of the other two-thirds were of bacillary origin as well as perhaps some that were reported as amebic, we shall not be greatly in error if we assume that the true propor- tion should be not far from five cases of bacillary dysentery to each amebic case. THE DIARRHEAL GROUP OF DISEASES 331 Table 53.—Dysentery (all types). Primary admissions, United States Army, 1917 to 1919 shown by etiological types. Total cases in the United States and Europe. Absolute numbers Cases Bacillary Balan-tidic Amebic Other protozoal Unclas-sified Total dysenteries in 1917_____...... 688 484 41 3,573 883 2,431 577 151 188 69 50 3 325 70 244 66 3 31 2 0 0 6 2 4 2 0 0 291 195 10 428 239 105 207 62 43 3 2 1 30 14 15 323 United States.......... ... . ... ____________ 237 Europe......._____.......................__ 27 Total dysenteries in 1918......... .. _____ 2,784 558 Europe........___ . _ ____ _____________ 2,063 302 86 114 Total for the period__ ____ __________ ....... 4,838 460 10 926 33 3,409 A few cases, as shown in the tables, were reported as of balantidic or other protozoal origin. The former organism is generally recognized as occasion- ally pathogenic with the production of chronic dysenteric symptoms. As for ciliates or other protozoa, however, the evidence of their pathogenicity is very doubtful, and the opinion is rather generally held among those qualified to judge that the finding of ciliates in a case of dysentery is an accidental occurrence without significance etiologically. In any case the number of cases so reported was so small as to merit no further consideration here. PREVALENCE AND DISTRIBUTION Bearing in mind the considerations just stated and the conclusions that in all probability the actual number of cases of true dysentery was twice that reported in the tables, and further that the reported proportion of amebic to bacillary cases can not be relied upon, but that we shall not greatly err if we assume that there were in fact about five bacillary cases to each of the amebic type, it is still possible to glean from the tables as reported information of great comparative value. It is possible to state from them the relative incidence in different countries and in different races. Of the 4,738 cases of dysentery reported, between April 1, 1917, and December 31, 1919, 254 were in officers and 3,547 in white enlisted men. The incidence of reported cases in officers was 1.23 per thousand per annum, while that for enlisted men was 0.99. One death only occurred among the officers and 54 among the white soldiers. The latter figure gives a death rate of 0.02 per thousand per annum, while the officers' rate is too small to be con- sidered and is recorded as 0. In the troops in the United States there were 107 cases in officers (0.86 per 1,000 per annum) and 1,261 in white enlisted men (0.64). One officer and 14 enlisted men (white), died, a death rate in each case of 0.01 per thousand per annum. In Europe there were 133 cases in officers (1.80) and 1,975 among the white enlisted men (1.34), while there were no deaths from dysentery among officers and 35 among white soldiers (an annual rate of 0.02 per thousand). 332 COMMUNICABLE AND OTHER DISEASES These figures show that both in Europe and in America the incidence of dysentery was higher among officers than among enlisted men, but that, among officers, the type of the disease was less severe, the death rates, low as they were, were higher in the case of the enlisted men. The incidence among officers was a little more than twice as high in Europe as in the United States and the relative proportion among enlisted men comes to exactly the same figure, in Europe being two and nine hundredths times the incidence of those in the United States. Remembering the practical certainty that many other dysentery cases occurred in the troops in Europe, we must assume that the true ratio of incidence in Europe to that in the United States was probably nearer 4 than 2 to 1. The type of the disease was more severe in Europe, or perhaps treatment less prompt and efficacious on account of battle conditions. This is shown by the difference in the case fatality in the two places, 1.11 per cent in the United States and 1.77 per cent in Europe. This difference is less than could reasonably be ex- pected considering the difference in conditions. Comparisons of the number of cases of discharge for disability between Europe and America are valueless, as large numbers of men were so discharged in America for disease originally contracted in France. There were 70 cases discharged for disability in the United States and only 8 in Europe. The greater severity of the European cases is further shown by the average number of days lost per case, 24.6 in the United States and 31 in Europe. These figures are for all types of dysentery. A division into bacillary and amebic types would bring the figures down to such small size as to render averages valueless and conclusions unreliable. In the Philippines, white troops encountered a more severe type of dysen- tery and conditions which rendered them more likely to contract the disease than was the case at home. Their rate of 8.94 per thousand per annum was more than four times the rate for the troops in Europe for the entire war period (1.34). In October, 1918, at the height of military activity in France there was a re- ported rate of 4.01. As this was the time when the greatest number of cases necessarily went unreported, and as by no means all of our troops in France were in the battle area, it is evident that the troops in the battle area must have been exposed to infection much more effectively than was the case in the Philippines for troops living under peace conditions. The Filipino strain of dysentery was more fatal, however, as is shown by the comparison of the case fatality rates, 1.77 per cent in Europe and 2.63 in the Philippines. The yearly death rate per thousand in the Philippines was 0.24, twelve times that of the Army as a whole. In Hawaii, the case rate for white enlisted men was far below the average for the Army and there were no deaths. In Panama, 28 cases gave a rate of 1.42 per thousand per annum, but there were no deaths. This does not neces- sarily indicate a milder type of the disease, as the case fatality elsewhere was so low, from 1 to 2 per cent, that deaths would hardly be expected among 28 cases. All the figures in the comparisons given above relate to white enlisted men or officers. Some interesting points are brought out by the study of the figures for the colored troops. (Chart XXXIX and Table 49.) In the first place, for the whole Army the incidence rates for the colored troops are 20 per cent lower than THE DIARRHEAL GROUP OF DISEASES 333 DYSENTERY. COHPARATIVE RATES WHITE & COLORED ENL. MEN-UNITED STATES APRIL. 1917- DEC, 1919 .0 .5 1.0 1.5 ADMISSIONS RATIOS PER 1000 2.0 2.5 3.0 3.5 4.0 4.5 5.0 .64 .90 DEATHS RATIOS PER 1000 .0 .05 .10 .15 .20 .25 l .30 .35 .40 .45 .50 .01 .04 0 1 2 CASE FATALITY PERCENTAGE RATES 4 5 6 7 8 9 10 1.12 4.59 .0 .05 .10 .15 NONEFFECTIVE RATIOS PER 1000 .20 .25 .30 .35 .40 .45 .50 .04 .06 DAYS LOST AVERAGE FOR EACH CASE 20 25 30 35 40 45 50 24.80 25.30 DISCHARGES FOR DISADILITY RATIOS PER 1000 0 .05 .10 .15 .20 .25 .30 .35 .40 .45 .50 .04 .01 WHITE COLORED| Chart XXXIX 334 COMMUNICABLE AND OTHER DISEASES those for white troops, while their death rates are 50 per cent higher. The negro appears less likely to become infected with dysentery, but offers less resistance to the disease once acquired. The case fatality in the colored was 3.64 per cent for the whole Army; that in the white troops 1.52. The number of cases in the colored troops, 220 for the entire period, was so small, however, as to somewhat lessen the value of this comparison. The rates for colored troops were lower in Europe than in the United States. This striking difference must have been due to the large proportion of colored troops engaged in work under the better sanitary conditions of the Services of Supply. That the rate was actually lower than in the camps at home may be interpreted as supporting the idea already advanced that seasoned troops are less susceptible to intestinal infection than are recruits. In the Philippines the colored incidence rate of 2.92 was also strikingly lower than the rate for the whites, and there were no deaths among colored troops. Here again the small number of cases involved prevents drawing conclusions. In Hawaii there were no cases of dysentery among 3,319 colored soldiers. Of the native troops, serving in their home environment, the Filipinos and the Porto Ricans showed to poor advantage, having the highest incidence rates, 5.98 and 6.76, respectively, after the white troops in the Philippines. The number of deaths was so small as to render averages without value, but their rates as shown were far above those of the Army as a whole. INCIDENCE BY MONTHS Chart XL shows the varying monthly incidence of the total reported cases of dysentery in enlisted men in the United States and in Europe. It is seen that there is some tendency for the occurrence of higher rates during the summer months, with a distinct lessening of the incidence in cold weather. In the United States the rates were higher during the first three months of the war period than was the case at any time later. This fact already has been men- tioned in the discussion of the incidence of the total diarrheal group. The reasons for the high rate at this time are not apparent, Of the 125 cases of dysentery reported from the white enlisted men in the United States for these three months, 57 were of the entamebic type, only 3 recognized as bacillary, and the balance, 65, were unclassified etiologically. These figures suggest that the accessions to the Army during that period of voluntary recruiting brought in an unusually large number of persons infected with the entameba. From this initial high point in June, 1917, there was a nearly uniform gradual fall in the rates until February, 1918, when they began to rise toward the second relatively high point in June of that year. From June, 1918, until May, 1919, the tendency was again downward, although the winter fall was not as low as in the previous year. From May, 1919, to the end of the year there were irregular rises and falls in the rates, but the absolute numbers of cases were so small at this time that the figures possess little value. It can be said, however, that there is little or no indication of a definite summer rise in 1919. Chart XXXVIII which shows the monthly incidence rates for the bacillary and entamebic types of dysentery separately, together with the unclassified group, shows also THE DIARRHEAL GROUP OF DISEASES 335 that in general the curves of the three classes of cases follow the same course with such minor divergencies as are to be expected from the small numbers of cases involved. In Europe, too, a relatively high rate was observed in the summer of 1917. This is of little significance, however, as it was the result of seven cases in a DYSENTERY. COMPARATIVE TREND ENL. MEN. U. S. ARMY-UNITED STATES & EUROPE ADMISSIONS & DEATHS BY MO., APRIL. 1917-DEC. 1919 100.00 80.00 LOGARITHMIC SCALE RATIOS PER 1000 1917 ADMISSIONS* U. S.- —i EUROPE 1919 DEATHS: U. S.- •»■»<•» o ■ c 1 EUROPE------ Chart XL strength of about 29,000. Two of the cases were reported as bacillary, one as entamebic, and four were unclassified. During the winter of 1917-18 the rates in Europe did not fall as low as those in the United States, but the summer rise was delayed until July, when decided military activity began, and a decidedly high rate prevailed until after the armistice began. From then until the follow- 336 COMMUNICABLE AND OTHER DISEASES ing summer the Army in Europe showed very low rates, much lower than was the case at home during the same period. In August and September, 1919, however, the rates again shot up to reach a point higher than was reported at any time during active operations. This outbreak, however, consisted of only 22 cases in a strength of about 48,000 men; 15 of the cases were recorded as bacillary, 1 as entamebic, and 6 were not classified. Perhaps the fact that at this time the army of occupation had received a large number of newly recruited replacements may account for this small outbreak. Leaving out of considera- tion this late peak and the one of July, 1917, on the grounds that the number of cases involved was too small to be significant, it is seen that the only high rates in the Army in Europe were those which occurred during periods of intense military activity. The conditions which of necessity prevailed during those months of battle will be described later. The death rates from the dysenteries, both in Europe and America, fluctuated so irregularly, due to the small number of cases involved, as to make their consideration useless. The same considera- tions prevent any conclusions from being drawn from the monthly incidence of cases among colored soldiers, or the troops in other countries than the United States and Europe. ETIOLOGY In spite of intensive study on the part of all the armies involved, the World War added very little of moment to our knowledge of the etiology of these con- ditions. Much work was done in the laboratories on the specific etiological agents, particularly of the bacillary types, and much experience accumulated confirming the knowledge previously attained as to the importance of food, feces, flies, and fingers in the mechanical transfer of the pathogenic agents. The influence of climate has long been known, and the higher rates to be expected in tropical and subtropical countries were experienced during the war as shown by the incidence in the Philippines and to some extent in Panama. The effect of race has already been discussed, and it has been shown that the colored soldier appeared to have less tendency to contract dysentery than the white soldier, but that once attacked his chances of death were greater. More interesting and important is the consideration of the predisposing causes incidental to war conditions as shown by reports from the American Expeditionary Forces. In the camps at home conditions were well under con- trol. In battle sanitary discipline usually was impossible of enforcement, and during the military operations at Chateau Thierry, St. Mihiel, the Argonne Forest, and elsewhere dysentery and other diarrheal conditions prevailed in epidemic form. Of the many descriptions of such outbreaks a few have been selected to give an idea of the conditions which prevailed. August 6, 1918, a mild type of bacillary dysentery was reported in the First Army and a request made of the director of laboratories at Dijon to send an officer to investigate it,8 Accordingly a medical officer reported at First Army headquarters 9 and began a study of the epidemic which had existed in that sector since early in July. It was difficult to determine the prevalence of the disease, as perhaps not more than 2 per cent of the cases were hospitalized and sick call was held very irregularly. At the time of the call for an invest- gation the 3d Division had 500 cases, with 60 in hospital, the 28th Division 300 THE DIARRHEAL GROUP OF DISEASES 337 cases, with 1 in hospital, and the 32d Division 1,200 cases, with 20 in hospital. In the 1st Battalion, 165th Infantry, it was estimated that 70 per cent of the command had diarrhea. The nature of the disease is shown by the following quotation from the report of the investigator.9 The large majority of the cases were clinically characterized by a simple though severe diarrhea, usually coming on suddenly and, in some cases, resembling the effects of a saline purge. Many cases subsided without treatment of any kind. Many yielded to simple treatment with saline cathartics, or castor oil, followed by bismuth. A great many cases persisted for three or four days and a percentage variously estimated at from 3 to 5 lasted longer and had blood and mucus in the stool. About the same percentage had a tempera- ture of 100° or over, and a number of cases were seen by the undersigned in which the tem- perature was 102°, some even going up to 104°. In these cases also there was tenesmus. In many cases there were systemic symptoms consisting of pain in the muscles and back and feeling of great prostration. In the writer's own case, and in that of several nurses and doctors observed, systemic symptoms and prostration were noted. Then the condition was one of diarrhea which in perhaps 90 per cent of the cases was not accompanied by severe systemic symptoms, disabling the men merely for one, two, or three days. Among these cases, however, there were more severe ones, some of which took on the form of mod- erate true dysentery, a very few showing the picture of severe types of dysentery. The report stated that diarrhea of a similar type was prevalent among neighboring French troops. Water in the entire area was bad; B. coli was present in all examinations, and it could not be regarded as safe without chlorina- tion or boiling. Efforts at chlorination had been general, but it was frankly stated that during the time of battle it was quite impossible to chlorinate the water for the men in the more advanced posts and later it was found that water was not being chlorinated in many commands, owing in some cases to the difficulty in obtaining calcium hypochlorite. In this connection the investi- gator stated:9 It is our opinion that the disease may have been started by the drinking of unboiled water from contaminated sources and that some of it is being kept going in this way; never- theless that this was not the only and main cause of the continuance of the disease was shown by such examples as the following: Mobile Hospital No. 2 had had nothing but chlorinated water since the beginning and have taken good care of their latrines, but have always been next to units with open latrines and many flies. At least 10 per cent of the command has had diarrhea. The 146th Field Artillery, as reported by Captain Stark, had only boiled water for a short period during which diarrhea appeared. Since this command, however, was subsequently scattered and detachments could not be controlled as far as drinking from unauthorized sources was concerned, water could not entirely be excluded as being in part at least responsible, and 8 out of every 10 men have had the disease. Sanitary conditions throughout this entire area were atrocious. At first, of course, there were many unburied bodies of men and horses throughout the area; at the time of the arrival of the undersigned, human bodies had been buried, but there were still many unburied horses. The writer no longer saw any unburied human bodies, but was told that until a few days before August 10 there had still been unburied bodies and many had not been buried very deeply. Major McKoy told the writer of some German bodies that he had seen several days after the writer arrived, buried with the hands sticking out of the ground, and there were areas of the country in which on riding through in an automobile one passed through a strongly noticeable stench. Feces disposal except in a few instances was in a condition of utter neglect. To de- scribe wcll-cared-for latrines would consist merely in picking out a few exceptions. The wretched conditions of the latrines applied not only to the front and forwarded areas, but also to areas as far back as Ussy. Many latrines were seen, some at Ussy, some in the town 56706—2S----22 338 COMMUNICABLE AND OTHER DISEASES of Chateau Thierry, and many in other places, consisting of shallow ditches, half or more rilled with feces, with no attempt whatever to oven cover them with dirt, Flies swarmed in and about them, and in some cases such as the latrine in the Chateau de la Foret near \ die Moyenne, and one in the medical supply depot of the 32d Division in Chateau Thierry, they were within short distances of messes. In addition to this, feces were deposited without any regard to latrines. In many of the woods occupied by troops there were piles of feces here and there throughout the area, on the ground, uncovered, with the paper used for cleansing purposes scattered irregularly about them. This was true not only of woods in the forward areas, but in such places as gardens at the backs of houses, such as, for instance, the one men- tioned above in Chateau Thierry at the medical supply depot of the 32d Division. Again the men in the forward areas had made use, for defecating, of the shallow trenches dug for the immediate protection of a few men at a time, and no attempt had been made to cover them. This condition was true of places like the woods occupied by the 304th Field Artillery, and at Moreuil where the 77th Division units entered places previously occupied by units of the 4th Division and found them in the condition described above. The abundance of flies was greater than the writer has ever seen anywhere before. This was probably due to the fact that the areas had been so thickly covered by breeding places, dead bodies of animals and men, and manure, and because of the coincident hot weather. During the early part of the writer's stay it was impossible to sit at a mess and eat any of the food placed on the table before myriad flies had settled upon it, and the tables in the kitchen and the food in the kitchen were at all times covered with flies. The investigator concluded his report by saying that it was believed the epidemic of diarrhea which had been prevalent in the Paris group of the First Army was not due to any single cause. It was believed to have been started by the drinking of unchlorinated water and the contamination of food by feces; and kept alive chiefly by flies in this latter manner. Medical officers were advised by the chief surgeon, A. E. F., of the insani- tary conditions as follows:10 Intestinal flux has been quite prevalent recently in the American Expeditionary Forces. Whether we call it cholera morbus, dysentery, diarrhea, enterocolitis, or acute intestinal indigestion, we can not blink the fact that the causes of practically every case have been preventable and well within the control of the officers and men of the American Expeditionary Forces. The ingestion of dirty food and water is the simple and the correct explanation of the extensive epidemics which have caused a large burden of unnecessary suffering and inconvenience to our men in every part of France. The dirt has in 99 per cent of the cases been our own dirt and the food and water have been of our own providing. Feces have got into the food. All varieties of infecting organisms familiar to dwellers in temperate zones and plenty of tropical organisms have been identified. Among them the commonest have been Shiga, Flexner, Hiss-Y, Wheeler, paratyphoid, and the Entameba histolytica. Do not unload the responsibility for summer diarrhea upon the filthy fly; carriers— i. e., men sick with diarrhea, typhoids, dysenteries, etc.—have served food in many kitchens. Officers and men, even in parts of France far from the turmoil and disorganization of the recently captured areas south of the Vesle, constantly drink water from unapproved sources in utter disregard of orders issued for their protection. A diarrhea of only one day, followed by three days of constipation, in a negro private of Engineers was found to be due to the Flexner bacillus. Most of those clinically recovered from what seems a simple dietetic diarrhea continue, as do typhoid convalescents, to spread their infection by hand contact with their fecal discharges. That France has been well seeded must be acknowledged if one will but count the harvest. It is verily in our own hands to prevent a continuance or a recurrence. This graphic picture of the conditions allowed to persist after a great battle, as well as the opinion expressed from headquarters, shows what may be expected when the lessons of sanitary discipline have not been sufficiently THE DIARRHEAL GROUP OF DISEASES 339 well ingrained upon new troops. Had the germs of cholera or even of typhoid fever been present instead of the comparatively mild strain of dysentery bacilli, the results would have been calamitous. That the American Expeditionary Forces learned its lesson and perfected its sanitary discipline is shown by the remarkably low rates for intestinal diseases which followed the signing of the armistice and to which attention has already been called. The conditions just described served as a causative factor in the occur- rence of both major types of dysentery as well as of other intestinal infections grouped in the reports as diarrhea and as enteritis and colitis. The results of such conditions have long been known and they are repeated here only to emphasize the lesson they teach. In the matter of specific etiology of the dysenteries little of importance was added to the sum of our knowledge by the extensive research conducted not only in the laboratories of the American forces but also by all the other armies engaged. It would appear from the reports that the outbreaks of dysentery during the period of active military operations differed from those usually occurring in civil life in being of mixed etiology. In civil life an out- break of dysentery is usually the result of one type of organism and all cases show the same type and all are directly or indirectly due to the same source of infection. In such conditions as those just portrayed, where perhaps hundreds of thousands of men are involved, the chances for the spread of infection are so favorable that several different strains or varieties of organisms find it easy to get a foothold and so not all the cases of the same outbreak are due to the same bacterial agent. In the outbreak described, the investigator 9 reported that: In several instances, dysentery bacilli were isolated which agglutinated in Shiga serum, but showed some slight irregularity on the Russell double sugar medium. But since the stock Shiga bacilli brought from Dijon showed the same irregularity on this medium, one felt justified in regarding these organisms as of true dysentery. In one case bacilli of the Flexner type were isolated. Dysenterylike organisms, but unidentified, were isolated from other cases. In two cases paratyphoid bacilli, probably B. paratyphosus were isolated from the blood. The difficulties of isolation of this group of bacteria even under favorable circumstances have been described. It is therefore to be expected that no large proportion of successful isolations will result from any given outbreak. A few typical instances of investigations in the field follow. In July, 1918, an epidemic of diarrhea was reported among the personnel of the 355th Infantry at Grand.11 During the 17 days covered by the report there were about 170 cases. Examination of the stools was negative for organ- isms of the typhoid-dysentery group and for ameba3. The blood was also negative. The outbreak was attributed to the use of polluted water. An outbreak of diarrhea in August, 1918, in A. R. C. Base Hospital No. Ill and in Evacuation Hospital No. 5, at Chateau Thierry, was investigated.12 Eighty cases were examined bacteriologically. B. dysenterix Shiga was found in 4, the Flexner variety in 1, the " Y " type in 2, and the B. paratyphosus B in 2. An investigation of an epidemic among troops in Camp No. 1 and troops in the vicinity of St. Nazaire, in August, 1918, failed to reveal any organisms of the dysentery group.13 The outbreak was thought to be due to bacterial infection of a mild type and spread most probably by water and flies. 340 COMMUNICABLE AND OTHER DISEASES An officer of the base laboratory, intermediate section, reported cases of diarrheal disease at Komorantin and Gievres.11 Xo cases of dysentery were diagnosed at the former place, but diarrhea had been common. At Gievres one case each yielded B. dysenterix (Morgan 1) and B. dysenterix (Shiga). The cases were not of a severe type. An epidemic in the 37th Division was investigated and in October, 1918, it was reported that the Shiga bacillus had been isolated from soldiers and from civilians living in the vicinity.15 The cases were attributed to water and to contact infection through flies. The nature of an atypical dysentery-like bacillus found at the embarkation hospital, Newport News, Ya., was investigated in September, 1918.16 The theory was advanced that the change in environment resulting from any intestinal disturbance, constipation, diarrhea, etc., invariably changed the normal flora and resulted in an increase of atypical, nonlactose, fermenting bacilli which often outgrow the causative agent. The conclusions drawn from this investigation were as follows: 17 (a) The investigation failed to establish any causal relationship between atypical bacilli and dysenteric infection. (6) Repeated bacteriological tests are of value in making a diagnosis, (c) Where bacteriological results are negative or doubtful, serological tests may prove of value in establishing the cause of infection. The importance of early examination of stools was shown by the experience with 1,050 cases from which 158 successful isolations were made. Sixty-eight per cent of the successful isolations were made in the first five days of the dis- ease, after which the percentage of positive results rapidly diminished whether the dejecta remained characteristically dysenteric or not. During the World War there was a tendency on the part of some workers further to subdivide the already complicated group of dysentery bacilli. Thus several varieties of para-Shiga and of para-Flexner bacilli made their appearance. The truth will probably prove to be that there are two species of dysentery bacilli represented by the Shiga and Flexner types, and that other slightly different organisms are varieties of the two main species which will prove to be more or less interchangeable. The British investigators, Willmore and Shear- man,5 made the statement that almost weekly a new type of bacillus, nonmotile Gram-negative anaerogenic, nonlactose fermenting, turned up on their plates. Each new type showed infinite gradation affinities with, and divergence from, the classical in its bearing toward recognized agglutinating sera and fermenta- tion of sugars. From the consideration of all the reports it is apparent that we emerged from the war with the original Shiga type as the most important etiological factor in the bacillary dysenteries; the Flexner comes second. There are several allied organisms beside the paratyphoid B which seem to have entered into the production not only of true clinical dysentery but of the milder diarrheas as well. Little has been added to our knowledge of the etiology of entamebic dysentery as the result of the war. Two new species of apparently nonpath- ogenic amebae were discovered in British laboratories. The E. nana of Wenyon and O'Connor,18 and the Dientameba fragilis of Jepps and Dobell.19 The former is important in the diagnosis of entameba carriers, as the cysts at times THE DIARRHEAL GROUP OF DISEASES 341 resemble those of E. histolytica. Kofoid, Kornhauser and Plate20 found E. nana to be the commonest ameba found in returned American troops in the large series of examinations which they conducted/ CARRIERS Opinions have been divided as to the importance of carriers in the epi- demiology of bacillary dysentery. The importance of the carrier in entamebic dysentery is unquestioned. Russell21 regarded acute and chronic carriers of dysentery bacilli as equally as important in the propagation of dysentery as are typhoid carriers in the spread of typhoid fever. He arbitrarily considered a patient a carrier if bacilli persisted in his discharges more than three months from the date of first symptoms. There is usually a clear history of dysentery. Carriers of the Flexner bacillus may remain free from symptoms and show no abnormalities in the stools. Shiga carriers, on the other hand, are more apt to present the picture of chronic cases, seldom recovering, even for a short time, sufficiently to be considered healthy. He called attention to the intermittent character of the discharge of bacilli in known carriers. The carrier of dysentery bacilli, according to Nichols,22 is apparently of less importance in the spread of bacillary dysentery than are carriers in the spread of typhoid fever and cholera. There are fewer true carriers in bacillary dys- entery; the individual carrier is less chronically ill and excretes fewer bacteria. The spread of infection is usually due to acute and chronic cases. Incubationary carriers are known; however, in view of the absence of a test for susceptibility, and in view of the relapsing character of the attack, it is difficult to diagnose them. In temporary convalescent carriers, the excretion of bacilli diminishes after clinical recovery. According to Nichols, the number does not become low for about two months, and it requires repeated examinations to exclude the carrier state. Chronic convalescent carriers on the other hand, running up to 1 year, occur in from 1 to 5 per cent in different series. It is difficult to draw the line between relapsing carriers and chronic cases. Nichols and Russell agree on the difference between Flexner and Shiga cases from the carrier stand- point. The Flexner cases are more apt to result in the carrier state while the Shiga cases tend to become chronic. Nichols concluded that contact carriers have usually been considered rare, but with improvement in the technique of examination they have been found more frequently. The percentage of cases that became carriers and the proportion of exami- nations that resulted in positive findings of dysentery bacilli were variously reported by different workers. Arkwright, Yorke, Priestley, and Gilmore23 examined 50 dysentery convalescents for the carrier state. The cases varied from three to six months after the onset of symptoms. The Shiga bacillus was found in two and E. histolytica in nine. Kennedy and Rosewarne 24 examined several hundred typhoid and dysentery convalescents for the detec- tion of carriers. More than 5,000 examinations were made. The results showed 6 dysentery carriers, of which 3 were of the "Y" type and 3 Shiga. Fletcher and Mackinnon25 examined 935 dysentery convalescents and 847 ' For further details in this connection, consult Chapter XIX of this volume. 342 COMMUNICABLE AND OTHER DISEASES convalescents from other diseases, such as enteric and trench fevers. Among the dysentery convalescents, 6.95 per cent were found to be dysentery carriers; 2.78 per cent persisted in the carrier state. There were 58 carriers of the Flex- ner organism and 13 of the Shiga. Of the nondysenteric cases, 1.06 per cent were carriers of dysentery bacilli. Two-thirds of these patients gave a history of dysentery; all were of the Flexner type. All the Shiga carriers were per- sistent and suffered from chronic dysentery and mental depression. The Flex- ner carriers were usually in good condition and fit for work under favorable conditions. The carrier of Flexner bacilli does not excrete the organism con- tinuously but intermittently, with periods of perhaps five or six weeks during which it can not be found. This renders the diagnosis of the carrier state extremely difficult and indicates the necessity of frequent examinations over a considerable period before a given patient may safely be considered free from bacilli. According to Dopter,26 the main source of entamebic infection during the war was the presence of carriers of the organism among the French colonial troops from North Africa. These men infected the soil of the trenches they occupied, and healthy troops relieving them became infected in their turn. Thus with the general interchange of troops the infection became widely scat- tered. The number of cases was never large enough to menace military effec- tiveness, but sanitarians were preoccupied with the thought that the creation of an army of entameba carriers might present a serious problem to the countries concerned on the return of their soldiers to civil life. Sporadic cases of entamebic dysentery have been known for years in all parts of the United States, but the condition has remained somewhat of a pathological curiosity. However, during the Mexican border mobilization in 1916, Craig27 identified the organism in 158 cases of dysentery among some 110,000 men. The cases were milder than those usually seen in the Philippine Islands, possibly because treatment was instituted earlier. True and con- valescent carriers were demonstrated and were regarded as the source of the disease. There was no evidence of contact infection. Dobell23 examined 200 soldiers for E. histolytica as a routine measure and found 22, or 11 per cent, infected. Half of these denied any history of diarrhea or dysentery. Among these men, 4 were undoubted contact carriers. Mat- thews and Smith,29 at the Liverpool School of Tropical Medicine, examined the stools of 4,062 dysentery patients from the Western Front and found 12.1 per cent infected with the ameba. The degree of infection in American troops both at home and abroad is indicated by the results of examination of returned soldiers at Debarkation Hospital No. 3 at New York City and of home-service men at the port of embar- kation; 230 overseas men and 576 home-service men were thus examined.20 Of the former, 12.8 per cent and of the latter 4.3 per cent were found to harbor E. histolytica. Very few of the men had dysenteric symptoms at the time of examination. Later, an examination was conducted at the University of California on students who had served as soldiers overseas. On this occasion repeated examinations were possible and each of 154 men received an average of 3.8 examinations. Of these men, 67 per cent were found positive for E. his- THE DIARRHEAL GROUP OF DISEASES 343 tolytica. The authors of the investigation conclude that the number of ameba carriers in the country must have been substantially increased by the return of infected soldiers from overseas. These figures confirm the statement earlier made that the proportion of carriers of E. histolytica who manifest no clinical evidence of their condition is very large. SYMPTOMATOLOGY AND PATHOLOGY The clinical course of the average case of dysentery observed during the World AVar naturally presented nothing different from the cases seen elsewhere; however, certain additions to our knowledge were made, either by American workers or by those of other armies, which deserve passing mention. There is no discoverable record of anything to show the incubation period of bacillary dysentery. The onset was usually described as sudden, with fre- quent bloody stools, prostration, tormina, and rectal tenesmus. Generally, the cases were mild or moderately severe in type. No cases were described of the type resembling cholera—acutely toxic with death occurring without change in the number and character of the stools. Russell,21 in his description of bacil- lary dysentery, states that the stool itself is quite characteristic and at the height of the disease is quite unlike the stool in any other disease, not excluding amebic dysentery. It is small and consists exclusively of blood and mucus, without a trace of fecal matter. Under the microscope one sees red blood cells in enor- mous numbers, and epithelial cells in masses; they are thrown off by the mucous membrane. These are often to be recognized as columnar epithelial cells, arranged like closely aligned pickets on a fence, like a typical textbook picture. In addition, single epithelial cells in all stages of swelling, degenera- tion, and necrosis are seen. The single swollen cells are often roundish and sug- gest at first quiescent ainebae, but they do not possess the power of motion or the ability to send out pseudopodia. They may also be readily distinguished from amebic cysts by the large size and different character of their nuclei. These various elements are embedded in masses of glairy and stringy mucus. As the disease progresses and increases in severity the character of the stool changes from that described above, the epithelial masses increase in size until one sees sloughs of large ulcers, or even a pseudomembranous cast of the entire circumference of the gut. Under the microscope it is no longer possi- ble to make out the structure of the epithelial cells, since the entire mass is coagulated and necrotic. The fluid part of the stool is no longer watery, but serous, and dark from altered hemoglobin. Such stools are extremely offensive. Bacillary dysentery usually runs an acute course, terminating with recovery in the course of a few days or weeks. A small percentage become chronic or terminate fatally. Although not always true, this was the experience of the Army during the World War. The case fatality was 2.17 and but 1 case was discharged for disability. The chronic cases suffer from depression, emaciation, and relapses. Jacob30 described a series of cases in which relapse occurred between the nineteenth and twenty-first day. Normal temperature preceded the relapse by one to three weeks. Intestinal symptoms were absent or stools were much like those of diarrhea; however, he isolated the Shiga and Flexner strains from the stools 344 COMMUNICABLE AND OTHER DISEASES durmg the relapse. Headache and joint pains were frequently present. Pain along the colon is not an uncommon complaint. The proctoscope often reveals ulceration in the lower bowel. PROGNOSIS The prognosis of dysentery as observed during the World War is very favorable. Of the 4,738 cases of all types of dysentery reported, but 73 ter- minated fatally. This gives a case fatality of 1.54 per cent. Taking into con- sideration the admittedly large number of cases never reaching the hospital, or being entered upon the records, it is evident that even this low fatality is stated much too high. The prognosis appears to be decidedly less favorable in the colored race than in the white. The case fatality in 220 cases in negroes was 4.55 per cent, while of 3,547 cases in white enlisted men, but 1.48 per cent died. Again, the small number of cases in the colored, 220, with 8 deaths, introduces a large probable error and lessens the value of the comparison. The same considerations render the figures for case fatality of the various types of dysen- tery of less value than would be the case had a larger proportion been classified etiologically in the reports. The case fatality for bacillary cases was 2.17 per cent, while that of the entamebic cases was 1.29 per cent. The entamebic cases were responsible for 85 of the 86 dysenteric cases discharged for disability during the war. This is to be expected on account of the chronic and relapsing character of this disease. Indeed, Craig27 recom- mended that the carriers of the entameba who are not readily cleared up after a reasonable period of treatment should be discharged from the service as a measure of protection to uninfected troops. Experience has shown that such men can not stand the strain of active campaigning and soon suffer relapses and become a burden rather than an asset to the service. The average case of bacillary dysentery lost 19.6 days from duty; the amebic, 34.6. The unclassified dysenteries averaged 21.6 days lost, a figure much nearer that of the bacillary group than that of the amebic cases. This confirms the deduction previously made that the vast majority of the unclassified cases were of the bacillary type. Prognosis is of course modified by the promptness and efficacy of treatment and hence proved more favorable in the training camps in the United States than was the case under battle conditions in France. AUTOPSY FINDINGS There are on file in the Surgeon General's Office the protocols of 35 autop- sies performed on dysentery cases. These are classified as follows: Bacillary dysentery, 7 cases; amebic dysentery, 8 cases; mixed infection, bacillary and amebic, 3 cases; dysentery with negative laboratory findings, 9 cases; com- plicated dysentery, 8 cases (pneumonia, 4; ulcerative endocarditis, 2; influenza, 1; and tuberculosis, 1). The autopsy findings in the bacillary cases were those commonly seen in this type of dysentery. In 6 of the 7 cases the heart showed acute myocarditis. In 5 cases occurring in the American Expeditionary Forces the diagnosis of bacillary dysentery was made by laboratory examination of the stools. Two cases were diagnosed a few days before death, the patients having been admitted THE DIARRHEAL GROUP OF DISEASES 345 in extremis; one case dying from Flexner infection showed slight degenerative changes in the liver. All of the amebic cases coming to autopsy showed abscess of the liver. The entameba was found in the pus of the abscess, in the intestinal ulcers, or both. The lesions differed only in extent, and consisted of ulceration of the large bowel and in some cases the lower 2 feet of the ileum. The ulcers were generally very numerous and at times confluent, so as practically to destroy the mucosa. No perforations were reported. The other changes found in these cases were secondary to perforation of abscesses into the pleural or peri- toneal cavities. The liver abscesses were located in the convex portion of the right lobe of the liver in all cases but one, which involved the left lobe only. The diagnosis had been made clinically in but one case; in 2 others it was sus- pected while of the remaining 5, tuberculous peritonitis was diagnosed twice and appendicitis, lobar pneumonia, and bronchopneumonia once each. From the necropsy standpoint, 8 of the 9 cases of dysentery coming to examination without laboratory diagnosis were most probably bacillary dysen- tery. The location of the lesions, edema of the intestinal wall, areas of ulcer- ation, pseudomembrane, and necrotic mucosa indicate the grounds on which this conclusion is based. In one case without laboratory findings, the con- ditions resembled those of the amebic type. Symptoms had persisted for four months before death. DIAGNOSIS Under war conditions the diagnosis of a case of dysentery must necessarily be made usually upon clinical grounds exclusively. The differentiation of type in bacillary dysentery and even the distinction between bacillary and amebic cases require the use of laboratory equipment and trained personnel. There- fore, under field conditions, the majority of cases were reported as "dysentery, unclassified." The occurrence of a considerable proportion of unclassifiable cases of clinical dysentery among the troops in the camps in the United States shows that even under favorable conditions a specific diagnosis can not be arrived at in every case. The difficulties and uncertainties of diagnosis, and the resultant effects upon the statistics have been touched upon incidentally in previous paragraphs. The importance of early diagnosis has been indicated in relation to the early institution of serum treatment. In the prompt identification of the bacillary forms all authorities agree that it is of first importance to secure a properly selected, fresh stool for bacteriological examination. Kligler and Olitsky31 reported failures to isolate B. dysenterix from cases of clinical bacillary dysentery and attribute the failure to (1) improper selection of stool specimens for culture and (2) the use of unfavorable culture media. The stool selected should be one containing blood and mucus, with little or no fecal matter. It is essential to plate the stool directly, or at least very shortly after it is evacuated. Experiments with artificial mixtures of Shiga bacilli and feces showed a 50 per cent reduction in 4 hours, and from 85 to 90 per cent reduction in 24 hours when kept at room temperature. They recommended the use of a modified Endo-medium or the eosin-methylene blue medium. 340 COMMUNICABLE AND OTHER DISEASES A simple and satisfactory medium was devised in the central medical department laboratory, A. E. F., for the isolation of B. dysenterix from stools.32 It consists of: c. Distilled water_________________________________________10° c- Agar_____________________________ --------- ...15 gm. Peptone (difco)__________________________________________10 Sm- Dipotassium phosphate----------------------------- - - "* £m- To each 100 c. c. is added: Lactose, 20 per cent solution________________________________5 c. c. Glucose, 5 per cent solution---------------------------------1 c- c- Rosolic acid, 1 per cent in 90 per cent alcohol------------------1 c. c. China blue, 0.5 per cent in water----------------------------1 c- c- The hydrogen ion concentration of this medium is 7.4 to 7.5 and it needs no adjustment. If the sugars are clean and white it needs no filtration. The dysentery bacilli grow as luxuriantly on this as on any other medium, and the lactose nonfermenters are readily recognized. In addition to the precautions suggested by Kligler and Olitsky, the impor- tance of securing, if possible, a stool for diagnosis early in the course of the disease should not be overlooked. Recent work suggests that the bacterio- phage developed in the intestine after the first few days of the disease may be the inhibiting agent which causes failure to growT on the part of the infect- ing organism even when doubtless present in large numbers. With the dis- appearance of the lytic agent during convalescence it is frequently again possible to isolate the bacillus in large numbers. The application of the agglutination test to the patient's serum as a means of diagnosis has not resulted in great success. Specific agglutinins would not be expected to develop in much concentration until the disease had progressed several days. This would militate against the use of this test in early cases when diagnosis is most important. The American opinion is voiced by Kligler,16 who remarks that it is a well-known fact that agglutinins for the Flexner bacillus are present in fairly high concentration (1:50 or 1:75) in normal individuals. This is not true for Shiga agglutinins, which are rarely demonstrable in dilutions over 1:10. It would thus appear that the diagnosis of Shiga infection might be predicated upon a positive agglutination in specific serum at a dilution of 1:20 or over, but that Flexner infection could only be diagnosed were the test posi- tive at a dilution of at least 1 :100. War experience has shown the fallacy of ascribing pathogenic properties to bacteria isolated from the stools of dysentery patients merely because they con- form in cultural characters to dysentery bacilli. An accurate diagnosis must be based both on cultural and specific serological criteria and sometimes even upon animal experimentation. Examination of fresh stools early in the course of the attack, the use of suitable media, and skill in their use are essential for satisfactory results. A single negative examination is of little or no value. To our knowledge of the diagnosis of amebic dysentery little was added as the result of war experience. The importance of the differentiation between E. histolytica and E. nana, especially in the diagnosis of cyst carriers has been brought out earlier. THE DIARRHEAL GROUP OF DISEASES 347 The differential diagnosis between the bacillary and amebic types of dysentery must be ultimately based upon laboratory findings. However, dif- ferences in the clinical appearance of the patient and in the general as well as microscopic appearance of the stool may be valuable in making this differentia- tion. The amebic patient, generally speaking, is less toxic, the temperature is little if at all elevated, the number of stools, although increased, is small as compared with the bacillary type, rarely exceeding 10 to 14 per day, and the course of the disease is more prolonged. In bacillary cases of moderate to severe grade there is usually a sudden onset, the patient is toxic, temperature high, stools numerous—30 to 40, or more, in 24 hours. He presents the appear- ance of a very sick man and the disease is usually of short duration. Descrip- tions of the microscopic characters of the stools in these two conditions published during the war period have been superseded by the exact cytological diagnostic work of Willmore and Shearman,5 Manson-Bahr,6 and others, which appear to have made the distinction easily possible on microscopic grounds. TREATMENT This is a subject necessarily treated differently for the different types of the disease. So, too, the treatment of the acute, initial attack must differ from that of the chronic forms in cases in which the disease obtains a prolonged hold. This latter unfortunate happening is usually the result of delay in starting treatment and is characterized pathologically by an ulcerated condition of the intestine even in the bacillary cases, and symptomatically by intermittent diarrhea, usually without much blood or mucous, but showing pus, anemia, and varying degrees of prostration. There is no record of this type of disease having attracted attention in the American forces during the World War although presenting a serious problem to some of our Allies, especially in the East. Consequently only the treatment of the acute attack will be considered here. The most important thing in the treatment of acute bacillary dysenter}^ is the establishment of at least a probable diagnosis. In epidemic times this is usually evident, although when both bacillary and amebic dysentery are preva- lent the differentiation is important. The treatment should be along lines both specific and symptomatic. The specific treatment of bacillary dysentery con- sists of the administration of a reliable polyvalent antidysenteric serum in a sufficient dosage and as early as possible. This treatment has not been used extensively in the United States, possibly because severe clinical forms of dysentery are not common here and possibly because the treatment has not habitually been administered early enough on account of delay for the purpose of obtaining a bacteriological confirmation of the diagnosis before the adminis- tration of serum. According to Russell21 the serum is best given in large doses following Shiga's rule, 1 dose of 10 c. c. in mild cases, 2 such doses at intervals of 6 hours, in cases of moderate severity, and in severe cases 10 c. c. twice a day for 2 or 3 days. The tendency seems to be to increase the dosage, and even a dose of 100 c. c. daily has been given to severe cases with apparent benefit. 34S COMMUNICABLE AND OTHER DISEASES The British believe53 that the value of the specific serum has been established and that the sooner it is administered the better. They recommend an initial dose of from 20 c. c. to 60 c. c. Bahr and Young'4 recommend administration of the serum in all doubtful cases while awaiting the results of laboratory examination. They believe that the benefits obtained by prompt administra- tion outweigh any objections to the treatment of an occasional nonbacillary case and state that it does not act deleteriously in any case, irrespective of the nature of the disease. In a memorandum on medical diseases in the tropical and subtropical war areas, the British state that the action of antidysenteric serum is often remarkable, as much as 400 c. c. having been given in severe cases, and (apparently) it has been the means of saving the patients.35 The French used serotherapy extensively but with varying results.26 Among the Germans, Schittenhelm36 remarks that, as in the case of diphtheria, it should be given as soon as possible. He recommends the intramuscular route as more rapidly effective. The dose used by the Germans was larger than that used by the Americans. The patient should be confined to his bed, and the use of the bedpan en- forced. The diet should be nonirritating and at first liquid, using the strained types of diet which leave little residue. An important point in the nonspecific treatment is the clearing of the bowel by means of salines. A method for accom- plishing this is as follows: A dose of 20 c. c. of saturated solution of magnesium sulphate is given every four hours, each dose followed an hour later by 10 drops of aromatic sulphuric acid in water. This results at first in an increase in the number of stools, but within two days they are greatly reduced in number, pain becomes less, and general improvement is noted. The following saline treatment was recommended by Balfour:33 !* Sodium sulphate_______________________________________ gr. lx. Acid, sulph. aromat_____________________________________ m. xv. Tr. zingiberi___________________________________________m. v. Aq. menth. pip________________________________________ oz. ss. M. This mixture above should be administered every 2, 3, or 4 hours until the stools become watery. It is claimed to be better than magnesium sulphate. Bismuth subnitrate, 60 grains, and salol, 3 grains, every 6 hours are useful in the later stages. In very severe cases, drained by the constant evacuations, Balfour recommends the Rogers cholera treatment,33 the intravenous adminis- tration of hypertonic salt solution to restore blood volume and prevent acidosis. Ipecac and its alkaloid are without value in bacillary dysentery and opium and its derivatives are probably harmful by forcibly checking the number of evacu- ations and retaining within the intestine the toxin of the invading organ- isms. d d With the postwar development of the cytological method of diagnosis in the dysenteries, it has become possible in the great majority of cases to render an opinion as to the type of dysentery, bacillary or amebic, within a few minutes after a stool specimen has been received in the laboratory. The use of this aid places the early administration of the serum upon a sound scientific basis; and judging from our experience in the Philippine Islands, a majority of cases could be diagnosed and treated with success in a medical echelon very close to the front, and need never reach the larger hospitals. THE DIARRHEAL GROUP OF DISEASES 349 Little new developed from war experience in the treatment of acute amebic dysentery, although much work was done along this line. It resolves itself into the effective administration of emetine. First suggested as a remedy for dysen- tery in 1829 by Bardsley 37 of Manchester, it was found to be amebacidal by Vedder 38 of the United States Army (1910-11), and its use in amebic dysentery was established in 1912 by Sir Leonard Rogers.39 The routine treatment con- sists in the daily administration of 1 grain of the alkaloid subcutaneously for a period of 12 days. Such a course usually causes a rapid improvement with cessation of dysenteric symptoms, but it can not be relied upon to cure the disease in the sense of completely removing the infecting amebae. It is necessary to keep the patient in bed during such a course of emetine, not only for the purpose of controlling the diet, but also as a protection to the heart. Dale 40 showed that emetine in large doses is cumulative in its action, and that neuritis has followed its use. Two fatal cases of emetine poisoning were reported in 1916 from Base Hospital No. 2, at Fort Bliss, Tex.41 The possible deleterious effect on the heart is pointed out by Wenyon and O'Conner, whose report describes two cases. Attempts to develop a form of emetine administration more effective in clearing up the infection than the alkaloid alone led to introduction by Du Mez 42 of the double iodide of emetine and bismuth which contains 58 per cent of iodine, 12 per cent bismuth, and 29 per cent emetine. The alkaloid is grad- ually liberated under the action of the alkaline secretions of the intestine. It is less emetic in its action than is emetine alone, but may cause nausea in some instances. This may be mitigated by the previous administration of 10 to 12 drops of the tincture of opium, preferably after the patient has retired for the night and after a light meal. Under this treatment it does not appear to be necessary to confine the patient to his bed. The dose is 3 grains daily, prefer- ably in a single dose rather than in divided doses. The treatment is continued for 12 days. This treatment is usually regarded as less effective in the removal of the symptoms of the acute state than is the subcutaneous emetine treatment, but is more effective in clearing up the carriers. The use of emetine bismuth iodide in conjunction with the hypodermic injections of emetine would seem to be beneficial in that convalescence is estab- lished earlier and patients are less apt to become carriers.43 But it can not be considered as a substitute for emetine, as attempts to treat acute cases with it alone ended in failure until emetine was used in addition. Patients may be completely cured by the emetine treatment, but prob- ably two-thirds of the cases, though completely relieved from their symptoms, still harbor the organism, as shown by the excretion of cysts. Such patients are almost sure to suffer relapse at some later date and of course are the main source of infection of others. The clearing up of carriers has thus become a major problem of the treatment. Wenyon and O'Conner18 advised the combined oral and hypodermic use of emetine hydrochloride in the treatment of carriers. One grain of the drug is given hypodermically in the morning daily for 12 days, and one-half grain in a keratin-coated tabloid is given by mouth each evening. They reported 30 carrier cases treated by this method with no relapses. In 37 carriers treated by the hypodermic method alone, there were 10 relapses, and in 5 350 COMMUNICABLE AND OTHER DISEASES the dnig failed to act. Of six cases treated orally, half showed either no reaction to the drug or suffered relapse. Jepps and Mcakins ,4 concluded that emetme bismuth iodide cured 95 per cent of E. histolytica carriers, and that the best method of administration is in the form of a loose powder contained in a cachet, in daily doses of 3 grains. At least 36 grains should be given in all. The Med- ical Research Council 45 reports on the results of treatment of 155 E. histolytica carriers with emetine bismuth iodide in various forms, and in doses of 3 grains daily for 12 or more consecutive days. A single first course of treatment cured 90 per cent of their cases. When they remain uncured after such treatment, the best method of re treatment is to give them a double course of the drug; that is, 3 grains daily for 24 days. Such treatment has not cured every case, but there is no evidence that those who are not curable by such means constitute more than 5 per cent of all carriers of E. histolytica. In conclusion, it may be said that emetine hydrochloride, alone or in con- junction with emetine bismuth iodide, was the preferred form of specific therapy for amebic, dysentery during the World War, while the use of the double salt gave the best results in the treatment of carriers. PREVENTIVE MEASURES The preventive measures used during the World War fall into two classes, the general and the specific measures. The former comprise nothing that was not previously known, but instructions issued by the War Department on the subject and examples of conditions under which the troops had to operate are of value. Some such examples have been given already. Of the general preventive measures the early diagnosis and isolation of the sick, discovery, isolation and treatment of carriers, destruction of flies and pre- vention of fly breeding, safe-guarding of water supplies, precautions to prevent contamination of food, and the proper disposal of feces were the methods on which we depended for the limitation of the dysenteries as well as of the typhoid group and other intestinal infections. In 1917 the Surgeon General issued the following instructions relative to the causation and prevention of the dysenteries:46 Dysentery—Causes and nature.—Dysentery, or inflammation of the large intestine, is caused by two classes of microorganisms, an ameba and certain bacteria. The former gives rise to amebic, the latter to bacillary dysentery. The bacterial or bacillary form of dysentery is more widely distributed over the world than the amebic. While the former is found in all climates, the latter is chiefly restricted to warm countries. But persons suffering from amebic dysentery may carry the disease from a warm to a cold climate. Sources of infection.—The amebae and bacilli which cause dysentery are contained in the intestinal contents and are discharged with them. They are, therefore, subject to the same manner of distribution as are the typhoid bacilli, and the preventive measures to be employed are identical with those employed in typhoid fever. It may be well, however, to emphasize the common occurrence of carriers of dysentery bacilli and amebse among exposed and recovered cases and the necessity of enforcing habits of personal cleanliness and other related measures to control the disease. Diarrhea, etc.—In addition to dysentery, slighter and nondysenteric forms of intestinal trouble are more or less common. As the results of chill or indiscretion in diet, diarrhea griping, and even bloody stools may arise. But any case of persistent diarrhea in which blood and mucus are being discharged should be regarded as suspicious and submitted to a THE DIARRHEAL GROUP OF DISEASES 351 laboratory examination in order to determine whether it may be dysentery. The amebae are searched for by direct microscopic examination; the bacilli may be obtained in culture, or an agglutination test made with the patient's blood to determine their presence. The intestinal group of diseases.—(a) Typhoid and paratyphoid fever, cholera, with amebic and bacillary dysentery form a group of intestinal infections in which the causative microorganisms are discharged with the excreta and gain access to healthy persons through the mouth. The general principles of their prevention are practically identical. The first effort should be made to destroy the infectious agents at their source, namely, in the dis- charges from the intestine. The next effort should be to control the water and food supply and the personal habits of the men, so that any of the microorganisms which escape destruc- tion may not find their way into the digestive tract in a living condition. (b) No man should be employed as cook or handler of food or water who is a carrier of B. typhosus, B. paratyphosus, A or B, or cysts of Entameba histolytica. (c) Stools of all cooks and food handlers (including handlers of water and drivers of water and ice wagons) will be examined for typhoid, paratyphoid A and B, and dysentery bacilli, and for cysts of Entameba histolytica. In the case of enlisted men, notation of positive findings should be made upon the service record. As missed and mild cases are undoubtedly responsible for much spread of infection, it is advisable, when military considerations permit, to hospitalize, at least for a brief period, as large a proportion of these cases as possible to permit the disinfection of dejecta, clothing, linen, etc. Such a measure is par- ticularly practicable in the case of troops not actively engaged with the enemy. Specific vaccination against the dysenteries, using a polyvalent vaccine prepared along the same general lines as is that against the typhoid group, had been practiced to some extent before the war. According to Russell,21 such measures are theoretically correct and under suitable conditions should give good results. Antidysenteric vaccination was not used as a routine measure in the Army during the World War and practical experience confirmed the judg- ment that it is rarely necessary. Dysentery was not, except for very brief periods, an important cause of disability in the areas occupied by our troops- The main objection to its routine use, unless special conditions demand it, has been the severe character of the reaction induced by effective doses of the vaccine. To overcome this difficulty several expedients were tried. One was the introduction of sensitized vaccines by Boehnke and Elkeles47 in 1915 and by Gibson 48 in 1917. The Boehnke prophylactic was prepared for the German Army by adding the B. dysenterix toxin and antitoxin in varying proportions to an emulsion of dysentery bacilli of various types. This was termed "dys- bakta." It is doubtful according to Russell,21 whether the advantages of such a mixture are marked enough to justify the use of repeated small doses of the contained horse serum. Dopter 49 and Besredka 50 attempted to produce vac- cines which could be administered orally. Under experimental conditions they attained some degree of success and the application of their methods to the human is still under trial. So far, the degree of success attained has not been such as to make oral vaccination the method of choice. The application of the lipovaccine to the prevention of dysentery was at- tempted. Officers at the Army Medical School51 produced such a vaccine. It contained 2,000,000,000 Shiga bacilli, with the same number of the Flexner and of the "Y" types, per cubic centimeter. The local and general reaction 352 . COMMUNICABLE AND OTHER DISEASES to a dose of 1 c.c. of this vaccine was said to be no greater than that induced bv the regular saline triple typhoid vaccine. Olitsky52 confirmed the safety and practicability of producing a vaccine by the emulsion of various types ol dysentery bacilli in oil. The method is still in its experimental stage. A main difficulty appears to be the attainment of effective sterilization of the vaccine. Against amebic dysentery the same general hygienic measures as have proven of value against the bacillary form should be effective. The prophy- lactic use of emetine might be of value in situations where a high incidence of the disease was to be expected. The French under these conditions used 4 or 5 grains of emetine hydrochloride dissolved in tincture of opium in the propor- tion of 1 to 15. Of this mixture, S to 10 drops were added to a cup of strong tea and taken each night. The method is comparable to the prophylactic administration of quinine in malaria and might serve an equally useful purpose. NONSPECIFIC DIARRHEA, ENTERITIS, AND COLITIS The affections included in this heterogeneous group of generally mild diarrheal affections were classified under one heading or the other, according to the individual preference of the reporting officer. If his preference was for a symptomatic diagnosis, the case was called diarrhea; if for a pathologic or anatomic designation, it became enteritis or colitis on the records. The occurrence of these diseases is shown in the basic table from which most of our figures have been drawn—Table 49. The totals shown in Table 49 for the group as a whole include the dysentery cases as well, but the percentage of the total cases represented by the dysenteries as reported is so small, about five, that their inclusion is without effect upon the relative position of the dif- ferent personnel groups when the latter are compared. Therefore it would be a work of supererogation to go again into the effect of geographical location of troops, race, etc., in regard to the incidence of these diseases. What has already been said with regard to the group as a whole is equally true of the non- specific diarrheas and enterocolitis. In the discussion of the true dysenteries it was brought out that many such cases were undoubtedly reported under the nonspecific headings for various reasons which were there discussed. It seems probable that most of the fatality associated with the conditions now under discussion was the result of this in- clusion among them of cases of true dysentery. Another possibility is that a certain number of chronic cases wrere also included among them. Most of such cases were probably classified in the tables under the heading "Miscel- laneous diseases of the intestinal tract," but others could easily have been re- ported as "chronic diarrhea" or "chronic colitis" and so have become included in our figures. Such chronic cases would have tended to increase the fatality of the group, its proportion of discharges for disability, and the number of days lost from duty over what would have been the case had only acute cases been reported. In spite of such probable inclusions, the type of disease represented was evidently mild, as shown by the average duration of the cases. The figures show that these cases in the United States occasioned only from three to five days' loss of time per case. In Europe, owing to the inclusion of a considerable THE DIARRHEAL GROUP OF DISEASES 353 proportion of the more severe dysenteries, and to the loss of time occasioned by the delays in reaching hospitals, the average time lost was longer. It is evi- dent, however, from the descriptions of epidemics in the battle zones that the great majority of the diarrhea cases were not severe enough to go regularly on sick report. No specific statement of the etiology of these milder diarrheas as dis- tinct from the dysenteries is possible. Dietary indiscretions, or more frequently the character and condition of the only food available, have been blamed in some instances. However, in the latter case the actual cause of the trouble may with more probability be considered to have been bacterial infective agents contained in the food. The same may be said of the drinking of pol- luted water. Such water probably always contains the germs of dysentery or typhoid or paratyphoid fevers, and the result of its use would naturally be the mixed type of epidemic seen in France. The monthly incidence of these conditions as shown in Chart XXXYI indi- cates that in the United States, where the curves were not broken by periods of military activity, there is a definite seasonal increase of incidence, culminating in July or August. At this season air temperature renders almost any food exposed to infection a suitable culture medium for bacteria of the types under considera- tion, and the large number of flies usually to be seen about food in connection with the filthy feeding and breeding habits of this insect provides an easy expla- nation of the method in which infection reaches the food. By no means the last word has been said on the subject of the etiology of diarrheal infections. It is entirely possible that many mild attacks which occur more or less typically in epidemic form in the civilian population have a specific etiology at present entirely unknown. That most cases, however mild, owe their inception to some infective agent, whatever it be, may be considered to be proven by the close correlation between the incidence of these milder diseases with those of known bacterial etiology. Those measures of sanitation which suffice to limit typhoid, cholera, and dysentery, serve also to reduce the inci- dence of the milder diarrheas. When conditions permit effective sanitary discipline all these conditions are reduced almost to the vanishing point, REFERENCES (1) Medical and Surgical History of the War of the Rebellion, Part Second, Medical Volume, Government Printing Office, Washington, D. C, 1879, 1. (2) Report of the division of sanitation and inspection, Chief Surgeon's Office, A. E. F., by Col. Haven Emerson, M. C, May 31, 1919, to the Surgeon General, U. S. Army. On file, Historical Division, S. G. O. (3) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. 1541. (4) Report on diarrheal diseases, Base Hospital No. 89, A. E. F., made by the commanding officer. On file, S. G. O., 710-1 (old), Dysentery. (5) Willmore, J. G., and Shearman, C. H.: On the Differential Diagnosis of the Dysenteries. The Lancet, London, August 17, 1918, ii, 200. 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A.; Kornhauser, S. I.; and Swezy, O.: Criterions for Distinguishing the Endamoeba of Amcebiasis from Other Organisms. Archives of Internal Medicine Chicago, 1919, xxiv, No. 1, 35. (21) Russell, F. F.: Bacillary Dysentery. Tice's Practice of Medicine. W F Prior Co Hagerstown, Md., 1924, iv, 375. (22) Nichols, Henry J.: Carriers in Infectious Diseases. Williams & Wilkins Co Balti more, 1922, 64. (23) Arkwright, J. A.; Yorke, W.; Priestley, O. H.; and Gilmore, W.: Examination of Fifty Dysentery Convalescents for Carriers. Journal of the Royal Army Medical Corns London, 1916, xxvii, No. 6, 755. p ' (24) Kennedy, A. M., and Rosewarne, D. D.: Observations upon Dysentery Carriers. The British Medical Journal, London, 1916, ii, 863. THE DIARRHEAL GROUP OF DISEASES 355 (25) Fletcher, Wm., and Mackinnon, D. L.: A Contribution to the Study of Chronicity in Dysentery Carriers. National Health Insurance, Special Report Series, No. 29, Medical Research Committee, London, 1919, 5. (26) Dopter, M.: Les Maladies Infectieuses pendant la Guerre. Librairie Felix Alcan, Paris, 1921, 119. (27) Craig, C. F.: The Occurrence of Endamoebic Dysentery in the Troops Serving in the El Paso District from July, 1916, to December, 1916. The Military Surgeon, Wash- ington, 1917, xl, No. 3, 286 and 432. (28) Dobell, C: Incidence and Treatment of Entamoeba histolytica Infection at Walton Hospital. The British Medical Journal, London, 1916, ii, 612. (29) Matthews, J. R., and Smith, A M.: The Intestinal Protozoal Infections Among Con- valescent Dysenteries examined at the Liverpool School of Tropical Medicine. Annals of Tropical Medicine and Parasitology. London, 1919, xiii, No. 1, 83. (30) Jacob, L.: Klinischie Beobachtungen bei Bazillenruhr. Zeitschrift fuer Hygiene und Infectionskrankheiten, Leipzig, 1917, lxxxiii, 467. (31) Kligler, I. J., and Olitsky, P. K.: Method for the Isolation and Rapid Identification of Dysenteric Bacilli. The Journal of the American Medical Association, Chicago, 1918, lxxi, No. 26, 2126. (32) Levine, Max: Dysentery and Allied Bacilli. Journal of Infectious Diseases, Chicago, 1920, xxvii, 31. (33) Balfour, A.: Notes on the Treatment of Diarrhea and Dysentery Issued by the Advisory Committee for the Prevention of Epidemic Diseases in the Mediterranean Expedi- tionary Force. Journal of the Royal Army Medical Corps, London, 1915, xxv, No. 5, 473. (34) Bahr P. H., and Young, J.: War Experiences in Dysentery, 1915-1918. Journal of the Royal Army Medical Corps, London, 1919, xxxii, No. 4, 26S. (35) Memoranda on Medical Diseases in the Tropical and Subtropical War Areas, 1919. His Majesty's Stationery Office, London, 67. (36) Schittenhelm: Handbuch der Aerztlichen Erfahrungen im Weltkriege, 1914-1918. Innere Medizin. Ambrosius Barth, Leizig, 1921, Band iii, 136. (37) Bardsley, J. L.: Hospital Facts and Observations. Burgess and Hill, London, 1830, 148. (38) Vedder, E. B.: A Preliminary Account of some Experiments Undertaken to test the Efficacy of the Ipecac Treatment of Dysentery. Bulletin of Manila Medical Society, Manila, March, 1911. (39) Rogers, L.: The Rapid Cure of Amoebic Dysentery and Hepatitis by Hyperdermic Injections of Soluble Salts of Emetine. The British Medical Journal, London, June 22, 1912, i, 1424. (40) Dale, H. H.: A Preliminary Note on Chronic Poisoning by Emetine. The British Medical Journal, London 1915, ii, 895. (.41) Johnson, H. H., and Murphy, J. A.: The Toxic Effect of Emetine Hydrochloride. The Military Surgeon, Washington, 1917, xl, 58. (42) Du Mez, A. G.: Two Compounds of Emetin which may be of service in the treatment of Entamoebiasis. The Philippine Journal of Science, Manila, 1915, x, No. 1, 72. (43) Lambert A. C.: The Treatment of Amoebic Dysentery with Emetine and Bismuth Iodide. British Medical Journal, London, 1918, i, 116. (44) Jepps, M. W., and Meakins, J. C: Detection and Treatment with Emetine Bismuth Iodide of Amoebic Dysentery Carriers among Cases of Irritable Heart. The British Medical Journal, London 1917, ii, 645. (45) Great Britain, National Health Insurance Joint Committee. Medical Research Com- mittee. A Contribution to the Study of Chronicity in Dysentery Carriers. His Majesty's Stationery Office, London, 1919, No. 29. (46) Special Regulations No. 28, August 10, 1917, War Department. Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1585 Report of the sanitary inspector, 35th Division, October 11, 1918. On file, Record Room, S. G. O.,720-1, A. E. F. 356 COMMUNICABLE AND OTHER DISEASES (47) Boehnke and Elkeles: Ruhr schuetzimpfungen mit Dysbakta. Muenchener Medi- zinische Wochenschrift, Muenchen, 1918, lxv, Part 2, No. 29, 7S4. (4N) Gibson, H. G.: A New Method of Preparation of a Vaccine against Bacillary Dysentery which abolishes severe local Reaction. Also Experiments with this Vaccine on Animals and Man. Journal of the Royal Army Medical Corps, London, 1917, xxviii, No. 6, 615. (49) Dopter, Ch.: Vaccination antidysenterique experimentale par les voies digestives. Comptes Rendus Hebdomadaires des Seances et Memoires de la Societe de Biologie, Paris, 1908, i, 868. (50) Besredka, A.: Du mecanisme de I'infection dysenterique de la vaccination contre la dysenterie par la voie buccale et de la nature de l'immunite antidysenterique. Annales de I'Institut Pasteur, Paris, 1919, xxxiii, No. 5, 301. ----- Reproduction des infections paratyphique et typhique. Sensibilisation an moyen de la bile. Ibid. No. 8, 557. (51) Whitmore, E. R.; Fennel, E. A.; and Petersen, W. F.: An Experimental Investiga- tion of Lipovaccines. The Journal of the American Medical Association, Chicago, 1918, lxx, No. 7, 427. (52) Olitsky, P. K.: An Experimental Study of Vaccination against Bacilli Dysenteriae. The Journal of Experimental Medicine, New York, 1918. xxviii, 69. CHAPTER IX SMALLPOXa The most important fact disclosed by an investigation of the records of occurrence of smallpox in the United States Army during the World War is, as might be anticipated, the demonstration on a gigantic scale, of the impor- tance and value of vaccination as a preventive measure. Appreciation of the value of vaccine virus as a preventive agent presupposes a knowledge of the history of smallpox and the toll of human lives it took in pre vaccination days, and, for that matter, in recent times, in populations not adequately protected. For example, history tells us that all the inhabitants of Greenland died during the course of one epidemic and the country was not repopulated for 300 years°; that in 1707 one-third of Iceland's population of 50,000 succumbed to the dis- ease;1 that from 1701 to 1800 an average of 1 of every 12 persons dying in London each year died of smallpox;2 that in 1752 during an epidemic of smallpox in Boston, with a population of about 10,000 people not immune to smallpox, about 2,000 were rendered immune by inoculation with smallpox, the only method of immunization then known, approximately 2,000 fled the city, and of the remaining 6,000 nonimmunes more than 5,500 suffered attacks of smallpox;3 and that in two Indian (Moqui) villages in Arizona with a total population of 900 individuals, smallpox in epidemic form attacked 590 and killed 184.4 These are a few of innumerable instances that will serve to illustrate the havoc that smallpox has wrought. The history of military medicine of prevaccination days is replete with reports of epidemics of smallpox comparable in nature and severity with the examples cited for civil populations. When Jenner, in 1798, gave to the world the method for controlling and preventing this disease—vaccination—this measure gradually was adopted by all civilized countries. With the passage of time and with additions to scientific knowledge, it has been possible constantly to improve the methods of prepara- tion of the vaccine virus and to develop better and more satisfactory methods of administration, with the result that to-day the procurement of a potent, purified virus is, as compared with 30 years ago, a simple matter in all civilized communities. In so far as military medicine is concerned the prevalence of smallpox in the French forces as compared with the German forces during the Franco- Prussian War (1870-71) offers very striking evidence of the value of vaccina- tion. Perhaps the most conservative and most reliable statistics of the reactive prevalence of the disease in the opposing military forces are those recorded in the official German Medical History of the War of 1870-71. These figures are as follows: French Army.. German Army. Total ' Rate per i 1.000 cases /' n. strength Total deaths 14,173 j 540 4,835 61 1,963 278 ■ Unless otherwise stated, all figures for the World War period are derived from sick and wounded reports sent to the Surgeon General.—Ed. 357 :.f)8 COMMUNICABLE AND OTHER DISEASES General vaccination of the military forces was a matter of custom in the German Army at that time,5 whereas in the French Army such was not the case. During the Russo-Japanese War the Japanese forces were well vaccinated and of the million men engaged in that conflict only 362 contracted smallpox (4 per 10,000 of strength), of which number only 35 died.6 OCCURRENCE IN THE ARMY PRIOR TO THE WORLD WAR A brief reference to the trend of the smallpox rates in the United States Army during the past few decades and a comparison of its prevalence during war periods are considered desirable and will bring more clearly into relief the very excellent results obtained through the application of protective measures during the World War. The admission and death rates for white enlisted per- sonnel, United States Army, 1840 to 1919, inclusive, are given in Table 54 and shown graphically in Chart XLI. Table 54.—Smallpox—Admissions and deaths, white enlisted men, United States Army, 18'fi to 1919—Rates per 1,000 of strength Years 1840 .. 1841_______ 1842______ 1843______ 1844______ 1845______ 1846______ 1849"_____ 1850. . 1851. 1852... 1853... 1854... 1855 1856... 1857... 1858._. 1859... I860. 1861... Admis- sions 0.40 0 1.70 .30 . 12 . 12 .55 7.22 2.23 1. 19 1.20 1.31 2.59 3.74 .21 .63 1. 10 .90 0 3.36 Deaths .43 .22 Years Admis-sions Deaths Years 1862_____ 4. 68 1.36 1882______ 4.71 1.44 1883______ 1864... .. 8.08 3.21 1884______ 1865... .. J 4.62 1.75 1885______ 1866... . 3.37 .70 1886______ 1867_____ 1.07 .17 1887. 1868_____ .84 .05 1888______ 1869_____ -i 1.02 .10 1889______ 1870... .. J .93 .07 1890______ 1871... . .56 .07 1891______ 1872... . 1.65 .25 1892______ 1873_____ 1.58 .36 1893______ 1874... _! .16 .04 1894______ 1875... .51 .05 1895______ 1876. .22 0 1896______ 1877. . .83 .28 1897______ 1878 .28 0 1898______ 1879... . .78 .05 1899______ 1880... . .28 0 1900______ 1881 .24 .05 Admis- sions Deaths 0.48 . 14 0 0 .23 .05 .22 . 13 .05 .33 .05 0 0 0 .66 3.38 1.91 0.05 .05 0 0 0 0 .04 0 0 .10 0 0 0 0 0 0 .16 .85 .79 Years 1901_____ 1902_____ 1903_____ 1904....... 1905_____ 1906_____I 1907....... 1908_____ 1909______ 1910_____ 1911_____ 1912_____ 1913______ 1914_____ 1915_____ 1916_____ 1917_____ 1918.. . . 1919_____ Admis- Deaths sions 1.27 0.30 1.02 . 17 .50 .05 .32 .05 . 11 0 .17 .02 .10 0 .19 0 .01 0 . 18 .01 .07 0 .08 0 . 11 .03 .09 .01 .05 0 .06 0 .21 0 .20 0 .07 .01 • No record for the years 1847 and 1848. The interesting points shown in Chart XLI are two in number: First, the highest admission and death rates since 1840 occurred in 1864 during the Civil War, since which time the general trend of the smallpox admission and death rates in the Army have been downward, except for the period of the Spanish- American War and the Philippine insurrection. Second, prior to the World War the Army had always experienced a sharp increase in smallpox admission and death rates during war periods, whereas during the WTorld War the admission rate was but little higher than for the years immediately preceding, and the death rates for smallpox were essentially the same. A somewhat more detailed analysis of the admission and death rates dur- ing war periods discloses information of importance. The comparative admis- sion and death rates for the Civil War, Spanish-American War and Philippine insurrection, and for the World War are incorporated in Table 55. SMALLPOX 359 SMALLPOX. WHITE ENLISTED MEN U. S. ARMY ADMISSIONS AND DEATHS. 1840 - 1919 •CM)---------,,,,,., 7S0- ■ I.I 1 1 1 -!- ■ 1 1 -r- __Mip»J__L 1 _r 1 ■ ; ' i ■ ■ WO — . - L\ :.; .' i 1 5»0----J-f.4-+-_^ ----,_!_ __ ♦CO- •......— - - —_-_ 1 1 ■ ' Chart XLI Table 55.—Smallpox—Admissions and deaths, United States Army in the Civil War, Spanish- American War, and Philippine insurrection, and the World War—Absolute numbers and ratios per 10,000 ° CIVIL WAR White troops May 1, 1861, to June 30, 1866_____________ Colored troops July 1, 1863, to June 30, 1866........------ SPANISH-AMERICAN WAR AND PHILIPPINE INSURRECTION Total Army, white and colored, 1898-1901______________ Army in United States, 1898-1901_______________......- Army in Cuba and Porto Rico, 1898-1900______________ Army in Philippine Islands, 1898-1901---------------- WORLD WAR (Apr. 1, 1917, to Dec. 31, 1919) Entire Army______________________________________ Army in United States.........---------------------- Army in Europe___........:------------.....-------- Army in Philippines b-----------......-------------- Army in other countries c_______........------------- Transports_______.....---------......---.........--- Native troops, Philippine Islands---------..........— Native troops, Porto Rico.......--------------------- Total mean annual strengths 2,193,427 183,395 446,221 212,658 48,686 177, 542 4,128,479 2,235,389 1,665, 796 21,451 22,620 108,033 18, 576 11,831 Admissions Absolute numbers 12,236 6,716 825 126 20 674 853 780 24 11 10 4 23 1 Ratios per 10,000 55.8 366.2 18.5 5.9 4.1 38.0 2.1 3.5 . 1 5.1 4.4 .4 12.4 Deaths Ratios Absolute per numbers 10,000 strength 4,417 2,341 258 4 4 249 19.5 122.1 5.8 .2 .03 .005 .03 1.4 2.1 .2 Case mor- tality 36.10 34.85 31.27 3.17 20.00 36.94 1.64 .13 20.83 27.27 30.00 50.00 ° Source of information: (1) Medical and Surgical History of the War of the Rebellion, Part First, Medical Volume, pp. 640 and 710. (2) Annual reports of the Surgeon General, 1899, 1900, 1901, 1902. (3) Statistical tables, Office of the Surgeon General, 1917-1919. 1 Includes troops in China. ' Not including Hawaii, Panama, and native Hawaiians; including 8,388 officers. 360 COMMUNICABLE AND OTHER DISEASES The rates in Table 55 are based on the total of the mean annual strengths for the periods covered. The table shows a marked decrease in rates for each war period as compared with the immediately preceding war period. Based on a rate per 10,000 of strength for each war period, the rates were as follows: Civil War (white troops) 56, Spanish-American War, 19; World War, 2. During the Civil War vaccination as a protective measure was not well carried out for a number of reasons; and while no epidemics occurred, there was a considerable number of sporadic cases.7 The colored enlisted men incorporated in the Union Army during the Civil War were protected only in small measure by protective vaccination, with the result that the rate per 10,000 of strength for colored enlisted men during the period was 366 as compared with a rate of 56 for white enlisted men in the same army.7 An examination into the geographical distribution of the cases of smallpox that occurred during the Spanish-American War and Philippine insurrection is illuminating. Table 55 shows that whereas there was a total of 825 admissions for smallpox during the period referred to, 674 of these cases occurred in troops on duty in the Philippine Islands. The comparative rates per 10,000 of strength were as follows: Total Army, 19; troops on duty in United States, 6; troops on duty in the Philippine Islands, 38. The high rates in the Philippines caused the comparatively high rate for the Army as a whole during this period, and the high rates in the Philippine Islands were due to lack of protection by vaccination and inability to secure a potent vaccine virus for troops on duty in those islands during the first year or more of the occupation.8 The first expeditionary forces sent to the Philippine Islands during the Spanish-American War were dispatched hurriedly, and our present knowledge of the keeping qualities of vaccine warrants the statement that many of the individuals when called to active service were vaccinated with an inert virus. On arrival in the Philippines, these forces immediately came in contact with virulent smallpox in epidemic form. It is a matter of record that under the Spanish regime and for a few years subsequent to American occupation more than 40,000 Filipinos died each year of smallpox.9 American troops gradually came to occupy many small and large towns throughout the islands, with consequent intimate exposure to virulent smallpox. There was the further complication that there were no adequate provisions for the production of the virus in the Philippines, and supplies brought from the United States frequently were not adequately protected by cold storage en route, with the result that they proved to be inert when used. There was the still further complication that even when a potent vaccine became available in Manila itself, no ice was available in which to pack it for shipment to military garrisons in the Provinces. These were the factors that account for the high rate of incidence in the early days of our occupation of the Philippines. The principal factor militating against the protection of our forces, the nonavailability of potent vaccine SMALLPOX 361 virus, soon was overcome by the establishment of a laboratory, under Govern- ment supervision, for the production of the vaccine virus. When and as §uch a vaccine became available the admission rates immediately dropped, as is shown in Chart XLI. When locally produced vaccine virus became available steps were taken to protect the civil population, with the result that the dis- ease in epidemic form disappeared in the wake of the vaccinating squads. As an example of the striking influence of this protective measure may be cited the fact that the deaths from smallpox in the native population in the Provinces adjacent to Manila were reduced from 6,000 annually to zero and in Manila itself not 1 death from smallpox was recorded for the 7 years prior to 1914.9 Subsequent to 1914, as a result of relaxation in administrative control and inefficiency and incompetency on the part of subordinate Filipino health officers charged with the administration of smallpox vaccine, a large unprotected popu- lation—young children—came into being. The result was that in 1918 and 1919 the population of the Philippine Islands suffered the greatest smallpox catastrophe of modern times.9 Incomplete statistics show that more than 60,000 persons died of smallpox during this period and more than 90 per cent of the deaths occurred in unvaccinated children.10 Notwithstanding the fact that smallpox in widespread virulent epidemic form attacked the Filipino population during the period of the World War, the military forces (American and Filipino) on duty in the Philippines during the same period were singularly free. In a military force of approximately 40,000 men only 3 deaths from smallpox occurred. Reduced to approximately comparable figures, the statement is justified that the ratio of recorded deaths from smallpox during the epidemic in the native population as compared with that in the military population was as 40 is to 1. The senior writer of this chapter has been informed by those conversant with the situation that, as a matter of fact, it may conservatively be estimated that 100,000 Filipinos died during the course of the 1918-19 epidemic, in which case the comparative ratio would be about 80 to 1, rather than 40 to 1. The actual results accomplished in the prevention of smallpox in the Ameri- can military forces during the past 75 years probably can best be expressed in the statement that for every 1 case of smallpox occurring during the World War, 9 occurred during the Spanish-American War and Philippine insurrection and 28 occurred during the Civil War (white enlisted men only). The case fatality rate during the Civil War was 39 per cent; during the Spanish-American War and Philippine insurrection, 31 per cent; and during the World War it dropped to the extraordinarily low figure of 1.6 per cent. (See Table r)5.) This low mortality rate is probably accounted for in minor degree by the fact that the type of smallpox prevailing in the United States during the World War was of low virulence; however, the principal factor responsible for the low death rate was the high degree of protection afforded by vaccination. M2 COMMUNICABLE AND OTHER DISEASES Table 56.—Smallpox—Admissions and deaths, by countries of occurrence, officers and enlisted men, United States Army, April 1, 1917, to December 81, 1919— Absolute numbers and ratios per 1,000 Total mean annual strengths 4.128,479 4, 092, 457 206, 382 Admissions Deaths Absolute numbers Ratios per 1,000 strength Absolute numbers 14 14 1 Ratios per 1,000 strength 853 829 11 0.21 .20 .05 0 0 0 Total enlisted American troops: White ...........................________ 3, 599, 527 286, 548 612 204 2 .17 .71 9 2 2 0 .01 Total... ..............._______________ 3,886, 075 36, 022 818 24 .21 .67 13 0 Total Army in the United States including Alaska: 124, 266 9 .07 White enlisted........____________.......__________________ Colored enlisted____....................____________________ 1,965, 297 145,826 573 198 .29 1.36 1 ----- 0 Total enlisted_____......_______________________________ 2, 111, 123 771 .37 1 0 Total officers and men.....________________..........._____ 2, 235,389 780 .35 1 0 U. S. Army in Europe, excluding Russia: Officers..........._____.........____________.........._____ 73,728 1 .01 1 .01 White enlisted. ____ ... _______ ... ________........______ 1, 469,656 122,412 16 5 2 .01 .04 2 0 Colored enlisted. _________________________.......____...... Color not stated_____________________________........______ 2 Total enlisted......____....._________......______........ 1,592,068 23 .01 4 o Total officers and men.....__ _______________........_____ 1,665,796 8,388 24 1 .01 .12 5 o Officers, other countries___________ ________________________ U. S. Army in Philippine Islands: White enlisted..___......___________........ ... 16,995 4,456 11 .65 3 18 Colored enlisted___________......_________.....____________ Total enlisted____........._________________________ . 21,451 11 .51 3 U. S. Army in Hawaii: White enlisted___......__________________________________ 16,161 3,319 | | Colored enlisted_______.....____..........._______________ . i 19,480 19, 688 1 U. S. Army in Panama: White enlisted______________________ | U. S. Army in other countries not stated: White enlisted_________._____________________________ . 9 3 Colored enlisted... _______________......._______ ____ . Color not stated___ ___.............._____________...... Total____________________________________________ 14, 232 9 .03 3 .21 Transports: White enlisted_________________________________________ 97, 498 10, 535 3 1 .03 .09 2 .19 Color not stated_____......_____________________________ Total______________________________________________ 1 OS, 033 18, 576 5,615 11,831 ____ 4 .04 2 .02 Native troops enlisted: Philippine Scouts_____________________________________ 23 1.24 Porto Ricans____________________________________ _ __ 1 .08 .....__ OCCURRENCE DURING THE WORLD WAR As stated above, smallpox played a very minor part as a cause of sickness and death in the United States Army during the World War. The total mean annual strength of the Army for the period April 1, 1917, to December 31 1919 SMALLPOX 363 was 4,128,479, and during this period only 853 cases of smallpox were recorded as primary admissions. The admission rate per 1,000 of strength for the period was therefore 0.2, or 2 men in every 10,000. Of those who had the disease only 1.6 per cent died (14 deaths), and the death rate expressed in terms of strength was only 3 deaths in every 1,000,000 men. It will be noted that the expression "primary admissions" is used in referring to the total number of cases. In all the basic tables presented in this chapter the absolute numbers used will be primary admissions unless otherwise specified. Only one disease was used in statistical tabulations, and this was the primary admission. It occasionally happened that an individual admitted for one disease (primary admission) contracted some other disease—for example, smallpox—before release from hospital. This concurrent disease, or complication, was tabulated separately, and the tables of concurrent diseases show that in addition to the primary admissions (853) a total of 126 cases of smallpox were concurrent with other diseases, making a grand total of 979 cases (.24 per 1,000 of strength). GEOGRAPHICAL DISTRIBUTION The geographical distribution of smallpox during the World War is shown in Table 56. Briefly, the facts of interest disclosed by this table are as follows, the admission ratios per 1,000 being converted into ratios per 100,000 of strength that they may be expressed in whole numbers: Admissions United States (including Alaska), American troops, commissioned and enlisted Europe (excluding Russia), commissioned and enlisted.__..........-------- Philippine Islands, American troops, enlisted___________________________ Philippine Islands, Filipino troops____________________________________ Hawaii, American troops, enlisted------------------------------------ Hawaii, Hawaiian troops___________________________________________ Porto Rican troops.......-------------------------.....------------- Panama, American, enlisted_________________________________________ Absolute numbers Ratios per 100,000 780 24 11 23 0 0 1 0 35 1 51 124 0 0 8 0 Deaths Absolute numbers Ratios per 100,000 In order of importance the occurence geographically was the Philippine Islands, United States, Porto Rico, and Europe. As will be explained below, a large proportion of the 780 cases encountered in troops in the United States occurred in nonprotected individuals reporting for duty at mobilization camps in the incubationary stages of the disease. IN THE UNITED STATES Mobilization of the military man power of the United States for the World War was accomplished in large mobilization camps and the occurrence of small- pox in 39 of the larger of these camps is tabulated in Table 57. The rates per 1,000 of strength are based on the total mean annual strength for the period. 364 COMMUNICABLE AND OTHER DISEASES Table 57.—Smallpox. Admissions by camps of occurrence, white and colored enlistee men, United States Army, April _, 1917, to December 31, 1919. Absolute numbers and ratios per 1,000 Camp Beauregard, La... Bowie, Tex....... Cody, N. Mex___ Custer, Mich____ Devens, Mass____ Dix,N. J___..... Dodge, Iowa____ Doniphan, Okla... Fremont, Calif___ Funston, Kans___ Gordon, Ga....... Grant, 111_______ Greene, N. C____ Greenleaf, Ga____ Hancock, Ga____ Jackson, S. C____ Kearny, Calif____ Lee, Va........... Lewis, Wash____ Logan, Tex....... McArthur, Tex.. McClellan, Ala.. Meade, Md...... Mills, N. Y_____ Pike, Ark......... Sevier, S. C_____ Shelby, Miss____ Sheridan, Ala___ Sherman, Ohio... Taylor, Ky...... Travis, Tex_____ Upton, N. Y____ Wadsworth, S. C. Wheeler, Ga____ Others_________ Total mean annual strengths White admissions Absolute numbers Ratios per 1,000 strength 0. 15 .52 .13 .33 .02 .07 1. 17 1.20 .13 1.38 .18 .28 .23 5 .22 6 .15 9 .34 1 .03 1 .04 2 .05 19 .45 19 .51 4 .10 3 .10 1 .04 Total (all camps in U. S.)_____________ 1,270, 324 Colored admissions Total admissions Absolute numbers Ra«« ! Absolute I JL'fSn . 21 4.82 3.24 1.17 2.02 .28 1.21 1.87 1.05 1.41 .25 3.98 5.05 .62 3.63 1.04 .91 1.06 .55 2.95 1.57 0. 19 .50 . 13 .48 .02 .08 1.72 1.20 .13 1. 58 .33 .53 .24 .12 .04 .36 .25 .22 .44 .21 .04 .41 1.01 .36 .23 .04 .19 .49 .59 .18 .09 .08 2.95 .39 Examination of Table 57 shows that in only four of the camps—Camps Dodge, Iowa; Doniphan, Okla; Funston, Kans.; and Pike, Ark.—did the rates of occurrence exceed one case per 1,000 of strength. In only 10 of the remaining 35 camps did the admission rate exceed 0.25 per 1,000 of strength. It is evi- dent, therefore, that smallpox occurred only sporadically during the mobiliza- tion of our forces. Furthermore, the historical records of the various camps and hospitals on file in the Surgeon General's Office indicate that a large propor- tion of the cases arising in the camps occurred in individuals already in the incu- bationary or acute stage of the disease on arrival at camp and to a considerable extent in individuals soon after the arrival at camp and before protection could have been afforded by vaccination. The following evidence in support of this statement has been epitomized from these historical records: Camp Bowie, Tex. Of the 13 cases occurring in this camp, no evidence could be adduced that contact played any part. Three recruits reported at camp in the prod- romal stages of the disease and one case was contracted through exposure while on furlough.11 SMALLPOX 365 Camp Devens, Mass. Only one case occurred at this camp and he contracted the disease prior to induction into active service.12 The low rate at this camp as well as at all other camps located in the northeastern section of the United States is a re- flection of the thoroughness with which protective vaccination is carried out in the civil communities of the States concerned. Camp Dodge, Iowa A total of 67 cases occurred at this camp.13 In six instances the disease occurred in one organization and was attributed to contact. Twenty of the cases were admitted to hospital within a period of 14 days after arrival in camp, most of them having acquired the disease prior to arrival, and in 30 other instances the disease developed within less than a month after arrival. Small- pox is known to have been unduly prevalent in the States—Iowa, Minnesota, and Illinois—from which this camp drew its quota for training, and the preva- lence of smallpox at Camp Dodge was merely a reflection of the prevailing conditions in civil communities. Camp Funston, Kans. A total of 89 cases occurred at this camp, and the troops in training in this camp were drawn from an area in which smallpox was known to be uncom- monly prevalent in the civilian population.14 Camp Pike, Ark. Of the 50 cases arising at this camp, 29 were admitted to hospital within 14 days of their arrival at camp and 1 individual reported at camp in the eruptive stage of the disease.15 The training quota for this camp was drawn from the States of Alabama, Arkansas, Louisiana, and Mississippi, and the occurrence of smallpox at Camp Pike was a reflection of the undue prevalence of small- pox in some of those States. Camp Taylor, Ky. Of the 23 cases at this camp, it is stated that 13 were in the incubationary stage of the disease at the time of arrival at camp.16 From what has been said in preceding pages, the inference may be drawn that the greater prevalence of smallpox in some mobilization camps, as com- pared with others, was attributable to the more extensive prevalence of the disease in certain States or groups of States than in others. In support of this statement a statistical analysis is offered in Table 58. 366 COMMUNICABLE AND OTHER DISEASES Tablk 58.—Smallpox. Numbers of admissions and ratios per 1,000 enlisted men (white and colored), United States Army, by States and groups of States, and comparable ratios per 1,000 among the civilian population of these States and groups, April 1, 1917, to December 31, 1919 • States Military personnel „. , Civil- -------!----ian pop- ulation Mor- (mor- bidity bidity rate rate per per 1.000 1,000) Military personnel Total ! Num- niean ber of annual admis- strength sions New England group: Maine__________ . 6,465 New Hampshire. ___ 1,911 Vermont____________i 5,834 Massachusetts_______ 66, 538 Rhode Island________; 5,405 Connecticut___ _____| 1,912 Total_____________ 88,065 Middle Atlantic group: New York___________155,384 New Jersey__________114,683 Pennsylvania... ____ 31,153 Total....._________301,220 East North Central group: Ohio_______________ 58,713 Indiana_____________' 20,131 Illinois______________ 65,093 Michigan___________[ 46,112 Wisconsin_______ ...j 8,512 Total. West North Central group: Minnesota__________ Iowa______________ Missouri___________ North Dakota___ South Dakota____ .. Nebraska___ . Kansas_____ ___ Total_____ _____ South Atlantic group: Delaware___________ Maryland__________ District of Columbia.. Virginia_____•________ West Virginia________ 198, 561 11,224 42, 495 14, 402 276 410 6,378 63, 325 138, 510 3,388 73,312 20,095 136, 536 1,105 .36 1.65 1 2.99 !_ States Total Num- mean ber of annual \ admis- strength sions South Atlantic group—Con. North Carolina_______ 35,927 South Carolina_______106, 902 Georgia_____________161. 205 Florida______________ 31,170 Total______________569,640 East South Central group: Kentucky..........___' 60,254 Tennessee___________ 2,921 Alabama____________ 62,278 Mississippi__________ 34,028 Mor- bidity rate per 1,000 0.19 .19 .22 .03 Civil- ian popu- lation (mor- bidity rate per 1,000) 18 Total.................159,' West South Central group: Arkansas______....... Louisiana___________ Oklahoma.............. Texas_______________ Total. Mountain group: Montana____ Idaho__..... Wyoming___ Colorado____ New Mexico. Arizona_____ Utah_______ Nevada_____ Total. Pacific group: Washington. Oregon_____ California... Total. 53,554 29,916 32, 949 269, 641 386,060 1,925 432 4,478 7,404 36, 527 21, 978 5,685 165 186 .72 1.25 .97 .80 .37 .47 1.03 .33 3.12 2.31 2.03 2.70 .19 .32 1.46 1.26 .! 3.17 78, 594 41 .52 1.87 82, 243 10, 452 94,357 33 3 12 .40 .29 .13 1.38 1.27 .34 187. 052 48 .26 " Source of information: (lj Sick and wounded reports made to the Surgeon General, U. S. Army. (2) Public Health Reports—Notifiable Diseases, Prevalence in States, 1917, 1918, 1919. Government Printing Office, Washington, D. C. The data in Table 58 are assembled by groups of States in conformity with the grouping adopted by the United States Bureau of the Census. It will be noted in the statistics covering the civilian population that certain States have been omitted. The principal reason for this is that such States had not been admitted to the registration area and authoritative figures were not available. It should also be explained that the rate in the civilian population for each group of States is an average of those rates available for the States comprising the group rather than for all States comprising the group; for example, the rates for the New England group are based on the rates for four States rather than six. Analysis of this table lends adequate support to the statement that the rate of occurrence of smallpox in military personnel in mobilization camps during the World War was dependent on its rate of occurrence in the civilian population in near-by States and was a reflection thereof. This can best be appreciated by inspection of Chart XLII. SMALLPOX 367 l.OI - 1.87 RATES PER IOOO Chart XLH.—Smallpox in the United States Army and civil population, April 1, 1917, to December 31, 191.). Occurrence by groups of States. Ratios per 1,000 of population 3(>er 1,000 strength Abso-lute num-bers Nonef-fective ratios per 1,000 strength U. S. Army in Europe, excluding Russia: Officers___ ____________.....___ 46 0.62 | 3 0.04 1,669 0.06 1,469, 656 122,412 1,959 9 356 1.33 1 61 .04 3 0 92,352 484 12, 372 .17 .07 .01 10 1, 592, 068 2,324 1.46 71 .04 3 0 105, 208 .18 Total officers and enlisted men. 1,665, 796 8,388 2,370 3 1.42 .36 74 .04 3 0 106, 877 126 .18 .04 U. S. Army in Philippine Islands: 16,995 9 - 53 2 .12 259 .04 4,456 21,451 16,161 3,319 9 | .42 2 1 .09 259 .03 U. S. Army in Hawaii: 1 12 - 74 .06 444 .08 19,480 12 .62 1 .06 444 .06 U. S. Army in Panama (white en- 19, 688 2 .10 46 .01 _ U. S. Army in other countries and not stated: White enlisted_________________ C) 27 1 1,237 Colored enlisted______.....____ Color not stated_______________ 5 94 Total enlisted......_______... 14,232 32 2.25 1 .07 1,331 .26 Transports: White enlisted........___...... 97,498 10, 535 206 1 2.11 .09 8 .08 6,362 71 .18 Colored enlisted_______.......... .02 Total enlisted___..........___ 108,033 207 1.92 8 .07 6,433 16 i Native troops enlisted: Philippine Scouts______________ 18, 576 5,615 11,831 1 1 .05 . 1JS 12 34 0 Hawaiians............______ 02 Porto Ricans__________________ ° Separate strength of white and colored not available. This disease was much more common among white enlisted men than among any other troops in the American Army, white enlisted men numbering 10,993 primary admissions and colored, 97. Among the former, there were 338 deaths and among the latter, 2 deaths. The admission and death ratios are equally striking in comparison. White enlisted men had an admission ratio of 3.05 and a death ratio of 0.09 per 1,000 strength, as compared with the admission ratio of 0.34 and the death ratio of 0.01 for colored enlisted men. This same difference between the two races is shown by the number of days lost: There were 472,967 days lost from duty among white enlisted men and 4,369 among colored. It has long been known that the occurrence of scarlet fever among the colored is far less than among white people; experience during the World War was in accordance with this. Although scarlet fever SCARLET FEVER 393 occurs in tropical countries among natives, its occurrence there is of less impor- tance than among white people in temperate zones. The occurrence of this disease among native troops of the American Army during the World War was of no importance from a disability standpoint. Among the 36,022 native enlisted troops, there were 2 cases and no deaths. When viewed from the standpoint of seasonal prevalence, the occurrence of scarlet fever was greatest during January, February, and March, 1918. Though this was true for some of the other epidemic diseases, namely, epidemic menin- gitis and mumps, the diseases just mentioned were more common among colored troops, while scarlet fever was more common among white troops. The largest number of primary admissions was reported for the month of March, 1918. The largest number of deaths reported from scarlet fever for any month during the war was also in March, 1918. There were 40 deaths during that month, all of which were among white troops. The seasonal occurrence com- mencing in October, 1918, and ending in April, 1919, although marked, was to a much less degree than during the preceding year, not only in admissions, but also for deaths. The warmer months of the World War period were marked by a very small occurrence of scarlet fever in the Army. Table 61.—Scarlet fever. Admissions and deaths, white and colored enlisted men, United States Army, United Slates and Europe, by months, April 1, 1917, to December 81, 1919 White enlisted men United States Month and year Mean strengths 1917 April_______________' 183,758 May______......._ . I 245,454 June_____......._____! 309,205 July______......______ 458,817 August______. ______' 562,714 September____________ 776, 466 October_______________I 1, 032, 244 November __________' 1,061,422 December____ ______i 1,129,065 A bso lute num Ratios um" sPterren'g0th num >ers slrenBln' bers Abso- lute 115 150 170 118 66 97 130 319 631 7.51 7.33 6.60 3.0!) 1. 41 1. 50 1. 51 3.61 6.71 Total, 1917 479,929 1,796 1918 January_______________ 1,096,434 February_____________ 1,095,039 March . ___________ 1,129,223 April_________......... 1, 168,558 May________________ 1,197,757 June.. ____________ 1,303,746 July.................. 1,328,513 August______......... 1,284,247 September___________ 1,321,440 October__________ ...' 1,343,933 November___________ 1, 255, 195 December_____________' 941.219 Total, 1918______ 1,205,442 1,130 1,099 1,092 947 449 134 92 50 46 107 446 277 5, 869 3.74 12.37 12.04 11.60 9.72 4. 50 1. 23 .8! .47 .42 .96 4.26 3.53 Ratios per 1,000 strength 0.33 .39 .08 .08 .02 Europe United States Colored enlisted men r Mean strengths .01 626 12, 794 2.S. S21 50. 882 70. 266 92. 139 123, 429 160, 178 Admissions Abso- lute num- bers Ratios per 1,000 strength Deaths Admissions Abso- lute num- bers 44, 928 38 .42 29 .32 37 .39 32 .33 4 .04 ~3~ ~\03~ 193, 223, 283, 388, 587, 796, 1,063, 1, 266, 1, 527, 1, 635, 1, 682, 1, 591, 936, 589 1, 489 0.34 1.95 2.72 167 3.72 168 152 236 174 185 136 74 47 51 68 74 124 10. 43 8.17 10.00 5.38 3.78 2.05 .84 .45 .40 .50 .53 .93 1.59 Mean Ratios strengths per 1,000 j strength Abso- lute num- bers 0.49 .45 4,870 5,826 5, 171 6, 675 8,519 9, 409 21,795 39, 225 36,851 Ratios per 1,000 strength 2.46 Deaths Europe Admissions ,, I Mean i,,to" Ratios strengths num- IH>r 1.000 Abso- lute bers Ratios per 1,000 strength 11,529 50, 705 49,955 54, 814 59, 015 87, 650 89,305 124,976 168,422 164, 846 182, 705 150, 587 104, 140 1. 10 .92 1.63 0.33 .09 935 2, 392 5, 346 723 .95 1.92 3.06 1.02 .82 .13 .10 . 14 .07 .13 2.31 .12 3 4.15 1.24 1.04 .42 ---.. . 25 .13 36 . 04 107, 260 74 01 63,090 Month not stated ... Total for period. 672. 471, 406, 339, 291, 216, 215, 156, 149, 139, 132, 135, 937 815 839 836 810 903 104 791 360 877 403 441 279,926 220 104 58 9 8 4 2 2 1,113 7.15 7.07 6.49 3.67 2.39 .44 .45 .31 .17 .17 .73 1. 3.97 .25 . 13 .06 .07 .04 488, 683 310, 083 115,693 853,425 569, 842 271, 633 111,634 48, 006 30,315 21, 055 18, 920 18, 379 488, 139 1,965, 297 8, 77S 1, 469, 656 0 No deaths occurn ed among colored enlisted men in Europe. .57 1 6 t . 05 68. 337 1 ......... 140,396 1 .09 . 76 2 .02 .02 .04 66,104 44, 634 29, 824 20, 780 ______ 131,219 1 47 2 1 27 ......'........1 123,152 _____1 119,801 58 3 .36 ____!__.......1 108,650 .75 1.07 1.50 .79 3.42 18, 562 20,058 18, 013 1 .65 _______!________! 64,166 _______]________j 12,508 ....________! 1,741 11,322 9,084 8,792 8,935 ________j 1,287 ____ 185 ________ 83 1.31 i .61 13 .03 27, 037 2 < .07 ____!________ 58,599 1 .02 --------. 1 61 1.33 .04 145, 826 87 ; .60 2 1 .01 122,412 9 .07 OO 396 COMMUNICABLE AND OTHER DISEASES OCCURRENCE IN THE ARMY IN THE UNITED STATES Table 60 shows that there were 9,038 primary admissions for scarlet fever reported in the Army in the United States during the war. The occurrence of the disease among white enlisted men contributed the vast majority of admis- sions. There were 8,778 primary admissions among these troops, with 265 deaths. The admission ratio was 4.47 and the death ratio, 0.13 per 1,000 per annum. As stated above in discussing the occurrence of scarlet fever in the total Army, the occurrence was of minor importance among colored troops. There were 97 primary admissions among these troops with 2 deaths, giving an admis- sion and death ratio of 0.34 and 0.01 per 1,000 per annum, respectively. Scarlet fever was responsible for the loss of 382,628 days from duty among officers and enlisted men in the United States admitted as primary admissions. The noneffective ratio per 1,000 strength was 0.47. The relative importance of scarlet fever to the Army is better exemplified when compared with the non- effective ratios for several other diseases; for example, the noneffective ratio per 1,000 strength for influenza was 7.09; mumps, 2.58; epidemic meningitis, 0.18; typhoid fever, 0.07. White enlisted men in the United States lost 372,267 days from duty; while colored enlisted men lost 3,814 days. The average duration of hospitalization for white enlisted men was 42.4, for colored enlisted men 43.8, and for the total Army in the United States 42.3 days. The distribution of scarlet fever in the United States Army during the World War, is graphically represented by States in Chart XLIII. Ratio per 1,000 strength of total reported cases occurring in each State (including camps) is the basis upon which this chart is prepared. No cases were reported from the States of Delaware and Nevada; the number of troops stationed in these States was very small, the mean strength being 3,338 and 165, respectively. The highest ratios, in general, are found in the northern and north central portions of the United States. States in the southeastern part of the United States, generally speaking, had the lowest occurrences. The highest admission ratios were for the States of Montana, Wyoming, Colorado, Utah, and Kansas. These ratios were 53.51, 30.15, 14.99, and 10.55 per 1,000 per annum, respec- tively. The lowest ratio was for Vermont and Louisiana. This ratio was 0.17 per 1,000 per annum for each of these States. Of the total 8,865 primary admis- sions for scarlet fever among enlisted men in the United States during the World War, 4,816 occurred in the camps enumerated in Table 62, and 4,049 occurred among enlisted men stationed outside of these camps, as extra-camp cases. Table 62.—Scarlet fever. Admissions and deaths, by camps of occurrence, white and colored enlisted men, United Slates Army, April 1, 1917, to December 31, 1919 Average strength for period, total Primary a White enlisted men Colored enlisted men White and colored enlisted men Camps dmissions Deaths Primary admissions Deaths Primary admissions Deaths Case fa- Absolute numbers Ratios per 1,000 strength Absolute numbers Ratios per 1,000 strength Absolute numbers Ratios per 1,000 strength Absolute numbers Ratios per 1,000 strength Absolute numbers Ratios per 1,000 strength Absolute numbers Ratios per 1,000 strength tality rates per cent r 20,625 26,193 22,636 37,631 47,921 49, 786 39,032 26, 747 6,780 8,980 15,414 56,222 44,871 49,256 29,710 11,959 37,994 12,836 42,011 22,267 25,472 57, 635 47,792 27, 734 25,271 28,664 50,033 24,197 49,587 27,786 30,432 26, 507 42, 750 3,367 46, 962 44,264 44,871 31, 809 25, 726 339 3 10 61 181 79 139 386 75 5 6 14 603 12 227 65 27 372 11 14 31 182 64 520 37 188 32 186 74 502 40 10 30 361 0.15 .40 2.69 4.99 1.73 3.09 11.62 2.80 .79 .67 .91 12.05 .32 5.36 2.48 2.26 10.22 1.13 .38 1.56 7.15 1.25 11.00 1.39 7.73 1.21 4.43 3.23 12.28 1.53 .35 1.17 9.77 3 10 61 181 79 139 390 75 5 6 14 609 15 229 65 27 402 11 14 31 182 64 520 37 188 32 205 74 508 40 11 30 366 0.14 .38 2.69 4.81 1.65 2.79 9.99 2.80 .74 .67 .91 10.83 .33 4.65 2.19 2.26 10.58 .86 .33 1.39 7.15 1.11 10.88 1.33 7.44 1.12 4.10 3.06 10.24 1.44 .36 1.13 8.56 ( amp Bowie, Tex___.. .. 1 2 2 1 1 8 1 0.04 .09 .06 .02 .02 .24 .04 1 2 2 1 1 8 1 0.04 .09 .05 .02 .02 .20 .04 10.00 t amp Codv, N. Mex___ 3.27 r amp Custer, Mich _ 1.10 r amp Devens, Mass ... 1.26 t amp Dix, N.J_____ .71 t amp Dodge, Iowa____....... 4 0.69 2.05 ( amp Doniphan, Okla 1.33 f r < c r < c f ( c c c c c ( ( ( c ( ( c c c c c t c c ( c r c amp Fremont, Calif 1 'amp Funston, Kans 12 1 10 3 4 27 1 1 4 .24 .03 .24 .11 .33 .74 .10 .03 .20 6 3 2 .97 .44 .29 12 1 .21 2 ' .04 1.97 'amp Gordon, Ga. 1 . 15 13.33 10 3 4 27 1 1 .20 .10 .33 .71 .08 .02 4.36 4.61 14. SI 30 18.81 6.71 9.09 7.14 4 .18 12.90 10 2 1 .21 .08 .04 10 .21 2 1 .07 1 j .04 1.92 5.40 .53 5 .12 19 2.36 5 .10 2.43 Jarap Mills, N. Y 'amp Pike, Ark_____________________ 28 .69 1 .04 6 .69 1 .11 29 1 .58 .04 5.70 2.50 1 .61 ___ 10 .27 .86 10 .23 2.73 128 24 85 27 5 3.01 .64 2.11 .90 .21 5 .12 128 24 87 27 5 2.73 .55 1.94 .85 .19 5 .11 3.90 2 .05 ■ 2 .43 2 .04 2.29 ::::::::.. Total............._________ 1,270,069 4,816 4.15 143 .12 78 .71 2 .02 4,894 3.85 145 .11 2.96 OO CO ^1 398 COMMUNICABLE AND OTHER DISEASES The remarks made in the beginning of this chapter on the occurrence of scarlet fever in the Army by race and season apply largely to such occurrences in the United States. It was to be expected that the occurrence of this disease, as in the case of other exanthematous diseases, would be greatest during the first months of service, when unseasoned troops were massed in cantonments. This was especially true, when considering the fact that many recruits came from rural districts where the percentage of persons immune to scarlet fever is generally accepted as being low. Although a high percentage of persons of the soldier age are immune to scarlet fever, yet among a large number of soldiers SCARLET FEVER: BY STATES OF OCCURRENCE, WHITE AND COLORED ENLISTED MEN, UNITED States Army, for the world war period, april 1,1917 - december 31,, 1919. RATIO PER IOOO STRENGTH □ LESS THAN i.PER lOOO STRENGTH. l.O TO 2.SO 2.SO TO 5 v5 TO lO PER lOOO STRENGTH MORE THAN lO PLR - - Chart XLIII nonimmunes will be found. The greater occurrence of scarlet fever in the Army in the United States than in Europe is shown in Table 60. The pri- mary admission rate for the total Army in the United States was 4.04 and for the Army in Europe, excluding Russia, was 1.42 per 1,000 strength. This difference is explained on the basis of length of service, which offered oppor- tunity for the majority of cases of scarlet fever to occur in the United States before the soldier was sent abroad. SCARLET FEVER 399 On the basis of length of service and season, the largest number of cases and the highest admission ratios were during the late fall, winter, and early spring of 1917 and 1918. (See Table 61.) The highest admission ratio for any period during the war, and for any country in which the American troops served, was 12.37 in January, 1918, for white troops serving in the United States. There were two waves in the Army stationed in the United States during the World War. This is shown best by the occurrence among white enlisted men. The first wave commenced in the fall of 1917, reaching the peak in January, 1918, from which time there was a progressive decrease until the following September. The largest number of primary admissions per month was 1,130 for January, 1918, and the smallest number during that year was in September, which was 46. The admission ratio among white troops was 12.37 in January, 1918, and progressively decreased to 0.42 per 1,000 strength in September. The second wave of occurrence among white troops commenced in October, 1918, and, as in the case of the previous year, ended in January of the following year, 1919, with 401 primary admissions during that month. The admission ratio was 7.15 per 1,000 strength during January. The downward trend com- menced in February, 1919, with 278 primary admissions, and reached the low point with two primary admissions in September. The admission ratio de- creased from 7.15 in January to 0.17 in September. OCCURRENCE IN THE AMERICAN EXPEDITIONARY FORCES The occurrence of scarlet fever in the American Army in Europe was not a matter of grave concern. The total number of primary admissions in Europe (excluding Russia) was 2,370, or about one-fifth of the total number of cases reported for the World War. The admission ratio was 1.42 per 1,000 strength. The total number of deaths from this disease was 74, giving a death rate of 0.04 per 1,000 per annum. There were 106,877 days lost from duty by the total Army in Europe, giving a noneffective ratio of 0.18 per 1,000 strength. As in the United States the white enlisted men contributed the majority of the cases. There were 1,959 primary admissions, with 61 deaths, among these troops, with admission and death ratios of 1.33 and 0.04, respectively, per 1,000 strength. The noneffective ratio was 0.17 per 1,000 per annum, based on 92,352 days lost from duty. Scarlet fever was rare among colored troops in Europe; there were nine primary admissions and no deaths. The average time lost among them from duty was 53.7 days and the case mortality was nil. The seasonal occurrence among white troops in Europe followed the same general seasonal trend as in the United States. Two waves of occurrence marked the winters of 1917-18 and 1918-19. The crest of the first wave was reached in January, 1918, with the report of 168 cases and an admission ratio of 10.43 per 1,000 strength. The crest of the second wave was reached in December, 1918, with 124 primary admissions, giving an admission ratio of 0.93 per 1,000 per annum. The crest of this second wave occurred one month earlier than the crest of the second wave in the United States. Not only was the occurrence less marked among white troops in Europe than in the United States, but there were fewer deaths. The total number of 400 COMMUNICABLE AND OTHER DISEASES primary admissions for white troops in Europe was 1,959 and for the United States 8,778. There were 61 deaths among white troops reported in Europe as compared with 265 in the United States. The duration of hospitalization was longer for colored troops in Europe than for white troops. The average number of days lost from duty by the former in Europe was 53.7 and in the United States 43.8. It is of interest to note also that duration of hospitalization was longer for white men in Europe than in the United States. The duration of hospitalization was, respectively, 47.1 and 42.4 days. FACTORS INFLUENCING OCCURRENCE Scarlet fever is an acute infectious disease and unquestionably has a spe- cific cause. The virus, whatever it may be, is one of low infectivity as com- pared, for example, with that of measles. It is believed that the virus lies in the discharges from the nose and throat; also in the discharges from patients with complications, such as suppurative otitis media occurring during the course of the scarlet fever. There seems to be ample evidence to justify the statement that desquamations during the course of scarlet fever do not contain the virus and, therefore, are not a source of contagion. However, in view of the absence of any positive knowledge of the duration of the period in which patients remain a source of infection, desquamation still remains worthy of being a guide to quarantine. It is not known at just what time the discharges are most heavily laden with the virus, or how long the patient remains an active carrier. The importance of certain factors influencing the occurrence of scarlet fever has been demonstrated. This disease is a typical disease of childhood, with the majority of cases occurring before the tenth year1 and 90 per cent before the sixteenth year. From this time the occurrence by age diminishes. Race unquestionably has its influence, and our medical records of the war show conclusively that scarlet fever occurred far more frequently among white troops than among colored troops. The occurrence of this disease among native Filipino, Hawaiian, and Port Rican soldiers was almost negligible. It is true that the diagnosis of any disease which is largely dependent upon the inter- pretation of skin manifestations is much more difficult in the negro than in the white man. Although this might account for some missed cases, it would not account for the great difference in occurrence in whites and negroes. As in the case with the other exanthematous diseases, scarlet fever had distinct seasonal distributions, with the largest number of cases during the cold, damp months of the year, and the smallest number of cases during the hottest and driest months. Although scarlet fever was distributed over the United States and reported from nearly all States and camps, in certain camps and certain States the inci- dence was much greater than in others. Camp Pike, Ark., was a notable center for this disease. The number of cases at Camp Hancock, Ga., was greater than the average in the camps of the United States. The greater occurrence in these camps has been attributed to the poor physical condition of the troops drawn from Mississippi, Louisiana, Arkansas, Alabama, and Georgia. Vaughan and SCARLET FEVER 401 Palmer2 held that troops from the Southern States possessed a susceptibility that was general as well as specific; they were subject not only to the ravages of pneumonia, but to other diseases as well, and their death rate from all causes was higher and their sickness incidence was greater than that of troops from other parts of the country. Statistics contained in the reports of the United States Census Bureau show the occurrence of scarlet fever to be greater in the northern than in the southern portions of the United States. The States of Montana and Colorado showed the highest incidence of scarlet fever during the World War for extra- camp troops; that is, soldiers who were not a part of camp garrisons. The States showing the greatest occurrence among all troops, camp and extra-camp were Montana and Wyoming. Taken alone, the following three camps stood at the head of the list during the war: Camp Lewis, Wash., 10.88; Camp Funston, Kans., 10.83; and Camp Hancock, Ga., 10.58 per 1,000 strength. These ratios include both white and colored troops, and are quoted here to show that, although scarlet fever is more common in the northern part of the United States, as a rule, its occurrence was greatest in some of the camps located in the South during the war, although the troops in such camps were drawn largely from Southern States. Scarlet fever has been called a "neighborly disease, as it spreads from family to family in direct proportion to the intercourse of people and the interchange of things between families."1 These conditions exist among troops, and in all probability contributed to the spread of the disease in the Army. PATHOLOGY There are no known specific lesions of scarlet fever. Even the skin erup- tions disappear after death except in the hemorrhagic form. The pathological anatomy is that following fever and secondary infection by pus organisms. The complications are usually incident to streptococcus invasion. Ludy, Hunt, and Cogsweli3 reported a series of necropsies on scarlet fever cases at Camp Hancock, Ga., and called special attention to the general adenopathy, with involvement of the submaxillary and inguinal lymph glands, as being present "in 100 per cent of the cases." This enlargement was such that one could grasp the glands between the thumb and forefinger and in the fresh subject they gave a mushy feeling. The microscopic pathology was that of hyperplasia, inflammatory in type. Hyperplasia of the mesenteric and retro- peritoneal glands and spleen was also present. SYMPTOMS During the stage of invasion, scarlet fever is manifested by the following cardinal symptoms and signs: Sudden onset, vomiting, sore throat, elevated temperature, rapid pulse, dryness of the skin, and acute fever. Diagnosis of scarlet fever can not be made with certainty during this stage; however, the above symptom complex served during the war as an index for transferring patients to hospital and placing them in observation wards until an accurate diagnosis could be made. Not until the appearance of the skin eruption is it possible to diagnose scarlet fever, according to most observers. This eruption appears in from one to two days after onset of the disease as a scattered red 56706—28---26 402 COMMUNICABLE AND OTHER DISEASES punctate rash or a deep subcuticular flush. It appears first on the neck and chest, spreading rapidly to the armpits and over the body in general. It is inflammatory in nature, producing an intense hyperemia; the bleaching of the skin, due to anemia produced by pressure, is quickly relieved upon the release- of pressure. The skin, at first, is intensely red, the so-called "boiled lobster " appearance. The rash, scarlet at first, becomes darker in a few days. The face shows an erythema, with a paleness surrounding the mouth. This perioral pallor is commonly present in scarlet fever. Scaling commences at different times in different cases. It may be slight, with fine desquamation, as was noted in many mild cases during the war; or it may be very extensive, with scales as large as the palm of the hand, in this respect resembling dermatitis exfoliativa. The duration of desquamation also varies and may extend into weeks. Ludy, Hunt, and Cogswell3 reported the presence of the "strawberry tongue" in 92.8 per cent of their cases. The intensity of the sore throat is at times great; and when an organized exudate is present on the tonsils, the examination suggests the diagnosis of diphtheria. Before the days of micro- scopic examinations of throat swabs for the Klebs-Loeffler bacillus, the differ- ential diagnosis of these two diseases was often confused. One hundred and eighty-eight of the primary admissions for scarlet fever during the World War were associated with diphtheria, the diagnosis of which was based on microscopic examinations. These figures are quoted to show the occurrence of diphtheria and scarlet fever as concurrent diseases in the Army during the war. In the beginning of the disease, the skin of scarlet fever patients feels hot and dry. It later becomes moist and, if pinched, minute hemorrhages from the rupture of capillaries usually occur. This finding is common in scarlet fever, but occurs in some other diseases. The increased fragility of the blood vessels is believed to be the underlying cause of the minute hemorrhages that occur in some of the more severe types of scarlet fever, designated as the hemorrhagic form. Some writers have laid great stress on the enanthem, claiming that a punctate eruption on the mucous membrane of the palate, tonsils, and cheeks, when combined with a punctate eruption over the armpits and in the groin, is characteristic of scarlet fever. In the 500 cases of scarlet fever studied at Camp Hancock,3 the eruption occurred on the neck, chest, and abdomen in 40 per cent; the entire body, 26.5 per cent; chest and neck, 17.6 per cent; chest and back, 5.9 per cent; and chest and arms in 5.9 per cent of their cases. Early albuminuria has long been looked upon as a frequent concomitant of scarlet fever. In the 500 cases reported from Camp Hancock albumin w^as found in 67.3 per cent and casts in 35.3 per cent cases during the first week.3 The urine usually shows urobilinogen and is negative for the diazo reaction. The importance of these findings is in the differential diagnosis. Routine examination of the urine was commonly carried out in the base hospitals during the war for the detection of nephritis. The presence of red blood cells was considered of great importance in the diagnosis. Much has been written on the blood picture in the early diagnosis of scarlet fever, the diagnostic points being leucocvtosis and eosinophilia. Friedlander and McCord 4 conducted investigations along these lines at Camp Sherman, Ohio, and reported that 78.9 per cent of the cases showed leucocvtosis, while SCARLET FEVER 403 42.1 per cent showed eosinophilia. Where the white cell count was more than 10,000 they reported leucocytosis and where the number of eosinophiles was more than 2 per cent they recorded eosinophilia. Of 75 cases, 18.6 per cent showed an eosinophilia of 3 per cent or over. Ludy, Hunt, and Cogswell2 reported eosinophilia of over 5 per cent in 36 per cent of their cases, 4 per cent in 10 per cent, and more than 2 per cent in 54 per cent. These authors believe that the presence of an eosinophilia in a scarlet fever suspect is a valuable point in diagnosis, provided other causes of eosinophilia can be excluded. Leucocv- tosis of over 12,000 occurred in 19 per cent of the Camp Hancock cases, 12 per cent showed between 10,000 and 12,000 leucocytes, and 40 per cent between 7,000 and 10,000 leucocytes. The prevailing cell, when leucocytosis occurred, was the polymorphonuclear neutrophile. The type of the disease, the inten- sity of the eruption, and the degree of desquamation bore a definite relationship to the blood picture. The more marked the prodromal symptoms, the greater was the leucocytosis, the less the eosinophilia, and the less the desquamation. Desquamation commences where the eruption first appears, as a rule, and lasts several weeks. In some instances the desquamation is prolonged into the seventh or eighth week. As previously stated, it is not believed that the scales contain the scarlatina virus, but desquamation was used during the war as an index for releasing patients from quarantine. Desquamation is usually slowest on the palms of the hands and soles of the feet and reference to these areas was usually made before reporting desquamation complete. Ludy, Hunt, and Cogswell3 believed that scarlet fever, without eruption, exists and that the diagnosis in such cases can be made on the presence of soft inguinal adenitis plus sore throat and some of the other symptoms described as common to scarlet fever. COMPLICATIONS AND SEQUEL/E There were 1,781 cases of scarlet fever reported as concurrent with other diseases. The total number of cases reported for the war, primary and con- current, was 13,456. Among the total primary admissions, 3,825 developed complications or were associated with other diseases while in hospital; that is, 32.7 per cent. Table 63.—Scarlet fever. Complications, sequelse, and concurrent diseases, April 1, 1917, to December 31, 1919 Secondary diseases Measles__________________ Diphtheria_______________ Erysipelas......__________ Diphtheria carrier_________ Meningitis carrier_________ German measles__________ Mumps__________________ Septicemia, general_______ Acute articular rheumatism Arthritis. Otitis media___________________________ Mastoiditis____________________________ Pericarditis____________________________ A cute endocarditis_____________________ Valvular heart diseases_________________ Myocarditis and myocardial insufficiency. Diseases of the lymphatic system-------- Pneumonia: Broncho_____________________...... Lobar_____________________________ Nephritis: Acute_____________________________ Chronic___________________________ Case fa- Per cent Admis- tality of pri- sions rates,per mary ad- cent missions 114 7 6.14 0.97 188 4 2.12 1.61 38 1 2.63 .33 71 0 .61 6 0 .05 32 0 10 .27 259 3. 86 .22 14 s 57.1 .12 72 1 1.38 .62 81 7 8.6 .69 363 20 5.5 3.11 74 6 8.1 .63 16 5 31.2 . 14 32 4 12.8 .27 54 1 1. 85 .46 31 4 13.5 .27 " 1 1.3 .66 257 123 47.8 2.20 195 " 39.4 1.67 84 14 16.6 .72 48 6 12.5 .41 404 COMMUNICABLE AND OTHER DISEASES The more important complications and diseases reported as concurrent with scarlet fever in the Army during the World War are given in Table 63, from which it is seen that otitis media was the most common complication. Otitis media and its complications are, perhaps, the most important complica- tions developing in the course of scarlet fever. This is particularly true on account of the impairment of hearing, with partial or total deafness that often develops. The above table shows that otitis media developed in 3.11 per cent of the total primary admissions. There were 363 such cases, of which 20 died, giv- ing a case mortality of 5.5 per cent. The heart complications were also common. A total of 1.14 per cent of the primary admissions developed heart complications, of which 14 died. Nephritis was not a common complication among the soldiers suffering from scarlet fever, 84 cases of acute nephritis and 48 cases of chronic nephritis having been reported among the total primary admissions. The case mortality, however, was high; that is, 16.6 per cent in the acute cases and 12.5 per cent in the chronic cases. Arthritis complicating scarlet fever was not com- mon during the war; 81 cases or 0.69 per cent of the total admissions, with 7 deaths, were reported. The case mortality was 8.6 per cent. General sep- ticemia was reported in 14 cases and, as would be expected, the case mortality, 57.1 per cent, was high. Diphtheria was frequently associated with scarlet fever. Among the 188 cases, there were 4 deaths, giving a case mortality of 2.12 per cent. The total occurrence of diphtheria among the primary admissions amounted to 1.61 per cent. Measles occurred in 114 cases, with 7 deaths, and German measles in 32 cases, with no deaths. The pneumonias were relatively common among the primary admissions for scarlet fever. The records show 257 cases of bronchopneumonia and 195 cases of lobar pneumonia as complica- tions. The case mortality, as would be expected, was high. It was 47.8 per cent for bronchopneumonia and 39.4 per cent for lobar pneumonia. Occurrence of the pneumonias among the primary admissions totaled 3.87 per cent. Scarlet fever occurred as a concurrent disease in 344 cases of measles, 64 cases of diphtheria, 54 cases of German measles, 288 cases of mumps, 64 cases of pneumonia, 21 cases of arthritis, and 10 cases of nephritis (Table 64). The case mortality was 2.6 per cent among cases of scarlet fever reported as an associated disease of measles, while it was 6.1 per cent of cases of scarlet fever where measles occurred as a concurrent disease. This same difference occurred where diphtheria and scarlet fever were concurrent. Where diphtheria occurred as a concurrent disease, the case mortality was 2.12 per cent; where the reverse condition existed—that is, where the primary admission was for diphtheria and scarlet fever was the concurrent disease—the case mortality was 1 5 per cent Among the 98,225 cases of measles reported as primary admissions, scarlet fever was reported in 0.35 per cent. Among the 10,909 cases of diphtheria, scarlet fever occurred as a concurrent disease in 0 58 per cent TAr, ^Ss°_-va^L^^s.^"'iff »-Ms?.. ins? Primary diseases Measles......... Diphtheria____ German measles Mumps_____'.. Arthritis______-_ Admis- sions Deaths 344 64 54 288 21 Case mortality Primary diseases 2.6 1.5 0 .7 Endocarditis______ Bronchopneumonia - Lobar pneumonia... Nephritis (all)_____ Admis- sions Deaths Case mortality 50.0 6.6 17.6 SCARLET FEVER 405 According to Ludy, Hunt, and Cogswell,3 reporting their observations in cases of scarlet fever at Camp Hancock, Ga., albuminuria was present in 67.3 per cent during the first week, 58.8 per cent during the second week, and 8.8 per cent at the end of the sixth week of the disease. Casts were present in 35.3 per cent during the first week, 14.4 per cent during the second week, and 2.9 per cent at the end of the sixth week. In another series suppurative otitis media developed in 11 per cent of 500 cases, arthritis in 5.9 per cent, and broncho- pneumonia in 6.5 per cent. Three of the cases had relapse and three developed jaundice. Streptococcus throat cultures were positive in 36.2 per cent; 92.8 per cent had "strawberry tongue"; 35 per cent were admitted with skin erup- tion; 100 per cent had inguinal adenitis, and 65 per cent had the rash of scarlet fever before admission to hospital. An enanthem was present on the hard and soft palates in 92.9 per cent of the cases, and 70 per cent developed marked desquamations. Nephritis was reported as not being common at Camp Han- cock. The only serious complications reported were otitis media and pneu- monia. The pneumonia was said to have been of a peculiar type, markedly resembling influenza-pneumonia. One case of severe arthritis was reported from this camp. The occurrence of scarlet fever at Camp Lewis, Wash., was reported as being of a mild type, with few important complications. Pneumonia occurred in three cases and nephritis and endocarditis each in one case. Transient albuminuria was reported in 14 per cent of the cases. Nephritis appears not to have been as common a complication of scarlet fever in the Army as in civil life, where its occurrence is said to be from 10 per cent to 25 per cent.5 DIAGNOSIS The clinical diagnosis of scarlet fever is justified by the presence of such manifestations as fever, with sudden onset; sore throat; fine punctiform rash, involving the hair follicles situated on a normal base, appearing first on the neck and chest, then becoming generalized, vividly red in the beginning, turning darker as the disease progresses; pallor about the mouth; tongue coated and showing prominent red papillae protruding through this coat; vomiting; early albuminuria; rapid pulse; and eosinophilia. The justification of this diagnosis is increased by the feverish appearance of the patient, the presence of urobil- inogen in the urine, absence of the diazo reaction, and presence of peripheral blood capillary fragility. During the World War, the typical case of scarlet fever was not difficult to diagnose; however, medical officers reported mild cases that did not present the full clinical picture. There were cases also where the differentiation from measles and German measles was difficult. The latter disease at times pre- sented a fine, vivid erythematous rash that strongly resembled that of scarlet fever. It was necessary at times to observe patients in quarantine before a positive diagnosis could be made. Toxic erythema caused confusion in some cases, but observation afforded opportunity to make the differential diagnosis. The enanthem and submaxillary and inguinal adenopathy were important diao-nostic findings in the cases studied at Camp Hancock; the presence of enanthem was reported in 92.9 per cent and the adenopathy in 100 per cent of 406 COMMUNICABLE AM) OTHER DISEASES the cases.2 Skin eruption was not present in all cases, and marked desqua- mation occurred in 70 per cent. Although scarlet fever without eruption was reported during the war,3 the difficulty of diagnosis was greatly increased without the presence of this valuable diagnostic sign. PROGNOSIS If the occurrence of deaths from scarlet fever be taken as an index to the severity of the disease, the ratios for the various camps show a great difference in severity during the war. The death ratios for the large camps in the Tinted States varied from 0 to 0.71 per 1,000 strength. No deaths occurred from scar- let fever at 14 of the large camps. (Table 62.) Camp Hancock, Ga., reported the highest death rate; i. e., 0.71 per 1,000 strength. The death rate at Camp Pike, Ark., was 0.58 per 1,000 per annum. The death ratio for the remaining camps was, in each instance, below this figure. The death ratio for the 4,816 cases occurring in the large camps of the United States was 0.11 per 1,000 strength, and the case mortality varied between broad limits. The highest case mortality rates were reported from Camp Greenleaf, Ga.; Camp Gordon, Ga.; and Camp Johnston, Fla. These were, respectively, 14.8 percent, 13.3 per cent, and 12.9 per cent. It is noted that the highest case mortality rates were in the southeastern part of the United States. The average case mortality for the camps located in the United States was 2.96 per cent. As shown pre- viously, scarlet fever occurred more frequently among white troops and the death rate was higher than among colored troops. Scarlet fever was not, to any great extent, the cause of permanent disability in the Army during the war. Table 60 shows that 18 men were discharged from the service on account of disability following this disease. All of these cases were among white enlisted men. The records do not permit such detailed analysis as to make it possible to state the disability more specifically. Since scarlet fever is an acute disease, naturally the 18 cases discharged from the service were discharged on account of some chronic complication, the exact nature of which can not be stated. PREVENTIVE MEASURES Since there were no specific preventive measures known for scarlet fever at the time of the World War, the discussion of prophylaxis in this disease is confined to general preventive or control measures. The general measures of value in preventing the spread of scarlet fever depend largely upon the suscepti- bility of individuals to this disease. The control of this disease is easier than the control of some other acute infectious diseases, for example, measles. Fomites have been shown to harbor the virus; therefore, thorough disinfection or destruction of articles of clothing, etc., was taken cognizance of in the con- trol of the disease during the war. Occurrence of milk-borne epidemics are contained in the literature on this disease; however, milk-borne scarlet fever was not reported in the Army. The exact time at which patients become a source of danger and the duration of this period have never been determined; since there is no known causative organism, there are no bacteriological guides upon which to base quarantine SCARLET FEVER 407 The importance of missed cases and patients developing a relapse after being dismissed from quarantine was referred to by several medical officers during the war. Ludy, Hunt, and Cogswell3 reported that 35 per cent of the 500 cases at Camp Hancock, Ga., were admitted to hospital with the skin eruption present. These cases must, therefore, have been a source of infection for some time before being transferred to hospital. Some cases of scarlet fever were so mild that the disease had developed fully before transfer was made. It seems probable, then, that cases occurred in many camps where the diag- nosis was made late in the disease or not at all, allowing the patient to remain with his organization. As a general preventive measure, it was customary to quarantine newly arrived troops 14 days before allowing them to mix freely with other members of the camp. This was possible where the number of men was small; however, in most instances this quarantine was never absolute. The quarantine referred to was not solely for the purpose of preventing scarlet fever, but was intended for other diseases as well, especially measles. Such quarantined soldiers were examined once or twice daily for the appearance of contagious diseases. The common practice, upon identification of a case of scarlet fever, was to send the patient to hospital and place all contacts, or the entire company, in quarantine. This quarantine was regulated by the division surgeon or the senior medical officer present, and was maintained for seven days. The seven- day quarantine seems to have been satisfactory, although there are cases on record where the incubation period seemed to have been longer. The length of quarantine of the patient was six weeks by regulations. The records show that the average time spent in hospital for all cases was 42.6 days. In the United States this average was 42.3 days, in Europe 45.09 days. During the war, as noted, medical officers did not believe that the scales contained the virus of scarlet fever, but continued to use desquamation as throwing some light on the probable duration of infectivity. It was generally accepted that as long as the patient showed abnormal nasopharyngeal dis- charges, suppurating otitis media, discharge from an open lesion, or swollen lymph glands about the neck, he should not be discharged from quarantine. These symptoms usually cleared up promptly. The complication, as a rule, that had the longest duration was chronic suppurative otitis media. At Camp Grant, 111., the presence or absence of eosinophilia was taken as an index to releasing patients from quarantine. Although precautionary measures were used to prevent patients from leaving the hospital too soon, relapses occurred. The records do not permit of an analysis of these cases. Ludy, Hunt, and Cogswell3 reported that 5.7 per cent of the cases at Camp Hancock gave a history of previously having had scarlet fever. TREATMENT Xo satisfactory specific treatment was known for scarlet fever before the World War, and none was developed during that time. The course of the disease can not be cut short, but certain precautionary measures have proved of value, especially in reducing the incidence of complications. All cases were 40S COMMUNICABLE AND OTHER DISEASES sent to hospital as soon as the disease was suspected, and isolated in wards especially set aside for that purpose. These were wards designated as isolation wards, with from one to a maximum of about six beds each. Where two or more beds were in a room, they were separated by sheet cubicles. In the event of an increased occurrence of this disease in camp, or in the case of contacts, transfer was often made to the hospital upon the presence of fever alone, although of unknown type. Rest in bed during the early stages of the disease, liquid diet, a well-ventilated and well-heated ward, comprised the palliative treatment. The diet was increased in proportion to the general improvement of the patient and falling of the temperature. The records show that attempts were made to prevent otitis media by the use of alkaline antiseptic mouth washes and gargles, and in some instances by the application of silver prepa- rations to the throat. The measures for preventing the occurrence of nephritis included the prevention of body chilling by rest in bed until convalescence was well established, the free use of fluids, and the limitation of proteins in diet, especially in the form of meats. During the stage of desquamation, vaseline or olive oil was used on the skin; and in some base hospitals carbolized vase- line was used where itching was troublesome. The treatment of complications was symptomatic. As regards otitis media, which was present in more than 3 per cent of the cases, the treatment was, in general, early incision of the drum membrane for drainage, followed by installation of 50 per cent alcohol several times a day into the external auditory canal. Paracentesis of the drum membrane was generally done in the ward. The nursing and diet services were generally separate for scarlet fever patients, and much attention was paid to the importance of boiling the eating utensils after use, separate thermometers, and destruction of nose and throat secretions. Discharges from suppurating ears and open wounds that developed during the course of scarlet fever were treated in like manner. REFERENCES (1) Vaughan, V. C: Epidemiology and Public Health, C. V. Mosby Co., St. Louis, 1922, Vol. I, Respiratory Infections, 242. (2) Vaughan, V. C. and Palmer, Geo. T.: The Communicable Diseases in the National Army of the United States during the Six Months from September 29, 1917, to March 29, 1918. The Military Surgeon, Washington, 1918, xliii, No. 3, 251; Ibid., 191S xliii, No. 4, 392. (3) Ludy, John B.; Hunt, Ernest L.; and Cogswell, Lloyd H.: Observations on 500 Cases of Scarlet Fever. The Military Surgeon, Washington, 1919, xlv, No. 4, 414. (4) Friedlander, Alfred, and McCord, C. P.: Notes on the Blood Picture in the early Stages of Scarlet Fever. On file, Historical Division, S. G. O. (5) Osier, Sir Wm.: The Principles and Practice of Medicine. New York and London D. Appleton & Co., 8th ed., 1914, 341. CHAPTER XII MEASLES a STATISTICAL CONSIDERATIONS PRIOR TO THE WORLD WAR During peace times when troops are in garrison, measles is a disease which gives relatively little concern to the medical department of an army; most troops, under such circumstances, having had some years of service, either have had the disease and thus developed an immunity to it, or, having been exposed, have escaped the disease by reason of the fact that they already pos- sessed an immunity. Therefore, during peace times, measles usually has been limited, in so far as serious outbreaks in the Army are concerned, to recruit depots. On the other hand, when the Army has been greatly expanded, as in mobilization for war, the incidence of measles greatly increased. Thus measles has played a very important part during the various wars in which the United States Army has participated. Chart XLIV has been prepared to show the incidence of measles in the Army for the period 1840-1919.x Prior to the Civil War, the Army had no colored enlisted men, so figures for white enlisted men only have been used to make the ratios comparable. This chart shows measles increased tremen- dously with mobilization of the Union Forces for the Civil War. During the years covered by the Civil War statistics, 67,763 cases were reported, with 4,246 deaths among white troops, with a case fatality of 6.27 per cent. Only a small part of this mortality was directly referable to measles;2 in many of the regiments only one death was caused by its epidemic occurrence. Since most of the mortality was the result of secondary pulmonary affections, the rate given does not adequately express the situation, for many deaths were charged to the pneumonic lesion without reference to the primary cause. Following the Civil War the occurrence of measles decreased, and in the year of 1866 the admission ratio was only 1.98 per thousand strength.3 From this time until mobilization commenced for the Spanish-American War (1898), the disease was not one of great importance in the Army. Although certain of the intervening years were marked by distinct increases, yet the annual admission ratio did not exceed 9 per thousand except during the year of 1896, when it became 10.30.4 In 1898, the admission ratio rapidly rose to 51.70 per 1,000 per annum.4 From 1899 until the mobilization of troops on the Mexican border in 1916, the occurrence averaged about 8.5 per thousand per annum.5 During the years intervening between the close of the Philippine insur- rection (1902) and 1916, serious outbreaks of measles were limited almost entirely to our recruit depots. Thus, during 1911, a severe epidemic, with a 5 per cent mortality, occurred at Columbus Barracks, Ohio.6 Of the 1,101 cases, with 25 deaths, in the total Army in the United States in 1911, 392 cases with IS deaths occurred at Columbus Barracks.6 o Unless otherwise stated, all figures for the World AVar period are derived from sick and wounded reports sent to the Surgeon Q eneral.—Ed. 410 COMMUNICABLE AND OTHER DISEASES On a small scale, conditions as they existed at Columbus Barracks during the time mentioned are illustrative of what occurred in some of the camps dur- ing mobilization for the World War; that is, recruits from all sections of the country were crowded into barracks, and among them were men from rural districts where there was a large percentage of measles nonimmunes. With overcrowding, particularly during the colder months of the year, epidemics inevitably occurred. In greater detail, the comparative trends of cases and deaths for the Civil War, the Spanish-American War and Philippine insurrection, and the World War are graphically shown in Chart XLV, by months of occurrence for white and colored enlisted men. From this illustration it is seen that the peak of admissions occurred in the early period of the respective wars. For the World MEASLES. WHITE ENLISTED MEN U. S. ARMY ADMISSIONS AND DEATHS. 1840-1919 »DMISSIONS----------- DEATHS Chart XLIV War, the peak occurred in November, 1917, and subsequent to that time there was a well-marked decline in the admission ratio. During the Civil War, the peak for admissions was reached during the first year, namely, in December, 1861. The peak was also reached early in the Spanish-American War. Since this war was waged during the summer season, measles and its complications did not become an important epidemiological problem. For the World War, the peak, taken by the death rate trend, also was reached in November, 1917. This was not the case in the Civil War, as the peak did not occur until March, 1864. During the second and third winters of the Civil War the death rate rose out of proportion to the number of cases reported. This may be accounted for bv improvement in diagnosis during the latter period of the war and in cases being actually charged to measles rather than to its pulmonary complications. The increased death rate may be accounted for by the enlistment of colored troops after July, 1863, as they had higher death rates due to pulmonary complications MEASLES 411 The number of deaths was not great following measles during the Spanish- Anierican War and Philippine insurrection. The peak, as shown on Chart XLV, was reached in March, 1902. The admission rate for white and colored troops combined for the entire period of the Civil War, from May, 1861, to June, 1866, was 32.22 per thousand per annum; the death rate was 2.02. During the Spanish-American War and Philippine insurrection, from May, 1898, through June, 1902, the admission and death ratios per thousand strength were 26.06 and 0.32, respectively. For the World War, based on occurrence in the United States and Europe only and from April, 1917, to and including December, 1919, the admission ratio was 25.28 and death ratio 0.63 per thousand per annum. It may be infer- red, then, that measles was better controlled during the period of the World War as a whole than during the other two wars under consideration, and while the death rate was twice as high as that for the Spanish-American War and Philippine insurrection, it was less than one-third as high as the corresponding rate during the Civil War. DURING THE WORLD WAR Discussions which follow are based, generally, upon the primary admissions. For the total Army the admission, death, and noneffective ratios were 23.79, 0.57, and 1.25 per thousand per annum, respectively. American officers and enlisted men contributed 96,817 admissions, 2,367 deaths, and a loss of time from duty amounting to 1,864,477 days. This occurrence was among the total mean annual strength of approximately 4,000,000 men. Officers, as shown in Table 65, with an aggregate strength of 206,382, contributed 974 admissions and 3 deaths, the loss of time from duty amounted to 12,015 days. The non- effective ratio was 0.16 per thousand per annum. The admission and death ratios were, respectively, 4.72 and 0.01 per thousand, the lowest in the Army where large bodies of troops were concerned. This is probably accounted for by the difference in age and living conditions among officers as compared with enlisted men. Among American enlisted men there were 95,843 primary admis- sions, with 2,364 deaths. The admission and death rates were 24.66 and 0.61 per thousand strength, respectively, and the loss of some 1,800,000 days, with a noneffective ratio of 1.31 is credited to them. Enlisted native troops, serving in their home territorv, had 1,408 primary admissions among a total of a mean annual strength amounting to 36,022. There were three deaths with admission and death ratios of 39.08 and 0.08 per thousand per annum, respec- tively. From the above it is seen that the highest admission ratios were among native troops, and the lowest among American officers. It was the opinion of medical officers that deaths did not follow uncom- plicated measles, but were due to complications and concurrent diseases. It was the practice in the statistical division of the Surgeon General's Office, as noted elsewhere (p. 5), to charge all subsequent developments to the primary cause of admission to sick report. This accounts for the deaths, permanent disability, and much of the time lost from duty credited to measles in this chapter. Therefore, for a comprehensive understanding of this chapter the reader should take the method of computation into consideration. 412 COMMUNICABLE AND OTHER DISEASES MEASLES (ALL) CIVIL. SPANISH-AMER. & PHIL. INSUR.. AND WORLD WARS WHITE AND COLORED ENLISTED MEN. U.S. ARMY BY MONTHS . , -.-, __.-__ __, _ RATIOS PER tOOO ■ i:!, l-i nm.[i].( i_ii.j_"" «>-I-«_«WoJ«_i_S5«-*_d-.____S;£f;>'o'"_"'_»5_- >-|-.C.i»t.J-_<->-! iaMisSi_.SalS.^S!its«S-i-U3_S-_.:3%-M38se-8.si»_l?3sxs.«sa%-l SPAN.-4MER. WAR I PHIL. INSUR.----------- WORLD WAR Chart XLV MEASLES 413 Table 65.—Measles. Admissions, deaths, discharges for disability, and days lost, by countries of occurrence, officers and enlisted men, United States Army, April 1, 1917, to December 81, 1919. Absolute numbers and rates per 1,000 Total mean annual strengths Admissions Deaths Discharges for disability Days lost Abso-lute num-bers Ratios per 1,00( strengtt Abso-lute num-bers Ratios per 1,000 strength Abso-lute num-bers Ratios per 1,000 strength Absolute numbers 1,877,944 1,864,477 12,015 Non-effective ratio per 1,000 strength Total officers and enlisted men in-cluding native troops______ 4,128,479 4,092,457 206,382 98, 225 96,817 974 23.79 23.65 4.72 2,370 2,367 3 0.57 .58 .01 149 149 0.04 .04 1.25 1.25 Total officers and enlisted men American troops..____ Total officers........_____ Total American troops: White___________ 3,599,527 286,548 90,112 4,870 861 25.01 17.00 2,228 116 20 .62 .40 142 7 .04 .02 1, 723,795 106,551 22,116 1.31 1.02 Colored........... Color not stated____________ Total_____........ 3,886,075 95,843 24.66 2,364 .61 149 .04 1,852,462 1.31 Total native troops (enlisted)____ 36,022 1,408 39.08 3 .08 13,467 1.02 Total Army in the United States including Alaska: 124,266 1,965,297 145,826 813 80,546 4,039 6.54 40.98 27.71 1 1,889 97 .01 .96 .67 9,511 1,503,341 87,946 .21 White enlisted. ______ 138 7 .07 .05 Colored enlisted........_____ 2, 111, 123 84,585 40.06 1,986 .94 145 .07 1,591,287 2 07 Total officers and men. 2,235,389 85,398 38.20 1,987 .89 145 .06 1,600, 798 1.96 U. S. Army in Europe, excluding Russia: 73,728 124 1.68 1 .01 2,084 08 .00 White enlisted_____________ 1,469,656 122, 412 7,529 668 847 5.12 5.46 318 19 20 .22 .16 2 189,822 16,017 21,822 .35 .36 1,592,068 9,044 5.68 357 .22 2 .00 227,661 .39 Total officers and men_____ 1, 665, 796 8.388 9,168 37 5.50 4.41 358 1 .21 .12 2 .00 229, 745 420 .38 . 14 U. S. Army in Philippine Islands: 16, 995 4,456 107 2 6.30 .45 1,960 38 .32 .02 21,451 109 5.08 1,998 .26 V. S. Army in Hawaii: 16,161 3,319 169 40 10.46 12.05 3 .19 2,657 582 .45 .48 19,480 19,688 209 121 10.73 6.15 3 .15 3,239 1,640 .46 U. S. Army in Panama: (White .23 U.S. Armv in other countries not sta t .ed: 263 s 10 2 1 6,984 411 263 [_.. Total ......____________ 14,232 281 19.75 2 .14 1 .07 7,658 1.47 Transports: 97,498 10,535 1,377 113 4 14.12 10.73 16 .16 1 .01 17,391 1,557 31 .49 .41 Total _______________ ins.033 1,494 13.83 16 | .15[ 1 .01 18,979 .48 Native troops enlisted: 18,576 5,615 11,831 127 1S6 1, 095 6.84 33.13 92.54 1 .05 1,412 1,373 10, 682 .21 .67 2 .17 2.47 « Separate strength of white and colored not available. 414 COMMUNICABLE AND OTHER DISEASES OCCURRENCE IX THE UNITED STATES More than eight-tenths of the primary admissions were among troops serving in the United States. (See Table (if).) There were Nf>,:.9N such ad- missions among the troops serving at home and in Alaska. In so lar as Alaska is concerned, for all practical purposes the number of measles admissions there was so small it need not be considered. The total annual mean strength of the Army in the United States was about two and a quarter million men, and among these there were 1,987 deaths. The admission and death ratios were 38.20 and 0.89 per thousand per annum, respectively. The loss of time from duty was considerable and amounted to 1,600,797.— Measles and State Alabama. . . . . Arizona________ Arkansas_____.. California...... Colorado.....___ Connecticut_____ Delaware_______ District of Coluinl Florida........... Hawaii_________ Illinois________ Indiana_______ Iowa.......___ .. Kansas_______ Kentucky_____ Louisiana____ Maine_______ . Maryland.. ___ Massachusetts... Michigan______ Minnesota_____ Mississippi____ Missouri_______ Montana_______ Nebraska______ Nevada_______ New Jersey____ New York_____ North Carolina. North Dakota.. Ohio__________ Oklahoma....... Oregon______ Pennsylvania. _ Porto Kieo.... Rhode Island. . South Carolina. South Dakota. Texas________ Utah__________ Vermont___ ___ Virginia.. _____ Washington . West Virginia..... Wisconsin.. Wyoming__ Total____ Admissic ns and deaths. is Admissions Absolute number 17 Deaths s and ra hos per 1,000 ° 1918 19 Admissions Absolute Ratios numbers per 1,000 1,106 0. 47 9 Der Absolute numbers 54 5 51 14 3 99 1 1 43 1 298 70 24 12 204 30 4 44 183 170 101 Estimated population Admissions Deaths ths 1918 Absolute numbers Ratios per 1,000 Absolute numbers Ratios per 1,000 Absolute numbers Ratios per 1,000 Absolute numbers Ratios per 1,000 0.196 . 136 . 187 . 049 Ratios per 1,000 2,395, 270 272,034 19,193 8.119 466 0.197 6,220 162 5, 335 23, 194 2,080 5,450 2.0 .6 3.0 7.4 2.1 4.2 470 37 336 154 0. 023 .015 1, 792,965 3,119,412 1, 014, 581 7,845 21,953 10,374 7,462 4.442 7.248 10. 497 5.897 216 188 69 126 .122 .062 .070 .100 615 3, 969 146 5, 884 .35 1. 18 . 16 4.30 . 029 .004 .003 1, 286, 268 216,941 85 14 48 137 11 341 120 214 313 341 254 103 155 519 259 89 732 60 .066 . 065 . 119 . 146 .049 . 054 .042 .096 .167 .142 .135 .132 . 112 .135 .083 .038 .366 .017 .072 .005 401, 681 938, 877 3,807 10. 309 14 .038 7,001 2, 187 17.4 2.3 187 135 18,844 5, 055 144 998 .43 .81 . 53 2. 93 1.73 .06 .002 .045 223,419 103 49, 512 30, 083 .469 7.941 10. 609 3 766 550 .014 .123 .194 .004 6,317,734 2, 854, 167 2, 224, 771 7, 575 5, 5S3 1,198 10, 793 1.2 2.0 .5 5.8 .04(i .024 .010 1, 874,195 2, 408, 547 22, 464 12.130 233 . 126 . 007 . 085 1, 884, 778 782,191 1,384,539 3, 832, 790 3, 133,678 2, 345, 287 2,001,466 10, 534 3, 035 10,613 23, 880 12,453 8,303 49, 422 5.673 3.904 7.726 6.324 4.025 3.591 25. 004 250 130 117 366 241 121 546 . 135 .167 .085 .097 .078 .052 .276 3, 525 1, 647 14, 660 29, 212 5,906 3,727 42, 045 1.9 2.1 10.6 7.6 1.9 1.6 21.0 418 55 3,709 9, 984 7, 090 4, 469 3.215 .23 .07 2.57 2.61 1.96 1.89 1.80 .017 . 00." .031 .048 .047 .043 3, 448, 498 24 10 3 .007 486, 376 3, 885 8.215 40 .085 1,288 1,584 2.6 1.2 807 655 1.50 .51 .019 1,290.877 13 .010 . 002 114, 742 1,465 13. 229 i .009 3, 080. 371 28,437 74,395 8,069 615 14, 065 9.2 7.0 3.3 .8 2.7 523 1,293 .170 .121 4,774 19,882 5, 768 552 16, 788 1. 53 1. 93 2.27 .86 2.94 55 355 .018 10,646,989 2, 468, 025 60, S60 5. 818 892 .085 .034 791,437 5, 273, 814 2, 377, 629 1, 135 27,971 11,264 4, 628 31,417 7,001 720 5,646 1,028 4, 746 15, 035 10, 426 23, 294 17, 244 3, 922 5,711 1,064 529, 498 1.483 5. 367 4.919 5. 369 3.628 5.683 1.150 3.436 1.434 1.051 33. 873 28. 569 10. 526 10. 795 2. 776 2. 260 5. 752 22 564 168 55 513 1,372 75 183 3 672 104 79 .029 .108 .073 .064 .059 1.114 .120 .111 .004 .149 .234 .216 7 270 254 57 802 425 128 81 33 1,009 34 15 .009 .051 .107 .064 .091 .341 .201 .049 .045 .219 .075 .041 10 197 37 3 .016 . 035 .018 888, 243 8, 798, 067 4,742 51,836 1,746 3,647 2,245 1,320 4,356 5,274 1,086 20, 546 5, 166 1, 438 19, 376 1. 033 5.3 5.9 1.4 5.7 1.4 1.8 .9 11.6 3.0 9.2 3.1 1.0 7.6 5.4 407 45, 710 133 218 359 157 .52 5.27 .004 1, 247, 677 20 16 8 637, 415 1,660,934 735, 434 .36 .21 .25 .027 .005 4,601,279 453, 648 366. 192 2, 234, 030 183 1, 728 4, 823 1,894 1,898 4.342 646 1 78, 528 .41 4.90 2.10 1.41 1.31 1. 66 3.37 1. 78246 2 16 73 20 . 004 . 045 . 032 1, 660, 578 1,439, 165 203 50 61 9, 406 .127 . 035 .024 . 038 102 .061 .015 190, 380 100 (i .039 . 032 .09928 54 1 .021 . 005 100, 157,374 . 09451 429, 764 4. 29086 9, 944 2,316 .02312 « Source of information: Reprints Nos. 505 (1917), 551 (1918), 643 (1919), Public Health Reports, V. S. Public Health Service, Washington, MEASLES 425 OCCURRENCE IX THE AMERICAN EXPEDITIONARY FORCES Among the total of the mean annual strengths for the American Expedi- tionary Forces of 1,665,796 officers and men, there were recorded 9,1 OS primary admissions for measles and 358 deaths. The admission and death ratios per thousand strength, respectively, were 5.50 and 0.21. Among these cases there was a loss of time from duty amounting to 229,745 days, giving a noneffective ratio of 0.38 per thousand per annum. The vast majority of cases were among white enlisted men. (See Table 65.) These troops contributed 7,529 of the primary admissions, a ratio of 5.12. Colored enlisted men contributed 668 primary admissions with a ratio of 5.46 per thousand strength. Of the total deaths, 318 were among white enlisted men and 19 among colored. There was 1 death among officers and 20 among enlisted men, whose color was not stated. The loss of time from duty among white troops amounted to 189,822 days, and for colored, 16,017. The noneffec- tive annual ratios were, respectively, 0.35 and 0.36. From these figures it is apparent that the occurrence of measles and the noneffectiveness were greater among colored than among white troops. The death ratio, however, was higher for the latter. Occurrence by months is better shown with figures for white than with figures for colored enlisted men. The first cases among white troops were reported during the month of June, 1917, when 7 primary admissions were recorded. The number steadily increased until January, 1918, when 507 pri- mary admissions were recorded. During the spring there were from 100 to 200 cases per month; however, commencing in the late summer, the number of cases increased until between 800 and 900 primary admissions were recorded per month, with the largest number of cases during September. In 1919, the num- ber of primary admissions was small, due to the withdrawal of the forces from Europe and the discontinuance of forwarding troops from the United States. This applies to the beginning of 1919 and not to the latter part, as recruiting was resumed and replacements sent to the army of occupation in Germany during the latter half of the year, thus accounting for the increase in occurrence among those troops. Chart L shows the trend taken by admissions and deaths for enlisted men serving in Europe. The peak was reached in July, 1917. This was followed by a decrease until September, when the trend again took an upward course, reaching a second but lower peak in November. Until February, 1918, the admission ratio remained between 25 and 50 per thousand, after which time the occurrence took a downward trend until April. From that time until the date the armistice was signed the trend of occurrence was about horizontal. The occurrence diminished in December and continued through January, 1919. Commencing in the summer, the trend suddenly took an upward course, reaching approximately 9 per thousand, followed by sudden decrease in September, reaching the lowest admission ratio for troops in Europe during the war. Dur- ing October, 1919, the trend was upward, reaching approximately 35 per thou- sand; this was due to replacements sent to Germany as mentioned above. 426 COMMUNICABLE AND OTHER DISEASES Emerson,10 in a report on communicable diseases in the American Expedi- tionary Forces, stated that 8,207 cases of measles and 86 deaths occtiired be- tween July 1, 1917, and April 30, 1919, giving a case mortality of 1.05 per cent. He explained that the high incidence rates in the first months, up to and includ- ing January, 1918, as compared with the rates after that time, were probably MEASLES. COMPARATIVE TREND ENL. MEN. U. S. ARMY-UNITED STATES & EUROPE ADMISSIONS & DEATHS BY MO.. APRIL. 1917-DEC. 1919 LOGARITHMIC SCALE RATIOS PER 1000 NOOO.O •00.0 (00.0 500.0 400.0 300.0 200.0 100.0 80.0 60.0 50.0 40.0 30.0 20.0 10.0 e.o 6.0 5.0 4.0 3.0 2.0 ' i 'H^ -4- — fi "1 W^T\ zizfzj — "-H - v i ; t r .' : | i i ; ..... - ■ t - ■ t '• ' i ^-r-t-t- r - 1 ' 1 1 1 : | ■ i i/i1 i 1 1 —1 " -"-►-* • -......t T "i f\ / ( i ' " T ; x ! 1 \ i / 1 H —i 1 Sj I **^^ i V- I > _T / i i ■» k T / i \ ^ \ \J I i i i i i » ! \ |/ 1 1— i iv / » * > \ ,_* 4__ 1 —i i— =t=! 8^ >^— -*- , 1 \ —r +■ i-t— i— i \ pit— I > / \ u_i \ 1 ' V- . > / 1 / ' / * J_ \ i _\ > I / :/ \ \T \ » ii K \ V t \ \___ T A- \ / \ n \ A ^___i t \ 1 1 \ \ / \ _ 7 ' I \ » «- < 3 => O. H > u » -> < «» o X U O HI < ADMIS: U. S.- 1918 —; EUROPE- 5 ' 5 s ? ? g o. »i a> u 3blUOU li. X < « « >-_:_io-.»-*o Chart L DEATHS: 1919 : U. S.—■ _ a w u o w a -> -> < «> oso —;EUROPE------- due to the fact that among troops who came over before the spring of 1918 there was a very much higher percentage of men who had not passed through measles or been exposed to epidemics in the training camps in the United States than was the case w^ith troops arriving in the American Expeditionary Forces after February, 1918. In the first 18 months of the American Expedi- MEASLES 427 tionary Forces, measles was very largely confined to troops just arriving at base ports, or to detachments of recent arrivals at the replacement camps or army units to which they were often hastily forwarded without being held over the incubation period. Between 50 and 80 per cent of all cases in the American Expeditionary Forces were reported from week to week in base ports—that is, up to the signing of the armistice. The number varied greatly according to the arrival of transports or convoys. After the discontinuance of new troop arrivals and the stabilization of commands, measles played but an insignifi- cant part among diseases in the American Expeditionary Forces. The cases that did occur after January 1, 1919, were chiefly in other parts of the American Expeditionary Forces than the base ports, especially in the armies and in the advance sections. Contrary to the general belief, as expressed by medical officers in the United States, Emerson held that measles, as a precedent or contributing cause to pneumonia, played a very unimportant role in the Ameri- can Expeditionary Forces, as it was rare. There is no reason to believe that measles in the American Expeditionary Forces was to any noticeable extent due to infections acquired by the soldiers from association with the French civil population.10 FACTORS INFLUENCING OCCURRENCE It is generally accepted that one attack renders the individual lastingly immune. Recurrences in unquestionable cases are rare; therefore, with a dis- ease so markedly contagious as measles, it is reasonable to assume that persons who have lived in close contact with others have developed measles in early life. This explains the larger percentage of immune persons among city dwellers and the susceptibility among country persons. These comparative facts are borne out by occurrences among recruits and drafted men obtained from urban and rural districts for the Army. It is generally conceded that mobilization has a direct bearing on the occur- rence of measles. This is due to the huddling together of susceptibles, a con- dition that can not be prevented in military life. During the World War many of the men were not only housed in standard barracks, but they also had a com- mon mess and a common amusement hall.11 In all these places they came in close contact while indoors. Some camps had central heating plants, while others had one or more stoves in each room.11 The former camps were generally located in the northern portion of the United States; the latter were generally in camps located in the South.11 Where heat was evenly distributed through- out the rooms, as in steam-heated barracks, men did not huddle together so much for the purpose of keeping warm or for amusement; in camps where stoves were used, men would collect around the stoves,7 and while in this close contact the virus of respiratory diseases was spread through droplet infection. Cough- ing, sneezing, and spitting were common. Outdoor exercises and duties, such as close-order drill, may have contributed to the spread of the disease, but cer- tainly to a far lesser degree. The occurrence of measles in the Army shows that it is most prevalent in the cold months. It is true it occurs during all months, but overcrowding is most common in cold weather, and as a result all acute respiratory diseases are 428 COMMUNICABLE AND OTHER DISEASES then more common. With a large number of recruits suddenly brought into camp, collected from every environment—immunes, persons actually suffering from the disease, and susceptibles—often arriving in camp on the same train, in the same cars, and placed in the same barracks, outbreaks were inevitable. Race as a factor is subject to question. Measles was more common among white than among colored troops. On the other hand, the Porto Ricans suffered more than any other troops in the American Army, the occurrence being more than three times that among the whites. The Hawaiian troops serving in their own country suffered second. There appears to be no explanation for the greater susceptibility of these persons over negroes. The difference in the records may be explained by the increased difficulty in diagnosing this disease among colored persons. The importance of measles to the Army during the World War, en grosse, and the relative importance among the several racial constituents, are shown in Table 68. The comparative occurrence during the World War of measles among white and colored enlisted men from the South and from other sections of the United States is shown in Table 69. The occurrence was approximately four times greater among southern white enlisted men than among white troops from the other sections of the country. About the same is true for southern colored enlisted men. Not only was this true for admission ratios, but also for death ratios. The case fatality was slightly higher among the southern white enlisted men, while southern colored enlisted men had a fatality slightly below that of colored enlisted men from the other sections of the United States. Table 68.—Measles. Admissions, deaths, discharges for disability, and days lost, by race, enlisted men, United States Army, April 1, 1917, to December 31, 1919. Absolute numbers and ratios per 1,000 Absolute numbers Annual ratios per 1,000 strength Per cent Race Admis-sions Deaths Dis-charges for dis-ability Total days lost Days lost per case Admis-sions Deaths Dis-charges for dis-ability Nonef-fective Case fatality rates Case dis-charged for dis-ability rates White __________ 90,112 4,870 127 186 2,228 116 1 142 7 1,723,795 106, 551 1,412 1,373 10,682 22,116 19.1 21.9 11.1 7.4 9.8 25.7 25.01 17.00 6.84 33.13 92.54 0.62 .40 .05 0.04 .02 1.31 1.02 .21 2.47 2. lis .79 0.16 .14 .67 2.47 1,095 2 .17 _....... .18 2.32 861 20 Total Army (en-hsted men)____ 97, 251 2,367 149 1,865,929 19. 2 24.80 .60 .04 1.30 2.43 .15 Table 69.—Measles. Admissions, deaths, and case fatality rates, white and colored enlisted men, United States Army, by sections of the United States, April 1, 1917, to December 31, 1919 Southern white enlisted men-------------.................... White enlisted men from other sections of the United States___ Southern colored enlisted men____________________________ Colored enlisted men from other sections of the United States... Total white enlisted men_________________........________ Total colored enlisted men_______________________________ Absolute numbers Annual ratios per 1,000 strength Admissions Deaths Admissions Deaths Case fatality rates (per cent) 41, 581 46,494 4,220 487 88,075 4,707 1,136 1,071 103 13 2,207 116 66.87 16. 53 21. 4S 6.79 25.64 17. 55 1.83 .38 .52 . is .64 .43 2.73 2.30 2.44 2.67 2.51 2.46 MEASLES 429 Officers suffered less than enlisted men. (See Table 65.) There are two possible explanations for this: First, officers lived in individual billets or with one or several other officers; overcrowding was the exception; their relation- ship to enlisted men did not bring them in close contact with them. Second, officers represented an older age group, and as such had greater opportunities for having contracted the disease at some prior date. The individual billeting of officers deserves chief attention in explaining why officers suffered less than enlisted men from measles. An analysis was made of 28,837 primary admissions for measles, white enlisted men, to determine the influence of length of service on the occurrence of measles. Among this number, 11,528 men had less than two months' service when they were admitted to sick report. Including men with three months' service, in 20,991 instances, measles occurred before these men had been in the service 100 days. This, as will be explained below, was a matter of much importance. Continuing the analysis further, it will be seen that the number of cases progressively decreased with each additional month of service for the first year, which contributed 28,002 of the 28,837 cases analyzed. SYMPTOMS Repeated observations made by medical officers lead one to believe that measles has perhaps one of the most constant periods of incubation for any of the eruptive diseases; that is, reckoned from the date of exposure to the appear- ance of the eruption. It was 13 days, and, in fact, was so regular that the 14-day quarantine period was considered entirely satisfactory. Reckoned from the date of exposure to the period of invasion, the time varied from 9 to 11 days. This seemed to represent the consensus of opinion of medical officers. The period of invasion is the most important stage from an epidemiological point of view. It is characterized by headache, chilliness, fever, mild catarrhal manifestations of the eyes, nose, throat, and bronchi, and cough. During this stage the individual does not feel sufficiently sick to report sick or be confined to bed. It is usually impossible to diagnose the disease during the early stages of this period, and, since the nasopharyngeal secretions have been proven to contain the virus during the stage of invasion, and since the soldier associates freely with his comrades during this time, the great danger of spreading the infection is obvious. Accordingly, the Office of the Surgeon General, the chief surgeon, A. E. F., and camp epidemiologists throughout the Army, repeatedly emphasized the importance of recognizing early symptoms of the disease. The initial symptoms, namely, coryza and catarrhal manifestations of the eye, suggest that the infectious agent develops first in the respiratory tract, but the primary lesion is not known. This period merges into the period of eruption, which manifests itself by an enanthem and an exanthem. The first changes, the enanthem, are seen in the mucous membrane of the mouth and throat as a catarrhal injection. On the buccal surface, Koplik spots appear. Hackett12 stated that at Camp Upton, X. Y., inspections were made of suspects twice daily, when Koplik spots and eruption were carefully looked for. These spots, however, were never seen. The Koplik spots were looked for as a routine in measles cases and suspects in 430 COMMUNICABLE AND OTHER DISEASES the Army during the war, but their presence was only occasionally reported. Generally speaking, cases in the Army were seen late in the period of invasion and usually the diagnosis was not made until the skin eruption had developed, by which time the Koplik spots are lost in the eruption on the mucous membrane of the mouth. The exanthem appears as red, flat, slightly elevated papules developing in from three to five days after the beginning of catarrhal symptoms. It is first noticed on the temples, neck, forehead, and about the edge of the hair. The eruption has a dusky hue as distinguished from the bright red of scarlatina. From these locations it spreads over the body. It was during the early eruptive period that the vast majority of cases were admitted to our military hospitals during the World War. The period of desquamation is characterized by a fine furfuraceous peeling of the epidermis, involving also the palms of the hands and soles of the feet. It lasts one or two weeks and is present in all cases; however, where the skin is oiled it may not be noticeable. In years gone by, it was a practice to hold patients in quarantine in military hospitals until this desquamation was com- plete. The scales are now looked upon as harmless and, therefore, of practically no value except in diagnosis. Although measles without eruption is recognized, there is no discoverable record of such cases in the Army. The urine often shows albumin, especially during the febrile period, and the diazo reaction is positive in about three-quarters of the cases. The latter may be of diagnostic value, especially when confusion with scarlatina exists. This test was only sparingly used during the war. The blood picture is not characteristic. During the period of incubation there is a leucocytosis involving the polynuclear cells. In the period of invasion the number of white cells decreases; during the period of eruption there is a leucopenia; during desquamation, the number rises to normal in uncomplicated cases. This blood picture was considered of some value in the contagious service at the base hospital, Camp Grant, 111., during the fall of 1917 and winter of 1918, especiallyin distinguishing measles from scarlet fever.13 Several types of measles are recognized, depending upon severity such as mild, hemorrhagic, malignant, and relapsing. Generally speaking, the disease, as reported, was mild in the Army during the war, but not without exception. Hamburger and Fox,14 reporting upon two measles epidemics at Camp Taylor, Ky., said the first epidemic was quite severe and the majority of patients were acutely ill from the start. The soldiers who later developed pneumonia and empyema, were particularly prostrated upon entrance to hos- pital, with flushed face, dusky cyanosis, full, bounding pulse, dyspnea, and labored, grunting breathing. The cyanosis was most strikmg, as one could almost tell from the color of the patient on admission to hospital that he was to develop or was already developing acute pneumonia. The type of pneu- monia varied; however, in most instances it was grouped as diffuse lobular or bronchopneumonia. This first epidemic occurred during September, October, and November, 1917; the second epidemic, which occurred in March, April, and May, 1918, was complicated not only by measles-pneumonia but also by a MEASLES 431 streptococcus epidemic, and was distinctly more severe than the first epidemic. Patients came into the hospital more acutely ill and prostrated than during the first epidemic, and died in considerably higher numbers. They died in spite of treatment, and nothing that could be done made the slightest impression on their condition. COMPLICATIONS, SEQUELS, AND CONCURRENT DISEASES In barracks where soldiers are housed, as well as in civilian institutions, such as asylums, schools, and other places where large numbers of persons live in dormitories, measles is more commonly followed by complications than where cases occur and are treated in the better class of private homes. This is due to cross infection by carriers, not of the measles virus but of such organisms as the streptococcus, which spreads principally through droplet infection. Among the 98,225 primary admissions to sick report during the World War with the diagnosis of measles, there were reported 22,809 complications, sequelse, and concurrent diseases. This does not mean that 22,809 cases of measles developed conditions directly attributable to it. This was the number of such diagnoses made after the individuals were admitted to hospital. The more important complications and concurrent diseases reported among the primary admissions for measles during the war are given in Table 70. As has long been known, the most important and frequent complications of measles are the pneumonias and otitis media. Experience during the war was no exception to this rule. Table 70. -Measles. Concurrent diseases and complications, enlisted men in the United States and Europe, April 1, 1917 to December 81, 1919 Concurrent diseases and complications Bronchopneumonia—------------- Otitis media......--------------- Lobar pneumonia________________ Mumps________________________ Suppurative pleurisy------------- Mastoiditis______.....------...... Scarlet fever_______________________ Tuberculosis of lungs--------....... Diphtheria and results------------- Erysipelas_________________________ Serofibrinous pleurisy............... Cerebrospinal meningitis (epidemic). German measles------------........ Pericarditis_______________________ Keratitis. Endocarditis, acute....... Acute miliary tuberculosis. Others____________________ Total......___________________........----------------------, 22,809 Admissions Deaths Case fa-tality Absolute Ratios Absolute Ratios rates (per numbers per 1,000° numbers 1,000° cent) 4,463 47.67 1,584 16.92 35.49 3,926 41.93 122 1.30 3.11 1,820 19.44 602 6.43 33.08 1,028 10.98 21 .22 2.04 645 6.89 268 2. SO 41.55 566 6.05 18 .19 3.18 344 3.67 9 .10 2.62 343 3.66 31 .33 9.04 149 1.59 9 .10 6.04 108 1.15 14 .15 12.96 105 1.12 2S .30 26.67 93 .99 37 .40 39.78 38 .41 .36 34 18 .19 52.94 31 .33 .25 23 8 .09 34.78 9 .10 9 .10 100.00 9,084 97.02 428 4.57 4.71 22,809 233.22 3,206 32.64 14.06 Ratio per 1,000 of measles. Table 70 shows 4,463 cases of bronchopneumonia, with 1,584 deaths. The admission and death ratios per 1,000 cases of measles were 47.67 and 16.92, respectively; the case fatality was 35.49 per cent. The next most common 432 COMMUNICABLE AND OTHER DISEASES complication was otitis media. There were 3,926 cases of measles reported with this complication, of which 122 resulted fatally. The otitis media developed in 4.2 per cent of the cases. The third most common complication was lobar pneumonia; there were 1,820 such cases, with 602 deaths. The admission and death ratios per 1,000 cases of measles were 19.44 and 6.43, respectively, the case fatality was 33.08 per cent. It is generally conceded that lobar pneumonia is not a common complication of measles; lobular or bronchopneumonia is the type usually seen. A review of some of the clinical records indicates that not all diagnoses of lobar pneumonia following measles were correct, and that in some instances at least the diagnosis should have been bronchopneumonia. Pleurisy was not an uncommon complication—there were 645 cases of sup- purative pleurisy and 105 of the serofibrinous variety recorded among the pri- mary admissions. There were 296 deaths reported among these cases. The case fatality with suppurative pleurisy was 41.55 per cent. The cases were preceded by pneumonia. Mastoiditis was recorded in 566 cases following otitis media. Among these there wrere 18 deaths, a case fatality of 3.18 per cent. Pericarditis was present in 34 cases, 18 of which terminated fatally, with a case fatality of 52.94 per cent. These cases, too, were preceded by pneumonia. Acute endocarditis was recorded in 23 cases, with a case fatality of 34.78 per cent. Eye symptoms are common in measles, and the condition is usually one of ca- tarrhal conjunctivitis, with some photophobia. Phlyctenular keratitis is not an infrequent complication or sequel of measles among children who live in poor hygienic surroundings. It is not commonly seen among the better class of people. Keratitis was recorded in 31 cases. It has long been considered that measles in some way tends to activate quiescent tuberculosis. Among the total primary admissions for measles, 343 cases of pulmonary tuberculosis were reported, a ratio of 3.66 per 1,000 measles. Among these cases were 31 deaths, a case fatality of 9.04 per cent. Acute mil- iary tuberculosis was reported in 9 instances and, as usual, terminated fatally. Francine,15 at Camp Gordon, Ga., made a statistical review of pulmonary tuberculosis among convalescent measles cases of the 82d Division there. Orders were issued directing that all measles convalescents be examined for pulmonary tuberculosis one month after return to duty from the hospital. As a severe epidemic had occurred, it was possible for the camp tuberculosis and cardiovascular board to examine and follow up 513 cases, which was about one- third of the total that had been discharged from hospital up to that time. Among these cases the lungs were reported as normal in 461, acute bronchitis in 18, clinical evidence of chronic active pulmonary tuberculosis in 16. In other words, of the 513 cases examined, 16, or 3.11 per cent, showed signs of active pulmonary tuberculosis. All of these cases were discharged from the service on surgeon's certificate of disability. Francine compared these statistical data with the results of the tuberculosis board which had examined the entire divi- sion. The tuberculosis rate for the division was reported as 0.92 per cent, and it would appear at first sight as if measles had been an important factor in reactivating the old lesions. This is subject to question, as the convalescents were more thoroughly examined than was the division, and the diagnosis in the 16 cases mentioned above was made after more refined and detailed examina- MEASLES 433 tion. He concluded that while 3.11 per cent accurately represents the number of cases of active pulmonary tuberculosis in this special group, it is too high if interpreted as an index for measles as a factor in the lighting up of old tubercu- lous foci. The findings by Francine are greatly in excess of those reported by Berg- hoff,16 at Camp Grant, 111., after having made a survey of 596 cases to determine the relationship of measles to pulmonary tuberculosis. These cases were first examined 14 days after admission to hospital and again at 30 days or 6 weeks after admission. All of these patients had previously been examined for tuberculosis while in camp during the routine examination. Only three of the convalescents showed unmistakable signs of a recent reactivation of an old tuberculosis directly attributable to measles infection. Of these three cases, one had suspicious findings after the second examination; the second case was a frank reactivation but, upon looking up the records, it was found that he had been under observation for tuberculosis one week prior to admission to hos- pital for measles; the third case was a frank example of an active pulmonary tuberculosis resulting directly from measles infection. Berghoff concludes that these figures seem to show that measles is not a predisposing factor toward pulmonary tuberculosis. Whether or not measles predisposes individuals to the occurrence of other exanthematous diseases is not known. Among the primary admissions for measles, scarlet fever occurred as a concurrent disease in 344 cases, diph- theria in 149, erysipelas in 108 and German measles in 38. (See Table 70.) Epidemic cerebrospinal meningitis was concurrent in 93 instances and mumps in 1,028. Hamburger and Fox,14 reporting on epidemics of pneumococcus, strepto- coccus, and measles infections at Camp Taylor, Ky., remarked that these epidemics could be chronologically arranged in five periods. The first, cover- ing September, October, and November, 1917, was designated as the lobar pneumonia period. The second, from November, 1917, to and including Jan- uary, 1918, was known as the first measles and measles-pneumonitis period. There were 967 cases of measles during this period, 80 of which developed pneumonia and 18 died; the case mortality was 19.4 per cent. Empyema followed measles-pneumonia in 18 cases, with a case fatality of 33.33. The third period, December, 1917, to February, 1918, was designated as the strepto- coccus atpyical pneumonitis and pleuritis period. Of great interest in this series of cases was the rapid and extensive development of empyema and the presence of hemolytic streptococcus in the pleural exudate. The fourth period was known as the second measles, measles-pneumonia, and streptococcus epidemic. It covered March, April, and May, 1918. During this time there were 414 cases of measles, of which 64 developed pneumonia and 17 died—a case mortality of 31 per cent, as compared with 19.4 per cent in the first epidemic. Empyema followed measles-pneumonia in 15 instances, with a case mortality of 13 per cent. This second measles, measles-pneumonia, and streptococcus epidemic was distinctly more severe than the first epidemic. Patients came into the hospital more acutely ill and prostrated during the latter group and 56706—28---28 434 COMMUNICABLE AND OTHER DISEASES died in considerably higher numbers. It is also noted that twice the number developed empyema, 3.6 against 1.8 per cent, although the empyema mortality was low^er. The reason given for this lower mortality was improvement in the methods of treating empyema. It was noted in the second epidemic that this form of pneumonia and streptococcus sepsis occurred often before empyema had time to develop, and these cases of measles, with associated streptococcus sepsis and a very high mortality, were among the most severe types of disease encountered at Camp Taylor, being comparable only with cases of profound general sepsis and profound toxemia. The fifth period marked the decline of the epidemics and was for May, June, and July, 1918. During this time there were 396 cases of measles, of which 9 developed pneumonia and died. The case fatality was 11.11 per cent. The total number of pneumonias of all classes was 114, of which 8 died, giving a case fatality of 7.9 per cent. The total num- ber of empyemas was 26, with a case fatality of 15.4 per cent. This fifth period is interesting, as it showed marked improvement in morbidity and mortality conditions with the advent of warmer weather, although at no time was the camp entirely free from infection. As a concurrent disease, measles was reported in 3,714 cases, with 162 deaths. These were admitted to hospital for other causes and the diagnosis of measles was made subsequently. Concurrent with scarlet fever, measles occurred in 114 cases, with 7 deaths; smallpox, 5 cases, no deaths; diphtheria, 23 cases, no deaths; German measles, 21 cases, no deaths; epidemic cerebrospi- nal meningitis, 32 cases, 17 deaths; mumps, 436 cases, 1 death; pulmonary tuberculosis, 141 cases, 3 deaths; bronchopneumonia 104 cases, 15 deaths; lobar pneumonia, 55 cases, with 5 deaths; influenza, 1,529 cases, with 92 deaths. During the autumn of 1918, the influenza pandemic period, Sellards,17 working at Camp Devens, Mass., investigated the occurrence of the influenza bacillus in cases of measles. These studies were conducted immediately after the subsidence of the influenza epidemic, when the Pfeiffer bacillus may have been unduly prevalent. Of the first 31 cases of measles examined, the Pfeiffer bacillus was recovered in 25 during the eruptive stage. Subsequent examina- tions showed that in three-fourths of these patients the bacillus disappeared with the subsidence of the acute symptoms of measles. A group of control individuals, seven in number, were examined, but no Pfeifferlike organisms were recovered; several reexaminations of the control group resulted nega- tively. No experimental evidence was obtained to show that these Pfeifferlike organisms have any etiologic relationship to measles. Bronchopneumonia, the most important of complications, reached its apex of occurrence in January, 1918. The rate declined during February, with a slight increase in March. During 1918, 544 deaths were attributed to this com- plication. Lobar pneumonia occurred most frequently as a complication in January, following which there was a decline. An analysis was made of 1,619 clinical records of cases of bronchopneu- monia following measles to determine the relationship of such cases to length of service. (Table 71.) Bronchopneumonia was most common among troops with two months' service or less and decreased with each additional month up to and including one year. After that time the number of cases was too small MEASLES 435 on which to base any definite conclusions. These same facts apply equally well to deaths. During the first three months of service or less, there were 1,283 of the 1,619 cases and 496 of the 625 deaths; that is, 79.1 per cent of the cases and 79.3 per cent of the deaths. A similar analysis (including 532 cases) was made of lobar pneumonia. (See Table 72.) As with bronchopneumonia, the majority of cases were reported during the first two months of service, and each additional month showed a distinct diminution, not only in cases but also deaths. Of the cases analyzed, 389, or 73.1 per cent, occurred during the first three months of service and 160 of 213 deaths. These occurrences are to be expected when it is seen that measles was most prevalent during the first two months of service, and that it decreased progressively by months thereafter. Table 71.—Measles with bronchopneumonia. Admissions, deaths, and discharges for disa- bility, by length of service, white enlisted men in the United States, April 1, 1917, to December 31, 1919 Absolute numbers Percentage rates Length of service Admissions Deaths 298 198 Discharges for disability Case fatality Case discharges 712 12 ii 41.85 34.68 42.86 34.78 47.05 1 69 571 1 93 4 to 5 months......... ________________ 196 S4 S 32 9 4. OS 92 2 17 8 to 9 months____...... _______________ ... ... _________| 17 S 10 to 11 months.....__ .. ________ .. __ ... _________' 6 1 year..........._ ... ... ._ ... ____________ ___.....1 4 .......... 14 _________ 6 2 to 4 years____........_______....... . _____ 5 35.71 10 to 19 years____________ ____________________ _________ 1 Table 72.—Measles with lobar pneumonia. Admissions, deaths, and discharges for disability by length of service, white enlisted men in the United States, April 1, 1917, to December 31, 1919 Absolute numbers Percentage rates Length of service Admissions Deaths Discharges for disability Case fatality Case discharges 236 153 92 34 5 3 2 6 97 63 33 15 3 5 7 6 41.10 41.17 35.87 44.12 60.00 2.12 4.58 6.52 1 33.33 1 16. 67 1 1 100.00 ... Vaughan,18 discussing the occurrence of measles in the Army camps dur- ing the winter of 1917-18, emphasized the importance of complications. At Camp Cody, N. Mex., among 235 cases of measles, 77, or 33 per cent, developed pneumonia, and 42 per cent died. Not only did measles predispose to pneu- monia, but predisposed to a fatal pneumonia. Among each 1,000 men with measles, 44 had pneumonia and 19 died, and of every 1,000 men without mea- sles, 17 had pneumonia and 2 died. Vaughan further remarked that a person who has recently had measles is ten times more likely to die from pneumonia than a person who has not recently had measles. 436 COMMUNICABLE AND OTHER DISEASES BACTERIOLOGY OF COMPLICATIONS The most important bacteria concerned in measles complications during the World War were the streptococcus, pneumococcus, tubercle bacillus, and influenza bacillus. More information is necessary before one can state defi- nitely the relationship that the Pfeiffer bacillus bears, not only to measles but to influenza. The role played by the tubercle bacilllus is one of reactivation. It is supposed that measles infection predisposes to the lighting up of old tuber- culous processes, especially of the lung. The relationship of the streptococcus and pneumococcus in measles had been under investigations for many years, but interest in this subject was increased by the widespread occurrence of measles and its complications in the Army during the war. Inflammation of the respiratory tract during an attack of measles readily permits the invasion of pathogenic bacteria. Irons and Marine,19 at Camp Custer, Mich., made important observations showing that the hemolytic streptococcus had been the principal cause of bronchopneumonia outbreaks following measles in the military camps. Cole and MacCallum20 reported, during their investigations at San Antonio, Tex., that the Streptococcus hemo- lyticus was present in cultures of sputum coughed up from the deeper parts of the respiratory tract in 30 cases of post-measles bronchopneumonia, and mice, inoculated with sputum from 17 cases, yielded the streptococcus in 16. Blood cultures taken during life yielded the Streptococcus hemolyticus twice in 15 cases. Of the 30 cases, death occurred in at least 14, and in all the Streptococcus hemo- lyticus was found in the lungs in practically pure cultures. The abdominal organs were found to be free from streptococcal invasion; however, areas of interstitial bronchopneumonia were characterized by streptococcal bronchopneumonia with the streptococcus present in the pleural exudate. In the purely lobular pneu- monia areas they were present in amazingly large numbers. According to Hek- toen,21 measles patients seem to become infected with hemolytic streptococci by direct droplet infection, contact, and dust infection by way of the throat; the in- fection also appears to spread more easily in military camps and in measles wards. Irons and Marine 19 found that the Streptococcus hemolyticus developed in the throat cultures of approximately 70 per cent of healthy soldiers during a period of respiratory infections. Cumming, Spruit, and Lynch 22 reported that, while 35 per cent of measles patients had streptococci in the throat, this was the case in only 6 per cent of healthy soldiers. Cole and MacCallum 20 found that 56.6 per cent of the patients in a measles ward harbored the Streptococcus hemolyticus in the throat, as compared with 21.4 per cent in a suspect tuber- culosis ward. They also found the Streptococcus hemolyticus in throat cultures of 11.4 per cent of measles patients on admission to hospital; after a duration of from 3 to 5 days in the ward, the per cent increased to 38.6, and after 8 to 16 days to 56.8 per cent. These observations, according to Hektoen,21 point unmistakably to the ease with which the Streptococcus hemolyticus passes from carrier to noncarrier and, in measles convalescence, sets up broncho-pneumonia and empyema. Levy and Alexander,23 discussing the susceptibility of measles convalescents to streptococcus infection at Camp Taylor, Ky., showred that complications and sequelae were responsible for long hospitalization and high noneffective rates. MEASLES 437 A careful study was made of 388 cases. On admission to hospital, all cases were sent to a special ward where they remained in bed, and from them daily cul- tures were made for the streptococcus. Carriers of this organism were placed in "dirty wards," or wards where patients were known to be infected with this organism. Patients with negative throat cultures were held for a second exam- ination. If negative on the second examination, such cases were transferred from the observation ward to "clean wards." Cultures were taken from the tonsils and pharynx and plated on human blood agar; bronchial cultures were made when possible. The results of bronchial cultures conformed to those of the throat cultures, therefore the former furnished no special information. Of the total cases examined, 89 or 22.9 per cent were noncarriers and 299 or 77.1 were found to be carriers. This is in marked contrast to the San Antonio findings, where only 11.4 per cent of measles cases were reported as carriers of the streptococcus hemolyticus.20 At Camp Taylor, Ky., the investigators found that of the noncarriers, 27 became carriers while in hospital, and of the 388 cases studied, 119, or 30.6 per cent, developed complications; of the latter, all except 4 were among noncarriers.23 The complications that developed in the noncarriers were acute tonsillitis, 1 case; acute bronchitis, 2 cases; cervical adenitis, 1 case. Among the carriers, 47 developed bronchopneumonia, 22 otitis media, and 15 empyema. That is, complications developed in 36.8 per cent of carriers and 6.4 per cent of clean cases; or 12.1 per cent of all cases developed bronchopneumonia, of which 34 per cent developed empyema. During the winter of 1917-18, Camp Taylor was heavily infected with the streptococcus hemolyticus, and almost every organization had representatives in hospital that showed this organism. Of the 388 cases studied by Levy and Alexander23 at Camp Taylor,Ky., 346 were from the depot brigade, which was composed principally of troops recently arrived in camp. One company of 95 men was examined and 83.2 per cent were found to be carriers. Men composing one draft assigned to Camp Taylor were examined to demonstrate whether this high carrier rate occurred in camp or was imported. To accomplish this end, 489 new recruits were examined as they stepped from the train. The result of this examination showed that 14.8 per cent harbored the Streptococcus hemolyticus; therefore, it was concluded that the men were also acquiring the carrier state in the camp. According to Capps,24 at Camp Grant, 111., where more than 900 cases of measles occurred during the winter 1917-18, only 20 developed bronchopneu- monia, most of which were of streptococcal origin. As a primary infecting organism in the causation of respiratory infections in our home camps, the streptococcus had a formidable record; but as a secondary infection, especially in pneumonia and measles, this organism was more dangerous than all others put together. Clendening25 studied the incidence of Streptococcus hemolyticus infection in lobar pneumonia following measles and scarlet fever at Fort Sam Houston, Tex. To the base hospital there, from December 1, 1917, to March 1, 1918, 319 cases were admitted as primary lobar pneumonia, 44 of which became reinfected with the Streptococcus hemolyticus. And among 97 cases of empyema, with 32 deaths, 18 were due to the streptococcus. During this same period, 438 COMMUNICABLE AND OTHER DISEASES there were 716 cases of measles, among which were about 150 cases of otitis media, 89 cases of bronchopneumonia, 12 cases of articular rheumatism, and 2 cases of meningitis with general sepsis. All were ascribed to the streptococcus. Knowlton,26 working at the base hospital, Camp Jackson, S. C, reported the results of routine throat cultures from October, 1918, to May, 1919, when measles cases were examined to determine what part the Streptococcus hemoly- ticus played. There were 458 cases of measles in an eight weeks' period which ended December 13, 1918. Postnasal cultures were taken in these cases. The percentage of positives varied materially in different weeks; the lowest was 19 per cent in the fourth week and the highest 45 per cent in the eighth week. The percentage also varied in different wards, the highest being in a ward where cubicles were not at first used. A special study was then made to determine what part the streptococcus played in complications. Among 458 cases of measles there were 13 deaths, or 2.7 per cent case fatality; 48 of the cases developed pneumonia, of which 10 showed empyema, with the Streptococcus hemolyticus as the predominating organism. Six deaths occurred among these empyema cases. There were 43 cases of suppurative oditis media, 5 of which developed mastoiditis. Knowlton found that pneumonia and otitis media occurred in the same proportion of patients whose throat cultures showed the streptococcus as among those whose cultures were negative. Of 458 throat cultures, 122 were positive and 336 negative. Cases with pneumonia as a complication were positive in 10.6 per cent. The cases with otitis media as a complication were positive in 9 per cent and negative in 9.8 per cent. He concluded that there was no relation between the presence of the Streptococcus hemolyticus in the throat and the occurrence of complications of measles. In an investigation of the occurrence of the streptococcus in the throats of measles patients on admission to the hospital at Camp Pike, Ark., during September and October, 1918, the following data were obtained:27 On admission_________ After 1 week in hospital. After 2 weeks in hospital After 3 weeks in hospital Number of measles Number patients harboring whose hemolytic throats strepto- were cocci swabbed 15 598 359 14 170 17 41 9 Per cent harboring strepto- coccus 2.51 3.9 10.0 22 The incidence of the Streptococcus hemolyticus in the throats of patients admitted to hospital with measles was comparatively low. With progress of the disease, as measured by the length of stay in hospital, the proportion of patients harboring the streptococcus gradually increased.27 DIAGNOSIS The diagnosis of measles is dependent upon clinical manifestations. No known serological or bacteriological findings are of diagnostic importance. These facts were known before the war, and experience gained during the war furnished nothing worthy of special mention. Although a common disease MEASLES 439 and in its characteristic form readily recognized not only by physicians, but also by the laity in the vast majority of instances, there are cases where differ- ential diagnosis is difficult and may lead to error. This undoubtedly accounts for the majority, if not all, of the so-called recurrent attacks of measles. The confusion with smallpox, so often spoken of in ancient writings, is not a matter of great concern at present, at least it did not exist in the Army during the World War. The prodromal scarlatinal type of rash may lead to the diagnosis of scar- latina, and vice versa, when patients are admitted to hospital in this stage of measles. The diagnosis of scarlet fever may be made and later the typical clinical picture of measles may develop, thus leading not only to confusion, but also to an additional diagnosis. This in all probability, accounts for some of the cases reported as a double infection of measles complicated by scarlatina, or vice versa. The somewhat similar nomenclature of measles and German measles is based upon clinical manifestations and not upon the etiology. These conditions are recognized as distinct and separate diseases, the points of differentiation being mentioned in the chapter on German measles. The necessity for a differentiation between these diseases is not uncommonly encountered; statistics from Camp Lewis, Wash., and possibly those from Camp Cody, N. Mex., during the last four months of 1917, indicate that medical officers on duty in those camps experienced some difficulty. During this period extensive epi- demics of measles prevailed in the Army camps throughout the United States. The general health of Camp Lewis remained good during the latter months of 1917 except for an outbreak of German measles.28 By December, this disease had reached epidemic proportions and 1,000 cases wrere reported sick during that month. Meanwhile, there was very little plain measles; however, as the epidemic of German measles died away, true measles became commoner and rose to about 200 admissions per month. Indeed, for a time in the spring of 1918, Camp Lewis had more true measles than any other camp in the United States save Camp Cody.28 The significance of the apparent substitution of German measles for true measles at Camp Lewis in the early winter of 1917-18 remains unsolved. During 1917, there were 9,244 primary admissions for German measles, Camp Lewis furnished 1,548 and Camp Cody 1,351. During this time, Camp Lewis reported 164 primary admissions for measles and Camp Cody 337. In view of the extensive occurrence of measles in other Army camps and the comparatively minor occurrence of German measles, it would appear that the diagnosis of these two diseases was confused in the two camps above mentioned. PROGNOSIS There appears to be no reason to believe that measles per se resulted in death or permanent disability during the war. The prognosis of this disease is the prognosis of its complications. Further, measles offers favorable con- ditions for the development of the pneumococcus and opens the doors to the streptococcus, the organisms that were most destructive to life and left more permanent disability in their wake among soldiers than all other known germs. It is o-enerally accepted that the death rate is higher among measles cases 440 COMMUNICABLE AND OTHER DISEASES treated in hospitals than in those treated in private homes. This is due to cross infections resulting in complications that may be increased by faulty technique, faulty hospital construction for isolation, careless attendants, poor ventilation, and overcrowding in hospitals. Conditions are most favor- able for fatal pneumonia epidemics in military camps when the disease appears during cold weather and when virulent pneumococci and streptococci are prevalent. These conditions existed in the fall and winter of 1917-1S. There w^ere 2,370 deaths recorded among the primary admissions and 162 among cases in which measles was a concurrent disease. The case fatal- ity was 2.4 per cent among the former. One hundred and forty-nine men were discharged from the Army on account of permanent disability following admission to hospital for measles. The majority of these cases suffered from disabilities directly attributable to pneumonia and its complications. More than 22,000 complications were reported among the primary admissions for measles. When viewed from this standpoint, it is seen that the prognosis was not so favorable in the Army as is generally accepted among the civil population. PREVENTIVE MEASURES The virus of measles is contained in the nasopharyngeal discharges and in the blood at an early stage of the disease. Thus communicability begins, certainly, before the appearance of the exanthem and in all probability before the Koplik spots; it may exist, at least to some degree, from the very begin- ning of the infection. Efforts to prevent spread from the respiratory system led to the system of isolation, the use of sputum cups, cubicles for patients, gowns and masks for attendants, and such terminal disinfection as wTas used during the World War. Appreciating the value of immunity conferred by previous attacks for purposes of quarantine, Munson,29 in 1916 caused a census to be taken at Camp Wilson, Tex., to determine from the statements of the soldiers whether or not they had previously had measles. With this information as a basis of quaran- tine for contacts, along with avoidance of overcrowding in tents, the sunning of bedding and personal effects, and with proper ventilation of sleeping quar- ters, outbreaks of measles at Camp Wilson were brought under control. Mun- son held that measles epidemics are preventable. He recognized that a census, based upon the soldiers' statements, is only approximately correct; however, it is sufficiently accurate for practical purposes, and the error lies largely in the direction of the soldier reporting a previous attack of measles when he really never had it. Sellards30 reported on a census of susceptibility to measles and its relation to quarantine procedures at Camp Meade, Md. This census differed from that reported by Munson,29 as the statement of each soldier was checked by a written report from his parents. Discrepancies were numerous and were almost entirely in the direction of the soldier having altogether forgotten attacks of measles that occurred in early life. To avoid prejudicing him, the soldier was given a card to complete, which showed not only measles but also scarlet fever, German measles, and meningitis. In 144 statements of soldiers claiming measles, the parents confirmed them in 133. In 89 cases where soldiers reported MEASLES 441 no measles the parents confirmed them in 49. This shows the greater portion, 92 per cent, of answers indicating a previous attack was confirmed by the parents, while, of those indicating that no previous attack of the disease had occurred, 55 per cent were not confirmed by statements of the parents. Sellards obtained similar results in a census at Camp Devens, Mass.31 These results introduced an clement of doubt into some of the conclusions drawn by Munson, since the number of measles cases developing at Camp Wilson, Tex., was only one-fifth of the entire number reporting themselves as susceptible. Munson concluded that the preventive measures probably protected four-fifths of the supposedly susceptible men, while of the 89 men at Camp Meade reporting themselves as susceptible, more reliable information from the parents indicated susceptibility with reasonable certainty in 22, or one-fourth of the number. A measles census was taken at Camp Pike, Ark.,32 and the results attained are rather striking. It was found that 61.5 per cent of the white recruits were classified immune and 38.5 as nonimmune. Approximately 30,732 immunes furnished 44 cases of measles, or 1.4 cases per 1,000 strength, while approxi- mately 19,261 nonimmunes furnished 956 cases of measles, or 49.6 cases per 1,000. It was reported that the infrequency of measles among the men classi- fied as immunes had been of great assistance in the selection of men for shipment to other camps and to ports of embarkation. Although, as shown above, there was some discrepancy relative to the value of a measles census, this informa- tion, when it is practicable to obtain it, is of great value in dealing with out- breaks of the disease. Gittings 33 reported on the military value of the immunity conferred by previous attacks of measles, scarlet fever, and mumps at Camp Mills, Long Island. In the fall of 1917, both measles and German measles were epidemic at that camp; and as patients were questioned on admission to the camp hos- pital, it was very noticeable that those suffering from German measles almost invariably gave a history of having had a severe attack of true measles, while those with measles denied ever having had a previous attack or admitted having had it only in a mild form. So noticeable was this that it became a factor of distinct importance in determining the diagnosis in early doubtful cases and often formed the basis for isolation into one or the other groups. Subsequent developments almost invariably substantiated the history. Com- menting on the value of previous attacks of measles at the United States Army General Hospital No. 9, Lakewood, N. J., Gittings stated that the observations made at Camp Mills were corroborated. These observations were based upon an analysis of 100 Hospital Corps men transferred from Camp Greenleaf, Ga. From them it was concluded that immunity conferred by previous attacks of measles, German measles, scarlet fever, and mumps should be recorded on the service record of the soldier at his first physical examination and that subse- quent attacks while in the service should be recorded, as this information pos- sesses practically the same significant value as does the record of typhoid and smallpox prophylactic vaccinations. Previous to the World War numerous investigators attempted to produce active or passive immunity in measles. Various methods were employed and favorable results reported in some instances. In so far as passive immunity is 442 COMMUNICABLE AND OTHER DISEASES concerned, Sellards,31 working at Camp Devens, used blood from active cases of measles on two volunteers to test their susceptibility to measles. These men were exposed to a child in the preemptive stage and were also thoroughly inoculated over the mucous membranes of the eyes, nose, and throat with mucous secretions from this patient. They developed no symptoms of the disease. Attempts at the production of active immunity, not only against measles itself but against some of its more important complications, were attempted in the camps during the war. MacCallum,34 in 1918, stated that in order to pre- vent the extensive occurrence of measles among the troops quarantine methods or some form of prophylactic vaccination might be feasible. Several months prior to this, it was reported from Camp Pike,35 investigations were begun on a vaccine made of the Tunnicliff coccus. The original plan was to secure complete statistics on the vaccination of 2,000 men. Soon after this work began, 1,350 of the 1,500 men who had received the first inoculation were transferred to Newport News, Va., thus making complete inoculations and observations impossible. These were casual troops and had repeatedly been exposed to measles. Four cases developed among the 1,350 men who had received the inoculation, and 16 cases developed among 1,500 others in the same depot who had not been vaccinated. Following the above-mentioned transfer, 500 men were given the first and second inoculations seven days apart. Two cases of measles developed among them between these inoculations. During the same period 15 cases developed among uninoculated troops. Before a third inocu- lation could be accomplished all but 146 were transferred. The 146 received a third inoculation and, in so far as was known, none developed measles. At the conclusion of these observations, 176 men had received the third injection. Among these there were 2 cases of measles. The experiments were not con- sidered complete or conclusive, but it was the impression that the vaccine produced some immunity, and pneumonia, as a complication, seemed to have been less common.35 Coincidentally with attempts to treat measles at Camp Gordon, Ga., it occurred to the chief of the medical service there 36 that it would be advisable, on account of the dangerous complications, to make some attempt to immunize measles cases against streptococcus infection. A vaccine was prepared with this in view, using various strains of streptococci obtained from the pleural cavity, heart's blood, lung, pertioneum, and cases of empyema. A series of 100 measles cases was used for these observations, 50 receiving the vaccine and 50 being used as a control. The vaccinated cases were given three injections at five-day intervals. Both test and control cases were kept under identical con- ditions. Of the 50 cases so vaccinated, 2 developed streptococcus broncho- pneumonia, and of the 50 control cases, 14 developed streptococcus broncho- pneumonia or empyema. These results were considered sufficiently satisfactory to warrant its continuance at Camp Gordon, and conclusions were drawn that while there were from time to time cases of streptococcic empyema and pneu- monia following measles, the condition no longer presented the menace to life and health which it had during the winter months. Munson,29 in 1916, reported the prevention of measles at San Antonio Tex., by requiring frequent medical examinations; the isolation of all suspects MEASLES 443 until a definite diagnosis could be made and of susceptible contacts for 14days; the establishment of sanitary regulations to prevent the transmission of the virus from soldier to soldier; the regulation of places of amusement and recrea- tion; the furling of tents to expose bedding and clothing habitually to the sun and air for at least two hours daily; the prohibition of the common drinking cup and of the practice of spitting in the barracks; the use of the measles census. All of these methods were employed during the war, but without accomplish- ing the results reported by Munson. As previously stated, during the fall of 1917 incoming troops were assigned directly to organizations without a period of detention.7 As soon as practicable incoming troops were assigned to organizations or placed in separate detach- ments, quarantined with the organization but in separate barracks for a period of 14 days. Daily examinations were made for the detection of contagious dis- eases during that period. After the first 32 divisions had been organized, incoming troops were assigned to a separate organization, the depot brigade which, at times, aggregated more than 10,000 men per camp.7 Segregation was attempted in the depot brigade as far as sleeping quarters, mess, and drill were concerned. In some instances, troops were held in more or less effective quaran- tine for the expiration of two weeks, but generally speaking they intermingled with other members of the camp during recreation and amusement. This method was an improvement over the assignment direct of incoming troops to permanent organizations; but the depot brigade existed for the purpose of preliminary training for and supplying troops to the division of the camp of which it was a part, and the prevention of the spread of the contagious diseases was not its prime function. In the summer of 1918, detention camps were authorized for the large cantonments.37 It was contemplated that all incoming troops would first pass through these detention camps where contagious diseases would be detected, patients isolated, and the command thus kept reasonably free. The armistice was signed before these detention camps were completed. In some camps a rapid examination of incoming men was made at the railroad station and suspicious cases were segregated.7 Quarantine was operated in some, by organizations in which measles occurred. In some instances whole companies were quarantined for 14 days; however, in most instances only immediate contacts were quarantined. Where a command was known to be infected, daily examinations of the entire command were made by medical officers, throats sprayed, and precautions taken to provide good ventilation and the best feasible separation of men at night.7 Cubicles were installed in some barracks, use being made of the shelter half as the means of separating adjacent beds; special local regulations were issued against spitting, and soldiers were cautioned against the dangers of coughing and sneezing while in the vicinity of others; alternate head and foot sleeping was ordered and enforced during the latter part of the war.7 Dust from roads and walks was looked upon as a pre- disposing cause, not only in measles, but also in other infectious diseases; hence roads were sprayed with oil in some camps, with apparently good results in the southwestern camps.7 The proper heating and ventilating of barracks were given serious con- sideration. Heating was difficult, particularly in the fall of 1917, as many of 444 COMMUNICABLE AND OTHER DISEASES the heating systems were incomplete.7 Many of the barrack buildings were heated with stoves and soldiers habitually congregated around them, thus increasing the dangers of droplet infection. Orders were issued in an attempt to prevent this.7 With inadequate heat it was difficult and at times impossible to enforce regulations for ventilation, so night inspections were commonly made by company and regimental medical officers to enforce this order.7 Contact with civilians was thought by some medical officers to be a cause of introducing measles into camp. However, in the American Expeditionary Forces, Emerson 10 found no evidence that infection was transmitted from the civilian population to members of the American Expeditionary Forces; no epidemics occurred after the armistice began, and most of the cases that did occur were reported from the armies in the advance section. Many medical officers felt that, owing to the ease with which the infectious agent of measles could be transmitted from person to person and to the high susceptibility of the nonimmune, any real effort to prevent the infection was more or less futile.10 In general, upon the detection of measles the patient was sent by ambulance to the hospital for segregation, observation, and treatment.7 In the early part of the war, little or no attention was paid to the possible spread of infection while en route to hospital, although these patients at times were dispatched in the same ambulance with others. After the use of the face mask at Camp Grant, 111., in the fall of 1917 38 was reported, this means of preventing the spread of infection was applied to patients in the regimental infirmaries and in ambulances. An order was issued that all patients suspected of having an affection of a respiratory nature should be masked until arrival in the proper ward at the hospital.39 As the war progressed and more experience was acquired, every effort was made to prevent the spread of infection from the time the patient was detected until arrival at his bed. It has been the practice in military as well as in civil hospitals to segregate patients with measles from those suffering from other diseases. This was the aim during the war; however, the vast majority of cases were received at the military hospitals during the second stage of the disease and had had ample opportunity to spread the virus to others before arriving at the receiving ward. Once received, they were placed in specially designated wards, where the attendants wore gowns and masks, and where sputum cups, special dishes, and thermometers were provided for these patients.40 The linen was sent to disin- fectors as soon as these appliances became available. In October, 1917, the base hospital, Camp Grant, 111., in an effort to prevent droplet infection, established the plan of masking measles patients and isolating them by means of cubicles, formed by sheets suspended on transverse and longitudinal wires stretched across the ward.41 As stated above, these preventive measures were received with favor and soon adopted throughout the Army.40 The paper sputum cup was later supplemented by the paper bag and paper napkin as receptacles for nasal discharges. These were collected at regular intervals and burned. It was realized that separate rooms would be better than wards for measles patients but this was not possible on account of the number of cases. Such practice would also have called for considerable additional personnel, which was not available. In fact, the hospitals were not constructed with any such practice in view. MEASLES 445 During the latter part of 1917, the problem that confronted the hospital was the actual care of measles in its acute stages. In December, this problem became more difficult on account of the pulmonary complications—principally pneumonia of the pneumococcus type. In the early part of 1918, the type of pneumonia, generally speaking, became the streptococcus type, many cases of which were followed by empyema. It was realized that measles infection lowers the resistance and predisposes the individual to a great variety of other infections and that the mortality depends largely on the occurrence of second- ary infections which accompany or follow the primary disease. The attention of medical officers in the field, therefore, was directed to the prevention of these secondary infections.40 Inasmuch as base hospitals could control the patients only from the time they were received in the hospital, the success of isolation depended on the percentage of secondary infections acquired after their admission. Levy and Alexander23 recommended that all new measles patients be held in segregation until identified as clean cases or carriers and then be assigned to wards accord- ingly. In one ward with 15 clean cases quartered with 15 contaminated cases, it was found, at the end of one week, that only 6 noncarriers remained. In another ward of 24 patients, of whom 12 were carriers, only 3 remained clean at the end of a week. Thus they showed that clean cases became contaminated when the ward was mixed. During another observation it was found that where proper segregation was maintained, strictly clean wards remained clean. They concluded that if the incidence of complications in measles is to be reduced, carriers must be separated and cared for in different wards. Lynch and Cum- ming 42 believed that the air-borne or respiratory diseases are essentially hand- to-mouth infections and that measures applied to prevent this will enormously reduce their occurrence. Friedman and Vaughan 43 remarked that in consider- ing the prevention of measles complications, while emphasis was rightly laid on direct transmission through droplet infection, the indirect means through attendants, utensils, etc., was being unduly neglected. They recommended cubicles of a more substantial nature than sheets: A wooden frame 8 feet long, 6^2 feet high, with a sheet or canvas tacked across it. This device rested on 18-inch bases and was placed between adjacent beds. Further, these authors treated cases at Camp Sevier, S. C, as bed patients until considered safe as to carriers by the ward surgeon. A gown was permanently kept in each cubicle and worn by every individual who entered. Individual thermometers, wash cloths, basins, towels, and glasses were kept in each cubicle. The dishes were soaked in lye solutions and then washed in hot water; bed pans and urinals were washed in water immediately after being used and then placed in large galvanized iron cans containing lye solution; medicine glasses, syringes, and ice bags were sterilized after use; the water taps and basins in the bathrooms were washed with lye solution. The number of cases reported by these authors is too small to base definite conclusions on; however, the above mentioned technique would be difficult to carry out in military hospitals and would require considerable additional equipment and personnel. Nevertheless, vigilance and discipline can do much toward controlling measles. Clendening's 25 plan was to segregate every case of pneumonia, measles, and scarlet fever for 24 hours, during which time throat cultures were made 440 COMMUNICABLE AND OTHER DISEASES and examined. The disposition of the case then was determined upon by whether or not the streptococcus was present. It was claimed that the incidence of bronchopneumonia was greatly reduced by this method. In many, if not in all, of the camps the Streptococcus hemolyticus was found associated with many cases of pneumonia that complicated measles; it also occurred to a variable extent independently. This organism was found in the throats of patients suffering from measles and in contacts, as well as in the throats of soldiers chosen at random. Whether it was brought by carriers or disseminated through the camp can not be stated; however, there are reasons to believe that such diseases as measles and influenza and the time of year, such as the winter season, played an important part. Otherwise there would have been outbreaks of pneumonia due to this organism as soon as the troops reached camp, which was not the case.44 In addition, there would have been no such clear connection between the measles curve and the pneumonia curve as was the case. Further, the principal outbreaks of pneumonia would not have developed in winter and would not have terminated abruptly in the spring. The camp epidemiologist, Camp Pike, Ark., in a special report on measles at that place, stated that owing to the crowded condition in the base hospital during the fall of 1917 measles cases were treated in barracks set aside for that purpose in each organization area.45 This report was based upon the compar- ative results between 538 cases treated in the base hospital and 256 treated in barracks. Among the former, 51 developed complications, of which 30 were pneumonia, with 11 deaths. Among the latter, 4 developed complications, 2 of which were pneumonia; in addition, there was 1 death following the complication of otitis media. In other words, 9.5 per cent of the hospital cases and 1.6 per cent among those in barracks were complicated by other diseases. The death rate among the former was 2 per cent and among the latter 0.4 per cent. These figures are small but significant. The essential differences in the care of these cases were: More space afforded cases treated in barracks than in hospital; the liability to cross infection was greatly reduced among the barracks cases, though nursing facilities were practically nil there, with the exception of orderlies to care for the food and excretions of the patient. When patients are out of bed and able to go about the ward, when they come in close contact with others, the danger of the transfer of measles has passed. However, the danger of transfer of secondary infecting agents often is still present. The danger of spreading secondary infection during convales- cence may be removed, to a great extent, by wearing gauze masks over the mouth and nose. This became a common practice after the dangers of cross infection were more fully recognized. During the major portion of the first year of our participation in the war, the men were sent to duty when the temperature had returned to normal, des- quamation was completed, and the physical condition was apparently good. The duration of hospitalization in many instances was also abbreviated as far as possible on account of the urgent need for additional beds. This practice led observers to believe that complications occurred and that patients were sent to duty before their physical condition justified it. As a result, the Surgeon General issued instructions that all convalescent measles patients would be held MEASLES 447 in hospital, or under observation, for at least two weeks after the temperature had returned to normal.40 Although there are no statistics available to show the value of this order, it is the consensus of opinion of medical officers that it measurably reduced the number of complications and deaths. Room disinfection following measles was not a routine practice in the Army even at the outbreak of the war. It was used in isolated cases, but, in so far as the records show, it fell into disuse as being of no value. The larger hospitals were provided with steam disinfectors for the sterilization of wearing apparel and bedding.46 These appliances had a capacity of 30 to 40 mattresses. Pillows, blankets, and mattresses were disinfected, at times, after measles, but not as a routine.7 The general practice was to send them to the disinfector when they were macroscopically soiled. Linen from the contagious services was run through the disinfector before being sent to the laundry, when time and opportunity were available. In isolated instances, following outbreaks of measles, regimental surgeons sent the blankets and mattresses of entire com- panies or detachments to the hospital for disinfection.7 This, too, was not a routine practice, and there is nothing in the records to indicate that it had any influence in controlling the disease. While the measles virus is short-lived outside of the body and is killed readily by exposure to sun and air, this is not true to the same degree of organ- isms causing secondary infections. Bacteria causing the latter may retain their vitality and pathogenicity for a long period after mucus secretions which con- tain them have dried. It was along these lines that terminal disinfection, as applied to bedding, linen, floors, and mess equipment was considered of special value. TREATMENT The general care of measles patients during the World War was that of other infectious diseases. The uncomplicated case required no special treat- ment. The treatment of measles carried out in the base hospital at Camp Jackson, which may be taken as the usual treatment used throughout the Army, follows:47 There were no striking developments in the treatment of measles during the war. Various methods were employed in attempts to minimize complications, but none of them was conspicuously successful, and until the causative agent is identified and a potent protective serum developed, there is little hope there will be any brilliant progress in treatment. In general, treatment was directed toward keeping patients as comfortable as might be, support- ing the strength, aiding elimination, and an effort to prevent intercurrent respiratory compli- cations. Many different methods to these ends were employed and the details varied some- what in each hospital, and at times in each ward. However, disturbing patients to admin- ister some drug which, theoretically, would prevent some possible complication or be given as a placebo was not justified by the results obtained. Procedures which promised well during the early trials were found valueless when given the test on a larger series of cases. The treatment at Camp Jackson which seemed to give most comfort to the patient was briefly as follows:47 The wards were kept well ventilated but not allowed to become cold, as cold air always increased the amount of coughing. It was not necessary to darken the wards; however, patients were shielded from direct sunlight and those with marked photophobia were removed to the darker parts of the ward. Artificial lights were carefully shaded and patients with annoying cough were grouped, as far as possible, at one end of the ward to minimize the 448 COMMUNICABLE AND OTHER DISEASES disturbance that they caused to others. Laxatives were given routinely on admission and aspirin for headache if necessary. Patients were encouraged to drink water freely. The diet was found to be practically self-regulating, and during the period of high temperature there was little or no desire for food, so liquids were practically the only form of nourishment taken. If vomiting developed, all food was withheld until it ceased, which usually occurred in 24 hours. There was much less nausea among patients so treated than among those given food during the period of nausea, and the period of starvation was so short that it did not impair the patient's strength. When nausea ceased, the patient was then allowed a general diet. Mastication aided in keeping the mouth and tongue clean and stimulated gastric digestion; liquids and soft diets all tasted alike to the patient with a foul mouth, while solid foods well seasoned were apt to be fairly palatable and when taken in larger amounts maintained nutrition at a higher level. This point was important to a patient facing the possibility of pneumonia, or some other serious disease, as a late complication. Not only was his resistance to infection greater, but his recuperative power, if infection occurs, was superior to that of an undernourished individual. Cough was often a troublesome symptom, preventing sleep alike to the individual and his neighbors. Cold air greatly aggravated it, as shown by the amount of coughing at night compared with the day. It was often the cus- tom to open ward windows at night, with a distinct lowering of the room tem- perature and increase in the amount of coughing. To keep the ward warm at night as well as in the day lessened cough demonstrably. For the measles patient whose cough is due to inflammation of the upper respiratory passages, warm air is a necessity. When cough was not controlled by temperature and moisture of the room, opium was used either in the form of codein by mouth or morphia hypodermically. As stated above, many attempts were made to prevent the development of upper respiratory complications. Germicidal solutions were used as a spray without success, patients washed their mouths and gargled with a bland alka- line solution twice daily when they brushed their teeth, vaseline containing some menthol was used for local discomfort in the nose, while liquid albolene was used if the mouth was sufficiently dry to cause discomfort. There was nothing to indicate that spraying was of value and the other forms of treatment enumerated were entirely symptomatic. Special attention was paid to the detection of complications in their early stages, and when detected the treat- ment was that of the complication in question. Otitis media, especially if due to the Streptococcus hemolyticus, developed with surprising rapidity, and rupture of the drum membrane was observed at times in a few hours after the onset of pain. Early paracentesis was necessary for treatment and the preven- tion of mastoid involvement. Meningitis appeared to assume its most fulminat- ing form when it developed during measles. It was recognized early during the war that measles patients who developed pneumonia should be isolated in wards specially designated for that purpose, as they were a potential source of infection for others. Therefore measles pneumonias were cared for separately and not allowed to remain with uncom- plicated measles or cared for in wards where primary lobar pneumonia or bronchopneumonia cases were. Some camps, as a routine, examined all measles admissions for streptococcus in throat smears, and when found the patients were assigned to separate wards. MEASLES 449 Treatment of the carrier state (streptococcus) was disappointing. Levy and Alexander23 reported that throat cultures made at intervals in many of the "dirty" wards showed that the carrier state, once acquired, persisted throughout the patient's stay in hospital and exceptions to this rule were rare. Attempts were made at mouth disinfection without success. Neutral solutions of chlorinated soda in half strength, which had been in common use as a gargle and spray in many Army hospitals, will not kill the Streptococcus hemolyticus even in vitro; while experiments with other mouth antiseptics, notably iodine in glycerin, though successful in the test tube, were clinically disappointing. Of the patients discharged from the hospital at Camp Taylor, who during their stay in the institution were proven to be carriers of the streptococcus, 71.7 per cent, in spite of treatment, still harbored the organism upon return to duty. REFERENCES (1) Based on Annual Reports of the Surgeon General, U. S. Army for the years 1840-1920. (2) The Medical and Surgical History of the War of the Rebellion, Medical Volume, Part Third, 649. Government Printing Office, Washington, D. C. (3) Annual Report of the Surgeon General, U. S. Army, 1866. (4) Annual Reports of the Surgeon General, U. S. Army, 1867-1898, inclusive. (5) Annual Reports of the Surgeon General, U. S. Army, 1899-1916, inclusive. (6) Annual Report of the Surgeon Ceneral, U. S. Army, 1912. (7) Based on reports of general sanitary inspectors. On file, Record Room, S. G. O., 721-1. (8) Duncan, Louis C: An Epidemic of Measles and Pneumonia in the 31st Division, Camp Wheeler, Ga. The Military Surgeon, Washington, 1918, xlii, No. 2, 123. (9) Histories of base hospitals in the United States. On file, Historical Division, S. G. (). (10) Emerson, Haven: General Survey of Communicable Diseases in the A. E. F. The Mil- itary Surgeon, Washington, 1921, xlix, No. 4, 398. (l\) Report of the Chief of the Construction Division, 1919. (12) Hackett, F. J.: Measles from the Standpoint of Military Medicine. Medical Record, New York, 1918, xciii, No. 11, 475. (13) Personal observations. (,14) Hamburger, W. W. and Fox, H.: A Study of the Epidemics of Pneumococcus and Streptococcus Infections, and Measles, at Camp Zachary Taylor, Ky., Autumn, 1917, to Summer, 1918. On file, Historical Division, S. G. O. (15) Francine, A. P.: A Statistical Review of the Pulmonary and Cardiovascular Defects Found in the 82d Division, U. S. National Army, Camp Gordon, Ga., with a Report of After-Results in 500 Measles Cases. The Military Surgeon, Washington, 191S, xliii, No. 2, 160. (16) Berghoff, R. S.: Measles a Predisposing Factor Toward Pulmonary Tuberculosis. Illinois Medical Journal, Chicago, 1919, xxxv, No. 2, 62. (17) Sellards, A. W., and Strum, Ernest: The Occurrence of the Pfeiffer Bacillus in Measles. Johns Hopkins Hospital Bulletin, 1919, xxx, No. 345, 331. (18) Vaughan, Victor C: Epidemiology and Public Health, Volume I, Respiratory Infec- tions, C. V. Mosby Co., St. Louis, 1922, 159. (19) Irons, E. E., and Marine, D.: Streptococcal Infections Following Measles and Other Diseases. The Journal of the American Medical Association, Chicago, 1918, Lxx, No. 10, 087. (20j Cole, Rufus, and MacCallum, W. G.: Pneumonia at a Base Hospital. The Journal of the American Medical Association, Chicago, 1918, lxx, No. 15, 1146. i21) Hektoen, Ludwig: The Bacteriology of Measles. The Journal of the American Medical Association, Chicago, 1918, lxxi, No. 15, 1201. (22) Gumming, J. G.; Spruit, C. B.; and Lynch, Charles: The Pneumonias: Streptococcus and Pneumococcus Groups. The Journal of the American Medical Association, Chicago, 191S, lxx, No. 15, 1066. 56706—28----29 450 COMMUNICABLE AND OTHER DISEASES (23) Levy, R. L., and Alexander, H. L.: The Predisposition of Streptococcus Carriers to the Complications of Measles. The Journal of the A merican Medical Association, Chicago, 191S, lxx, No. 24, 1827. (24) Capps, Joseph A.: The Limitation and Control of Streptococcus and Other Respiratory Infections. War Medicine, Paris, 1918, ii, No. 4, 571. (25) Clendening, L.: Reinfection with Streptococcus Hemolyticus in Lobar Pneumonia, Measles, and Scarlet Fever and Its Prevention. American Journal of the Medical Sciences, Philadelphia, 1918, n. s., clvi, 575. (20) Knowlton, R. H.: Report of Throat Cultures in Measles, The Journal of the American Medical Association, 1919, lxxii, No. 21, 1524. (27) Letter from Lieut.-Col. Eugene L. Opie, M. C, to the Surgeon General, October 31, 1918. Subject: Investigation of penumonia and measles at Camp Pike. On file, Historical Division, S. G. O. (28) Annual Report of the Surgeon General, U. S. Army, 1918, 169. (29) Munson, Edward L.: An Epidemiological Study of an Outbreak of Measles, Camp Wilson, Tex. The Military Surgeon, Washington, 1917, xl, No. 6, 066, to xli, No. 3, 257. (30) Sellards, A. W.: A Census of Susceptibility to Measles and its Relation to Quarantine Procedures. The Military Surgeon, Washington, 1919, xlv, No. 5, 562. (31) Sellards, A. W.: Insusceptibility of Man to Inoculation with Blood from Measles Patients. The Johns Hopkins Hospital Bulletin, Baltimore, 1919, xxx, No. 343, 257. (32) Memorandum from Col. W. P. Chamberlain, M. G, to Col. Deane C. Howard, M. C, Office of the Surgeon General, November 15, 1918. Subject: Medical inspection at Camp Pike, Ark. On file, Historical Division, S. G. O. (33) Gittings, Jack C: Observations on the Military Value of the Immunity Conferred by Previous Attacks of Measles, Scarlet Fever and Mumps. The Military Surgeon, Washington, 1919, xliv, No. 6, 640. (34) Letter from Contract Surgeon W. G. MacCallum, U. S. Army, to the Surgeon General, September 6, 1918. Subject: Experimental study of measles. On file, Historical Division, S. G. O. (35) Letter from Maj. E. F. McCampbell, M. R. C, Camp Pike, Ark., to Col. F. F. Russell, M. C, June 2, 1918. Subject: Measles vaccine. On file, Historical Division, S. G. O. (36) History of Base Hospital, Camp Wheeler, Ga. On file, Historical Division, S. G. O. (37) Memorandum from the Assistant Chief of Staff, Director of Operations, to the Assistant Secretary of War, August 20, 1918. Subject: Additional construction in National Army and National Guards camps. (Approval of Secretary of War affixed thereto.) On file, Record Room, S. G. O., Correspondence File 632 (General). (38) Capps, J. A.: A New Adaptation of the Face Mask in Control of Contagious Disease. The Journal of the American Medical Association, Chicago, 1918, lxx, No. 13, 910. (39) Circular Letter No. 1, Surgeon General's Office, March 25, 1918. (40) Circular memorandum from the Surgeon General, January 1, 1918. (41) History, Base Hospital, Camp Grant, 111., by Lieut. Col. H. C. Michie, M. C, command- ing officer. On file, Historical Division, S. G. O. (42) Lynch, Charles, and Cumming, J. G.: The Role of the Hand in the Distribution of the Influenza Virus and the Secondary Invaders. The Military Surgeon, Washington, 1918, xlii, 597. (43) Friedman, J. C, and Vaughan, W. T.: Comments on the Methods Employed in Prevent- ing Measles Complications. The Medical Clinics of North America, Philadelphia, 1911, ii, No. 2, 559. (44) Memorandum by Maj. John Howland, M. R. C, U. S. Army, Office of the Surgeon General, Washington, August 13, 1918. On file, Historical Division, S. G. O. (45) Letter from the camp epidemiologist to the camp surgeon, Camp Pike, Ark., January 3, 1919. Subject: Special report on measles during September, October, and Novem- ber, 1918. On file, Historical Division, S. G. O. (46) Based on plans for base hospitals. On file, Historical Division, S. G. O. (47) Memorandum on measles by Maj. Charles H. Lawrence, M. C, LT. S. Army. On file Historical Division, S. G. O. CHAPTER XIII MUMPS a STATISTICAL CONSIDERATIONS Table 73 shows that 230,356 cases of mumps wTere admitted to hospital for the total Army during the World War, giving a ratio of 55.80 per 1,000 strength. Among white enlisted men there were 179,948 primary admissions, with a ratio of 49.99 per 1,000 per annum; colored enlisted men had 38,619 primary admissions, with an admission ratio of 134.75 per 1,000 strength, three times that for the white troops. During the World War 43 white enlisted men and 7 colored enlisted men were discharged from the service on account of disability following mumps. The discharge ratios per 1,000 strength were 0.01 and 0.02, respectively. The discharge ratio for colored enlisted men, was twice that for the white. In explanation of these discharges, it is most probable that there were factors causing disability in these cases other than mumps. Because of the nonfatal character of mumps, its great importance to the Army is shown more particularly by the number of days lost from duty. For the total Army 3,884,147 days were lost from duty on account of this disease, giving a noneffective ratio of 2.58 per 1,000 strength. From a standpoint of noneffectiveness, mumps stood third on the list of important diseases for the Army; therefore, when compared with other diseases, and from a standpoint of noneffectiveness alone, mumps was of great importance. Table 73.—Mumps. Admissions, discharges for disability, and days lost, by countries oj occurrence, officers and enlisted men, United States Army, April 1, 1917, to December 31, 1919 Admissions Discharges for disability Days lost Total mean annual strengths Absolute numbers Ratio per 1,000 strength Absolute numbers Ratio per 1,000 strength Absolute numbers Non-effective ratios per 1,000 strength Total officers and enlisted men, including 4,128,479 4,092,457 206,382 230,356 229, 680 2,475 55.80 56.12 11.99 52 52 0.01 .01 3,884,147 3, 874, 722 37, 713 2.58 Total officers and enlisted men, American 2.59 .50 Total enlisted American troops: White _____________.......-- 3, 599, 527 286, 548 179,948 38, 619 8,638 49.99 134. 75 43 7 2 .01 .02 3,020,897 656,383 159,729 2.30 6.28 Total __________________ 3,886,075 36,022 227, 205 676 58.47 18.76 52 .01 3, 837,009 9,425 2.71 .72 Total Army in the United States including Alaska: 124, 266 1, MS 13.26 24, 447 .54 1,965, 297 145,826 117,498 22,482 59.78 154.15 35 7 .02 .05 1,877,193 374,904 2.62 7.04 2, 111, 123 139,980 66.31 42 .02 2, 252,097 2.92 2, 235,389 141, 628 63.36 42 | .02 2, 276, 544 2.79 -----, -----: " Cnless otherwise stated, all figures for the World War period are derived from sick and wounded reports sent to the Surgeon General.—Ed. 451 ■452 COMMUNICABLE AM) OTHER DISEASES Table 73.-— Mumps. Admissions, discharges for disability, and days lost, by countries of occurrence, officers and enlisted men. United States Army, April 1, 1917, to December 31, 1919—Continued Admissions Total mean Absolute annual numbers strengths Ratio per 1,000 strength Discha disal Absolute numbers rges for )ility Ratio per 1,000 strength Days Absolute numbers 12, 531 lost Non-effective ratios per 1,000 strength C. S. Army in Europe, excluding, Russia: Officers_____.....----......-.------ 73, 728 773 10. 48 .47 1,469, 656 122,412 57,554 15,023 8,503 39.16 122.72 6 0 1,063, 930 267, 234 157, 527 1.98 5.98 1 1,592,068 81,080 50.93 7 0 1, 488, 691 2. 56 1, 665, 796 8, 388 81,853 54 49.14 f 7 0 1, 501, 222 735 2.47 6.44 .24 U. S. Army in Philippine Islands: 16,995 4,456 356 65 20.95 14.59 5, 'J38 1,025 .96 .63 21, 451 421 19.63 6,963 .89 U. S. Army in Hawaii: 16,161 3,319 228 107 14.11 32.24 1 .06 4,482 1,623 .76 1.34 i Total__________________......._____ 19, 480 19, 688 335 82 17.20 1 .05 6,105 1,324 .86 4.17 .18 ' V. S. Army in other countries not stated: C) 1,850 107 107 32,239 2,220 2,004 Total..........________________ 14, 232 2,064 145.06 36, 463 7.02 Transports: 97,498 10,535 2, 380 835 28 24.41 79.26 1 .01 35, 791 9,377 198 1.01 2.44 l Total . ......- __________ 108,033 18, 576 5,615 11,831 3,243 504 43 129 30.02 27.13 7.66 10.90 2 .02 45,366 7,330 465 1,630 1.15 Native troops enlisted: 1.08 : .23 .38 1 • Separate strength of white and colored not available. Mumps caused more noneffectiveness among colored troops than among white troops; there were 3,020,897 days lost from duty among 3,599,527 white enlisted men and 656,383 days lost among 286,548 colored enlisted men. These figures give a ratio of 2.30 for white enlisted men and 6.28 for colored per 1,000 strength. Thus the noneffectiveness was approximately three times greater among colored troops than among white. Mumps was widely dis- tributed over the United States and was reported from all stations, as is showm in Table 74. The camps that had the largest occurrence among white enlisted men, were, in the order named: Camp Beauregard, La.; Camp Wheeler, Ga.; Camp Bowie, Tex.; and Camp Travis, Tex. The admission ratios per 1,000 strength for the camps mentioned wrere all above 213 per 1,000 strength. The camps reporting the smallest number of total cases were Camp Syracuse, X. Y.: Camp Forrest, Ga.; and Camp Cody, X. Mex. The first two camps were small, with a mean strength of about 10,000 troops. Camp Cody, X. Mex., though a camp of average size, reported only 333 cases, giving a ratio of 14.71 per 1,000 strength. The average number of cases per camp in the United States was 2,650 and the average ratio per 1,000 strength was 81.40. It is seen that MUMPS 453 of the 39 camps shown in Table 74, 16 reported cases above the average in number and 13 had a primary admission ratio above the average among total troops. Table 74.—Mumps. Admissions, by camps of occurrence, while and colored enlisted men, United States Army, April 1, 1917, to December 31, 1919. Absolute numbers Camps Average strength for period Camp Beauregard, La__ Camp Bowie, Tex______ Camp Cody, N. Mex___ Camp Custer, Mich____ Camp Devens, Mass____ Camp Dix, N. J________ Camp Dodge, Iowa_____ Camp Doniphan, Okla... Camp Eustis, Va_........ Camp Forrest, Ga__...... Camp Fremont, Calif___ Camp Funston, Kans___ Camp Gordon, Ga....... Camp Grant, 111_______ Camp Greene, N. C____ Camp Greenleaf, Ga---- Camp Hancock, Ga____ Camp Humphreys, Va... Camp Jackson, S. C____ Camp Johnston, Fla---- Camp Kearny, Calif---- Camp Lee, Va_________ Camp Lewis, Wash____ Camp Logan, Tex......_. Camp MacArthur, Tex. Camp Mc-Clellan, Ala... Camp Meade. Md___.. Camp Mills, N. Y_____ Camp Pike, Ark------ Camp Sevier, S. C_ _. . Camp Shelby, Miss.. Camp Sheridan, Ala--- Camp Sherman, Ohio___ Camp Syracuse, N. Y... Camp Taylor, Ky_____ Camp Travis, Tex----- Camp Upton, L. I., N. . Camp Wadsworth, S. C. Camp Wheeler, Ga....... Others_______________ Total___________ 20,625 26,193 22,636 37, 631 47,921 49,786 39,032 26, 747 6,780 8,980 15,414 56, 222 44, 871 49, 256 29, 710 11,959 37,994 12,836 42,011 22, 267 25, 472 57, 635 47, 792 27,734 25, 271 28, 664 50,033 24,197 49, 587 27, 786 30,432 26, 507 42, 750 3,367 46,962 44, 264 44,871 31,809 25,726 339 Primary admissions White enlisted men Absolute numbers 1, 270,069 4,725 5,387 333 1,676 722 849 2,616 1,377 306 40 455 5,874 2,752 1,390 2,423 243 849 344 4,183 1,162 1,752 3,388 4,676 416 1,076 723 672 1,079 5,848 5,245 2,637 977 2,224 4 2. 880 7,998 608 415 5,144 Ratios per 1,000 strength 233.88 213.43 14.71 46.20 15.80 18.88 78.73 51.48 48.39 4.45 29.52 117.35 72.33 32.85 92.55 20.32 23.32 35.27 113.42 58. 52 68.78 66.43 98.93 15.60 44.25 27.25 16.01 47.04 143.09 200.34 91.63 38.13 60.17 1.19 67.64 213. 22 15.12 13.77 215.13 85, 468 73.71 Colored enlisted men Total Absolute numbers 81 104 14] 557 1,476 """83" Ratios per 1,000 strength 191. 94 109.13 i u--i„*-1 Ratios Absolute , non numbers Pf^ 103. 98 250.90 84.74 254.22 182.02 1,092 2,364 1,163 387 238 613 1,102 412 875 26 90 25 276 503 214 1,456 125 378 43 912 338 1,073 1,009 88 248 10 17, 910 177.05 346. 50 167. 61 109. 66 149. 22 198.78 214,86 170.82 131.96 49.53 84.19 26.23 129.58 62.50 170. 26 167.02 77.84 228.81 48.59 157. 65 77.06 163.24 216.11 52.60 136. 64 29.50 4. 806 5, 491 333 1,817 1, 279 1,257 4,092 1,377 389 40 455 6,966 5,116 2,553 2,810 243 1,087 957 5,285 1,574 1,752 4,263 4,702 506 1,101 999 1,175 1,293 7,304 5,370 3,015 1,020 3,136 4 3,218 9,071 1,617 503 5,392 10 161.93 | 103,378 233.01 209.63 14.71 48.28 26.68 25.24 104.83 51. 48 57.37 4.45 29.52 123.90 114.01 51. 83 94.58 20.32 28. 61 74. 55 125.80 70. 68 1)8. 78 73. 96 98.38 18.24 43.56 34.85 23.48 53.43 147.29 193. 26 99.07 38.48 73.35 1.19 68.52 204.92 36.03 15.81 209. 59 29.50 81.40 OCCURRENCE IN THE UNITED STATES The seasonal occurrence, of disease is well shown by mumps in the Army in the I'nited States during the World War. The average admission ratio for mumps in the United States was 66.30 per 1,000 per annum. (Table 75.) In October, 1917, the admission ratios for white troops increased, reaching the maximum in February of the year following. Reviewing the occurrence among white troops only, we find that in October, 1917, 1,683 cases were reported as primary admissions. The ratio was 19.57 per 1,000 strength. In November of this year, 4,179 cases were reported as primary admissions, giving a ratio of 47.25 per 1,000 per annum. The following month, December, both the number of cases and the ratio were more than doubled. There were 10,368 primary admissions, giving a ratio of 110.19 per 1,000 strength. In January, 1918, again these numbers were practically doubled. There were 19,460 primary admissions and the ratio per 1,000 strength was 212.98. In February, 1918, although there was an increase, this increase was not in the same proportion as had oceured during the several preceding months. There were 21,092 primary 454 COMMUNICABLE AND OTHER DISEASES admissions, with a ratio of 231.14 per 1,000 strength. From this date the number of cases and the ratio decreased until the second seasonal occurrence, which occurred in the following November. The seasonal occurrence com- mencing in 1918 did not reach the same magnitude in the I nited States as did the seasonal occurrence which started in 1917. The seasonal occurrence of 1918 began one month later, with 2,729 primary admissions, giving an admission ratio of 26.09 per 1,000 strength. In December, twice as many cases were reported with more than double the admission ratio—that is, 4,7IS primary admissions and a ratio of 60.16 per 1,000 per annum. Although there was an increase in January, 1919, it was not in the same geometrical propor- tion as had occurred in the previous year. For this month, 6,027 primary admissions were reported with a ratio of 107.48 per 1,000 strength. In Feb- ruary, 1919, the occurrence of mumps began to decrease, and continued to decrease to the end of the war. There was no seasonal occurrence in the latter part of 1919. Table 75.—Mumps. Admissions, by months, white and colored enlisted men, United States Army, United States and Europe, April 1, 1917, to December 81, 1919 White enlisted men United States Europe Year and month Mean strength 183, 758 245,454 309, 205 458,817 562,714 776,466 1, 032, 244 1,061,422 1,129,065 Admissions Deaths Mean strength Admissions Deaths Absolute num-bers Ratios per 1,000 strength Absolute num-bers Ratios per 1,000 strength Absolute num-bers Ratios per 1,000 strength Absolute num-bers Ratios per 1,000 strength 1917 April______________ 485 634 771 31.67 30.99 29.92 May______________ June___________ . -13.420 28,821 50,882 70, 266 92,139 123,429 160,178 «9 256 335 288 258 708 1,478 8.05 106. 58 79.01 49.18 33.60 68.83 110.73 July______________ 754 19.72 578 ' 12.33 731 11.30 1, 683 19. 57 4,179 47.25 10,368 110.19 August........._____ September_____ ___ October________ November_________ 1 13 .01 .14 1 .07 Total 1917_____ 479,929 ----- 20,183 | 42. 05 14 .03 44,928 3,332 74.16 1 .02 1918 1,096,434 1,095,039 1,129, 223 1,168, 558 1,197, 757 1,303,746 1,328, 513 1,284, 247 1,321,440 1,343,933 1,255,195 941, 219 19,460 21,092 13, 950 7,181 4, 136 2,366 2,211 1,883 1,872 1,817 2,729 4,718 212. 98 231.14 148. 24 73.74 41.44 21.78 19.97 17.60 17.00 16.23 26.09 60.16 17 12 11 4 1 .19 .13 .12 .04 .01 193, 264 223,130 283, 268 388,048 587, 240 796,427 1,063,192 1,266, 592 1, 527,793 1,635,321 1,682,836 1, 591,962 2,693 3,087 3,234 1,626 1,579 1,293 1,264 1,587 3,018 4,347 6,477 8,864 167. 22 166.02 137. 00 50.28 32.27 19.48 14.27 15.04 23.70 31.90 46.19 66.82 1 2 February______ ____ March_______________ .11 April______ ________ .May______________ _ 2 1 3 8 10 3 5 .03 June____....._____ . 02 .03 July.... 1 .01 August____________ .01 .03 September_____ .. 6 5 2 11 .05 .04 .02 .14 .06 November.. ._ ____ .07 December_____ . .02 .04 Total 1918 1, 205,442 83,415 69.20 70 .06 936, 589 39,069 41.71 37 .04 672,937 471,815 406,839 339. 836 291,810 246,903 215,104 156, 791 149,360 139, 877 132,403 135,441 6,027 3,972 2,254 843 344 172 56 56 62 31 24 52 4 .07 1,488, 683 1,310,083 1,115,693 853,425 569,842 271, 633 111,634 48,006 30,315 21,055 18,920 18, 379 6,399 3,835 2,648 1,220 539 198 153 94 24 3 1 2 51.58 35.13 28.48 17.15 11.35 8.75 23.49 9.50 1.71 1.31 3 1 1 February__________ 101. 02 66.48 29.77 14.15 8.36 3.12 4.29 4.98 2.66 2.18 4.61 .02 March_________ _._ April_______ Mav________ ... 1 .03 .01 .01 July_____________ August____ _______ September___ ____ October___ . December__________ Total 1919_____ Month not stated 279, 926 13,893 49.63 5 .02 488,139 15,116 37 30.97 5 .01 Total for period. 1,965, 297 117,498 59.78 89 .05 1,469, 656 57, 554 39.16 43 .03 a Includes April and May. MUMPS 455 Table 75.—Mumps. Admission, by months, white and colored enlisted men. United States Army, United States and Europe, April 1, 1917, to December 31, 1919—Continued Colored enlisted men United States Europe Year and month Mean strength Admissions Deaths Mean strength Admissions Deaths Absolute num-bers Ratios per 1,000 strength Absolute num-bers Ratios per 1,000 strength 2.46 Absolute num-bers Ratios per 1,000 strength Absolute num-bers Ratios per 1,000 strength 1917 4,870 5,826 5,171 6,675 8,519 9,409 21, 795 39, 225 36,851 10 4 4 11 5 14 29 82 330 24.63 8.23 1 9.28 19.78 7.04 17.86 15.97 25.09 107.46 July.. 935 2,392 5,346 1 57 357 286.43 800.45 1 2.24 Total 1917______ 11,529 489 42.41 1 .09 723 415 574. 00 1 1 1.38 1918 50,705 49,955 54,814 59,015 87, 650 89, 305 124,976 168,422 164,846 182, 706 150, 587 104,140 1,870 2,406 1,351 1,257 2,060 1,859 1,047 931 1,080 1,486 2,094 2,094 422. 60 577.95 295. 75 255. 60 282.04 249.80 100.53 66.33 78.62 97.60 166. 87 241.30 3 1 5 1 3 2 1 2 3 1 1 1 .71 .24 1.09 .20 .41 .27 .10 .14 .22 .07 .08 . 12 8,673 9,664 11,541 12, 667 28,279 33,208 47,171 78,734 91, 270 138,827 148, 679 148,372 1,235 923 149 287 593 622 942 1,053 1,195 1,892 2,972 1,429 1,708.16 1,146. 58 1.54.89 271. 78 251. 59 224.79 239. 63 160.49 157.11 163.54 239. 87 115.58 1. 38 1 2 2 4 3 2 1 .36 July.. ____________ .51 .31 .53 .26 .16 .08 Total 1918______ 107, 260 19, 535 182.13 24 .22 63,090 13,292 210. 68 16 .25 1919 68,337 66,104 44, 634 29,824 20, 780 18, 562 20,058 18,013 11,322 9,084 8,792 8.935 1,357 766 194 93 20 16 8 238.32 139. 05 52.15 37.42 11.55 10.34 4.79 140,396 131,219 123,152 119,801 108,650 64,166 12,508 1,741 1,287 185 546 271 232 120 112 32 1 46.67 24.78 22.61 12.02 12.37 5.98 .96 1 1 .09 2 .36 ____ .09 . ___ ____ .... ... July 1 1.06 2 1 1.34 22.42 2 Total. _____ 27,037 2,458 90.91 * .07 58, 599 1,314 .03 2 .19 Total for period.._ 145,826 22,482 154. 15 27 122,412 15,023 1 122.72 19 .16 The above review of occurrence for white enlisted men in the United States applies, in general, to the occurrence of mumps among the colored enlisted men. Mumps was more common among colored enlisted men, but the ratios during the latter part of 1917 were lower than those for white enlisted men in the respec- tive months; however, the number of colored troops in the Army at that time was small. By January, 1918, the number of colored troops had greatly increased. The mean aggregate strength for 1917 was 11,529; during 1918, the mean aggregate strength was 107,260. Commencing in January, 1918, the occur- rence of mumps among colored enlisted men was greater than among white enlisted men. This occurrence continued until the spring of 1919. The highest ratio for colored enlisted men was in February, 1918, which was 577.95 per 1,000 per annum. From this date there was a decrease in the admission ratio until 456 COMMUNICABLE AND OTHER DISEASES the following October. As in the case of white enlisted men, the second seasonal occurrence, which commenced in October, 191S, although greater among white enlisted men, did not reach the magnitude of the preceding year. The largest number of cases of mumps reported among colored enlisted men for any one month was in February, 1918. There were 2,406 primary admissions in the United States for that month. From all points of view mumps was more important among colored than among white troops. As has been stated above, the admission, discharge, and noneffective ratios were higher among the former. The explanation is believed to lie in the fact that a larger proportion of colored troops was drafted from rural districts. It has been shown that the occurrence of mumps in the Army in the United States was a matter of serious concern during mobilization. Xo men were enlisted in the Army during the first two months of 1919 and comparatively few during the early spring. The admission rate, as shown by Table 75, was on the decline at this time, and much below that of the corresponding months of the preceding year. Large numbers of troops were returned to the United States from Europe during the latter months of 1918, and throughout the remain- ing portion of the winter and spring of 1919. In spite of the fact that large numbers of troops were sent into the larger camps of the United States from January, 1919, to June of that year, the admission ratio for mumps decreased. Therefore, one may say that demobilization had no influence on increasing the the ratio of mumps in the camps. OCCURRENCE IN THE AMERICAN EXPEDITIONARY FORCES Table 73 shows the part played by mumps in the Army in Europe during the World War. There was a total of 81,853 primary admissions, with an aver- age annual ratio of 49.14 per 1,000 strength. The highest admission ratio was for colored enlisted men—122.72 per 1,000 strength. As in the United States, colored enlisted men in the American Expeditionary Forces had an admission ratio far greater than did white enlisted men. The great importance of mumps in the Army overseas, as in the United States, was due to the amount of time lost from duty. Table 73 shows 1,501,222 days lost from this disease in the Army in Europe, giving a noneffective ratio of 2.47 per 1,000 per annum. Again the ratio was greater for colored enlisted men. White enlisted men had a noneffective ratio of 1.98 and colored enlisted men 5.98 per 1,000 per annum. FACTORS INFLUENCING OCCURRENCE Many factors enter into the occurrence of mumps. According to Zinsser1 "Our impression from Army experience is that there may be carriers." Radin2 found that 95 per cent of the cases at Camp Wheeler, Ga., occurred during the first two months of service. A physical condition below par was found to be a factor of some predisposing importance, and most of the cases were from rural districts. As mentioned above, mumps had distinct seasonal occurrences. From October to March, in temperate climates, mumps occurred most fre- quently. Racial influences were marked during the war, and there was a °reat MUMPS 457 difference in the occurrence of this disease between white and colored troops, being more common among the latter. It is also probable that crowding had a marked influence on the occurrence of mumps; however, there is no record of any experiments conducted along these lines during the World War period. One attack of mumps usually confers immunity, but not necessarily so. SYMPTOMS The usual onset of mumps was characterized by pain, swelling, and stiff- ness about the angle of the jaw, made more noticeable by opening the mouth. There was usually malaise and some fever. Like many other diseases where the bacteriology is not known, diagnosis was often very difficult. The leucocyte count was usually normal in the uncomplicated case; sometimes there was leucopenia. When complications occurred, especially orchitis, there was usually a mild leucocytosis. Radin 2 summarized the onset of mumps as fol- lows: Onset with no symptoms; onset with gastric disturbances and features suggesting pancreatitis; onset with pancreatitis, orchitis, and urethral dis- charges; onset with features of acute laryngitis and bronchitis; griplike onset, with fever, headache, malaise, sore throat, and pain in the bones; onset with inguinal pain and backache; and the ordinary onset. The same observer summarized the physical signs of mumps as (1) Hatchcock's sign; (2) pouting and pinkness of the orifices of Steno's duct; (3) swelling of the face in the parotid region; (4) doughy elasticity of the swelling; (5) discharge of secretion from Steno's duct on pressure over the gland externally. This author describes Hatchcock's sign as follows:2 "The sign is tenderness just beyond the angle of the jaw on running the finger toward the angle, under the mandible. If the parotid gland is at all involved, the patient winces with pain. This occurs before any swelling can be made out." Pouting of the orifice of Steno's duct, with a pink areola on the mucous membrane around the mouth of this duct, has often been described as occurring in mumps. It was reported as occurring only on the side where mumps was present. On inserting a cannula into the mouth of Steno's duct, a fluid will often be ejected if mumps is present. According to Radin, elevation of tem- perature was not constant, occurring in about 80 per cent of the cases; the range of temperature was most commonly from 99° to 101° F., and duration was from 1 to 24 days, with an average of 4 days. About 24 hours before the onset of a complication, a rise in temperature of from 1° to 3° was noticed. This was usually accompanied by leucocytosis, the polymorphonuclear leuco- cytes showing a relatively higher percentage in the orchitic than in the uncom- plicated cases. In the latter the average was 51.9 per cent; in the orchitic cases the percentage was 60.2. These findings were reversed in the case of lymphocytes; the relative percentage of lymphocytes was 38.4 in uncomplicated and 34.5 in orchitic cases. Vomiting, nausea, and orchitic pain may occur without apparent cause. The period of incubation is from two to three weeks.3 Radin 2 had occasion to report upon this subject in the case of two nurses who were not immune to mumps and placed on duty in a mumps ward. One nurse developed mumps in two weeks and the other in two and a half weeks after exposure. 45S COMMUNICABLE AND OTHER DISEASES Although mumps may involve the submaxillary, sublingual, and occasion- ally the lachrymal glands, as well as the parotid glands, the system of recording diagnoses in the Surgeon General's Office does not permit such detailed analysis of cases. The average duration per case was 16.86 days for the total Army. The average number of days in hospital for mumps in the United States was 16.07 days and in Europe 18.34 days. PATHOLOGY But little is known of the pathology of mumps. Although typical mumps involves the parotid glands only, the other salivary glands may be involved. Osier :i is the authority for the statement that the submaxillary and sublingual glands may become swollen, though not always; in a few cases they alone may be attacked. Radin 2 reported that a parotid gland was removed by mistake in a case of mumps at Camp Wheeler. After its removal, advantage was taken of the opportunity to observe the structure of the gland. This proved to be normal. Cervical and inguinal adenitis were not infrequent. Orchitis was frequent and redness of the scrotum and epididymitis often occurred. The thymus gland was enlarged in some of Radin's cases. Involvement of the pan- creas is supposed to occur in mumps at times, but the exact pathology has not been reported. In mumps meningitis, according to Larkin,4 the meninges showed lymphatic and edematous changes associated with some encephalitis. The spinal fluid was clear in these cases and showed an increased cell count (lymphocytes). The fluid was sterile on bacteriological examination. Larkin reported two cases of mumps meningitis, one with a cell count of about 20 per c. mm. and the other of about 200. Leucocytosis was present in the blood in both cases. The autopsy findings in one of Larkin's cases were as follows:4 * * * * * * * Autopsy.—At autopsy an early bronchopneumonia, acute diffuse splenitis, and acute parenchymatous nephritis were found. On removing the brain an extensive accumulation of slightly turbid fluid in the cisterna magna was observed. The pia-arachnoid was congested. In many places a perivascular exudate was seen in the form of grayish-yellow lines following the course of the blood vessels. The ventricles were somewhat distended. The fluid was clear". The ependyma was slightly granular. Cultures (aerobic) from the perivascular exudate and from the spinal fluid were negative. Microscopic sections showed the pia- arachnoid densely infiltrated with large and small mononuclear cells. The infiltration was definitely perivascular, but also extended into the areolar tissue and cortex. Similar cells were adherent to the arterial intima. ****** * DIAGNOSIS The ordinary case of mumps is not difficult to diagnose correctly, especially in the presence of an epidemic. There may be cases, however, of a mild type, or cases involving salivary glands other than the parotid gland, where the diag- nosis is difficult. The difficulty is increased by the absence of any positive laboratory findings characteristic of mumps. The following clinical signs and symptoms, when present, are pathognomonic: Swelling and tenderness of the salivary gland unilateral or bilaterial; pink and pouting orifice of Steno's duct, discharge of a whitish secretion from the duct upon pressure on the gland MUMPS 459 involved, or by aspiration; pain or a drawing sensation in the mouth on eating sour food; Hathcock's sign. These findings are usually accompanied by some elevation of temperature and an absence of leucocytosis. A sudden rise of temperature during the course of mumps leads one to suspect complications. These complications are usually accompanied by leucocytosis. Orchitis, with swelling and some tenderness, is the most common complication. It may be bilateral or unilateral, is often accompanied by epididymitis, and may be fol- lowed by atrophy. Pain in the ear on the side involved by mumps is not uncom- mon, and may be due to the swollen parotid gland or to otitis media. Head- ache, stiffness of the neck muscles, positive Kernig's sign, with sudden increase in temperature and the number of leucocytes, should lead one to suspect menin- gitis. Confirmation of the diagnosis is made by lumbar puncture. The spinal fluid in mumps meningitis is clear on withdrawal, has an increased cell count, and the fluid is sterile. A fine whitish sediment forms on standing. It is impor- tant to differentiate this form of meningitis from other forms, especially the epidemic variety. Larkin gives the following differential diagnostic table:4 Mumps Tuberculosis Influenza Appearance on withdrawal-.. Usually clear______..... Cloudy. Appearance after 14 hours___ Cell count_____________ Fine white sediment______ 200__________ "Spider web " or "Velum"— 200 Yellowish-white sediment. 500. Type____________________ Leucocytes. Bacteriology____.. ___. Pneumonia j Streptococcus infection Epidemic meningitis Appearance on withdrawal... Turbid____________ Turbid Turbid. Appearance after 14 hours___ Heavy purulent .. _______ Cell count________________ 500___________ 500 500. Type____________________ Leucocytes-.. . Streptococcus Leucocytes. Meningococcus. In submaxillary mumps, differential diagnosis from tonsillitis with cervical adenitis is necessary. In this form there is usually an epidemic of mumps present and the tonsils are normal; the swelling is under the center of the mandible and the salivary gland is involved. On the other hand, the confusing cervical adenitis is of inflammatory origin, not epidemic, and involves the lymphatic gland which is located somewhat farther back than is the salivary gland. TREATMENT Experience during the war developed no specific treatment for mumps, and none is known. It was the practice in the Army to isolate all cases and to retain them in quarantine until they were no longer a source of danger. Some hospitals adopted the plan of a 21-day quarantine; others based the quarantine on clinical findings of the individual case—when there was no longer swelling of the salivary glands and no complications were present, the cases were assumed to be free of infection. The presence of a temperature above normal was a counterindication for discharge from hospital; however, a normal temperature did not mean that the patient was not a source of danger. Cubicled beds and gauze masks were utilized as preventives of spread of the disease in hospitals, in some instances both the patients and the attendants 460 COMMUNICABLE AND OTHER DISEASES being masked. There is no record of proof, however, that either of these methods was of great value in preventing the spread of mumps. There was a difference of opinion as to the value of this practice. In some instances uncom- plicated mumps patients were allowed up and walked to their meals, while others were treated strictly as bed patients. A review of the available litera- ture does not show any great difference in the percentage of complications, especially orchitis, that developed with these two different forms of treatment. Some patients were allowed to get up for meals and to walk about generally, while others were required to remain in bed throughout the course of the disease.2 The ordinary uncomplicated case of mumps required no medication. When medicaments were administered, these varied in different camps. Radin2 reported that orchitis occurred one-third less frequently in patients treated with hexamethylenamin than in those patients who did not receive this form of medication. Orchitis was reported as being less common at Camp Grant where bromides were used.5 Particularly was this true among colored patients. Local applications of heat or cold were used, according to the preference of the patient. Radin used Dobell's gargle, hot applications, and camphorated oil over the swollen salivary glands, and aspirin and bromides internally for pain and nervousness. The early stage of otitis media was most commonly treated by instilling 2 drops of a 2 per cent phenolized glycerin into the external auditory canal, and sometimes into each nostril, twice daily. Where an exu- date was present, manifested by bulging of the tympanum, early incision and drainage was the procedure of election. Orchitis was treated by support, and counterirritation in the form of ice bags, ichthyol, or guaicaol carbonate. Rest in bed was the best form of treatment. Mumps meningitis was treated by spinal drainage. COMPLICATIONS AND SEQUEL_E Of the 230,356 cases of mumps reported as primary admissions, 40,008 developed complications of some kind. In addition to the above, there were 6,107 cases reported during the World War as concurrent with other diseases. The case mortality among the primary admissions was 0.08 per cent and the case mortality among cases of mumps reported as a concurrent disease was 2.11 per cent. The most common complication in mumps was orchitis. There were 24,337 cases of mumps admitted as primary admissions which developed com- plications of the genitourinary system, other than venereal; that is, 10.56 per cent. It is presumable that the vast majority of these cases were orchitis, epi- didymitis, or both. Radin2 reported this complication in 13.91 per cent of the cases at Camp Wheeler, Ga. Orchitis, bilateral, occurred in 102 cases, and unilateral orchitis in 452 cases. Epididymitis alone was reported by Radin in 5 cases. At Camp Shelby Miss., orchitis was reported as a rather frequent complication, and principally among the colored labor battalions. Fort Riley. Kans., reported orchitis present in from 20 per cent to 25 per cent of the cases of mumps in 1917 and in about 5 per cent in 1918. Camp Lewis, Wash, re- ported epididymitis in 7 per cent, orchitis in 21 per cent, and epididymitis and orchitis in 4 per cent of their cases. Orchitis was a frequent and an annovino- complication of mumps in the American Expeditionary Forces. Among the MUMPS 461 4,500 cases reported by Camp Hospital No. 52, A. E. F., orchitis was the only complication of special note. Next to orchitis, meningitis may be taken as the most important complica- tion occurring in mumps. Haden 6 reported 9 cases of mumps with cerebral complications, at Camp Lee, Va., among 476 cases of mumps. This complica- tion usually occurred late in the disease. In the careful study of more than 5,000 cases of mumps by Radin,2 no mention was made of meningitis. Larkin4 reported 2 cases of mumps meningitis at Camp Taylor, Ky., during the World War, 1 of which died. The autopsy findings in the case which died have been quoted previously in this chapter. Several cases of mumps with signs of menin- geal irritation manifested by headache, irritability, restlessness, slight cervical rigidity, suggested Kernig's sign, high temperature, and respiration, were re- ported at Camp Lewis, Wash. These signs disappeared in from 24 to 48 hours. In 1917, 2 cases of mumps meningitis among 1,800 cases of mumps were re- ported at Beauregard, La. One case of mumps meningitis was reported from Base Hospital No. 106, A. E. F. in 1917. Acute pancreatitis in mumps was reported during the war. The monthly sick and wounded reports of the Surgeon General's Office show 26 such cases. Radin 2 reported 14 cases at Camp Wheeler, Ga., or 0.31 per cent of the cases. This complication Wjas reported from Camp Lewis, Wash., in 0.2 per cent of the cases. Among the total primary admissions of 230,356 cases, otitis media was re- ported in 906, lobar pneumonia in 701, bronchopneumonia in 320, arthritis in 184, acute articular rheumatism in 231, measles in 436, scarlet fever in 288, bronchitis in 1,223, and diphtheria carriers in 208 cases. The records would indicate that the death rate of the concurrent disease was not increased by the coexistence of mumps. The report of Radin 2 permits analysis of the involvement of the various salivary glands in a large number of mumps cases studied by him. Both paro- tids alone were involved in 2,747 of his 5,756 cases, that is, 47.7 per cent; the right or left parotid alone was involved in 20.5 per cent; both submaxillary glands alone were involved in 16, or 0.27 per cent, of the cases, and the sub- maxillary salivary gland on one side alone was involved in 18 cases, or 0.31 per cent. The sublingual salivary glands were involved in 31 cases, either con- jointly with other salivary glands or alone. The parotid glands were involved in 73.71 per cent, the submaxillary glands in 7.64 per cent, and the sublingual glands in 5.21 per cent. One case of suppuration of the parotid gland was reported by Radin,2 but there was a question as to whether the gland proper was involved in the sup- purative process or whether the process was one of suppurative cellulitis. One case of parotid abscess was reported from Camp Pike, Ark., in October, 1918, following mumps. This case died. PREVENTIVE MEASURES From a military point of view, the control of mumps is a very important problem; however, no satisfactory method has yet been devised for controlling this disease. The length of time that a patient may be a source of infection is 462 COMMUNICABLE AND OTHER DISEASES not known. It is not known when the communicable stage starts, or when it definitely ends; therefore quarantine was not required during the war, except in isolating patients. Contact cases were not quarantined. On account of the high degree of contagiousness of this disease, it spread rapidly through the various commands soon after mobilization. At Camp Wheeler, Ga., Radin 2 reports that 32 per cent of the command developed this disease. The general preventive measures used there were removal of patients from their companies as soon as the disease appeared, retaining them in quarantine at the hospital until they appeared no longer a source of contagion. No measures used appeared to control, or even check, the spread. Since the virus has been reported to be contained in the saliva, boiling of all mess equipment, such as knives, forks. spoons, cups, plates, etc., would appear to be of great value, thus preventing the spread of mumps through this medium. It was customary to boil mess equipment during the World War, but there is no report upon its efficacy in controlling the spread of mumps. REFERENCES (1) Zinsser, Hans: A Textbook of Bacteriology. D. Appleton & Co., New York, 1922, 5th Ed., 930. (2) Radin, M. J.: The Epidemic of Mumps at Camp Wheeler, October, 1917-March, 191S. The Archives of Internal Medicine, Chicago, 1918, xxii, No. 3, 354. (3) Osier, Sir William: The Principles and Practice of Medicine. D. Appleton & Co., New York, 1914, 8th Ed., 349. (4) Larkin, Wm. R.: Mumps Meningitis—Report of Two Cases with Autopsy Findings. The Military Surgeon, Washington, 1919, xliv, No. 1, 92. (5) Rock, John L.: Some Observations on Mumps. On file, Historical Division, S. G. O. (6) Haden, Russell: The Cerebral Complications of Mumps with Report of Nine Cases. Archives of Internal Medicine, Chicago, 1919, xxiii, No. 6, 737. CHAPTER XIV GERMAN MEASLES a STATISTICAL CONSIDERATIONS German measles was not of particular importance to the Army during the World War and did not rank among the 30 most common diseases. There were 17,378 primary admissions for the total Army of more than four million officers and men, giving a ratio of 4.21 per 1,000 strength. (Table 76.) There were 524 primary admissions for officers and 17,039 for American officers and enlisted men. The admission ratios were, respectively, 2.54 and 4.16 per 1,000 per annum. There were 16,192 primary admissions for white American troops and 259 for colored American troops, giving admission ratios of 4.50 and 0.90 per 1,000 strength, respectively. There were 64 primary admissions where the clinical records did not specify color. Table 7<>.—(lerman measles. Admissions, deaths, discharges for disability, and days lost, by countries of occurrence, officers and enlisted men, United States Army, April 1, 1917, to December 31, 1919. Absolute numbers and ratios per 1,000 Total mean annual strength Admissions Deaths Discharges for disability Days lost (abso-lute num-bers) Nonef- Abso-lute num-bers Ratios per 1,000 strength 4.21 4.16 2.54 Abso-lute num-bers N2 82 Ratios per 1,000 strength Abso-lute num-bers Ratios per 1,000 strength (ratio per 1,000 strength) Total officers and enlisted men 4, 128, 479 17,378 4.092,457 17,039 206,382 524 0.02 .02 1 1 0 0 211,645 209,413 4,842 Total officers and enlisted American troops_______ _________________ Total officers ___________________ . 14 .06 Total American troops: White-.....__________________ 3, 599. 527 1 16,192 286,548 259 4.50 .90 -, .02 198, 684 4,930 957 15 4 1 0 05 Color not stated.....______ - 64 1 Total___......_____________ 3, 886, 075 36, 022 16,515 339 4.25 9.41 82 .02 1 0 204, 571 14 2,232 . 17 Total Army in the United States, including Alaska: 124,266 475 3.82 4,336 10 1,965, 297 145,826 15,449 243 7.86 1.67 74 4 .04 .03 188,378 4,616 . 26 1 .01 .C9 2, 111, 123 15, 692 7.43 78 .04 1 0 192,994 .25 Total officers and men_______ 2, 235, 389 16,167 7.23 78 .03 1 0 197, 330 .24 U. S. Army in Europe, excluding Russia: 73, 728 31 .42 380 .01 1,469,656 473 .32 .10 3 .00 6,998 197 930 .01 122,412 12 0 63 1 1,592,068 548 .34 4 .00 8,125 . 01 ], 665, 796 579 .35 2. 15 4 .00 8,505 126 .01 S, 38S 18 04 ---- --------- ---- ----- • Unless otherwise stated, all figures for the AVorld War period are derived from sick and Surgeon General.—Ed, wounded reports sent to the 463 4G4 COMMUNICABLE AND OTHER DISEASES Table 70. -Herman measles countries of occurrence, to December 31, 1919. Admissions, deaths, discharges for disability, and days lost, by officers and enlisted men, United States Army, April 1, 1917, Afisolute numbers and ratios per l,(H)t)—Continued Admissions Deaths Discharges for disability Total mean annual strength Abso- lute num- bers U. S. Army in Philippine Islands: White enlisted..........._____ Colored enlisted____.....____ 16,995 4,456 Total enlisted___ S. Army in Hawaii: White enlisted____ Colored enlisted__ Total enlisted. 16,161 3,319 19, 480 Ratios per 1,000 strength A bso- lute num- bers Ratios per 1.000 strength Abso- lute num- bers 2.85 .30 U. S. Army in Panama (white enlisted)_____..........._______ U. S. Army in other countries not stated: White enlisted_____.. _ ______ Colored enlisted___ _________ Color not stated... _______ Total. Transports: White enlisted-. Colored enlisted. Total________ 97, 498 10, 535 108, 033 Ratios per 1,000 strength Days lost (abso- lute num- bers) Nonef- fective (ratio per 1,000 strength) 125 1,119 71 136 2 1.40 .19 82 823 31 Native troops enlisted: Philippine Scouts.. Hawaiians________ Porto Ricans_____ 3. 12 4.27 21.72 1,159 15 700 184 1,348 .02 .02 . 19 .06 .10 .09 .31 a Separate strength of white and colored not available. It has long been known that German measles is not a fatal disease; there- fore all deaths reported for the Army during the World War were, in all prob- ability, due to some concurrent disease. Table 76 shows a total of 82 deaths charged to German measles, 77 of which were among white American troops, 4 among colored American troops, and 1 color not stated. The death ratio was 0.02 per 1,000 strength. One case was discharged from the service on account of disability following this disease. This was a colored American soldier. The permanent disability was due to some other cause. From the standpoint of noneffectiveness, German measles was a disease of some importance to the Army during the World War. Based on the com- parative number of days lost, it stood forty-ninth on the list of common dis- eases. For the total Army, there were 211,645 days lost from duty, giving a noneffective ratio of 0.14 per 1,000 strength. By far the greater proportion of the time lost w^as among the white enlisted men. They lost 198,684 days as compared with 4,930 days lost by colored enlisted men. The noneffective ratios were, respectively, 0.15 and 0.05 per 1,000 per annum. Table 76 shows 4,842 days lost by officers, giving a noneffective ratio slightly higher than that for colored enlisted men. This ratio was 0.06 per 1,000 strength. The highest admission and noneffective ratios for the total Armv were for native enlisted troops. Among a mean strength of 36,022 native troops GERMAN MEASLES 465 (Table 76) there were 339 primary admissions, with a loss of 2,232 days from duty. The admission and noneffective ratios per 1,000 strength were 9.41 and 0.17, respectively. The native troops served in their native countries. GERMAN MEASLES. COMPARATIVE TREND ENL. MEN. U. S. ARMY-UNITED STATES & EUROPE ADMISSIONS BY MONTHS. APRIL. 1917-DEC. 1919 UNITED STATES---------- EUROPE---------- Chart LI OCCURRENCE IN THE ARMY IX THE UNITED STATES Table 76 shows 16,167 primary admissions for the Army stationed in the continental United States. This number represents the vast majority of the cases reported during the war, most of which were among white enlisted men. The admission ratio was 7.23 per 1,000 strength. An analysis of these cases shows 15,449 among white and only 243 among colored enlisted men. The 56706—28---30 466 COMMUNICABLE AND OTHER DISEASES ratios per 1,000 strength were 7.86 and 1.67, respectively. This disease was more common among officers than among the colored troops; there were 475 primary admissions for the former, a ratio of 3.8 per 1,000 per annum. According to the system of recording deaths, 74 deaths among white and 4 among colored enlisted men in the United States were charged to German measles. The death ratios were 0.04 and 0.03, respectively. The number reported was so small that, even if they could correctly be attributed to German measles, they would make this a disease of minor importance to the Army during the war. The importance of this disease to the Army was principally in the number of days lost from duty. Table 76 shows that the officers and men stationed in the United States lost 197,330 days from duty on account of German measles. As would be expected, this was principally among the white enlisted men, since the disease was much more common among them. The noneffective ratio for the total Army in the United States was 0.24 per 1,000 per annum. The occurrence of German measles by camps in the United States showed wide divergence. (Table 77.) The largest number of primary admissions was reported from Camp Lewis, Wash., where 1,555 cases were reported during the war, the admission ratio per 1,000 strength being 32.54. Camp Cody, N. Mex., was second, with 1,351 primary admissions, the admission ratio, 59.68 per 1,000 strength, being the highest for any camp in the United States. The average admission ratio for all camps in the United States was 7.81. Though German measles was reported from practically all camps, there were no areas where it could properly be called endemic. Camp Pike, Ark., reported but 11 primary admissions. This is of special interest, since the endemic dis- eases at Camp Pike, in many instances, were above the average. Colored troops contributed less than one-fiftieth of the total admissions of 9,915 from the larger camps, there being only 210 primary admissions among them. Table 77.—German measles. Admis ions and deaths, by camps of occurrence, white and colored enlisted men, United Slates Army, with ratios per 1,000 strength, and case fatality rates, April, 1917, to December, 1919 Camps Camp Beauregard, La_.......__ Camp Bowie, Tex................ Camp Cody, N. Mex________ Camp Custer, Mich_________ Camp Devens, Mass......_____ Camp Dix, N.J____________ Camp Dodge, Iowa__________ Camp Doniphan, Okla_______ Camp Eustis, Va......_______ Camp Forrest, Ga___________ Camp Fremont, Calif________ Camp Funston, Kans________ Camp Gordon, Ga____ .. _..... ('amp Grant, 111____________ Camp Greene, N. C_________ Camp Grecnleaf, Ga_________ Camp Hancock, Ga__________ Camp Humphreys, Va......___ Camp Jackson, S. C....._____ Camp Johnston, Fla_________ Camp Kearny, Calif_________ ('amp Lee, Va_____________ Camp Lewis, Wash___......... Camp Logan, Tex___________ Camp MacArthur, Tex_______ Camp McClellan, Ala________ Camp Meade, Md________ Camp Mills, N. Y________ Camp Pike, Ark___ ______.. Camp Sevier, S. C__________ Camp Shelby, Miss_________ Camp Sheridan, Ala_________ Camp Sherman, Ohio________ Camp Syracuse, N. V________ Camp Taylor, Ky___________ Camp Travis, Tex__________ Camp Upton, Long Island, N. Y Camp Wadsworth, S. C......__ Camp Wheeler, Ga_...........__ Others............---------- Average strength for period 20,625 26,193 22,636 37,631 47,921 49,786 39,032 26,747 6,780 8,980 15,414 56,222 44,871 49,256 29, 710 11,959 37,994 12,836 42,011 22,267 25,472 57, 635 47,792 27,734 25,271 28,664 50,033 24,197 49,587 27,786 30,432 26,507 42,750 3,367 46,962 44,264 44,871 31,809 25, 726 339 White enlisted men Colored enlisted men White and colored enlisted men Admissions Deaths Admissions Absolute numbers Total____________...........-........ 1,270,069 18 31 1,351 180 363 322 100 208 7 1 72 515 283 36 23 33 681 26 454 48 456 549 1,548 217 48 30 447 313 11 61 36 367 29 1 307 26 174 309 24 Ratios . K_^i.,f- Ratios . Kt.-i„+- ner 1 000 Absolute , 000 Absolute strength numbers | strength numbers I 9,705 0.89 1.23 59.68 4.96 7.94 7.16 3.01 7.78 1.11 .11 4.67 10. 29 7.14 .85 .88 2.76 18.71 2.67 12.31 2.42 17.90 10.76 32.75 8. 14 1.97 1.13 10. 65 13.64 .27 2.33 1.25 14.32 .78 .30 7.21 .69 4.33 10.25 1.00 .04 .27 .03 .02 D .03 .15 .06 .03 . 18 .08 .08 .02 .03 47 Ratios per 1,000 strength 210 2.37 0 .74 5.41 1.45 9.30 0 5 .81 31 4. 54 0 0 0 0 .63 .97 5. 85 .41 Deaths Absolute -JJfggn numbers length 2.26 13.34 3.74 0 .47 3.60 1.59 0 0 0 1.13 0 1.90 Admissions Absolute numbers .03 19 31 1,351 181 375 329 154 208 7 1 72 520 314 36 23 33 682 2!) 484 49 456 564 1, 555 221 48 31 476 315 11 61 36 368 29 1 309 27 174 309 24 2 9,915 Ratios per 1,000 strength 0.92 1.18 59.68 4.81 7.83 6.61 3.95 7.78 1.03 .11 4.67 9. 25 7.00 .73 .77 2.76 17. 95 2.26 11.52 2.20 17.90 9.79 32. 54 7. 97 1.90 1.08 9.51 13.02 .22 2.20 1.18 13.88 .68 .30 6.58 .61 3.88 9. 71 .93 5. 90 7.81 Deaths Absolute numbers _________Case fa- tality Ratios ! rates (per per 1,000 cent) — --- I) 1 0.03 3.23 6 .27 .44 1 .03 . 55 1 .02 .27 n 0 .10 4 2. 60 4 .15 1.92 0 0 0 0 1 .06 1. 3(1 0 0 . 11 5 1. 59 0 0 0 0 1) 0 1 .03 . 15 n 0 .07 3 .62 (1 a . 16 .08 .07 0 (1 (1 (1 0 .04 0 0 0 0 .04 1.6(1 .26 .90 Oi 4(i8 COMMUNICABLE AND OTHER DISEASES When viewed by months and seasons of occurrence, the majority of primary admissions were reported in the United States for November-December, 191., and January-February, 191S, and among white troops. During these months, there were 2,133, 4,313, 2,980, and 1,139 primary admissions, respectively. During the fall of 1918 and the winter and spring of 1919, German measles was of but little importance to the Army.1 It is probable that the occurrence during the winter of 1917-182 was due to the comparatively large amount of nonimmune material in the Army and to confusion in diagnosis. Table 78.—German measles. Admissions, by months, while and colored enlisted men, United States Army, United States and Europe. Absolute numbers and ratios per 1,000, April, 1917, to December, 1919 Month and year 1917 April_______ May________ June________ July.....____ August----- September___ October....... November___ December___ White troops United States Europe Admissions Mean strengths Absolute *atj: numbers'^ ,ios ,000 183, 758 245,454 309,205 458,817 562, 714 776,466 1,032,244 1,061,422 1,129,065 Total 1917_____ 479,929 1918 January...... February____ March______ April_______ May________ June________ July________ August..... . September___ October_____ November___ December___ Total 1918. 1919 January_______ February______ March________ April__________ May__________ June........____ July__________ August________ September_____ October________ November_____ December______ Total 1919. Total for period. 1,096,434 1, 095,039 1,129,223 1,168, 558 1,197,757 1,303, 746 1,328, 513 1, 284,247 1,321,440 1,343,933 1, 255,195 941,219 1,205,442 672, 937 471,815 406,839 339,836 291,810 246,903 215,104 156, 791 149,360 139,877 132,403 135,441 strength 164 359 425 289 190 331 367 2,133 4,313 8,571 2,980 1,139 788 608 500 268 126 75 52 20 9 65 10.71 17.55 16.49 7.56 4.05 5.12 4.27 24.11 45.84 17.! 32.62 12.48 8.37 6.24 5.01 2.47 1.14 .70 .47 .18 .09 .83 6,630 5.50 1.19 1.58 1.95 1.27 .45 .10 .06 .09 Deaths Absolute numbers Mean Ratios | strengths per 1,000! strength 40 Admissions Absolute numbers Ratios per 1,000 strength Deaths 0.07 .01 .09 .26 626 12,794 28, 821 50, 882 70,266 92,139 123,429 160,178 .07 44,928 159 193, 223, 283, 388, 587, 796, 1,063, 1, 266, 1, 527, 1,635, 1, 682, 1, 591, . 03 936, 589 1,488, 683 1,310,083 1,115,693 853,425 569,842 271, 633 HI, 634 48, 006 30, 315 21,055 18,920 18,379 210 0.89 4.58 2.12 8.88 1.04 4.76 2.17 4.04 .59 .68 .59 .49 .12 .05 .12 .18 .05 .04 .11 .22 3 "i 104 .18 .15 .25 .25 .21 .40 .11 .25 Absolute '£?[% numbers £tren'gth 1.71 '"."65 .02 GERMAN MEASLES 469 Table 78.—German measles. Admissions, by months, white and colored enlisted men, United States Army, United States and Europe. Absolute numbers and ratios per 1,000, April, 1917, to December, 1919—Continued Colored troops - ----- United States Europe ° Month and year Mean strengths Admissions Deaths Admissions Mean strengths Absolute Ratios Absolute numbers Ratios per 1,000 strength Absolute numbers Ratios per 1,000 strength 1917 4,870 2 5,826 i 3 5,171 4.93 6.17 2.32 May... ____________......_____ ! --------,--------1".........—~..... July____________________.......__ 6,675 8,519 --------------,--------------j--------------j--------------- l 1.41 September_________........... 9,409 1.28 October___________....... 21,795 39,225 935 November......._____________ 30 9. 18 2,392 5,346 4 1 20 10 36,851 20 6.51 Total 1917________........-., 11,529 58 ! 5 03 723 4 K nt\ ■ 1918 January________......___.......... 50, 705 49,955 54,814 59,015 87,650 89,305 124,976 168,422 164, 846 182, 705 150, 587 104,140 37 8.76 13 3.12 4 .88 8,673 9,664 11,541 12, 667 28,279 33,208 47,171 78, 734 91,270 138,827 148, 679 148,372 2 1 2 77 February_____________ 1 .24 March____......._______ April_______ ________ 22 75 12 2 2 3 4.47 10.27 1.61 .19 .14 .22 2 1 .41 .14 2 May___.....______________....... June___________ ________....... 1 1 36 July_____________................. 25 September__________.......______ November______......____.....___ December___________.............. 1 .12 ----- Total 1918__________________ 107, 260 171 1.59 4 .04 63,090 7 1919 January....._______............... 68,337 66,104 44,634 29,824 20, 780 18, 562 20,058 18, 013 11,322 9,084 8,792 8,935 6 1 5 2 1.05 .18 1.34 .81 140,396 131,219 123,152 119,801 108,650 64,166 12,508 1,741 1,287 185 83 February___.................._..... March... ___ _.........________ 1 .10 April_____........................ May......_____________........... July_________________............. August_____..- ________________ . _____|__....._____ ____ Total 1919.......-.............. 27, 037 14 52 ___ I . 58, 599 1 .02 Total for period......._____ . 145, 826 243 1.67 4 ' .03 122,412 12 . 10 ° No deaths reported for colored enlisted men in Europe. The difference between the primary admissions reported from camps, as shown in Table 77, and the total number of primary admissions reported for the United States as a whole is accounted for by troops who had stations other than in the larger camps. Among these were 6,252 primary admissions. 470 COMMUNICABLE AND OTHER DISEASES OCCURRENCE IN THE AMERICAN EXPEDITIONARY FORCES The distribution of German measles among the American Expeditionary Forces was of far less importance, from every point of view, than in the United States. There were 579 primary admissions in the American Expeditionary Forces, with a total mean annual strength of one and a half million men; the admission ratio was 0.35 per 1,000 per annum. White enlisted men contributed most of the cases. There were 473 primary admissions among the white enlisted men, 12 among colored enlisted men, and 63 where color was not stated. Officers contributed 31 primary admissions and had the highest admission ratio for any American troops in Europe. This ratio was 0.42 per 1,000 per annum. The admission ratios for white and colored enlisted men in Europe, respectively, were 0.32 and 0.10 per 1,000 per annum. From the standpoint of time lost, this disease was of comparatively little importance to the American Expeditionary Forces—there was a total of 8,505 days lost, 6,998 of which were for white enlisted men, 197 days for colored en- listed men. EPIDEMIOLOGY Though the exciting cause of German measles is unknown, there is no question as to the identity of this disease or as to its contagious nature. Its infectiousness seems less than that of measles and scarlet fever and to be of but short duration. Table 76 indicates that the negro possesses a relatively high degree of immunity to German measles or that the disease was frequently not accurately diagnosed, since the number of admissions was much greater among white than among colored troops. According to experiences in the United States Army during the World War, the seasonal occurrence of this disease was that of the other exanthematous diseases; in other words, it was most common during the fall, winter, and early spring months. The highest admis- sion ratio, 9.41, was for native enlisted troops. If this is to be taken as an index of immunity, the native troops, particularly the Porto Ricans, are more susceptible to German measles than are even the white American troops. It is very probable that the infectious agent is contained in the naso- pharyngeal discharges of the patient—at least during the catarrhal stage of the disease. PROGNOSIS The available records contain no case where death which occurred during the course of an attack of German measles could not be attributed to some other cause. SYMPTOMS Patients afflicted with German measles neither appear nor feel verv ill. There is a great diversity of opinion as to the duration of the incubation period! Geiger reported the average incubation period among 173 cases studied as 17 days, the shortest being 11, and the longest 21 days.3 Vaughan gave the wide range of from 5 to 21 days.4 Premonitory symptoms are usually present and consist of malaise and mild headache, slight sore throat and, exceptionally, toxic symptoms, such as pain in the joints. Gastrointestinal symptoms are exceptional. There may be elevated temperature with a chilly sensation during this stage, or both may GERMAN MEASLES 471 be absent. The duration of this stage is characteristically short, and the skin rash usually makes its appearance within 24 hours. Some authors state that an enanthem is constantly present and consists of a macular rose-red eruption in the throat. It was on this account that German measles was originally regarded as a hybrid, having the sore throat of scarlet fever and the rash of measles. The mastoid and occipital lymph glands are usually enlarged and painful. Although this adenitis usually occurs late in the disease, it is some- times one of the earliest symptoms and the physician's attention may be attracted to it by the complaint of tenderness and stiffness of the neck. The eruption may be the first sign of the disease to attract attention. It appears on the face and, unlike scarlet fever, involves the perioral region. In the beginning it is usually discrete, macular, somewhat punctate, slightly elevated, and disappears easily on pressure. Itching is usually not present. Geiger reported 15 recurrences in a study of 173 cases.3 In 5 cases there were three separate attacks. In 2 cases, the second attack occurred three weeks after the first and was followed by a third attack five weeks later. COMPLICATIONS AND SEQUELS Geiger reported that complications were not infrequent in his cases, nor were they of a mild type.3 Acute arthritis was noted in 36 of his cases. Recovery was slow. In 4 cases hemolytic streptococcus was obtained in pure culture from the knee joint. In two cases acute nephritis was noted. Endocarditis was a complication in 1 case and otitis media in 8. Neither pneumonia nor jaundice was reported by Geiger. The statistical records of the Surgeon General's Office for the W^orld War period show 38 cases of German measles reported as concurrent with measles and 32 cases as concurrent with scarlet fever. Conversely, there were 21 cases of measles and 54 cases of scarlet fever recorded as concurrent with German measles, the only difference between these two classes being a question of which disease was reported as the primary cause of admission. There were no deaths among these cases. DIAGNOSIS The diagnosis of German measles is based upon the mildness of onset, the mildness of symptoms and signs, the incubation period, special adenopathy, and characteristics of the skin eruption. The differential diagnosis between German measles, measles, and scarlet fever is most important. Measles is differentiated by the following diagnostic points: The incubation period is shorter, and catarrhal symptoms of the respiratory tract are more pronounced. The differential diagnosis between German measles of the scarlatiniform type of rash and scarlet fever is more difficult. The distinctive points in favor of the latter are the shorter incubation period; more severe initial symptoms, as vomiting, sore throat, fever, headache, rapid pulse, "strawberry tongue," greater tendency to complications, and characteristics of the skin eruption. Toxic and drug rashes at times must be differentiated from the rash of German measles. The former skin rashes are irregularly distributed and they are polymorphous in character. Glandular involvement and catarrhal affec- tions of the respiratory tract are absent in the toxic and drug rashes. 472 COMMUNICABLE AND OTHER DISEASES Confusion in diagnosis undoubtedly existed in the early part of the war period, more especially in the fall of 1917. This is believed to account for the occurrence of German measles in epidemic proportions in some camps and its practical absence in others. No other explanation can be offered to account for these differences, since the military conditions were the same. The camp surgeon at Camp Lewis reported that German measles was epidemic in No- vember and December, 1917, with a total of 1,203 cases; however, that figure should be considered advisedly, as there was at that time still some confusion as to the diagnosis. This was the camp that reported the largest number of cases. The difficulty seems to have been principally in differentiating measles, which was epidemic in the camps at that time. Table 79, prepared from a selected group of camps, shows that, generally speaking, where the admission rate for measles was above the average for camps in the United States the rate for German measles was lower than the average; and, vice versa, where the rate for German measles was high the rate for measles was below the aver- age. This table shows a close similarity in the trend of scarlet fever with that of German measles when compared as above outlined and would indicate confusion in the diagnosis of these three diseases. Table 79.—Comparative occurrence, measles, German measles, and scarlet fever, in a selected group of camps in the United States, 1917 and 1918. Ratios per 1,000 1917 Camp Beauregard, La_____ Bowie Tex________ Cody, N. Mex______ Lewis, Wash_______ Pike, Ark....._____ Sevier, S. C......___ Travis, Tex.......... Wheeler, Ga_______ Wadsworth, S. C___ Total for camps 1918 Measles German measles Scarlet fever 0 Measles German measles Scarlet fever 461. 69 1.26 26.74 0.33 0.19 444.72 3.97 .27 2.93 .06 .42 41.86 176. 18 2.56 12.52 2.67 2.36 12.67 114. 82 8.67 23.67 10.67 12.69 477.47 .12 34.26 74.11 .25 5.71 371.40 2.94 0 33.66 1.89 2.03 452. 65 2.23 .82 19.77 .37 .53 508. 86 3.30 .35 4.27 .26 .16 .87 9.58 . 11 16.63 10.38 1. 22 120.92 21.20 2.69 22. 58 3.44 2.48 PROPHYLACTIC MEASURES There are no known specific prophylactic measures for German measles. Separation of soldiers from their commands and isolation until all evidences of the disease had ceased were the bases of prevention used during the war. The incubation period is the best index for handling contacts. TREATMENT There is no known specific treatment for German measles. There is no record of any special work along these lines during the World War. The disease is mild, as a rule, and symptomatic treatment, in general, usually suf- fices. The treatment of complications is entirely symptomatic. REFERENCES (1) Annual Report of the Surgeon General, U. S. Army, 1920, 167 (2) Ibid., 1919, Vol. I, 877. (3) Geiger, J. C: Epidemic of German Measles in a City Adjacent to an Army Cantonment The Journal of the American Medical Association, Chicago, 1918, lxx, No 24 1918 (4) Vaughan, Victor C: Epidemiology and Public Health. C. V. Mosb'v Co St T ,.!„■_ 1922, 179. y ' ^ouis, (5) Annual Report of the Surgeon General, V. S. Army, 1919, Vol. I, 878. CHAPTER XV ENCEPHALITIS LETHARGICA a Encephalitis lethargica may be defined as a subacute infectious disease of the sensory nervous system, occurring sporadically in man, characterized clinically by the triad syndrome, lethargy, cranial nerve palsies, and a febrile state, and pathologically by multiple inflammatory foci most commonly in the brain stem, subthalamic region, about the third ventricle, iter, and mesencephalon. The World War period marks the origin of the term "encephalitis lethar- gica" and the beginning of our present conception of this disease. Profound and prolonged sleep, however, has been observed in connection with many epidemics of influenza since early times. In 1917, von Economo 1 described 13 cases that had been admitted to his clinic with headache, lethargy, and cranial palsies. He differentiated between the somnolence of brain pressure and that of encephalitis, remarking that in the light cases it is striking how similar the somnolence is to physiological sleep, since the patients are easily awakened. Von Economo described the cases and designated the disease " encephalitis lethargica." While outbreaks of encephalitis lethargica (Schlafkrankheit) and "nona" have been connected with epidemics of influenza, the exact etiological relation- ship has not been satisfactorily explained. The World War occurrence, referred to by von Economo, appeared first in central Europe, thence spread into Ger- many, France, and England, in early 1918, and to the United States in the fall of the same year. Siemerling 2 reported 15 cases. The cases occurred in or in the neighborhood of Kiel, between the end of November, 1918, and April, 1919. This author observed the same symptoms noted by von Economo, and con- sidered his cases to be the same disease. In the spring of 1918 it appeared in France and England. Netter,3 working in France, confirmed von Economo's findings, giving a detailed history of the disease in 10 adults and 10 children. He expressed the opinion that it is a maladie autonome, the specific agent of which is endowed with an affinity for the nerve centers, stating further that the epidemic began simultaneously in France and England late in January. In England the disease was confused with botulism and poliomyelitis. References were made to the disease as " Acute infective ophthalmoplegia, or botulism" by Harris,4 and as "toxic ophthal- mophlegia associated with acute asthenia and other nervous manifestations" by Hall.5 Some 107 cases were reported in England and 121 in the provinces, mostly in March, April, and May, 1918. The subject was eventually taken in hand by the British Government and a complete investigation made.6 Evidence was brought forward establishing the disease as a distinct entity and differ- entiating it from poliomyelitis. As further evidence of distribution, Morguio 7 described an occurrence in Uruguay, and Arden-Delteil8 in Algeria. a Unless otherwise stated, all figures for the World War period are derived from sick and wounded reports sent to the Surgeon General.—-?-. ._„ 474 COMMUNICABLE AND OTHER DISEASES The first case of encephalitis lethargica in the United States on which any data are available occurred in the city of New York on September 4, 1918.9 Three additional cases were reported there during the following month. The portal of entry into North America is not known. However, during the latter half of 1918 the disease spread rapidly throughout the United States, and by May, 1919, cases had been reported from 20 States, the largest numbers occur- ring in Illinois, New York, Louisiana, Virginia, and Ohio. During that time 255 cases were reported. Encephalitis lethargica is not a reportable disease in many of the States and reports of its prevalence received by the United States Public Health Service are fragmentary. Some States do not report cases, while others record the cases which come to the attention of the State health officers. The United States Public Health Service has not considered it worth while to collect these fragmentary reports and tabulate them, since they would not show the real prevalence of the disease; therefore, the total incidence in the United States for the World War period can not be given. Because the disease is not found sep- arately in the lists of disease published prior to 1920, the Bureau of the Census reports no deaths due to this cause; however, during that year, 1,070 deaths were reported in the registration area of the United States.10 The first cases, so far as could be ascertained, among American troops in the United States occurred at Camp Lee, Va., early in November, 1918. These cases, 8 in number, 2 among officers and 6 among enlisted men, were later reported by Pothier.11 Since the diagnosis encephalitis lethargica did not appear on the list of diagnoses as published by the Surgeon General until 1920, the statistical tables for the AVorld War do not include the disease under this des- ignation. Therefore, it is not possible to give the total occurrence in the Army during that time; however, among the clincial records of World War patients it is found that there were a number of primary admissions with the diagnosis encephalitis lethargica, later classified under encephalitis. Examination of these clinical records shows 20 to have been encephalitis lethargica; 8 occurred in the United States and 12 in the American Expeditionary Forces. The cases occur- ring in the American Expeditionary Forces were 11 white and 1 colored, and in the United States, 7 white and 1 colored. Of these 20 cases, 4 died, 7 were returned to duty, 7 were discharged on account of disability; the disposition of the remaining 2 could not be determined. Of the deaths, 2 occurred in the United States and 2 abroad. ETIOLOGY Several theories have been advanced to explain the cause of encephalitis lethargica. In England it was first thought to be botulism or, perhaps, due to a poison, as solanin accumulating in the sprouts of potatoes and other vegetables. This theory was exploded by the findings of the British Government Local Board.12 It has been suggested to be a form of poliomyelitis. Encephalitis lethargica belongs to the class of polyencephalitic diseases and it has been suggested that the relationship to anterior poliomyelitis may be similar to that of paratyphoid to typhoid fever.6 The influence of lowered resistance, due to war conditions, and, as a result, the possibility of saprophytic organisms becoming pathogenic, was stressed.6 Breinl,13 reporting upon the ENCEPHALITIS LETHARGICA 475 ''mysterious disease" in Australia, expressed the opinion that it was an aber- rant form of acute poliomyelitis. Neal,14 on the other hand, thought it improb- able that encephalitis lethargica is a form of poliomyelitis. The only epidemics of encephalitis lethargica of the past have been in connection with epidemics of influenza. The association of these diseases formed the basis of many recent investigations. Siemerling2 attempted to associate his cases with the 1918 epidemic of influenza. Most of the cases gave a previous history of influenza. Smith9 remarked that almost all outbreaks have been preceded by influenza. Bassoe12 suggested that encephalitis may be a cerebral form of influenza, that the infection is akin to the virus of polio- myelitis, but not identical with it, and that nearly all cases are seen in persons more or less in a run-down state or exhausted. Hershfield15 reported 15 cases, 3 of which gave a distinct history of previous influenza attack. Twenty-five of Neal's 38 cases 14 and half of Pothier's cases11 gave a history of a previous attack of influenza. It must be acknowledged that the relationship of these twxo diseases has not been definitely determined. According to Zinsser16 the relationship to influenza is vague; but it is to be seriously considered, in view of the recent researches with influenza and filterable viruses in encephalitis. In one of von Economo's cases, an emulsion of the brain and cord was injected subdurally into a monkey by von Wiesner.17 The animal died 46 hours later in stupor. The brain is reported as having been typical of hemor- rhagic encephalitis from which von Wiesner recovered a Gram-positive diplococ- cus. This he cultivated and, on injection into apes, produced somnolence and mental weakness. The reports of these investigators led other scientists to search for the cause of epidemic encephalitis. Strauss, Hirshfeld, and Loewe18 obtained nasopharyngeal mucus of fatal cases, passed it through Berkefeld candles and injected rabbits both subdurally and intracranially. They claim to have produced the disease in these animals. Similar results were obtained with a rhesus. The monkey developed lethargy, general malaise, temperature, and ptosis of the left eyelid, but recovered. Rabbits, intracranially injected, died in from four to five days with punctate hemorrhages in the brain, intense congestion, marked meningitis, and mononuclear infiltrations about the vessels. The authors claim to have repeated these experiments many times. Loewe, Hirshfeld, and Strauss19 report a filterable virus obtained from the nasopha- ryngeal mucus of a fatal case. The virus is reported as being capable of producing lesions in monkeys and rabbits similar to those found in the human brain. The virus has been carried through four generations in rabbits, trans- mitted to a monkey in the fifth generation, and then brought back to rabbits. The cerebrospinal fluid of a fatal case caused the disease in rabbits, and transfers from brain to brain through filtrates have been successful in four generations. They suggest a possible connection between the disease and influenza. Experimental inoculations were carried out at the Army Medical School, Washington, D. C, with fresh material from one of Wegeforth's cases.20 The spinal dura was opened 28 hours after death in one case and aerobic cultures were taken from the subdural and subarachnoid spaces. These cultures were 476 COMMUNICABLE AND OTHER DISEASES negative. Specimens were also taken from three levels of the spinal cord, macer- ated, filtered, and injected into a monkey intracerebral-}', into another monkey by lumbar subarachnoid injection, into a rabbit, a monkey, and a mouse intra- peritoneal^. None of these animals became sick and the cultures were nega- tive. From a patient 11 days after the earliest symptom of the disease disap- peared, the spinal fluid was removed and injected into a monkey by lumbar inoculation, and into a rabbit by cysterna magna inoculation. An additional rabbit was injected into the cysterna, with this fluid and in addition with horse serum to produce a sterile meningitis. All of these animals remained unaffected Evidence of direct communicability from man to man is lacking. An analysis of the available records from stations where the disease was reported in the Army shows no evidence of communicability. Among the factors which may influence the occurrence of the disease, season, age, and sex are of interest. The apex of occurrence in the United States among Smith's cases was in March.9 Skversky's cases in the American Expeditionary Forces occurred during January, February, and March.21 Fair- banks 22 states that March and April showed the greatest prevalence. The age incidence is of importance from a differential diagnostic viewpoint between anterior poliomyelitis and encephalitis lethargica, the former occur ring more commonly among children under the age of 7 and the latter more commonly in persons older than this. Of course, the occurrence in the Army would fall entirely in the latter class. PATHOLOGY Characteristic lesions are confined to the central nervous system. Multi- ple inflammatory foci are found, particularly in the region of the basal ganglia, lateral ventricle, and about the aqueduct of Sylvius, also about the pons and medulla. Macroscopically there is usually only evidence of congestion of the meninges and cortex, with more or less edema. On sectioning the brain, and es- pecially sections through the basal nuclei, peduncle, pons, and medulla, punc- tate hemorrhages are found. Microscopically miliary hemorrhages are very numerous. Neal14 describes the lesions as mainly of three kinds: (1) Infiltra- tion, especially of the walls of the vessels (lymphocytes and plasma cells), to a less extent in other areas; (2) hemorrhages of varying size in both the white and gray matter; (3) lesions of the nerve cells—some degeneration of the ganglion cells. Wegeforth and Aver 20 report the pathological findings of four cases as follows: The pathology of these four cases of so-called "lethargic encephalitis" was presented with a varying degree of completeness. The brains all appeared alike. A great degree of engorgement of all vessels was conspicuous; moreover, the pia was noted as pinker than normal, and this is explained by the free blood present in the meninges. The brains were abnormally soft to touch. In every case the chief seats of the lesions were the brain stem and the basal ganglions. The important lesions may conveniently be divided into (1) peri- vascular exudation and (2) diffuse infiltration of parenchyma. While both types of lesions vary greatly in intensity, extent, and symmetry, they were seen especially in the gray matter about the canal, fourth ventricle, and aqueduct, though deeper tissues were also affected and white matter was not spared. The cells concerned in both types of lesion were all mono- nuclear; a small mononuclear cell and a large mononuclear cell, frequently phagocytic many ENCEPHALITIS LETHARGICA 477 of which appear to be neuroglia cells, together with the lymphocyte and plasm cells, were recognized. Polymorphonuclear leukocytes were conspicuous by their absence even in the case of short duration. Mitotic figures appeared in small numbers both in the perivascular and in the diffuse exudate. That the two processes were interrelated is apparent from the appearance of diffuse exudate chiefly in the immediate neighborhood of affected vessels. That the diffuse infiltrating exudate was not necessarily related to a destructive process is borne out by the normal or only slightly changed appearance of nerve cells in its midst; however, when the exudate was excessive, marked nerve cell changes, including neurophagia, resulted. Bacteria were sought for with care and none was seen. Lesions that may be considered subsidiary in our cases were hemorrhage and menin- gitis. Hemorrhages were few in number and very small, so insignificant, in fact, that they utterly failed of detection in the gross examination. However, a certain amount of free blood and fibrin, mixed with the perivascular exudate, was frequently seen. Blood vessel changes were of two types. There was almost constantly evidence of proliferation of the intima in vessels in areas of exudation, those in unaffected territory usually showing no abnor- mality. The second type of lesion noted was infiltration of the vessel walls (especially intraadventitial), with mononuclear cells, chiefly lymphocytes and plasma cells. This con- dition was observed by itself in the meninges and associated with perivascular exudate in the substance of the brain. It is likely that more of the exudate was intramurally situated than appearance indicates; this would explain the very moderate cellular infiltration of the meninges and associated low cell count in the spinal fluid. The cord and organs in the cases examined appeared essentially normal. It is unfortunate that no notes on the root ganglions are available. Lesions in the cerebral cortex were in all either nonexistent or negligible. SYMPTOMS For purposes of description, the symptoms may be divided arbitrarily into three stages, namely, the prodromal stage, stage of active manifestations, and state of convalescence. The prodromal stage is manifested by a more or less sudden onset, with dull headache, drowsiness, variable febrile manifestations, sometimes diarrhea, nausea, and vomiting, with or wuthout cranial nerve symptoms. The duration is ordinarily short, commonly two to five days. It merges into the stage of active manifestations when the triad syndrome, leth- argy, cranial nerve palsies, and the more marked febrile state are present. Disturbance of vision and diplopia, ophthalmoplegia or paralysis of the oculo- motor nerve, ptosis, rigidity of the neck muscles, vertigo, dysphagia, aphonia, and the more marked lethargic state characterize this stage. Twitching of the body or face and an ataxic gait, resembling Parkinson's disease, are often described. Sensory changes are but seldom described in the literature. The duration of this stage is variable, lasting from one to several weeks. It is true of this stage that confusion with anterior poliomyelitis, on the one hand, and brain tumor, on the other, exists. The stage of convalescence is marked by improvement in the lethargic state, normal temperature, diminution or disappearnce of the cranial nerves palsies, tremor, and ataxia. Wegeforth and Ayer20 remarked that it was unusual to find signs of organic nerve disease in the first week. In the second week, sometimes later, wide- spread neurological disorders became evident, with cerebral symptoms. Drowsi- ness occurred in almost every case, sometimes developing into coma, and at times alternating with irritability or anxiety. However, orientation and cere- bration were usually uneffected until just before death. The long projection nerve fibers showed profound disturbance in seven of their cases, as indicated 478 COMMUNICABLE AND OTHER DISEASES by ataxia, spasticity, Babinski's reflexes, and clonus. Diplopia was present in seven cases, although oculomotor palsy was seldom actually seen. The second most frequent local disorder was weakness of the facial muscles, usually unilat- eral, and seen in five cases. Pupillary disturbances and irregularity, inequality, and abnormal reaction were common. Weakness of the jaw muscles was observed three times, while profound disturbance of respiration was twice noted. They make special emphasis of the clinical manifestations—insidiousness of onset, recurrent and incomplete paralysis, and implication of cerebral nerves confined to motor functions. Skversky21 reported two of his cases as showing a fairly well-marked Parkinsonian picture. In 9 out of 10 of his cases there was a definite febrile period either preceding, or concomitant with, the attack of encephalitis lethargica, that included coryza, mumps, bronchopneumonia, and in one case possibly paratyphoid B. Before admission, the following symptoms were complained of: Headache in 5 cases; diplopia, 2; dysphagia, 1; temperature, 4; mental dullness, 6; and an unsteady gait in 1. After admission, 4 cases showed involvement of the third and seventh cranial nerves. Nystagmus was present in 3, masked face, 5; tremor, 5; insomnia, 2; slow speech, 3; and the pill-rolling movement in 1 case. Spaeth,23 reporting on ocular symptoms of encephalitis, observed in 5 cases, showed reduced pupillary reaction to light in 3 and to accommodation in 4; diplopia was complained of in 3 cases; dilatation was present in 3 and irregularity in 1. Hershberg24 reported involvement of the third, sixth, seventh, and ninth nerves in his patient at Base Hospital No. 69, A. E. F. There was deviation of the uvula to the right. The Kernig and Babinski reflexes were absent. Nystagmus was present and the eye grounds were negative. It was the lethargic condition in persons suffering from this disease that suggested the diagnosis "sleeping sickness." Bassoe 12 stated that there is not so much real sleep as is indicated by the sleepy expression. In fact, some patients suffer from insomnia and the lethargy bears almost the same relation to sleep that laughter of the pseudobular paralysis patient does to the normal laugh. Vaughan 25 held that the stupor is partly apparent and partly real Blood findings were reported upon as being negative. A mild leukocytosis was occasionally present, but often nothing of diagnostic value. In like manner, the spinal fluid showed no characteristic change. COURSE AND PROGNOSIS The course and ultimate results are extremely variable. Some cases run a rapid, mild course, ending in from two to three weeks with apparently com- plete recovery. Other cases run a stormy course, terminating in death in a few days, while some show a slow convalescence extending into months and leav- ing the individual permanently incapacitated. Skversky,21 discussing the slow convalescence, stated that it often requires months and then leaves the individ- ual with an unsteady gait, general weakness, a masked face, etc. Hershfield16 reported the duration of the active stage from 6 to 60 days, with an average of 32 days. It is difficult to prophesy as to the residual disturbances. A spastic gait, paralyses of the limbs, speech difficulties, and mental and emotional instabil- ity have been reported. Fairbanks22 reported that opthaimophlegia and facial ENCEPHALITIS LETHARGICA 479 paralysis may clear up on one side before attackmg the other, and that either form of paralysis may clear up and then recur. This author further reported that the mergence from lethargy and the restoration of general health is ex- tremely slow. Duration of the clinical phenomena is so variable and conva- lescence so prolonged that it is difficult to give even an average duration of the affection. Eliminating the abortive cases, it is safe to state that six weeks is the minimum duration. In the majority of cases many weeks, even months, may pass before full restoration to health—if it occurs—is achieved. Impair- ment of intellect may remain. Among other sequelae, tremor and disturbance of coordination are conspicuous. The tremor may be of the paralysis agitans type, or it may be of a finer degree and either general or confined to the extrem- ities. Ataxia is commonly of the cerebellar type, but is also frequently present for fine movement of the fingers. Disturbances in swallowing, or in speech, may be more or less noticeable for a long time, yet are rarely persistent. Accord- ing to Fairbanks,22 the lack of emotional expression in the face often extends over a long period. As previously stated, a study of the cases in the Army during the World War can be only fragmentary. An analysis of 20 clinical records shows 2 deaths in the United States among 8 cases, and 2 deaths among 12 cases in the Ameri- can Expeditionary Forces. These 20 cases are the only ones that permit of de- tailed analysis. The records show that 7 were returned to duty, 7 discharged from the service on account of disability, 4 died, and 2 were unaccounted for. Among the cases returned to duty, the duration of hospitalization varied from 18 to 115 days, an average of 53.3 days. Among those discharged on surgeon's certificate of disability, the period of hospitalization varied from 32 to 329 days, an average of 180 days. DIAGNOSIS Diagnosis usually can be made by the more or less sudden onset with leth- argy, cranial nerve palsy, practically normal blood and spinal fluid findings, with febrile manifestations, and the absence of sensory, trophic, and meningeal irri- tation symptoms. This disease has been confused with others, notably botulism poliomyelitis, tubercular meningitis, myelitis, brain tumor, and brain abscess. The strong clinical, epidemiological, and pathological evidence that enceph- alitis lethargica is a distinct disease from classic poliomyelitis is supported by animal experimentation. The symptoms of tuberculous meningitis may simulate those of encepha- litis lethargica. Fairbanks 22 remarked that it may be impossible to differ- entiate the two and may require post-mortem findings to overcome the doubt. An onset with meningeal symptoms and pinched facial expression so charac- teristic of tuberculous meningitis is strongly suggestive. The results of lumbar puncture showing increased pressure, pleocytosis of mononuclear cells, and formation of the pellicle on standing, taken along with the finding of tubercle bacilli on microscopic examination (or after animal inoculation), would con- firm the diagnosis. Myelitis is differentiated by the presence of sensory, trophic, and sphincter changes, possibly optic neuritis, and absence of the cranial nerve palsies; fur- thermore, lethargy is not usually seen in myelitis. Although fatal cases run a 4S0 COMMUNICABLE AND OTHER DISEASES short course and often die of respiratory failure, this failure is due to paralysis of the muscles of respiration. Respiratory paralysis is a common cause of death in encephalitis lethargica. When it occurs, it is due to involvement of the respiratory center. In brain tumor, the onset is usually more gradual, there is absence of ele- vated temperature and usually presence of optic nerve changes from pressure, as well as localizing symptoms. These latter, however, may be absent if the growth is located, for example, in the frontal lobe. As previously stated, one case discharged from the service on account of disability was diagnosed encepha- litis lethargica, later changed to psychoneurosis, and then to brain tumor. PREVENTIVE MEASURES AND TREATMENT In the absence of any evidence of direct communicability, and in the absence of recognized etiology, nothing is known of the prophylaxis in this disease. So far as the records would indicate, there were no steps taken during the war to prevent its spread. As previously mentioned, there was no discover- able connection between the occurrence of one case and another that would point to direct or indirect transmission. Treatment was symptomatic. Most authors agree that spinal puncture is advisable. Some seem to think that a release of spinal fluid is beneficial and should be repeated. At any rate, it serves a valuable purpose in diagnosis. No specific or prophylactic treatment is known or was developed during the war period. REFERENCES (1) Economo, C. v.; Die Encephalitis lethargica. Jahrbucher fur Phsychiatrie, Leipzig und Wien, 1917-18, xxxviii, 253. (2) Siemerling, E.: Ueber eine Enzephalitisepidemie. Berliner klinische Wochenschrift, Berlin, 1919, lvi, part 1, No. 22, 505. (3) Xetter, A.: L'encephalite Lethargique epidemique. Paris Medical, 1918, xxix, No. 31,81. (4) Harris, Wilfred: Acute infective ophthalmoplegia, or botulism. Lancet, London, April 20, 1918, i, 568. (5) Hall, Arthur J.: Note on an epidemic of toxic opthalmoplegia. Lancet, London, April 20, 1918, i, 568. (6) Report of an Enquiry into an Obscure Disease. Encephalitis Lethargica. Reports to the Local Government Board on Public Health and Medical Subjects. His Majesty's Stationery Office, London, 1918, n. s. No. 121. (7) Morguio, L.: Lethargic encephalitis. Revista Medica del Urquay, Montevideo 1918 xxi, 463. (8) Arden-Deltiel: Un cas d'encephalite lethargique observe a Alger. Bull, et mem. Soc med. hop. de Paris, 1918, 3, s., xlii, 577. (9) Smith, H. F.: Epidemic encephalitis (Encephalitis lethargica, Nona). Reports of studies conducted in the United States. U. S. Public Health Reports, Washington 1921, xxxvi, No. 6, 207. ' (10) Letter from the Assistant Surgeon General, U. S. Public Health Service, to Maj H C Michie, M. C, dated March 5, 1924. Subject: Encephalitis lethargica. On file Historical Division, S. G. O. (11) Pothier, O. L.: Lethargic encephalitis; Preliminary report, Camp Lee, Va. The Journal of the American Medical Association, Chicago, 1919, lxxii, No. 10, 715 (12) Bassoe, Peter: Epidemic Encephalitis (Nona). The Journal of the American Medical Association, Chicago. 1919, lxxii, No. 14, 971. ENCEPHALITIS LETHARGICA 4S1 (13) Breinl, A.: Clinical, Pathological and Experimental Observations on the "Mysterious Disease." A Clinically Aberrant Form of Acute Poliomyelitis. The Medical Journal of Australia, Sydney, 191S, i, No. 11, 209. (14) Neal, J. B.: Lethargic Encephalitis. International Clinics, Philadelphia and London, 1919, ii, 29th Series, 184. (15) Hershfield, A. S.: Epidemic Encephalitis in Chicago. An Analysis. Illinois Medical Journal, Chicago, 1919, July, xxxvi, No. 1, 27. (16) Hiss, P. H., jr.; Zinsser, Hans; and Russell, F. F.: A Text Book of Bacteriology. D. Appleton and Co., New York, 1922, 919. (17) Von Wiesner, R. R.: Die Aetiologie der Encephalitis Lethargica. Wiener klinische Wochenschrift, Wien, 1917, xxx, No. 30, 933. (18) Strauss, I.; Hirshfeld, S.; and Loewe, L.: Studies in Epidemic Encephalitis. New York Medical Journal, New York, 1919, cix, No. 18, 772. (19) Loewe, L.; Hirshfeld, S.; and Strauss, I.: Studies in Epidemic Encephalitis. The Journal of Infectious Diseases, Chicago, 1919, xxv, 378. (20) Wegeforth, P., and Ayer, J. B.: Encephalitis Lethargica. The Journal of the American Medical Association, Chicago, 1919, lxxiii, No. 1, 5. (21) Skversky, A.: Lethargic Encephalitis in the A. E. F.: A Clinical study. The American Journal of Medical Sciences, Philadelphia, 1919, n. s., clviii, No. 6, S49. (22) Fairbanks, A. W.: Encephalitis Lethargica. The Boston Medical and Surgical Journal, Boston, 1919, clxxxi, No. 20, 578. (23) Spaeth, E. B.: Ocular Symptoms of Encephalitis Lethargica. On file, Historical Divi- sion, S. G. O. (24) Hershberg, H.: Report of a Case of Lethargic Encephalitis, Base Hospital No. 69, A. E. F., New York Medical Journal, 1919, ex, No. 22, 899. (25) Vaughan, Victor C.: Encephalitis Lethargica. The Journal of Laboratory and Clincial Medicine, St. Louis, 1918-19, iv, No. 7, 381. 56706—28----31 CHAPTER XVI INFECTIOUS JAUNDICE; TYPHUS FEVER; TRENCH FEVER" INFECTIOUS JAUNDICE Infectious jaundice is not a new disease, epidemics having been reported upon as far back as the first half of the eighteenth century.1 In 1914 certain Japanese investigators isolated a spirochete from cases in their own country to which they gave the name Spirochxta icterohxmorrhagix.1 The intermediate host of the parasite is the brown rat. This spirochete is to-day generally accepted as the specific cause of the disease. The United States Army reported a total of 452 cases of spirochetal jaundice during the period of the World War, with a resultant loss of 9,251 days and 15 deaths. The distribution of these cases by countries is indicated in the fol- lowing table: United States, 279; Europe, 108; Philippine Islands, 15; Panama, 9; other countries, 5; transports, 1; total officers, 35; total Army, 452. To these 452 original admissions must be added 80 instances in which the same malady occurred concurrently with other diseases, making a grand total of 532 cases. TYPHUS FEVER Typhus fever has been long known, and the World War added little, if anything, to clinical knowledge concerning it. Its transmission by the louse is accepted. Its incidence in the Army during the World War was as follows: United States, 15; Europe, 7; other countries, 19; officers, 1; total, 42. To the 42 original admissions for typhus fever must be added 5 more cases in which this malady appeared as a concurrent disease. Three of these individ- uals died and the disease was responsible for 1,335 days lost. Although the war did not, properly speaking, advance in measurable degree the clinical, epidemiological, and etiological phases of the available knowledge concerning typhus fever, nevertheless, the startling epidemics of the disease which occurred in Russia, Poland, and other countries during the war period served to stimulate the labors of the Typhus Research Commission of the League of Red Cross Societies to Poland, the results of whose investigations became available in the main report of this commission which appeared in 1922.2 This commission looked upon "the determination of the exact nature of the specific cause of the disease * * * as the most important goal."2 The transmission of typhus fever by the louse was accepted at the start. The one organism found to be most definitely and uniformly demonstrable in lice that had fed upon typhus patients was Rickettsia prowazeki. This Rick- ettsia was identified in each instance upon its appearance as observed in serial sections of lice. It was found in the lice of 27 out of 52 experiments.3 Changes in technique based upon experience secured positive results in practically every one of the last third of the experiments. • Unless otherwise stated, all figures for the World War period are derived from sick and wounded reports sent to the Surgeon General.—Ed. 484 COMMUNICABLE AND OTHER DISEASES Rickettsia pediculi was found occasionally. Microorganisms other than Rickettsia did not appear in any of the 52 experiments in which lice were nour- ished upon typhus patients. Animal experimentation designed to prove Rickettsia prowazeki the specific cause of typhus fever is reported in detail. The authors' conclusions are as follows:4 The presence of Rickettsia prowazeki in lice in our experience is proof of the presence of the virus of typhus. A variable percentage only of lice nurtured upon typhus patients acquire the virus of typhus; and this holds true in boxes where all lice have equal opportunities to become infected. After allowing for the technical difficulties in making adequate search for Rickettsia and injections from the same louse and for the uncertainty of the reaction of guinea pigs to typhus blood in the test for immunity, we believe that the data from the above experiments are sufficient proof that the virus of typhus and Rickettsia prowazeki are inseparable. Concerning Rickettsia, it is stated 5 that this "is the group name given by da Rocha-Lima (1916) to minute microorganisms with certain peculiarities found in lice. The name honors the memory of Howard Taylor Ricketts, who first described microoganisms possibly of this type in connection with studies upon typhus (Ricketts and Wilder, 1910)." The present knowledge of Rick- ettsia is summarized as follows:6 A satisfactory definition of Rickettsia is not possible at present. The properties in common of the 13 or 14 microorganisms so far described under this name are as follows: Morphology.—Bacteriumlike on the whole. They are smaller than bacteria and occur characteristically in pairs. Large forms, bacillary and filamentous, have been described in connection with two carefully studied Rickettsias—Rickettsia prowazeki and Rickettsia lectularius—and it seems probable that a simple cycle or sequence in morphological develop- ment is a characteristic of the pathogenic forms. Staining reactions.—Difficulty of staining with the common staining solutions used for bacteria is a striking feature, as is the failure to retain the stain by Gram's method. The only satisfactory staining methods are the modifications of Romanowsky's method; of these, the most satisfactory is Giemsa's solution. Mobility.—Motile forms have not been seen. Cultivation.—So far all have resisted cultivation with the exception of the Rickettsia from the sheep louse. It grows on a relatively simple glucose blood agar medium. Resistance to physical and chemical agents.—Not enough work has been done to generalize. The viruses of typhus (da Rocha-Lima, 1919, p. 240) and Rocky Mountain spotted fever (Wolbach, 1919) are extremely susceptible to heat, drying, and chemical agents. On the other hand, the virus of trench fever resists 80° C. of dry heat for 20 minutes and drying for many months (Byam and Lloyd, 1919). Host specificity—AH Rickettsias have insect hosts which in the case of the pathogenic ones are the vectors. All are highly specific for their insect host, while the pathogenic ones may infect widely separated mammals. Hereditary transmission.—In every instance where careful study has been made it has been found—with the exception of the Rickettsia of typhus—that the organisms pass down through successive generations in the eggs. Da Rocha-Lima has offered some evidence that this is also true of Rickettsia prowazeki, and Sergent, Foley, and Vialette 1914 (quoted by NuttaU, Parasitology, vol. 10), accidentally communicated typhus to a monkey and a a man with the offspring of lice which were supposed to be infected only with relapsing fever Classification is of course impossible, and it is probable that we have already included under Rickettsia a number of very different microorganisms. The Rickettsia of the sheep louse has little to distinguish it from bacterium; yet we believe the Rickettsia of typhus has a number of peculiarities which necessitate its separation at present. The Rickettsialike INFECTIOUS JAUNDICE; TYPHUS FEVER; TRENCH FEVER 485 cause of Rocky Mountain spotted fever, which we prefer for the present to consider under a distinctive name, while resembling in many ways Rickettsia prowazeki, is very unlike the morphologically simple Rickettsia of trench fever. At the present the opinion seems generally held that Rickettsia prowazeki is the specific cause of typhus fever. This knowledge may be credited to the epidemiological opportunities indirectly afforded by the World War. TRENCH FEVER In 1915 there made its appearance among British troops on the Western Front a disease7 which came to be known as " Trench fever "s and which gradually was recognized as a specific infection. The armies in Salonika likewise reported cases of this disease.9 There is no available evidence indicating that this disease had ever been recognized as a clinical entity before 1915. OCCURRENCE IN THE ARMY The following figures, which represent the occurrence of trench fever in the Army, include a number of experimental cases, but do not embrace relapses from either experimental or natural causes. The total number of primary admissions was 798, divided as follows: Officers, 54; white enlisted men, 531; colored enlisted men, 2; color not stated, 211. All of these cases, except 12, occurred in our forces in Europe; the 12 cases were admitted in the United States. To the 798 primary admissions are to be added 103 cases which were concurrent with other diseases for which admission was made, thus giving a total of 901. Among these, there were 2 deaths, 1 white enlisted man and 1 color not stated. Both deaths were in Europe. The foregoing figures suggest a point of interest as regards the racial distribution of this disease. The admission rate per 1,000 was, for white enlisted men in the whole Army, 0.15, as against 0.01 for colored enlisted men; and in Europe 0.35 for white enlisted men and 0.02 for colored enlisted men. Assuming the probability that essentially the same conditions as to louse infes- tation obtained in both white and colored combat troops, this notable difference in race incidence would seem at first glance to indicate a relatively higher immunity on the part of the colored man. On the other hand, colored troops had relatively much less service in the trenches than did white troops, and it is probably much nearer the truth to assume that lice infected with the virus of trench fever were largely, if not wholly, confined to the combat areas. ETIOLOGY AND TRANSMISSION The researches of the trench fever research committee of the American Red Cross6 whose report was issued in 1918 afforded at the time of publication the last word on the etiology and transmission of this disease.10 For the investi- gation of the problems concerning the etiology and transmission of the disease, human subjects were necessary, since the disease was not transmissible to animals. The consent of the commander in chief, A. E. F., to the use of soldiers i> The members of the commission were as follows: Maj. Richard P. Strong, M. C; Maj. Homer F. Swift, M. C; Maj. Eugene L. Opie, M. C; Capt. Ward J. MaeNeal, M. C; Capt. Walter Baetjer, M. C; Capt. A. M. Pappenheimer, M. C; Capt. A. D. Peacock, R. A. M. C. (T); and Lieut. David Rapport, M. C. 486 COMMUNICABLE AND OTHER DISEASES who might volunteer for this human experimentation was secured by the chief surgeon, A. E. F., Out of hundreds who volunteered, 82 were selected. All these volunteers were subjected to detailed physical examination to exclude any unfit, and bacteriological examinations were then made of the blood, urine, and feces to eliminate those who might be suffering from chronic infections, and carriers. The whole detachment was strictly segregated, and the most com- plete records as to temperature and condition of skin and clothing were made. A semiweekly bath and weekly sterilization of clothing were a part of the routine. In seeking the specific etiological factor, the first step was an inquiry into the possibility of infection with any members of the enteric group of bacteria. Briefly, the examinations of blood, urine, and feces in cases of spontaneous and experimental trench fever by methods adopted in the search for the typhoid and paratyphoid bacilli were consistently negative. Serological reactions gave no indication that any of these organisms was culpable. Structures resembling spirochsetes had been previously found by at least one worker on the hematology of trench fever.11 He looked upon the possibility of their being the causative factor in the disease as not incompatible with the filterability of its virus since "some spirochsetes are known to be filterable * * *." Otherwise the search for spirochsetes in the blood (as conducted by the members of the Red Cross commission by the method of anaerobic cultures) was entirely unsuccess- ful. The Wassermann test likewise was consistently negative, and thus failed to give any suggestion that trench fever might be a modality of syphilis, or due to any spirochsete of close biological relationship to Spirochxta pallida. The commission confirmed the earlier experiments of McNee, Brent, and Renshaw that the disease was infectious and transmissible by the blood. Thirty-four volunteers who previously had been studied with great care were inoculated with blood or some constituent portion thereof taken from trench fever patients during the febrile paroxysms. Of these, 23 contracted the disease with an incubation period of from 5 to 20 days. Careful consideration of the results of experimental inoculation brought the commission to the conclusion that " The virus or organism of trench fever is present particularly in the fluid por- tion of the blood, and is not contained within the blood corpuscles themselves." Investigation of the filterability of the virus resulted in proof that "at least one stage of the development of the virus of trench fever is filterable and ultra-microscopic," though elsewhere it is stated that the "virus is not filterable with ease in centrifuged plasma or serum." Concerning the thermal death point of the virus, it was found that the virus resists a temperature of 60° C. moist heat for 30 minutes, and is fully virulent after such treatment, but is killed by a temperature of 70° C. moist heat for 30 minutes. Obviously, therefore, a temperature of 55° C. for 30 minutes, which destroys the Pediculus humanus and its ova, does not suffice to destroy the virus of trench fever which may be present on the underclothing of trench fever patients. Furthermore, its stability is perhaps one of its most striking characteristics. Immediate suspension of the thoroughly dried virus in a large volume of saline solution for several hours does not attenuate its virulence, and it has already been pointed out that it resists drying in the urinarv INFECTIOUS JAUNDICE; TYPHUS FEVER; TRENCH FEVER 487 sediment of trench fever cases and in louse excrement. For these reasons the organism causing trench fever may apparently be most appropriately classified as a resistant filterable virus. The virus is invariably present in the blood in the early stages; it is not present in the feces; it is present in the urine; some- times it appears to be present in the mixture of saliva and sputum, as indicated by successful inoculation experiments. Thirty-eight of the 82 volunteers were employed in experimental investi- gation of the transmission of trench fever by the louse. A pure-bred strain of lice was obtained from the Lister Institute for this purpose. The so-called " box method" of handling these lice was made use of. When lice were to be allowed to feed upon trench fever patients the small, round, cardboard box in which they were confined was placed, after removal of the cover, upon the surface of the skin of the forearm. The period of feeding was in each instance not less than 30 minutes and was repeated three times a day. Lice were placed upon healthy volunteers at varying intervals of time after removal from the patients, with intent to exclude direct mechanical transmission through the medium of the parasite's biting mouth parts, and as well to obtain information with regard to the length of time the louse might remain infective. These experiments led to the conclusion that the disease "is transmitted naturally by the louse, Pediculus humanus, Linn., var. corporis, and that this is the important and common means of transmission; that the louse may transmit the disease by its bite alone (the usual manner of infection), or the disease may be produced artificially by scarifying the skin and rubbing in a small amount of the infected louse excrement." Also "that a man may be entirely free from lice at the time he develops trench fever, the louse that infected him having left him some time previously as its host, and that the louse need only remain upon the individual for a short period of time in order to infect him." It was further- more shown that no evidence could be obtained pointing to the hereditary transmission of the virus of trench fever in the louse; and finally there is evi- dence that, if the virus undergoes development in the louse, it requires 6 to 10 days to do so; there is a little evidence that suggests the minimum incubation period to be about 4 days and that "lice may remain infected for at least 10 days and possibly 13." The most suggestive discovery in all attempts to identify the specific cause of this disease has been Rickettsia bodies. Swift 12 states that "while it is difficult not to believe that there is a causal relationship between the virus of trench fever and the Rickettsia bodies, it will be difficult to establish defi- nitely such a relationship until it is possible to obtain pure cultures of the bodies and with them to reproduce the disease. In this connection it must be recalled that the relation of Rickettsia bodies to other microorganisms has not been established. They may be specific microorganisms; they may be a granular stage through which some other microorganism is passing; or, finally, they may be cell inclusions, the result of the action of some invisible virus on the cell protoplasm, and thus resemble the Guarnieri bodies in vaccinia, the Negri bodies of rabies, the molluscum bodies in molluscum contagiosum, and the cell inclusions in trachoma." Ledingham 13 succeeded in producing agglutination of Rickettsia in emulsions prepared from dried lice excreta by the use of immune 4SS COMMUNICABLE AND OTHER DISEASES sera from four experimental rabbits and one guinea pig. He found, however, that agglutination disappeared beyond a dilution of 1 in 40. From critical consideration of the foregoing it would seem that the final conclusion as to the specific cause of trench fever must be that it is not yet indubitably known, although available evidence now points more suggestively to a Rickettsia than in any other direction. SYMPTOMS The period of incubation in louse-borne trench fever varies from 14 to 30 days, though the suggestion is offered that this might be shortened in cases of infection resulting from large amounts of virus.10 Certain vague prodromata— headache, fever of a low grade, and pain in the extremities—are complained of by a minority of individuals. Otherwise the onset is sudden and characterized by dizziness, headache, retrobulbar pain, particularly on movement of the eyeballs, nystagmus when the eyes are directed to either side, conjunctivitis, and a sudden elevation of temperature to 103° or 104° F. The febrile reaction varies much in its characteristics. It may last about a week, to be followed by a period of defervescence and a short relapse, or it may persist for several (often six) weeks and be marked during that period by indefinite relapses; and, finally, it may assume quite distinctively the form of a regularly relapsing fever with apyretic intervals lasting six or seven days. A less frequent picture is that of a low continued fever which persists, with only slight remissions, or none at all, from one to two months. The skin in three cases out of four presents an eruption consisting of erythematous spots or papules, most intense on the ven- tral and dorsal surfaces of the torso. The individual lesions average 3 or 4 mm. in diameter, are pink in color, and the color disappears under pressure. The period of their duration is short, often no more than 24 hours. Most charac- teristically they first appear during the initial stage, but they are sometimes first seen during a relapse. The blood picture is variable. Many cases show a moderate leucocytosis (13,000 to 17,000), which recurs with each relapse. On the other hand, in certain cases the leucocytes are normal, while a few manifest a leucopenia (occasionally as low as 3,500). The urine frequently contains albumin in small amounts, but there is no other evidence of true inflammation of the kidney. The spleen is enlarged in a considerable majority of instances. The most impressive subjective symptoms of trench fever are pain and tenderness. These are referred particularly to three regions or systems—the bones, the head, and the muscles. The "shin pains" are present in 75 per cent or more of all patients. They are boring or lancinating in character and increase in severity so much at night as seriously to interfere with sleep. They appear most characteristically on the third day of the disease or later, but in certain cases do not occur until the first or second relapse. They are accom- panied by marked tenderness of the tibia to pressure. Pain of a similar char- acter occurs in the scapula in many cases. Joint pains occur with a frequency equal to that of shin pains in both the upper and lower extremity. The head- ache is a universal symptom. It is commonly frontal or postorbital, though it may be generalized, and it lasts for two or three days, usually recurring with INFECTIOUS JAUNDICE; TYPHUS FEVER; TRENCH FEVER 489 each relapse. It is accompanied by a peculiar tenderness to pressure in the supraorbital region which occasionally involves the entire scalp. Muscle pain is complained of in the lower extermities, in the abdominal wall (either localized or generalized), in the lumbar region where it occurs in 80 per cent of all cases, in the muscles of the shoulder girdle, and in the cer- vical muscles. It is accompanied by tenderness on palpation. Anorexia and coated tongue are the most prominent of the gastrointestinal symptoms. Although the pain is so constant and so marked and the reflexes are exag- gerated, it is not believed that the central nervous system is directly attacked by the virus of trench fever. The nervous manifestations are probably no more than may be accounted for on the basis of toxemia. The pulse usually parallels the temperature in the first stages of the disease, but later shows a tendency to acceleration. The dyspnea, tachycardia, pre- cordial pain, increase in the size of the heart, all indicate marked involvement of that organ. It has been assumed either "that trench fever virus has a selec- tive action on the heart muscle such as we see in rheumatic fever or in the specific infiltration in syphilis 'of the heart,' or that the 'toxin in trench fever acts upon the heart muscle in a similar way to that seen in pneumonia, typhoid fever, influenza, bronchitis, or other acute infections.' "10 COMPLICATIONS AND SEQUEL_E The most important of these is concerned with the heart, and has been variously termed "effort syndrome," "disordered action of the heart," and "tachycardia." The circulatory manifestations of trench fever have already been described. The persistence of the indicated cardiac condition after the apparent cessation of activity is probably to be ascribed—at least, in large measure—to the desire of medical officers to return soldiers to duty as soon as possible. Convalescence appears to be essentially a lengthy procedure in this disease, as in dengue fever, and acceptance of such a view in the management of convalescence will allow for complete recovery without the appearance in any marked degree of this cardiac disorder. Thus, the American Red Cross com- mission, previously quoted, states that— Among our patients, we feel that up to the present time none have shown a condition of D. A. H. after the infection was overcome. This probably is due to the fact that our sub- jects were carefully chosen, and those who had previously shown symptoms of cardiac weak- ness were not inoculated. The subjects were all young and strong, and at the time of inocu- laton were not suffering from other infections, nor had their resistance been lowered by long duty in the trenches or exposure to other forms of strenuous work * * * On the other hand, the absence of permanent effect upon the heart may have been due to the opportu- nity we had of holding the patients until we felt they were fit for active duty. Except for the cardiac complications and sequelse of trench fever, the concurrent diseases in the Army were widely various, and were not such as to indicate a pathological relationship between themselves and the original infec- tion. 490 COMMUNICABLE AND OTHER DISEASES PATHOLOGY Since the disease uncomplicated is never fatal, and since it is not trans- missible to animals, the pathology is a sealed book. The clinical evidence of changes in the heart and spleen, as well as the blood findings, have been referred to under symptoms. DIAGNOSIS Diagnosis is to be made upon the symptoms and signs hereinabove de- scribed, of which the shin pains and shin tenderness are perhaps the most essen- tially characteristic. From influenza, trench fever may be differentiated by the absence of respir- atory symptoms and signs, by the characteristic pain and tenderness, by the relapses, by the splenic enlargement, and by the eruption. Typhoid and paratyphoid fevers are of gradual onset, are accompanied by certain digestive disorders, present a spleen which is less enlarged (if at all) and softer than is the case in trench fever, lack the characteristic pains and tender- ness, show a leucopenia, and give a blood serum capable of agglutinating the causative organism in high dilution. Bacillus typhosus and Bacillus paratypho- sus may also be recovered from the blood, feces, and urine. Trench fever and malaria differ very characteristically in their tempera- ture charts, in the matter of febrile paroxysms, in the skin eruption, pains, and tenderness which are present in the former disease, and in the absence of the malarial parasite in the blood of trench fever cases unless the two diseases coexist. Relapsing fever, because of its mode of onset, its pain, and rash, may be confused with trench fever; but a crisis on the seventh day with a relapse at the end of another seven-day period in relapsing fever indicates a difference between the febrile processes. Both liver and spleen are enlarged in relapsing fever, the spleen alone in trench fever. The causative spirochetes are present in the blood of relapsing fever and absent therefrom in trench fever. Salvar- san exerts a marked effect upon relapsing fever, but none on trench fever. Dengue fever may suggest trench fever in its mode of onset and distribution of painful areas, but the acute stage of dengue is short, with an intermission occurring on the third to fifth day. The rash in dengue fever is erythematous or scarlatiniform during the first paroxysm and measleslike in the second par- oxysm. Dengue is invariably characterized by a marked leucopenia; trench fever presents a moderate leucocytosis in a great majority of cases. In typhus fever the onset is more gradual than in trench fever and is accom- plished in successive steps. Toxemia becomes increasingly more profound as typhus fever progresses, while the toxic manifestations of trench fever—such mild ones as there may be—are more intense within the first few days after onset and rapidly subside. The characteristic relapses of trench fever are not found in typhus fever. The skin eruption in typhus appears on the third to the fifth day and is macular in character, changing to petechial. Typhus fever has a high mortality; trench fever is never fatal. Malta fever is to be differentiated from trench fever, first, by the different temperature curve, by the absence of the eruption and characteristics pains INFECTIOUS JAUNDICE; TYPHUS FEVER; TRENCH FEVER 491 and tenderness, by recovery of the causative organism from the blood and urine, and by serological methods. There is, however, no serological or other laboratory procedure which is specific for the diagnosis of trench fever. PREVENTIVE MEASURES General preventive measures during the war consisted essentially in the delousing of officers and men, together with their effects, a detailed description of which is in Volume VI, Sanitation. No attempts, apparently, were made to attenuate by heat the virus of this disease as it occurs in louse excrement and in the urine of trench-fever patients, and to vaccinate experimentally with such material. Since the infection of laboratory animals is not possible, such experimental attempts at vaccination could hardly lead to results of practical value for the reason that the source of such vaccine could only be trench-fever patients themselves, of whom a very considerable number would undoubtedly be necessary to supply material suf- ficient in amount for large bodies of troops. Again, no reference can be found to the attempted protection of noninfected individuals by the use of serum from convalescent patients. The relatively small number of cases of trench fever reported for the whole United States Army can not bespeak efficiency of the preventive measures in operation among American troops, in view of the fact that the major portion of our combat troops were louse infested at the time of the signing of the armistice. But other considerations must be taken into account. A study of the statistics of trench fever in the Third Army shows that three-fourths of all its cases occurred in two divisions, as follows:14 Incidence of trench fever in troops of Third Army, January 1 to March 1, 1919 Cases Cases 42d Division________________________ 143 Third Army troops___________________ 9 2d Division_________________________ 55 Third Corps troops___________________ 2 1st Division_________________________ 16 Fourth Corps troops----------------- 1 52d Division_________________________ 11 ---- 4th Division_________________________ 8 Total------------------------ 251 3d Division_________________________ 6 Again, the Third Army alone reported within only two months (January 1 to March 1, 1919) nearly a third of all the cases in the whole American Expedi- tionary Forces for the entire period of the war. That these figures represent the actual state of affairs is difficult to believe. They tend to suggest rather that in reality the cases in the Army exceeded the reported number of 901, and that many diagnoses were missed either because of transfer of the infected individuals from one station to another or—more especially—"because medical officers were not acquainted with the manifestations of the disease." u This impression is definitely reinforced by a consideration of the far greater uniformity with which trench fever is shown to have invaded the various units of the British Expeditionary Force. 492 COMMUNICABLE AND OTHER DISEASES TREATMENT No specific method of treatment is available. Salvarsan and the other antisyphilitic arsenicals are without effect. A symptomatic therapy consisting of complete rest in bed during the infectious period, a diet of good nutritive value, and the exhibition of such drugs as aspirin and Dover's powder in doses sufficient to control the pains are indicated. The most important factor in treatment is the recognition of the necessity for prolonging the convalescent period until the cardiac condition and action have become entirely normal. Patients should be kept in bed until all probability of a relapse is at an end. The amount of time allowed out of bed should then begin with a few hours and gradually be increased daily, provided no return of the cardiac symptoms is noticed. As soon as the patient reaches the point of remaining up and about all day, guarded and carefully supervised exercises are to be begun. These must be carefully controlled and the appearance of dyspnea, cardiac palpitation, dizziness, pain, fatigue, headache, excessive increase in pulse rate, and cyanosis are the signal for moderation in the amount of exercise taken. The exercises employed are of two kinds: Setting-up exercises and practice inarches. As soon as the patient can endure a practice march of 5 miles with full field equip- ment and return therefrom without evidence of undue weakness his convales- cence is looked upon as completed REFERENCES (1) Jobling, James W., and Eggstein, A. A.: The Wild Rats of the Southern States as Carriers of the Spirochseta Icterohemorrhagise. The Journal of the American Medi- cal Association, Chicago, 1917, lxix, 1787. (2) Wolbach, S. Burt; Todd, J. L.; and Palfrey, F. W.: The Etiology and Pathology of Typhus. (Report of the Typhus Research Commission of the League of Red Cross Societies to Poland). Harvard Universitv Press, Cambridge, Mass., 1922, 3. (3) Ibid., 43. (4) Ibid., 112. (5) Ibid., 116. (6) Ibid., 123-4 (7) Graham, J. H. P.: On a Relapsing Febrile Illness of Unknown Origin. The Lancet, London, September 25, 1915, ii, 703. (8) Hunt, G. H., and Rankin, A. C: Intermittent Fever of Obscure Origin. The Lancet, London, 1915, ii, 1133. Also, Hunt, G. H., and McNee, J. W.: Further Observa- tions on Trench Fever. Quarterly Journal of Medicine, Oxford, 1915-16, ix, 442. (9) Hurst, A. F.: Trench Fever. Journal of the Royal Army Medical Corps, 'London 1917, xxxviii, 207. (10) Report of Commission of American Red Cross Research Committee on Trench Fever. Oxford University Press, 1918. (11) Coles, Alfred C: Spirochsetes in the Blood in Trench Fever. The Lancet London March 8, 1919, i, 375. (12) Swift, Homer F.: Trench Fever. Archives of Internal Medicine. Chicago 1920 xxvi, 76. ' ' (13) Ledingshaw. J. C. G.: Agglutination Experiments with Trench Fever Rickettsia The Lancet, London, June 12, 1920, i, 1264. (14) Swift, Homer L.: Trench Fever in the American Expeditionary Forces. The Journal of the American Medical Association, Chicago, 1919, lxxiii, No. 11, 807. CHAPTER XVII VINCENT'S DISEASE Vincent's disease, as it was known during the World War, was variously designated, according to location or pathological process, as trench mouth, trench gums, trench throat, ulcerative tonsillitis, Vincent's angina, epidemic ulceromembranous stomatitis, ulcerative gingivitis, and angina necrotica. As the disease first received attention on a large scale among troops while servmg in the trenches, and it was thought that conditions incident to this service at least predisposed them to infection, it was spoken of most commonly, during the war, as "trench mouth," "trench throat," and "trench gums." By some it was thought to be a new disease. All authorities are not agreed as to the origin and cause of the affection. Some contend that Vincent's angina almost invariably commences as gingivitis, acute ulcerative, sub-acute, or chronic;1 others are of the opinion that it is not a separate entity, a disease in itself, but is a manifestation of some other process, notably syphilis. Sobernheim2 is often referred to as authority for the statement that the Wassermann re- action is positive in Vincent's angina. Further, there is dispute as to the etiological part played by B. fusiformis and Vincent's spirochseta, as well as other spirochsetes in the mouth, notably the S. dentium. Vincent's disease is an acute or chronic, mildly contagious disease of the mucous membrane of the mouth, with occasional manifestations in the throat, bronchi, eye, and genitalia. It is characterized clinically by a rather slow or chronic onset, with a local lesion or lesions, pain in the acute form and little or none in the ulcerative, lymphadenopathy of the glands draining the area involved, offensive breath, interference with deglutition when the lesion is located in the mouth or throat, and comparatively little constitutional disturbance. It is characterized pathologically by the formation of a pseudomembrane or "punched out" ulceration, with a red bleeding base and the presence of the B. fusiformis and the Spirochxta vincenti. The number of cases of Vincent's disease reported in medical literature prior to the war would indicate that it was rare until the widespread occurrence among troops on the Western Front, described by Bouty.3 Investigation showed that among the British and French troops, especially in the trenches, a disease of the mouth, gums, and tonsils, which came to be called "trench mouth," "trench throat," and "trench gums," was so common that it constituted 23 per cent of all throat complaints. It was found that these conditions were asso- ciated with an admixture of fusiform bacilli and spirilla. Before the entrance of the United States into the war, the ulcerative form of Vincent's disease was practically unknown in the Army. Rarely cases of the acute type, characterized by presence of a pseudomembrane in the throat (rarely on the gums), with severe angina and marked constitutional symptoms, were diagnosed as Vincent's angina. These cases were so few that it was not deemed necessary to record this term in the Army list of diagnoses. Soon after the arrival of American troops in Europe, cases of "trench mouth" appeared on 493 494 COMMUNICABLE AND OTHER DISEASES the sick and wounded reports and the number of reported cases of \ incent s disease greatly increased. Cases appearing under the terms "trench mouth and Vincent's angina were tabulated and carried separately in the files; however, the statistical tables for the World War show only cases reported as "trench mouth." In this chapter both trench mouth and Vincent's angina will be considered as one and the same disease—Vincent's disease. OCCURRENCE IN CIVIL POPULATION In modern American textbooks the statement is made that Vincent's disease is not common among the civilian population. Theisen4 found that, between 1909 and 1910, 687 throat swabs were examined in the Michigan State Laboratory for diphtheria, and that 178 of the cases proved not to be diphtheria at all but were cases of Vincent's disease. Vincent himself found the disease in 2 per cent of all cases of membraneous angina. One is led to believe, therefore, that it is more common among civilians than heretofore believed. IN ARMIES Bouty,3 in 1917, stated that during the two preceding years there had been a gradual and marked increase in the number of cases of Vincent's disease among the troops in France, both British and French. In times of peace the rate was from 2 to 3 per cent of all throat complaints among French troops. Chalier5 reported 46 cases of throat conditions among 2,500 men during 22 months. Of these, 26 per cent were Vincent's disease, while Deglos 6 found 21 cases of ulceromembranous stomatitis, Vincent's disease, among 255 men sent with sore throat to his contagious hospital. The acute ulcerative form of gingivitis was found present in about 0.7 per cent of the British troops in France seeking dental treatment, and in about 0.3 per cent among soldiers living under various conditions but not reporting for dental treatment.1 From the available fragmentary reports, it would appear that Vincent's disease, commonly designated by German and Austrian authors as Plaut- Vincent disease, was prevalent among the German and Austrian forces. Sauer- wald7 described an outbreak of 45 cases among the German troops in 1917. These cases occurred in a hospital center and were described as Vincent's angina and noma. Sachs8 demonstrated some cases in a military hospital in Vienna in April, 1917. IN UNITED STATES ARMY Table 80 shows the number of primary admissions, deaths, discharges from the service on account of disability, and days lost from duty, by country, race, and year of occurrence, for Vincent's disease during the World War. This table includes enlisted men only. It shows that the number of cases of Vincent's disease, under the designation of trench mouth, was small, the majority having been reported from Europe, while the primary admissions for what was diag- nosed Vincent's angina ran into the thousands and were about evenly divided between the United States and Europe. It is of interest to note, however, that the number of primary admissions for Vincent's disease by years increased throughout the war, although the size of the Army fluctuated greatly beine considerably smaller in 1919 than during the preceding year. Table 80.— Vincent's disease. Admissions, deaths, discharges for disability, and days lost, white and colored enlisted men and native troops, United States Army, by countries of occurrence, April 1, 1917, to December 31, 1919, absolute numbers VINCENT'S ANGINA Total Army (enlisted men) United States 2 Europe Philippine Islands E IE awaii Chi-na Pan-ama Transports Other countries Native troops Years a> X) o "o O T3 » -3 -t-o a o "o o a |§ |'| E-i > 3 a& o o u 3 o ■a "3 a O 1 CD 2 ■a a? o o O "3 o Colored Color not stated 3 'o 9 _ 2 T3 o k4 o "o U 1 ""3 "3 0 Eh 24 15 260 75 262 ■a 0 "3 O "3 0 Eh 2 5}