Medical Department of the U.S. Army in the World War
THE MEDICAL DEPARTMENT OF THE
UNITED STATES ARMY IN THE WORLD WAR
VOLUME VI: SANITATION
IN THE UNITED STATES
BY
COL. WESTON P. CHAMBERLAIN, M. C.
IN THE AMERICAN EXPEDITIONARY FORCES
BY
LIEUT. COL. FRANK W. WEED, M. C.
PREPARED UNDER THE DIRECTION OF
MAJ. GEN. M. W. IRELAND
THE SURGEON GENERAL
WASHINGTON: GOVERNMENT PRINTING OFFICE : 1926
IN THE AMERICAN EXPEDITIONARY FORCES
CHAPTER I
SANITARY ORGANIZATION
BY
COLONEL HAVEN EMERSON, MC
535
INFLUENZA-PNEUMONIA
The other epidemic, much more serious in character than that of diarrhea, andthe greatest cause (from sickness) of noneffectiveness and deaths in theAmerican Expeditionary Forces, was influenza. This disease prevailed in a mildform from the middle of April, 1918 (when there was a general epidemic in thecamps in America), until the middle of July, but without interfering materiallywith military activities. At this time there was a marked increase in the sickrate from this cause for a week or two while the disease swept through acommand, but recoveries were prompt, complications rare, and deaths very few.6
In September the disease returned (as it did in the United States), whenlarge shipments of troops were arriving from home and when every resource of menand material was being strained to prepare for or to take part in theMeuse-Argonne operation. The weather was unfavorable, ordinary precautionsimpossible in the life and death urge of the front, the means of evacuation andthe hospitals were strained to their capacity by battle casualties, and thedisease, or rather the accompanying pneumonia, was of a most severe, oftenmalignant type. Troop movements were extensive and urgent; military necessitydemanded every sacrifice for the benefit of the offensive operations. Theconditions combined to make adequate preventive measures and early andsufficient hospital care nearly impossible.6
It was not only in the advance zone that the disease prevailed; it was verysevere in the rear and base areas. Heavily infected during the voyage, troopshad a loss as high as 10 per cent within the three weeks after embarking. Idealopportunities of spread from man to man, long delays and insufficient provisionfor rest, food, and medical supervision during train transport to training areasor replacement divisions, added to the number of cases of the disease. Crowdingin billets and barracks, beyond the limits of safety, was common. Delay indiagnosis and in removal to hospital added to the danger from pneumonia. In thehospitals insufficient precautions for preventing communication of the infectionin the wards probably contributed to a heavy incidence of pneumonia andconsequently to a high death rate.6
By the second or third week in October, 1918, the epidemic began to declineand by December following, it was at an end. In the latter part of January,1919, there was a third, mild wave; but this time there was no considerable lossof life. By the middle of March this third wave had subsided, and in April, asis usually the case at this season, the incidence of all the respiratorydiseases reached very low figures.6
The incidence and death rates of influenza in the American ExpeditionaryForces were much lower than in the United States. There were more seasonedtroops in France than at home, where there were hundreds of thousands of newmen, and many passed through the infection in the United States before going toFrance.
539
NOTIFICATION OF CONTAGIOUS DISEASES TO THE FRENCH AUTHORITIES
By order of the chief surgeon, A. E. F., under date of February 29, 1918, allsurgeons of organizations or units were required to make declaration to thelocal civil and military authorities, immediately upon diagnosis, of all casesof contagious disease occurring in their organizations.6
Besides the aforementioned, the Franco-American liaison was of great benefitand importance on certain points: (a) Delivery of sera to American medicalofficers by French laboratories; (b) sterilization and analysis of drinkingwater in railroad stations.
Consequent to ministerial circular letter of October 18, 1918, the principleof collaboration of the American and French medical authorities concerningreports relative to bacteriological, chemical, and sanitary tests of watersupplies along railroad lines traveled over by troop convoys was recognized, andthe necessary steps were taken to advise laboratory officers in charge of wateranalysis of it.
An agreement was reached between .the high commissioner for Franco-Americanaffairs and the Minister of Public works consequent to a request by the AmericanWater Supply Service, Director General of Transportation, and MedicalDepartment, and it was decided that control and analysis of water supplies inrailroad stations and along railroad lines would be exercised jointly by theAmerican and French medical officers. Likewise, "drinking water"posters in both French and English were to be placed, at the discretion of theAmerican and French medical officers, wherever justified, in stations.6
INFLUENZA EPIDEMIC-RECIPROCAL REPORTS
By ministerial telegram, October 29, 1918, the Undersecretary of State forthe French Medical Department informed the regional chief medical officers thatall information at their disposal concerning influenza, its spread, evolution,etc., should be communicated daily to the American Medical Department throughthe regional liaison officers.6 Vice versa, a letter from the chiefsurgeon dated October 24, 1918, bearing on the influenza epidemic, called theattention of all members of the Medical Department to the urgent necessity ofmaintaining liaison and daily interchanges of information with the Frenchmedical officers, with a view to detecting the appearance of cases of influenzaand of studying the preventive measures necessary to check its spread. It wasrecommended that all medical officers, as far as possible, should obtain fromthe French Medical Department all available information which might prove ofvalue to the Medical Department, and should likewise communicate their views andfindings in the same manner to the French Medical Department.
The liaison between the Medical Department and the French medical officersproved to be most valuable in that which concerned local questions of a sanitarycharacter relative to American troops (camp sites, dangerous territory, etc.).
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(6)
EXCERPTS FROM
CHAPTER XV
AN ANALYSIS OF THE INCIDENCE OF COMMUNICABLEDISEAESES
BY
COLONEL HAVEN EMERSON, MC
1106
INFLUENZA AND PNEUMONIA
Between July 1, 1917, and April 30, 1919, inclusive, there were reported inthe American Expeditionary Forces 191,590 cases of influenza and 29,381 ofpneumonia. During the same period there were 545 deaths from influenza and12,849 deaths from pneumonia, or a case mortality of. influenza of 0.28 per centand of pneumonia of 43.7 per cent, and a combined case mortality of 6.06 percent. The number of cases and deaths reported and the incidence of these twodiseases by months per 100,000 strength were as follows:
1107
It would be entirely unprofitable to attempt to tabulate orreport lobar pneumonia and bronchopneumonia separately under such conditions ofthe diseases as prevailed in the American Expeditionary Forces. Rarely was itpossible to make any type determination upon cases of pneumococcus infection,and the number of cases reported by types was so small as to present no interestin a general statement such as this.
Of 104,225 cases of influenza and 9,576 cases of pneumoniareported in the British Expeditionary Forces between September 28, 1918, andApril 19, 1919, inclusive, 7,693 died, giving a combined case mortality of 6.75per cent.
Of the 131,951 cases of influenza and 14,041 cases ofpneumonia reported in the French Army in the zone of the army between September20, 1918, and April 30, 1919, inclusive, there were 10,531 deaths, or a combinedcase mortality of 7.21 per cent.
The case incidence of influenza in the French Army in theinterior was from 2.7 to 11.7 times as high as in the zone of the army. The caseincidence of influenza per 100,000 strength in the French Army in the zone ofthe army and in the interior for the months of July, August, September, andOctober, 1918, were as follows:
At no time did the incidence of influenza in the AmericanExpeditionary Forces exceed 2,500 per 100,000 strength per month.
The monthly case incidence rates per 100,000 in the BritishExpeditionary Forces. and in the French Army in the zone of .the army forinfluenza and pneumonia are as follows
It is particularly interesting to note that the highestincidence of influenza, as shown by weeks, fell in the American ExpeditionaryForces in the week ending September 22, 1918, the highest reported from theFrench Army in the zone of the army fell in the 10-day period October 10-20, andthe highest incidence reported from the British Expeditionary Forces fell in theweek ending November 2.
1108
The ratio of pneumonia to influenza in the AmericanExpeditionary Forces did not vary materially during the period of the epidemic.Pneumonia cases reported by weeks from June 15, 1918, to February 9, 1919,inclusive, were about 12 per cent of the number of cases of influenza reportedduring the same weeks, the exact percentages by weeks being as follows:
Percentage of pneumonia as compared with influenza cases, byweeks
In October, November, and December, 1917, and in January, 1918, the incidenceof infectious respiratory diseases, so-called "clinical influenza,pneumonia, both lobar and bronchopneumonia," reached very high rates, but,owing to the small number of American troops then in France, and becausedetailed study of communicable diseases in camps or hospitals had not yet beenmade, no comparison of rates was made, and the seriousness of the condition wasnot appreciated at the time. It may well be that the unusual conditions whichthe troops had to face, especially the crowded and ill-prepared living quarters,combined with very severe winter weather, were responsible 'for a more thanusual seasonal expression of these diseases.
During February and March, 1918, the usual subsidence of influenza occurred,and in April the incidence was low. During the latter half of April, epidemicsof a benign, acute, febrile infection appeared, first (April 15) at a camp nearBordeaux. In one week the affection, which resembled mild influenza, reached itsheight, and in two weeks more it disappeared from the camp without any secondarypneumonia or other complications, and having caused no deaths, Several camps anddetached groups of white and negro troops in the vicinity of Bordeaux similarlywere affected, from 2 to 10 per cent of the comrnand developing the diseasesuddenly on the same day.
The onset was sudden, with symptoms altogether like those of influenza. Thepatients were afebrile in two to three days and back at work in four to fivedays, In about 10 per cent of the cases there was a mild bronchitis, but therewere no other signs or symptoms of pulmonary involvement.
On May 1 the disease appeared in Tours, and by May 24 the episode at thispost was at an end. The clinical picture was identical with that at Bordeaux. OnMay 3, the disease, commonly called "three-day fever," appeared
1109
at Langres, at a camp hospital. On May 22, a base hospital at St. Nazairepassed through a similar experience, and from this group of cases the influenzabacillus was found in nasal and bronchial discharges in a high percentage of thecases. May 13-24, the disease appeared and ran its course at Chaumont. May20-24, it appeared at Bourbonne-les-Bains.
By June 1, the disease was widespread throughout the AmericanExpeditionary Forces, and evidence of civilian physicians was very definite tothe effect that the disease had prevailed mildly in the civil population inFrance during March and April.
The disease showed sometimes one and sometimes anotherpredominating symptom, but a typical clinical picture was as follows: Abruptonset with headache, usually occipital, severe, and at times with meningealsymptoms, severe backache and general muscular pains, fever, general soreness inthe chest, especially substernal, with a mild sore throat and a slight cough. Nodistinct chill occurred, but the temperature often rose to 103? F., andsometimes to 104? or over. There was extreme prostration, and in some instancesmen fainted while on duty and had to be carried to bed. Recovery was rapid.There were no complications.
During July, the disease disappeared largely from among thetroops in the American Expeditionary Forces, and until the middle of Septemberthere was the usual seasonal freedom from respiratory infections.
In September, influenza in a much more severe formreappeared, and may be said to have raged in the American Expeditionary Forces,reaching its height in the third week of September. It was at this time that thedisease, which had meantime spread to England and the United States, appeared inits most serious form on the crowded transports arriving at our base ports inEngland and France.
The seriousness of the situation may be judged from the factthat in severa1 convoys of transports, carrying a total of about 100,000 troops,there was a loss by death from pneumonia, complicating influenza on shipboard,of 2 per cent of the strength within three weeks from the date of embarkation inthe, United States.
After the severe recrudescence of the disease in September,October, and November, the cases fell off, until in December, 1918, the rate wasmuch lower than for December, 1917. In January, 1919, there was, a third wave ofless severity and affecting a smaller proportion of the American ExpeditionaryForces.
During all the period from September, 1918, to February,1919, the clinical manifestations of the disease were extraordinarily severe,the complication of pneumonia developing in 5 to 10 per cent of the cases, andthe deaths among the cases complicated with pneumonia running as high. as 50 percent. The cases often were overwhelmed by the infection and died within 24 hoursof the onset. The lungs showed a picture of coalescing, patchy pneumonia, oftenwith hemorrhagic tracheobronchitis. Emyema as a complication was rare.
Infection and resistance are subjects Concerning which therewas more opinion than fact in dealing with influenza, but experience with largebodies of
1110
men of practically the same age group, under a variety ofenvironmental, occupational, and climatic conditions justifies the followinggeneral conclusions:
The infection is conveyed by direct discharge of nasal,mouth, and tracheobronchial secretions of patients from at least the earliestobservable moment of appearance of symptoms until a week after the subsidence offever in uncomplicated cases, or until the cessation of cough or other catarrhalsymptoms in cases complicated by bronchitis or pneumonia.
The infection may be conveyed by the hand, and by utensilsand toilet articles when these vehicles have been soiled recently by moistrespiratory discharges of an infected individual.
The chances of infection are increased with close andcontinuous personal contact, as in crowded barracks, mess halls, or meetingplaces.
The severity of infection appears to bear a close relation toso-called "lowered resistance," a condition. apparently developed byfatigue, exposure to wet and cold, worry, strain, insufficient or irregular foodand sleep.
Infection can be diminished in severity and extent in acommand by providing not less than 40 square feet per capita in living quarters,securing separation of sleeping bunks so that heads are separated by apartition, requiring boiling water for washing mess kits, preventing promiscuouscoughing, sneezing, and spitting in and about quarters, and particularly bysegregating under hospital conditions all men found with the slightest symptomsof cold, malaise, or fever, on medical inspection, carried out upon the entirecommand each morning and afternoon.
