The Medical Department Of The United States Army in The World War
CHAPTER XXIX
DEPARTMENT OF SANITATION AND PUBLIC HEALTH, GERMANOCCUPIED TERRITORYa
The office of the department of sanitation and public health for civilaffairs in German occupied territory was establishedpursuant to the provisions of General Orders, No. 1, advance generalheadquarters, A. E. F., Treves, Germany,December 13, 1918; however, the organization of the office had beenbegun by verbal orders issued by the commanderin chief, A. E. F., about one week previously. It was the duty of thisdepartment to supervise and control the civil sanitaryservice in the occupied area with a view of protecting the health ofthe troops of the American Army of occupation andof guaranteeing to the civil population adequate medical service. Thepersonnel of the department consisted of 12 officers,4 nurses, and 9 enlisted men.
DISTRIBUTION OF TROOPS
The army of occupation, i. e., the third Army of the American ExpeditionaryForces, consisted of eight divisionsorganized into three corps, with headquarters at Coblenz. These troopsoccupied an area west of the Rhine along theMoselle River, roughly 80 miles from southwest to northeast, from Trevesto Coblenz, and about 50 miles in width,together with the northern half of the Coblenz bridgehead east of theRhine. This territory included the kreise (circles) ofPrum, Bitburg, Treves, Saarburg, Daun, Wittlich, and Berncastel, inthe Government district of Trier, and Adenau,Ahrweiler, Cochem, Mayen, Coblenz, and Neuweid, in the Government districtof Coblenz, with most of the Governmentadministrative area of Montabaur, in Hesse Nassau. The estimated civilpopulation of the territory occupied, and withwhose sanitary control this division was charged, totaled 835,000.
GERMAN PUBLIC HEALTH SERVICE
Information was obtained concerning the personnel and organization ofthe German public health service by personalinterviews with the civil officials in Treves and Coblenz and by astudy of published regulations and reports of the service.It was found that it was administered by civil officials appointedby the Minister of the Interior. In each of the Governmentadministrative areas, a civil medical officer was charged directlywith the supervision of sanitary matters within his area; hewas responsible to the administrative head of the district. As healthofficer of the community, he was the technical adviserof the administration with reference to all sanitary and public healthmatters. In general he supervised water supply andsewage disposal; received reports of communicable diseases and sawthat lawful measures against their spread were
aBased on: Report on the Department of Sanitation and Public Health, Civil Affairs, Treves, Germany. Period Dec. 7, 1918, to May 28, 1919, dated Nov. 1, 1919, by Col. Henry A. Shaw, M. C. On file, Historical Division, S. G. O.
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enforced; made sanitary inspections of food supplies, including milk,meat, etc.; supervised the sanitation of schools andthe medical examination of public prostitutes. He could not initiatesanitary regulations, but he kept in touch with allmatters affecting the health of the community, and was held responsiblefor making proper and timely recommendationsfor the prevention of disease and the general improvement of sanitaryconditions. He made weekly reports ofcommunicable diseases and yearly reports of general health conditionsto the administrative head of the district.
COORDINATION OF THE CIVIL AND MILITARY SANITARY SERVICE
As the German public health service appeared to be adequate and sufficientfor the needs of the civil population, themanifest policy was to continue the organization in force, with suchsupervisory control and assistance by the AmericanMilitary Establishment as might be found necessary. This was satisfactorilyeffected by directing division commanders tosupervise the administration of the civil sanitary service within theirdivisional limits. As these areas corresponded fairlyclosely with administrative areas, division surgeons were enabled tocooperate effectively with the local health officer,obtaining from him information concerning the health of the civil populationand the sanitary conditions of the country andat the same time giving him information concerning the health conditionsof the military units. In this the work of the civiland military organizations was coordinated, each reporting to the otheressential data affecting public health.
Reports from division surgeons of cases of communicable disease in bothcivil and military populations reached the officeof the chief sanitary officer through the chief surgeon, Third Army.Weekly reports of communicable diseases in the civilcommunity were also received from the chief German sanitary officialof the district of Treves and of Coblenz. Cases oftyphoid fever were in addition reported from the director of the Germanlaboratory at Treves. Division surgeons made aspecial monthly report to the chief sanitary officer through channelsregarding important matters pertaining to public healthand sanitation in the civil population, a separate report being renderedfor each administrative area. Thus, reports werereceived and tabulated from both civil and military sources enablingthe chief sanitary officer to keep in touch with healthconditions in both communities.
MEDICAL SERVICE FOR THE CIVIL POPULATION
One of the first endeavors of the office was to get in touch with theGerman civil sanitary officials both in Trier and inCoblenz for the purpose of obtaining information concerning the adequacyof the established public health service withrespect to personnel and material, and also to learn whether the needsof the civil population were satisfied as to medicalattendance, hospital and laboratory facilities, and medical suppliesand drugs. Though the public health service, as notedabove, was found to be generally adequate and competent, it was reportedthat there were insufficient German physicians to care for the civil populationin the occupied territory.
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HOSPITALS
All hospitals were under the administration of the Minister of the Interiorof Prussia and made regular reports concerningthe number of beds, the character of patients, the number of admissionsand discharges, and the causes of death. In theentire district of Coblenz there were reported to be 39 institutionsfor the care of the sick, with a total of 3,825 beds, andof these only 2,282 were occupied. In the Treves district there were2,214 beds available, this number being sufficient tocare for the needs of the civil population. The total number of bedsin Coblenz was approximately 5 per cent of thepopulation and in Treves 2.2 per cent. In both districts the numberof hospital beds had been increased during the war tocare for soldiers and was larger than the number that sufficed in timeof peace.
The civilian authorities were informed that in emergency, and also incase of communicable disease, where isolation couldnot be promptly obtained by German civilians, such patients would beadmitted to American military hospitals.
LABORATORIES
A well-equipped laboratory under the control of the public health servicehad been established in Treves and was foundto be very efficiently administered.
MEDICAL SUPPLIES AND DRUGS
Reports from hospitals, laboratories, public health officials, physicians,and druggists showed that many of the essentialmedical supplies and drugs were either exhausted or to be found inextremely limited quantities. Such were gauze, cotton,and soap for surgical work; rubber articles; certain drugs, as iodineand the iodides, sulphur, boric acid, camphor, and thevegetable cathartics. Estimates were made of the needs of the populationbased on the number of hospital beds, andrecommendation made that certain enumerated supplies and drugs be furnishedby the Medical Department, UnitedStates Army, to German hospitals and laboratories in the occupied area.These recommendations were approved insubstance, and the necessary measures taken to carry them into effect.The cost of the supplies was charged to theGerman Government.
HEALTH CONDITIONS
A comprehensive study was made of the health of the civil communityin Germany during the war and particularly in theoccupied area, the material for which was drawn from official reportsfrom civil and military sources, from interviews withGerman physicians and civil officials, from vital statistics publishedby the German Government, and from personalexamination of various groups of the German population.
VITAL STATISTICS
Births.-The average birth rate for this region during severalyears previous to the war had been about 30 per thousand; in 1914 it was23.8; in 1917, 15.6, and in 1918, 16.1. Illegitimate births in the occupiedarea in Germany showed little variation in the rural districts before andduring the war, but in the cities the rate was about doubled in 1917 and1918 as compared with 1915.
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Deaths.-In the occupied area the death rate for several yearsprevious to the war averaged 15 per thousand inhabitants; in 1915 it was20.5 and in 1918, 27.2.
Communicable diseases.-There had been a marked increase in thenumber of communicable diseases in Prussia in 1914 and 1915. This was tobe expected on account of war conditions involving rapid mobilization oftroops and billeting with civilians; many localities were left with insufficientmedical personnel. In the American area the most notable increase in thesediseases had been in typhoid fever, tuberculosis, diphtheria, and especiallydysentery; previous to the war this disease had been almost negligiblein this region, but it appeared in Trier in 1914 and in Coblenz in 1915,increasing during the following years; in Coblenz there were over 700 casesin 1917, and in Treves more than 1,000 in 1917, and nearly 1,900 in 1918.
Among the civil population of Germany, tuberculosis in all its formshad more than doubled during the war, a fact shownchiefly in death statistics, as living cases were not reported. A correspondingincrease of tuberculosis among the livingwas indicated by the fact that the Government insurance offices inthe cities of Trier and Saarbrucken paid benefits to 48 cases of pulmonarytuberculosis in 1914; the number rapidly increased during the war and in1918, 208 persons received insurance for this disease. Of all the etiologicalfactors entering into this increase the shortage of food was most important.This increase had been much less marked among the comparatively well-fedrural population than among the city dwellers who were more strictly rationed.
FOOD PROBLEM
One of the most interesting matters for investigation was the food problemin Germany, since this question in one form or another was met with atevery turn.
To solve the problem of a diminished food supply, Germany proposed nationalrationing. This was begun early in 1915, first in regard to bread and thenextended in the same year to potatoes and meat and finally to nearly everyessential food product. The rationed articles could be obtained only ontickets, in specified amounts and at prices fixed by the Government. Afterthe failure of the potato crop in the fall of 1916, food conditions wentfrom bad to worse, so that before the end of the war the ration allowancesin most parts of Germany were less than half the usually accepted estimatesfor physiological requirements for health. In general, it may be statedthat the allowances in 1914 averaged about 3,000 calories for various localities;in 1915, about 2,000 calories; in 1916 and 1917 about 1,500 calories, andin 1918 between 1,200 and 1,500 calories. In December, 1918, the allowancesfor Cologne were 1,480 for Coblenz 1,490, and for Treves 1,408 calories.The rationed articles for this period in Treves were as follows for oneweek:
Grams | Calories | Cost in marks | |
Bread, whole rye, 4-pound loaf | 2,000 | 4,800 | 0.96 |
Potatoes, 1 pound per day | 3,500 | 3,073 | .63 |
Sugar | 156 | 620 | .18 |
Meat, including 25 grams sausage | 150 | 260 | .18 |
Fat (margarine) | 50 | 450 | .43 |
Marmalade, cereals, dried soup, etc. | 594 | 650 | .81 |
| 6,450 | 9,853 | 3.63 |
Per day | 11.8 | 1,408 | .52 |
1Pounds.
825
Because of illicit traffic in food supplies, hoarding was practicedby farmers and by the wealthy, and among these therewas not so great inconvenience and distress as among the poor in thelarge cities.
FOOD VALUE OF THE RATION
That the ration allowance during the latter months of the war was pitifullyinadequate is shown by a glance at the following figures:
Average diet | Treves ration | ||
Protein | per cent | 12-15 | 8.3 |
Fat | .do. | 18-20 | 10 |
Carbohydrates | .do. | 60-65 | 81.7 |
Total calories | 3,000 | 1,408 |
The ration was diminished both relatively and absolutely in proteinand fat, and in caloric value reduced almost one-half incarbohydrates, and more than half in total amount. The dietary of thepoor people was somewhat augmented by theaddition of such vegetables as cabbage, carrots, beets, and greens,which could be purchased during the winter in openmarket at very reasonable prices. While these vegetables added to thebulk of food, its caloric value was probably not increased much more than175 or 200 units.
EFFECTS OF FOOD SHORTAGE
It was difficult to estimate the effect on the civil population of thisinforced reduction in diet; in any event, the resultsrelated only to a limited portion of the inhabitants. In general, farmersand country people had enough for their own needsand more; the well-to-do always found ways to procure an abundanceof food. Those who suffered real physicalprivation were the poor in the cities; this class has been estimatedfrom 10 to as high as 25 per cent of the totalpopulation; the lower figure was probably nearer the truth.
This loss of weight was not an unmixed evil, as there was evidence,at the time of our occupation, of improved physicalcondition of the obese and overfed, the gouty and the diabetic.
Children of school age, 6 to 13 years, were found to have suffered directlyas the result of improper and insufficientnourishment. Two thousand five hundred children in Treves and vicinitywere found in general to be under the averagenormal height and weight of German children during peace times. A largenumber were found to be small in stature andthin in build, pale and anemic and with poor nutrition; these conditionswere found most frequent and most marked amongthe poor. Reports to the same effect were received from numerous sourcesin Germany.
In a comprehensive psychiatric survey of the school children of Treves,it was found that, chiefly as the result ofmalnutrition, there was a lowering of the whole standard of schoolwork; loss of nervous energy exhibited by 40 per centof the children; an increase in the number of border-line defectivesof not more than 1 per cent of the total schoolpopulation; and an increase in the number of children failing to passtheir grades from 8 per cent in pre-war
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years to 15 per cent in 1917 and 1918. These conditions were, however,not found in nearly so marked a degree in thecities of Cologne, Bonn, and Coblenz.
War edema so commonly seen throughout Germany was very generally attributedto insufficient nourishment. The British,it was learned, noted that it appeared when fat was markedly reducedin the dietary, and that the symptoms cleared upwhen fat was added.
As a result of the food survey which this office began early in January,the following report (in part) was made January 31to the officer in charge, civil affairs:
The evidence at hand indicates undernourishment of babiesand young children. Nursing mothers are not properly nourished, and theirbabies do not gain in weight as they should. Bottle-fed babies can notbe properly fed on account of the lack of milk. Children are undernourishedmainly by reason of the lack of fats and milk. In regard to the sick, oneof the most important considerations is a proper diet. There is ample evidencethat sick are dying or that convalescence is greatly lengthened on accountof lack of a nourishing and easily digestible diet. White bread, rice,milk, and some easily digested fats are essential.
With regard to the general population, there is no doubtthat the middle class and poorer people who can not afford to pay exorbitantprices for food are undernourished, and in many cases resistance is therebylowered so that they become more susceptible to disease. As it is manifestlyimpossible to secure a perfectly even distribution of all the food availablein the American area, it is almost certain that some of the essential articlesof diet in the ration allowance will before the next harvest become exhaustedin certain localities, such as the industrial centers, and that it willbe impracticable, perhaps impossible, to supply such districts fromGerman food stocks. It is therefore believed that our Government shouldhave on hand the necessary supplies to make good these deficiencies andshould be able to control the distribution. It is probable the first seriouscry for food will be for bread. The present dietary is deficient in proteinand fat. The deficiencies would be made up by wheat, which is rich in protein,and by pork, which in addition to protein is rich in fat. Potatoes willprobably be demanded in certain localities, as this vegetable is even moreof a staple than bread. Rice is an excellent substitute for potatoes. Inaddition, bacon or margarine might be economically issued to replace thedeficient fat. Canned beef or canned salmon would form valuable additionsto the present dietary and if on hand in excess might be used to advantage.
The following recommendations were made at the same time:
That steps be taken to increase the dietary of nursingwomen, children, and the sick by the addition of wheat flour, rice, condensedmilk, and butter or margarine.
That the United States Government be prepared to issueto the general population wheat flour (preferably whole wheat), meat (preferablypork), bacon or margarine, and rice.
The food situation in the American area remained practically unchangedduring the winter of 1918-19 and earlyspring of 1919. The component parts of the ration varied somewhat fromtime to time, the general situation getting ratherworse than better, until with the opening of spring and the adventof a wealth of green vegetables conditions began toimprove. On April 20, 1919, the first American food was brought inand sold to German civilians, increasing the ration toabout 2,100 calories. Articles on sale consisted of flour, rice, cannedmilk, bacon, canned beef, and canned salmon, butunfortunately the prices were so high that very little of the foodreached those who were most in need of it.
An investigation of the physique of school children in Treves indicatedthat many of the physical defects noted and muchof the suffering and hardship
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endured by them were due to the unhygienic surroundings in which theylived. With a view of obtaining definiteinformation as to the living conditions of the poorer portion of thepopulation, a house-to-house survey, including over1,000 families, was made by American Army nurses accompanied by Germansocial welfare nurses. This surveyshowed that because of overwork, neglect of homes and children, andespecially because of the war ration, disease, especially tuberculosis,had increased among the poor people in the city of Treves. The followingfacts in their report are quoted:
Average number of persons per family | 7.1 |
Average number of rooms occupied per family | 3.52 |
Average number living children per family | 4.08 |
Average number dead children per family | 2.07 |
Number of families with sickness at time of visit | 757 |
Number of families with history of tuberculosis | 282 |
Number of families with some member tuberculous | 379 |
Average earnings per family per week, marks | 61.02 |
Average cost of living per family per week, marks | 51.89 |
(At the time of this survey, the value of the mark was about 8 cents.)
