Communicable Diseases, Table of Contents
CHAPTER I
TYPHOID AND THE PARATYPHOID FEVERS
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 percent (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 statistics 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. They are sufficiently reliable, however, to justify their use in reviewing, for comparative purposes, the prevailing trend of the d isease. 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 manifestly was impracticable to confirm all clinical diagnoses of typhoid and paratyphoid fevers by laboratory methods; but the laboratory and clinical investigations 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 percent,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
aUnless otherwise stated, all figures for the World War period are derived from sick and wounded reports sent to the Surgeon General-Ed.
16
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 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 wasunderstood.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.
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 10per 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 importance shown in the chart is the precipitate downward trend in typhoid admission rates which commenced in 1909. This reduction coincided with the introduction 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 ratesa
|
War |
Average annual strength |
Admissions |
Deaths |
Case mortality rate | ||
|
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 |
79,462 |
29.86 |
29,336 |
11.02 |
36.92 |
|
Spanish-American War (1898)-U.S. Army |
147,795 |
20,926 |
141.59 |
2,192 |
14.83 |
10.47 |
|
South African War (1899-1901)-British Army (2.5 years) |
209,404 |
59,750 |
114.13 |
8,227 |
15.72 |
13.77 |
|
World War (1917-1919)-U.S. Army (2.75 years) |
1,501,265 |
1,529 |
.37 |
277 |
.05 |
14.85 |
aSource 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 percent. Calculation of the case mortality rate from the recorded morbidity and mortality for the Civil War gives a case fatality rate o 36.9 per cent which, manifestly is much too high. Reversing the process and calculating the morbidity rate from the
18
19
recorded mortality statistics on the basis of a case fatality rate of 10 percent, gives an admission rate for the Civil War period somewhat in excess of 100rather than one of 30.5 per 1,000. This rate undoubtedly approximates more nearly the actual prevalence of the disease.
The incidence rate of 141.59 per 1,000 per annum for the Spanish-American War(1898) doubtless is quite accurate, as the case mortality rate calculated from recorded morbidity and mortality is 10.47 per cent. The Spanish-American War was f short duration and the vast majority of the 20,000 or
20
more cases of typhoid fever occurred within a comparatively short period of time during the summer and fall of 1898.
The recorded morbidity rate for the British Army during the South African War probably is somewhat less than was the actual occurrence of the disease, as the case mortality rate, based on recorded morbidity and mortality, is somewhat higher (13.77 percent) than that ordinarily to be anticipated.
The incidence rate of 0.37 per 1,000 per annum for American troops during the World War is in striking contrast with all previously recorded war-time rates and demonstrates in a very telling manner that epidemics of typhoid fever can be prevented in armies. The recorded case mortality rate for American troops during the World War was approximately 14.85 percent, which is considerably in excess of the case death rate ordinarily to be anticipated. As explained above this high recorded death rate in all probability is due in large part to the fact that deaths were charged to typhoid fever that actually were due to influenzal pneumonia. A comprehensive special investigation of typhoid fever in the United States Army in France, made at the time the disease was prevailing, which is given fuller consideration below, demonstrated very clearly that the case death rate was not in excess of 11 per cent of the individuals attacked.3
COMPARISON OF DEATH RATES FOR TYPHOID FEVER IN THE UNITED STATES ARMY AND IN THE CIVIL POPULATION
From Table 2 it is possible to gain a definite conception of the comparative prevalence of typhoid in American civil communities and in the Army. The statistics incorporated in Table 2 are presented graphically in Chart III.
TABLE 2.-Typhoidfever. 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
|
Year |
|
Year |
Death rates per 1,000 per annum | ||
|
|
Male civilians, |
White enlisted men |
Male civilians, | ||
|
1890 |
0.55 |
0.59 |
1905 |
0.30 |
0.40 |
|
1891 |
.48 |
.64 |
1906 |
.28 |
.38 |
|
1892 |
.56 |
.57 |
1907 |
.32 |
.37 |
|
1893 |
.67 |
.55 |
1908 |
.34 |
.35 |
|
1894 |
.87 |
.53 |
1909 |
.25 |
.31 |
|
1895 |
.56 |
.55 |
1910 |
.18 |
.33 |
|
1896 |
.74 |
.51 |
1911 |
.09 |
.27 |
|
1897 |
.30 |
.38 |
1912 |
.03 |
.24 |
|
1898 |
15.26 |
.46 |
1913 |
--- |
.24 |
|
1899 |
2.52 |
.44 |
1914 |
.04 |
.20 |
|
1900 |
1.67 |
.57 |
1915 |
--- |
.16 |
|
1901 |
.84 |
.49 |
1916 |
.02 |
.16 |
|
1902 |
.95 |
.46 |
1917 |
.04 |
.15 |
|
1903 |
.47 |
.44 |
1918 |
.05 |
.13 |
|
1904 |
.36 |
.42 |
1919 |
.06 |
.09 |
It may be noted that for the years 1900 to 1903, inclusive, the Army rate was considerably in excess of that for the registration area of the United States, with so marked a downward trend for the Army rates that the two differed but slightly for the last year of the four-year period. For the years 1904 to 1909, inclusive, the rates for the two groups were very nearly the same.
21
From 1910 onward, however, while the rate for the civil population had a very considerable downward trend, comparable rates for the Army were at an extraordinarily low level, and this decline took place within a period of three years (1910-1912). During the period, 1910 to 1919, the civil population was not subjected to any unusually adverse environmental conditions and the reduction of the mortality rate by more than one-half during the 10-yearperiod can be attributed primarily to improvements in environmental sanitation plus an unknown but probably quite considerable amount of prophylactic vaccination during the later years of the period.
In so far as the Army is concerned, the high rates for the years 1900 to 1903 were due to conditions approximating those of war. It was during this period that considerable numbers of troops were operating in the Philippines. Profiting by the experience gained during the Spanish-American War(1898) and the immediately following Philippine insurrection, the Medical Department of the Army redoubled its efforts to prevent typhoid fever in Army personnel. No very noticeable reduction in rates was attained, however, until 1910. During 1910 and 1911 the rates were cut in half and in 1912 the reduction was so marked that the death rate was only one-tenth of that which prevailed prior to 1909. It was in the latter part of 1909 that prophylactic typhoid immunization was introduced in the Army as a voluntary measure,6and in 1911 it was made mandatory for all military personnel.7
The typhoid mortality rates for the civil population tabulated i n Table 2 are crude rates, and when corrected for age and sex the results attained in the Army in the prevention of typhoid fever during the World War become more striking. With minor exceptions the military personnel in active service during the World War (1917-19) ranged between 20 and 34 years of age. The death rate from typhoid fever for males of the civilian population of that age group for the period averaged about 0.117 per 1,000 per annum, as compared with a rate of 0.05 per 1,000 per annum for military personnel.
OCCURRENCE OF TYPHOID FEVER IN THE ARMY DURING THE WORLDWAR
Armies are much more apt to become seeded with typhoid bacilli brought in by recruits from civil life during periods of hurried mobilization than during the more orderly and leisurely recruitment incident to times of peace. If, therefore, typhoid fever is of common occurrence in civilian communities it may be anticipated that it will gain a foothold and spread with great rapidity in armies during periods of mobilization, provided preventive measures are not effective.
When mobilization was ordered in 1917 typhoid fever prevailed to a much less degree throughout the United States than was the case at the beginning of the Spanish-American War. It was of very common occurrence in the civil population of our country in 1898, was introduced into all mobilization camps, and spread with great rapidity.8
During the 15 or 20 years preceding the World War there had been so marked and continuous a reduction in typhoid rates in the civil population throughout the United States that the likelihood of the wholesale introduction of the disease into our mobilization camps in 1917, by incoming recruits, was
22
somewhat remote. As a matter of fact, a total of only 546 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. Thewater supplies, as a rule, were not above suspicion of contamination, typhoid fever was of no uncommon occurrence in the civilian population, it was known tohave occurred in troops occupying sectors in which most of our divisionsoperated,9 large numbers of cases of typhoidfever occurred in the relatively unprotected British Expeditionary Force in France during the early stages of the war,10and 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 possibilityof acquiring the disease from outside sources in France therefore, was, almostunlimited, and had our preventive measures not been effective the diseaseundoubtedly would have prevailed quite extensively.
TOTAL NUMBER OF CASES
It is necessary to have clearly in mind that this discussionrelates to the occurrence of typhoid fever in individuals who had been protectedagainst the disease by prophylactic vaccines, in so far as it was possible tocarry out this procedure efficiently during the stress of hurried mobilization.In a considerable number of instances the service records of individuals failedto bear notation that three doses of antityphoid-paratyphoid vaccine had beengiven; but investigation of the administrative procedures adopted in carryingout this protective measure and the safeguards instituted to prevent troopsgoing overseas without such vaccinations, warrants the statement that but fewindividuals received less than three doses of the saline vaccine or one of thelipovaccine. Prior to July 1, 1918, it was the custom to administer three dosesof saline vaccine and after that date either three doses of saline vaccine orone of lipovaccine.11 All drafted men receivedprotective 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 ofour military forces was 4,128,479; during the same period, 1,529 primaryadmissions for typhoid fever were reported, the typhoid rate per 1,000 ofstrength being 0.37. The progress made in the control of typhoid fever since theSpanish-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 per1,000, during the World War it fell to 0.37 per 1,000, the relative proportionsbeing approximately 382 to 1.
23-24
TABLE 3.-Typhoid fever and typhoidvaccination-Admissions, deaths, discharges for disability, and days lost fromduty, officers and enlisted men (white, colored, and native troops), UnitedStates Army, April 1, 1917, to December 31, 1919. Absolute numbers and ratiosper 1,000 per annum
|
|
Total mean annual strengths |
| |||||||
|
|
Deaths |
Discharges for disability |
Days lost | ||||||
|
Absolute numbers |
Ratios per 1,000 |
Absolute numbers |
Ratios per 1,000 |
Absolute numbers |
Ratios per 1,000 |
Absolute numbers |
Non- | ||
|
Total officers and enlisted men, including native troops |
4,128,479 |
1,529 |
0.37 |
227 |
0.05 |
24 |
0.01 |
109,374 |
0.07 |
|
Total officers and enlisted men, American troops |
4,092,457 |
1,527 |
.37 |
227 |
.06 |
24 |
.01 |
109,315 |
.07 |
|
Total officers |
206,382 |
49 |
.24 |
77 |
.03 |
--- |
--- |
4,367 |
.06 |
|
Total enlisted American troops: |
|
|
|
|
|
|
|
|
|
|
White |
3,599,527 |
1,348 |
.37 |
182 |
.05 |
24 |
.01 |
97,104 |
.07 |
|
Colored |
286,548 |
68 |
.24 |
25 |
.09 |
--- |
--- |
3,904 |
.04 |
|
Color not stated |
--- |
62 |
--- |
13 |
--- |
--- |
--- |
3,940 |
--- |
|
Total |
3,886,075 |
1,478 |
.38 |
220 |
.06 |
24 |
.01 |
104,948 |
.07 |
|
Total native troops enlisted |
36,022 |
2 |
.06 |
--- |
--- |
--- |
--- |
59 |
.00 |
|
Total Army in the United States (including Alaska): |
|
|
|
|
|
|
|
|
|
|
Officers |
124,266 |
18 |
.14 |
3 |
.02 |
--- |
--- |
1,132 |
.02 |
|
White enlisted |
1,965,297 |
483 |
.25 |
54 |
.03 |
11 |
.01 |
25,020 |
.03 |
|
Color enlisted |
145,826 |
45 |
.31 |
17 |
.11 |
--- |
--- |
2,435 |
.05 |
|
Total enlisted |
2,111,123 |
528 |
.25 |
71 |
.03 |
11 |
.01 |
27,455 |
.04 |
|
Total officers and men |
2,235,389 |
546 |
.24 |
74 |
.03 |
11 |
.00 |
28,587 |
.04 |
|
United States Army in Europe, excluding Russia: |
|
|
|
|
|
|
|
|
|
|
Officers |
73,728 |
27 |
.37 |
4 |
.05 |
--- |
--- |
2,844 |
.11 |
|
White enlisted |
1,469,656 |
776 |
.53 |
123 |
.08 |
13 |
.01 |
68,407 |
.13 |
|
Colored enlisted |
122,412 |
23 |
.19 |
8 |
.07 |
--- |
--- |
1,469 |
.03 |
|
Color not stated |
--- |
59 |
--- |
13 |
--- |
--- |
--- |
3,929 |
--- |
|
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 Islands: |
|
|
|
|
|
|
|
|
|
|
White enlisted |
16,995 |
--- |
--- |
--- |
--- |
--- |
--- |
--- |
--- |
|
Colored enlisted |
4,456 |
--- |
--- |
--- |
--- |
--- |
--- |
--- |
--- |
|
Total enlisted |
21,451 |
--- |
--- |
--- |
--- |
--- |
--- |
--- |
--- |
|
United States Army in Hawaii: |
|
|
|
|
|
|
|
|
|
|
White enlisted |
16,161 |
50 |
3.09 |
4 |
.25 |
--- |
--- |
3,305 |
.56 |
|
Colored enlisted |
3,319 |
--- |
--- |
--- |
--- |
--- |
--- |
--- |
--- |
|
Total enlisted |
19,480 |
50 |
2.57 |
4 |
.21 |
--- |
--- |
3,305 |
.47 |
|
United States Army in Panama, white enlisted |
19,688 |
--- |
--- |
--- |
--- |
--- |
--- |
--- |
--- |
|
United States Army in other countries not stated: |
|
|
|
|
|
|
|
|
|
|
White enlisted |
--- |
38 |
--- |
--- |
--- |
--- |
--- |
343 |
--- |
|
Color not stated |
--- |
3 |
--- |
--- |
--- |
--- |
--- |
11 |
--- |
|
Total |
14,232 |
41 |
2.88 |
--- |
--- |
--- |
--- |
354 |
.07 |
|
Transports: |
|
|
|
|
|
|
|
|
|
|
White enlisted |
97,498 |
1 |
.01 |
1 |
.01 |
--- |
--- |
29 |
.00 |
|
Total enlisted |
108,033 |
1 |
.01 |
1 |
.01 |
--- |
--- |
29 |
.00 |
|
Native troops enlisted: |
|
|
|
|
|
|
|
|
|
|
Philippine Scouts |
18,576 |
1 |
.05 |
--- |
--- |
--- |
--- |
8 |
.00 |
|
Hawaiians |
5,615 |
--- |
--- |
--- |
--- |
--- |
--- |
--- |
--- |
|
Porto Ricans |
11,831 |
1 |
.08 |
--- |
--- |
--- |
--- |
51 |
.01 |
|
|
| ||||||||
|
|
Discharges for disability |
Days lost | |||||||
|
Absolute numbers |
Ratios per 1,000 |
Absolute numbers |
Ratios per |
Absolute numbers |
Ratios per | ||||
|
Total officers and enlisted men, including native troops |
35,552 |
8.61 |
5 |
0.00 |
156,548 |
0.10 | |||
|
Total officers and enlisted men, American troops |
35,149 |
8.59 |
5 |
.00 |
155,614 |
.10 | |||
|
Total officers |
593 |
2.87 |
--- |
--- |
2,325 |
.03 | |||
|
Total enlisted American troops: |
|
|
|
|
|
| |||
|
White |
30,915 |
8.59 |
4 |
.00 |
129,713 |
.10 | |||
|
Colored |
3,606 |
12.58 |
1 |
.00 |
23,277 |
.22 | |||
|
Color not stated |
35 |
--- |
--- |
--- |
299 |
--- | |||
|
Total |
34,556 |
8.89 |
5 |
.00 |
153,289 |
.11 | |||
|
Total native troops enlisted |
403 |
11.19 |
--- |
--- |
934 |
.07 | |||
|
Total Army in the United States (including Alaska): |
|
|
|
|
|
| |||
|
Officers |
564 |
4.54 |
--- |
--- |
2,220 |
.05 | |||
|
White enlisted |
30,080 |
15.30 |
4 |
.00 |
121,528 |
.17 | |||
|
Colored enlisted |
3,562 |
24.42 |
1 |
.01 |
22,885 |
.43 | |||
|
Total enlisted |
33,642 |
15.94 |
5 |
.00 |
144,413 |
.19 | |||
|
Total officers and men |
34,206 |
15.30 |
5 |
.00 |
146,633 |
.18 | |||
|
United States Army in Europe, excluding Russia: |
|
|
|
|
|
| |||
|
Officers |
14 |
.19 |
--- |
--- |
72 |
.00 | |||
|
White enlisted |
363 |
.25 |
--- |
--- |
6,633 |
.01 | |||
|
Colored enlisted |
11 |
.09 |
--- |
--- |
306 |
.01 | |||
|
Color not stated |
34 |
--- |
--- |
--- |
298 |
--- | |||
|
Total enlisted |
408 |
.26 |
--- |
--- |
7,237 |
.01 | |||
|
Total officers and men |
422 |
.25 |
--- |
--- |
7,309 |
.01 | |||
|
Officers, other countries |
15 |
1.79 |
--- |
--- |
33 |
.01 | |||
|
United States Army in Philippine Islands: |
|
|
|
|
|
| |||
|
White enlisted |
39 |
2.29 |
--- |
--- |
189 |
.03 | |||
|
Colored enlisted |
12 |
2.69 |
--- |
--- |
19 |
.01 | |||
|
Total enlisted |
51 |
2.38 |
--- |
--- |
208 |
.03 | |||
|
United States Army in Hawaii: |
|
|
|
|
|
| |||
|
White enlisted |
230 |
14.23 |
--- |
--- |
656 |
.11 | |||
|
Colored enlisted |
21 |
6.33 |
--- |
--- |
67 |
.06 | |||
|
Total enlisted |
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: |
|
|
|
|
|
| |||
|
White enlisted |
10 |
--- |
--- |
--- |
95 |
--- | |||
|
Color not stated |
1 |
--- |
--- |
--- |
1 |
--- | |||
|
Total |
11 |
.77 |
--- |
--- |
96 |
.02 | |||
|
Transports: |
|
|
|
|
|
| |||
|
White enlisted |
152 |
1.56 |
--- |
--- |
490 |
.01 | |||
|
Total enlisted |
152 |
1.41 |
--- |
--- |
490 |
.01 | |||
|
Native troops enlisted: |
|
|
|
|
|
| |||
|
Philippine Scouts |
86 |
4.63 |
--- |
--- |
275 |
.04 | |||
|
Hawaiians |
17 |
3.03 |
--- |
--- |
91 |
.04 | |||
|
Porto Ricans |
300 |
25.36 |
--- |
--- |
568 |
.13 | |||
RELATIVE IMPORTANCE OF TYPHOID FEVER AS A CAUSE OF ADMISSION TO HOSPITAL FOR DISEASE AND OF DEATHS FROM DISEASE
The fact that typhoid fever, comparatively speaking, was of minor importanceas a cause of admission to hospital for disease during the World War is wellshown in Table 4.
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
|
|
|
Deaths | ||
|
|
Relative standing among 30 most common diseases |
Percentage relationship to total diseases |
Relative standing among 30 most common diseases | |
|
Officers: |
|
|
|
|
|
United States |
0.02 |
--- |
0.35 |
22 |
|
Europe |
.07 |
--- |
.71 |
11 |
|
Total officers (including other countries) |
.04 |
--- |
.47 |
15 |
|
American enlisted men, United States |
.02 |
--- |
.21 |
19 |
|
Europe |
.10 |
--- |
.69 |
10 |
|
Hawaiian Islands |
.42 |
--- |
10.26 |
2 |
|
Total enlisted (including other countries) |
.04 |
--- |
.39 |
13 |
|
Native troops: |
|
|
|
|
|
Filipino |
.01 |
--- |
--- |
--- |
|
Porto Rican |
.01 |
--- |
--- |
--- |
|
Total native troops |
.01 |
--- |
--- |
--- |
|
Total, U.S. Army |
.04 |
--- |
.39 |
13 |
Typhoid fever contributed only 0.04 per cent of the totaladmissions to hospital for all diseases, and in no country in which our militaryforces served did it prevail to such degree as to give it a rating in the listof the 30 diseases of most frequent occurrence. Of all deaths from diseaseduring the World War only 0.39 per cent were attributable to typhoid fever, andin the list of the 30 diseases most frequently resulting in death, in order ofimportance (1 to 30), it occupied the thirteenth place.
DISTRIBUTION BY GRADE (COMMISSIONED AND ENLISTED PERSONNEL)
The admission rate for commissioned personnel was appreciablylower 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 ofintelligence, a more comprehensive knowledge of personal hygiene and sanitationand their corollaries, more intelligent compliance with instructions and orders,and better personal hygienic and environmental sanitation.
RACIAL DISTRIBUTION
The morbidity rate for white enlisted personnel wasconsiderably higher than for colored-white American, 0.37; colored American,0.24 per 1,000. The most probable explanation of the higher rate in whiteAmerican troops is that it was due to the fact that a relatively largerproportion of white troops were engaged in operations in highly contaminatedareas (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 actuallyoccurred.
26
Complete investigation of localized outbreaks andcomprehensive studies of large groups of cases indicate that the case fatalityrate was approximately 11 per cent and were exact data available it doubtlesswould 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 accountof disability resulting from an attack of typhoid. Of the total number ofindividuals discharged for disabilities resulting from diseases, only 0.014 percent were discharged for disabilities incident to typhoid, and in the list ofthe 30 diseases most frequently resulting in discharge for disability typhoiddoes not appear.
NONEFFECTIVE RATES
A total of 1,529 primary admissions for typhoid were reportedand these men were absent from duty a total of 109,374 days. The average loss oftime from duty per case of typhoid was, therefore, 72 days.
SEASONAL DISTRIBUTION
In general, the seasonal distribution in troops during theWorld War conformed to the well-known seasonal distribution of typhoid fever intemperate and cold climates-highest incidence in the late summer and fallmonths, particularly for cases developing in the United States. In Europe,however, a very considerable proportion of the cases arose during the wintermonths- November, 1918, to March, 1919, inclusive-due, doubtless, toincreasingly constant exposure to massive doses of the infective agent.
GEOGRAPHICAL DISTRIBUTION
The recorded mortality rate for the civilian population ofManila, Philippine Islands, for the period 1917 to 1919, inclusive, was 1.8412per 1,000 per annum, while that for American and Filipino troops serving in thePhilippines during the same period of time was practically nil (1 case, or 0.05per 1,000, for the period).
The admission rate per 1,000 for total enlisted strength forthe 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 oftyphoid fever occurring in troops in the United States approximately two casesoccurred in troops in Europe and ten cases in troops serving in Hawaii.
TYPHOID FEVER IN HAWAII
An explosive outbreak of typhoid fever, definitely traced tothe water supply, occurred at Schofield Barracks, Hawaii, in the fall of 1917.The following abstract summarizes the epidemiology of this outbreak:13
Schofield Barracks, the largest Army station in Hawaii, islocated 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 oldsection of the station was supplied mainly with water collected in tunnels andbrought down through a system of tunnels and pipes from a range of mountainsadjacent
27
to and to the west of the station. The new section of thestation, about 1 mile distant, was supplied by a gravity system having its mainintake in the Koolau Mountain Range in the headwaters of the fork of theKaukonahua River on the opposite side of the island. This supply was not subjectto contamination except that certain sections of the tunnels in the upperreaches were open. Overflow and additional small streams came together, belowthe 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 apumping station to augment the permanent supply, when necessary. This auxiliarysupply was not supposed to be used without previously informing the sanitaryauthorities, through whom instructions would emanate as to the proper treatmentof the water. At times water from the auxiliary supply for the new post also waspumped to the old post to augment the permanent supply, but at no time was thisdone during the course of the epidemic to be reviewed. The pumping station forthis auxiliary supply was located at the lowest point of the watershed and thewater itself was subject to constant contamination from camps of Japaneselaborers engaged in construction work on the water supply system at the time theoutbreak of typhoid occurred. These camps were on the hillside below the watermains and about 45 feet above and 55 to 100 yards distant from the bed of thestream constituting the auxiliary supply.
In the early days of August, 1917, a Japanese laborer arrivedat one of the camps and, though he did not report for treatment, it was learnedat a later date that he was ill for some time with a continued fever thatdoubtless was typhoid. While ill, he was visited by a Japanese friend (Mizusawa)employed at one of the construction camps. Mizusawa had not been inoculatedagainst typhoid fever and came down with typhoid fever during the latter part ofAugust. He worked for several days after he became ill, continuing to live atthe 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 Honoluluon September 15 and was having hemorrhages from his intestines at that time.This patient was interrogated at the time the epidemic was under investigationand examination of his blood gave a positive agglutination reaction with B.typhosus in high dilution. While at the quartermaster construction camp thisman had used an insanitary privy located on the drainage shed of the streamconstituting the source of the auxiliary water supply for the new section ofSchofield 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 newerpart 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. Thesanitary authorities at Schofield Barracks had no knowledge of the fact thatthis was being done. On September 13 and 14 rather heavy rains occurred on thewatershed used as an auxiliary water supply and following these rains it wasnoted 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 toappear, and within a comparatively short period of time 100 cases had occurred.All individuals who contracted the disease gave a history of drinking thecontaminated water
28
within the incubation period of the disease. Of the totalpopulation-military and civilian-exposed to infection, 4,087 had beenvaccinated with antityphoid-paratyphoid vaccine and 812 had not been soprotected. No persons living in the older section of the post contracted typhoidexcept an occasional individual who gave a definite history of drinking water inthe newer section of the post on the evening of September 14 or the followingday. The comparative morbidity and mortality rates from typhoid fever in thesetwo 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
|
Groups |
Population |
|
Deaths |
Case fatality per cent | ||
|
|
Rate per 1,000 |
Absolute numbers |
Rate per 1,000 | |||
|
Vaccinated groups |
4,087 |
55 |
13.46 |
4 |
0.98 |
7.27 |
|
Unvaccinated groups |
812 |
45 |
55.42 |
7 |
8.62 |
15.56 |
aSource of information: Russell, F. F.: Typhoid fever in theAmerican Army during the World War. The Journal of the American MedicalAssociation, Chicago, lxxii, Dec. 20, 1919, 1863.
These statistics demonstrate conclusively the protectivevalue of prophylactic vaccination, the relative morbidity rate for thenonvaccinated to vaccinated being approximately 4 to 1. They show also that thecomplete eradication and prevention of typhoid can be accomplished only by acombination of prophylactic vaccination and efficient environmental sanitationand personal hygiene. The lower case mortality rate in the vaccinated group isconfirmatory of other observations that appear in medical literature.
TYPHOID FEVER IN EUROPE (RUSSIA EXCEPTED)
The greater frequency of occurrence of typhoid in Americantroops on active service in France than in the United States justifies asomewhat detailed discussion of the epidemiology of the disease in the formerarea of activity. In the United States many of the cases occurred inunvaccinated individuals, but all troops in Europe presumably had beenvaccinated; in the United States environmental sanitation in mobilization campswas excellent, while in Europe many defects existed, particularly so in thebattle areas where the military objectives necessary of attainment preventedproper attention to sanitation; and general exposure to typhoid infection wasmuch greater in France than in the United States.
The prevalence of typhoid fever in American ExpeditionaryForces for the period of the World War is shown in Table 3. The total number ofcases recorded as primary admissions was 885 (0.53 per 1,000). The occurrence ofthe cases by months is presented graphically in Chart IV.
The data incorporated in Chart IV pertain to allbacteriologically proven, as well as clinically diagnosed but notbacteriologically proven, cases of typhoid fever reported to the chief surgeon`s office, A. E. F. They include also cases reported as primary admissions fortyphoid fever as well as cases of typhoid
29
30
complicating, or concurrent with, other diseases or battleinjuries, and represent very closely the actual prevalence of typhoid fever inFrance. This chart shows that, prior to June, 1918, practically no typhoid feveroccurred 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 morbidityrate up to 0.03 and that again in December, 1918, and January to March, 1919,increases in rates occurred. The various elevations of the morbidity curvereferred to above correspond with the occurrence in a few organizations locatedin various parts of France and more particularly the somewhat widespread butlimited occurrence of the disease from November, 1918, to January, 1919,inclusive, in certain of the divisions that had taken part in the Meuse-Argonneoperation.
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-
|
|
|
|
Company No. 4, Camp Cody replacement unit, July, 1918 |
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 REPLACEMENTCOMPANY
On June 15, 1918, three replacement units left Camp Cody,Deming, N. Mex., for Camp Merritt, N. J., en route to France.14CompanyNo. 4, with an enlisted strength of approximately 248 men, was a provisionalone, both commissioned and enlisted personnel being made up of individualscasually 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 theonly one of the three in which typhoid fever occurred.
Company No. 4 sailed for England on June 28, arriving inLiverpool on July 11. During the passage across the Atlantic many cases ofso-called seasickness were reported, of which doubtless a considerableproportion were in reality typhoid fever. The company left Liverpool on July 11 and arrived in St. Aignan, France, via Cherbourg, shortly thereafter. Duringthis 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 daysafter the arrival of the company at St. Aignan, the last case of typhoid havingbeen admitted to hospital on July 28.
The following information is summarized from reports ofinvestigation of the outbreak in England14 and France.15
The incubation period of a large proportion of the cases wasof such length as to indicate that most of the men contracted the disease whiletraveling by train from Camp Cody, N. Mex., to New York. The three companiestraveled on the same train, but cases of typhoid arose in Company No. 4 only. Sofar as could be ascertained by inquiry, general sanitary conditions on the trainwere alike for the three companies.
31
The data on the service records and other evidence obtainedindicated that antityphoid-paratyphoid vaccines had been given to all men inCompany No. 4 at Camp Cody. Two of the men first taken ill in England statedthat they had not felt well prior to their departure from Camp Cody, but had notreported themselves to a medical officer because of their eagerness to go toFrance. One of these men developed a severe diarrhea, with cramps, while enroute to New York. The other man who did not have typhoid during the outbreakwas later proven to be a typhoid bacillus carrier. A kitchen car was used incommon by Companies No. 3 and No. 4, the personnel of one company being locatedin tourist sleeping cars in front of the kitchen car and that of the othercompany behind the kitchen car. The drinking water used by Company No. 4 wasdistributed from the usual type of water tank used on American railway cars andwas not readily subject to contamination on the train. There was, however, asupplementary supply for Company No. 4, consisting of a large open barrel filledwith water and placed in the vestibule between two of the sleeping cars. Thiscould very easily have become contaminated, as the only means for obtainingwater was by dipping the tin cup or canteen in the barrel. Washing and toiletfacilities aboard the train were taxed to the limit.
Available evidence suggests that two of the men in thecompany were in the early stages of typhoid during the railway trip, that therewas one bacillus carrier in the company, and that in all probability theunprotected drinking water in the open barrel was grossly contaminated by anindividual or individuals in the early stages of the disease or by carriers ofthe organism. Certain it is that the defects in environmental sanitation weremore marked during the railway trip than at any other stage of the journey toFrance.
In no other instance during the World War did such a largenumber of cases of typhoid fever occur in any one company, and in no otheroutbreak was the spread of the infection so sharply restricted. Ninety-fivecases occurred in an organization with a total strength of 248 men and the casedeath rate was 8.3 per cent (8 deaths). The outbreak in this organization wasmost carefully studied both clinically and bacteriologically and the diagnosiswas confirmed 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-Argonneoperation. Typhoid fever was known to have prevailed previously in endemic formin this sector, having been reported in both allied and enemy troops. Theinitial cases of typhoid fever in the division appeared during November, 1918,and failure to enforce sanitary discipline resulted in further spread of thedisease during December, 1918, and January, 1919. An epidemiologicalinvestigation of the occurrence of typhoid and paratyphoid fevers in thisdivision was made,16 the report of which is the source of thefollowing summary:
During the period November, 1918, to January, 1919,inclusive, a total of 97 cases of typhoid and 25 of paratyphoid fevers occurred inthe 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
vaccine had been administered to the entire division. Of thetotal number of cases of typhoid and paratyphoid fevers, 74 occurred in oneregiment, namely, the 307th Infantry, and most of the cases arising in thisregiment were reported from the 2d and 3d Battalions. These two battalions,after the armistice, were stationed in small towns along the river Aube. Thesevalley towns were flooded during the entire period from December, 1918, to January, 1919, and great difficulty was experienced in providing properlatrines, 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 organizationsof the divisions, except the 2d and 3d Battalions, 307th Infantry, and Company E, 305th Infantry, were located on somewhat higher and better drained groundduring this period.
Investigation of the outbreak indicated that sanitary discipline in the division 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 percent 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. Allregiments were involved, particularly the 315th and 316th Infantry.17Troop movements of the division are of interest as during the latter part ofOctober and the first part of November the regiments occupied territory aroundEtraye, Reville, Crepion, and Gibercy. This region had been occupied by Germantroops, and that diseases of the intestines were common in this area is shown bythe fact that the German hospital near Damvillers had special latrines reservedfor "intestinal cases." All regiments of the division, at one time oranother, occupied the Etraye and Crepion areas. The 313th Infantry was removedfrom this locality on November 23 and the 314th on November 11, while the 315thand 316th remained until December 26, 1918.
While in action during the first part of November the troopsdrank 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 thedivision was affected and 61 of the cases were diagnosed definitely as beingtyphoid fever.
An investigation for typhoid carriers was undertaken in the315th Infantry, the cooks and permanent kitchen police (336) being examined. Ofthese, 57 gave a history of diarrhea. Nine carriers were found (eight typhoid
33
and one paratyphoid A). Samples of water from varioussources in and about Crepion, Etraye, and Reville gave positive tests for B.coli. The evidence gathered indicated that the initial cases were acquiredby drinking contaminated water and that the spread of the disease was due mainlyto 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 inthe early part of 1919, limited very largely to the 2d Battalion, 350thInfantry, located at Morlaincourt.17 A total of 12 cases occurred,the highest number for a single week having been reported during the weekFebruary 12-18, 1919. The investigation of this outbreak disclosed the factthat 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 amongthe men using this water exclusively. The two remaining sources were found to begrossly contaminated, one of them arising as a spring under a house in whichthere was a case of typhoid fever. There were at least 27 cases of the diseaseamong civilians, and soldiers were billeted in a number of houses in which casesof typhoid were present. Eleven soldiers living in such houses contracted thedisease.
TYPHOID FEVER IN MEDICAL DEPARTMENT UNITS AT CUREL, FRANCE
In December, 1918, and January, 1919, there occurred amongtroops billeted at Curel (Haute Marne), France, an outbreak of typhoid fever with72 cases.18 Twenty-one deaths occurred, but it is known that a largenumber of secondary pneumonias developed as complicating factors, and the casemortality rate from typhoid itself was not excessive.
The troops stationed at Curel numbered about 70 officers and1,782 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. Allhad one or more cases of typhoid fever except Mobile Hospital No. 101 and theskeletonized sanitary trains. Evacuation Hospital No. 33 had 28 cases, 39 percent of the total, and Evacuation Hospital No. 25, 15 cases, or 21 per cent ofthe total.
The first organization arrived in this area November 29, theothers continuing to arrive until December 8, 1918. Water was not chlorinatedfrom November 29 to December 9 because of lack of supplies of hypochlorite. Thesupply of hypochlorite was again exhausted December 20, and did not again becomeavailable until December 27.
The water supply of the village was from four springs andmany wells. No sanitary survey of the water supply was made by American medicalauthorities until after the epidemic was under way; a survey made at that timeindicated that all the village water was nonpotable in its raw state. The chiefsource of water supply for the troops was a spring, within a radius of 125 feetof which were six privy vaults, four being on ground higher than the spring. Allwere overflowing with fecal matter.
34
Some cases of diarrheal disease were reported among theinhabitants of Curel, but no typical typhoid fever was seen. There was nodiarrhea or gastrointestinal disturbance among any of the organizations priorto their arrival at Curel and none of the organizations stationed there had seenservice in any of the front areas. Approximately 75 per cent of the troopssuffered with diarrhea during their stay at Curel. Gastrointestinal disturbancecommenced a few days after arrival of each contingent and persisted untilJanuary 7, when it began to diminish, finally disappearing altogether on January18. As a rule, the diarrhea was not severe in character, persisted for a fewdays 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 persistinguntil January 15. No contact relationships could be established. Theorganizations having the largest number of cases were billeted in sections ofthe village far distant the one from the other.
The individual service records of the personnel and otherinformation available indicated that all men had been vaccinated against typhoidand paratyphoid fevers. Some of the men were among the later draftees and hadreceived lipovaccine, but there appeared to be no relationship between theprevalence of typhoid fever in the various units and the type of vaccine used orthe length of time elapsing since vaccination. The general character of theepidemic, its rapid rise to a peak and sharp decline, with no definiteremissions, pointed to a water-borne epidemic. Confirmatory of thisinterpretation is the fact that the incubation period for most of the casesindicated that infection was acquired during the time when the water was nottreated. When regular and continuous chlorination of the water was begun, onDecember 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 inMarseille from the latter part of February to the latter part of April, 1919.19There were 64 cases with 7 deaths (case mortality, 11 per cent). The epidemicwas clearly proved to be of water-borne origin. The camp was divided into threesections, A, B, and C. All cases occurred in section C. The water supply forsections A and B was the regular supply used by the city of Marseille, whichpassed through a central sedimentation plant before use. It was probably notabove reproach, but the sedimentation process reduced the contamination to aminimum. The water supply for section C was an offshoot from the regular citysupply. It was piped into camp from an open canal which wound for manykilometers through villages, past farm houses, and country roads. Along thebanks of this canal deposits of human feces frequently were observed. Thesedisappeared after rainstorms, being washed into the canal. The water as itarrived 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 trucksand filling their radiators. On investigation it was found that 31 of the first33 patients admitted having drunk the raw water from these taps more than halfthe time, despite warnings issued against drinking this raw water and readyaccess to Lyster bags in which was an abundance of treated water. Correction ofexisting defects in the water supply in section C brought the outbreak to anend.
35
MINOR OUTBREAKS OF TYPHOID FEVER
Of minor outbreaks of typhoid fever that occurred in variousparts of France the following were the more important: In an Engineer detachmentat Bazoilles,20 15 cases, August, 1918; 323d Infantry, 81stDivision, 10 cases, December, 1918; Battery E, 321st Field Artillery, 82dDivision, 22 cases, January and February, 1919. These and other minor outbreakswere carefully investigated and their epidemiology was of like nature to that ofthe 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 Armysince itsformation, but the incidence of this disease has fallen off noticeablysince the army has settled down and opportunity has been afforded for theestablishment of improved sanitation. During the interval, December 22 to March11, 63 cases of typhoid fever were reported from organizations of the ThirdArmy. An analysis of these cases with reference to date of onset of the diseasebrought out the fact that in the majority infection was acquired either duringthe march to the occupied territory or in the days immediately following thearrival of organizations at their destinations. Since that time the incidence oftyphoid fever in the army has been in no sense alarming, and in one or twoinstances the infection was known to have been acquired outside the occupiedterritory. 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 asprimary admissions in the United States during the World War was 546 (0.24 per1,000 strength). The morbidity rates for all the large mobilizationcamps are tabulated in Table 6.
TABLE 6.-Typhoid fever. Admissions, enlisted men, by camps, September 1, 1917, to December 31, 1918. Absolute numbers and rates per 1,000
|
Camps |
|
1918 |
Camps |
1917 |
1918 | ||||
|
|
Rates |
Absolute numbers |
Rates per 1,000 strength |
Absolute numbers |
Rates |
Absolute numbers |
Rates per 1,000 strength | ||
|
Beauregard, La. |
2 |
0.51 |
3 |
0.19 |
Logan, Tex |
3 |
0.33 |
2 |
0.11 |
|
Bowie, Tex. |
13 |
1.78 |
4 |
.24 |
MacArthur, Tex |
19 |
2.53 |
2 |
.11 |
|
Cody, N. Mex. |
--- |
--- |
1 |
.06 |
McClellan, Ala. |
10 |
1.03 |
2 |
.10 |
|
Custer, Mich. |
--- |
--- |
4 |
.15 |
Meade, Md. |
--- |
--- |
8 |
.23 |
|
Devens, Mass. |
1 |
.12 |
--- |
--- |
Mills, N. Y. |
--- |
--- |
1 |
.07 |
|
Dix, N. J. |
20 |
3.15 |
2 |
.06 |
Pike, Ark. |
4 |
.47 |
10 |
.28 |
|
Dodge, Iowa |
1 |
.16 |
2 |
.07 |
Sevier, S. C. |
4 |
.56 |
4 |
.20 |
|
Doniphan, Okla. |
7 |
.98 |
1 |
.05 |
Shelby, Miss. |
1 |
.14 |
9 |
.43 |
|
Fremont, Calif. |
--- |
--- |
2 |
.13 |
Sheridan, Ala. |
9 |
1.52 |
5 |
.27 |
|
Funston, Kans. |
1 |
.10 |
4 |
.10 |
Sherman, Ohio |
1 |
.11 |
1 |
.04 |
|
Gordon, Ga. |
1 |
.13 |
8 |
.25 |
Syracuse, N.Y. |
--- |
--- |
1 |
.30 |
|
Grant, Ill. |
1 |
.14 |
1 |
.03 |
Taylor, Ky. |
4 |
.60 |
8 |
.25 |
|
Greene, N. C. |
--- |
--- |
11 |
.54 |
Travis, Tex. |
7 |
.82 |
7 |
.23 |
|
Hancock, Ga. |
4 |
.45 |
--- |
--- |
Upton, N.Y. |
--- |
--- |
3 |
.11 |
|
Jackson, S. C. |
2 |
.25 |
8 |
.28 |
Wadsworth, S.C. |
1 |
.11 |
5 |
.23 |
|
Johnston, Fla. |
--- |
--- |
3 |
.14 |
Wheeler, Ga. |
--- |
--- |
1 |
.05 |
|
Lee, Va. |
2 |
.26 |
17 |
.42 |
Total |
120 |
.48 |
145 |
.19 |
|
Lewis, Wash. |
2 |
.19 |
5 |
.16 | |||||
aSource of information: Annual Reports of the SurgeonGeneral, U. S.Army, 1918, pp. 118, 119, and 1919, pp. 922, 923.
36
The tabulation includes the years 1917 September to Decemberand 1918 only, as many of the mobilization camps were closed by the early monthsof 1919. No cases whatsoever of typhoid fever occurred in one-third (10) of thecamps listed in Table 6 during 1917 and in one-fifteenth of the camps in 1918.In 33 per cent of the camps less than three cases were reported in 1917, while44 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 inindividuals who reported at mobilization camps in the incubatory stage of thedisease.
The conclusion to be drawn from the information set forth inthis table is that, compared with our experience during the Spanish-AmericanWar, scarcely any typhoid fever occurred in our mobilization camps. It alsoevidences the fact that very rapid progress has been made in the eradication oftyphoid fever in the civil population throughout the United States of Americasince the Spanish-American War.
The other very important reversal of our Spanish-American Warexperience is that while one or more cases of typhoid fever occurred in allcamps-Camp Kearny, Calif., excepted-at some time during the World War, thedisease did not become disseminated throughout the commands as was souniversally the case during the Spanish-American War.
That a large proportion of the 546 individuals who hadtyphoid fever in the United States had contracted the disease before protectioncould have been afforded by vaccination is evident from the following abstractsfrom reports on file in the Office of the Surgeon General of the Army. Thesurgeon at Camp Devens, Mass., reported that the case of typhoid fever reportedfrom that camp in 1917 occurred in a drafted man five days after his arrival atcamp.22 The surgeon at Camp Dix, N. J., reported that the 14 cases oftyphoid occurring in that camp during October, 1917, were probably brought in bythe September increment of drafted men.23 The surgeon at CampSherman, Ohio, reported that the one case of typhoid fever in that camp in 1917was contracted by the soldier at Prospect, Ohio, and the man never had beenvaccinated.24 The same surgeon reported 12 cases (not included inTable 6, as the cases arose prior to federalization) in Company H, 3d OhioInfantry, that were charged to sources other than those for the camp. None ofthe men had been protected by vaccination, and had probably contracted thedisease by drinking water from a condemned well at Springfield, Ohio. There wereseven cases at Camp Travis in 1917, all brought in from outside sources. Thetriple vaccine offered general immunity.25 The 10 cases reported atCamp McClellan in 1917 occurred in the 5th New Jersey Infantry. The cases werebrought into the camp, and examination of the individual service records of thecommand showed that in practically every instance protective inoculation had notbeen completed.
The camp surgeon at Camp Gordon, Ga., reported that a fewcases of typhoid fever were treated in the hospital during 1918, but it waspossible to establish in every instance the fact that the individual brought theinfection to camp with him.26 The camp surgeon at Camp Shelby, Miss.,reported that this relatively rare disease in the Army camps was introduced inthis camp when there appeared 4 cases in July and 4 cases in August who wereeither
37
suffering from clinical typhoid fever when they entrained orgave manifestation of the disease after being in the camp only a few days.26Among the 8 cases of proved typhoid fever, 4 cases had received no typhoidinoculation, 2 cases only one dose, and 2 had two inoculations. The camp surgeonat Camp Greene, N. C., reported that typhoid fever occurred in a small number ofcases, particularly in a small epidemic in June and July, 1918, and mostly inrecruits who had not been inoculated.26
Of 74 deaths from typhoid fever among enlisted personnelserving in the United States, 41, or 55 per cent, occurred in individuals whohad been on active service for less than two months and these doubtless weredeaths from typhoid fever in individuals who either had not been givenprotective inoculations or in whom no active immunity had been produced for onereason or another.
In so far as the military forces serving in the United Statesare concerned there is ample justification for the statement that no epidemicsof typhoid fever occurred throughout the period of the war. This triumph inpreventive medicine is attributable to three factors-antityphoid inoculation;excellent environmental sanitation; and the progress made in the gradualelimination of typhoid fever from the civil population during the two precedingdecades.
The one outbreak of typhoid fever among civilians undergovernmental but nonmilitary control in the United States that assumed epidemicproportions occurred at one of the camps for interned enemy aliens at HotSprings, N. C., in the summer of 1918.27 The essential epidemiological featuresof this outbreak are as follows:
The epidemic, consisting of a total of 183 cases, was limitedto enemy aliens in the internment camp, and the cases were transferredfor treatment to United States Army General Hospital No. 12, located atBiltmore, N. C., about 50 miles distant. The epidemic was directly traceable toaccidental contamination of the water supply of one section of the camp, whichwas connected, for fire-prevention purposes only, with an intake from the FrenchBroad River, afterward found to be contaminated.
The epidemic began July 1, 1918, when 4 men became ill withtyphoid fever. During the month of July, 88 cases occurred and duringAugust, 95. August 23 marked the onset of the last case. At the beginning of theepidemic none of the interned aliens had been protected by inoculation againsttyphoid. Prophylactic inoculations with antityphoid vaccine first were offeredas a voluntary measure, but the response was so poor that it was decided to makethe 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 hadreceived 1 inoculation; the third of 21 who had received 2 inoculations; andthe fourth of 4 cases with 3 inoculations. The degree of protection furnished bythe belated effort to immunize men at the internment camp at Hot Springs isuncertain. Efforts were made to determine the relative degree of protectionafforded by vaccination during the epidemic, the comparative study being basedon the four groups mentioned above. The average duration of fever inuncomplicated cases
38
in the first group (unprotected) was 37 days, in the secondgroup (1 inoculation) 31 days, and in the third and fourth groups 24 and 29days, respectively.
In the first group 18 per cent of the cases developedcomplications, in the second group only 12 per cent, and in the third and fourthgroups no complications appeared. In the 13 noninoculated cases withcomplications the average duration of fever was 80 days, and in 9 patients withcomplications who had received 1 inoculation the average duration of fever was64 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 World War (Great Britain,France, Italy, Belgium, Germany, Austria, and the United States) is of more thanpassing interest, particularly if analyzed from the viewpoint of the preventivemeasures initiated by the armies of each nation. Complete statistical data arenot available; however, sufficient information is at hand to warrant itstabulation 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
|
Country |
|
1915 | ||||||||
|
|
Deaths |
Case fatality (per cent) |
Cases |
Deaths |
Case fatality (per cent) | |||||
|
|
Ratio per 1,000 |
Absolute numbers |
Ratio per 1,000 |
Absolute numbers |
Ratio per 1,000 |
Absolute numbers |
Ratio per 1,000 | |||
|
United States |
7 |
0.07 |
3 |
0.03 |
42.86 |
8 |
0.08 |
--- |
--- |
--- |
|
Great Britain |
388 |
--- |
47 |
--- |
12.11 |
2,351 |
4.00 |
130 |
0.22 |
5.53 |
|
France |
45,450 |
--- |
8,170 |
--- |
17.98 |
64,561 |
--- |
6,312 |
--- |
9.78 |
|
Italy |
--- |
--- |
--- |
--- |
--- |
18,665 |
18.01 |
--- |
--- |
--- |
|
Belgium |
524 |
6.14 |
121 |
1.42 |
23.09 |
1,900 |
10.30 |
324 |
1.76 |
17.05 |
|
Germany |
--- |
--- |
--- |
--- |
--- |
43,681 |
--- |
7,964 |
--- |
18.23 |
|
Austria |
7,188 |
--- |
844 |
--- |
11.74 |
125,771 |
--- |
13,573 |
--- |
10.79 |
|
Country |
|
1917 | ||||||||
|
|
Deaths |
Case fatality (per cent) |
Cases |
Deaths |
Case fatality (per cent) | |||||
|
|
Ratio per 1,000 |
Absolute numbers |
Ratio per 1,000 |
Absolute numbers |
Ratio per 1,000 |
Absolute numbers |
Ratio per 1,000 | |||
|
United States |
25 |
0.23 |
3 |
0.03 |
12.00 |
297 |
0.44 |
23 |
0.03 |
7.74 |
|
Great Britain |
2,568 |
2.02 |
30 |
.02 |
1.17 |
1,166 |
.61 |
33 |
.01 |
2.83 |
|
France |
12,656 |
--- |
484 |
--- |
3.82 |
1,659 |
--- |
135 |
--- |
8.14 |
|
Italy |
28,142 |
11.95 |
--- |
--- |
--- |
7,773 |
2.58 |
--- |
--- |
--- |
|
Belgium |
335 |
1.72 |
22 |
.11 |
6.57 |
240 |
1.13 |
13 |
.06 |
5.42 |
|
Germany |
31,180 |
--- |
1,892 |
--- |
6.07 |
16,571 |
--- |
623 |
--- |
3.76 |
|
Austria |
24,292 |
--- |
1,570 |
--- |
6.46 |
9,551 |
--- |
748 |
--- |
7.83 |
|
Country |
|
1919 | ||||||||
|
|
Deaths |
Case fatality (per cent) |
Cases |
Deaths |
Case fatality (per cent) | |||||
|
|
Ratio per 1,000 |
Absolute numbers |
Ratio per 1,000 |
Absolute numbers |
Ratio per 1,000 |
Absolute numbers |
Ratio per 1,000 | |||
|
United States |
768 |
0.30 |
133 |
0.05 |
17.32 |
467 |
0.47 |
71 |
0.07 |
15.20 |
|
Great Britain |
334 |
.12 |
20 |
.01 |
5.99 |
--- |
--- |
--- |
--- |
--- |
|
France |
665 |
--- |
110 |
--- |
16.54 |
--- |
--- |
--- |
--- |
--- |
|
Italy |
3,881 |
1.31 |
--- |
--- |
--- |
--- |
--- |
--- |
--- |
--- |
|
Belgium |
187 |
.89 |
24 |
.11 |
12.83 |
31 |
--- |
19 |
--- |
61.29 |
|
Germany |
20,932 |
--- |
926 |
--- |
4.42 |
--- |
--- |
--- |
--- |
--- |
|
Austria |
4,799 |
--- |
664 |
--- |
13.84 |
--- |
--- |
--- |
--- |
--- |
|
| ||||||||||
|
Country |
|
Deaths |
Case fatality (per cent) | |||||||
|
|
Ratio per 1,000 |
Absolute numbers |
Ratio per 1,000 | |||||||
|
United States |
1,572 |
0.35 |
233 |
0.05 |
14.82 | |||||
|
Great Britain |
6,807 |
1.02 |
260 |
.04 |
3.82 | |||||
|
France |
124,991 |
14.86 |
15,211 |
1.81 |
12.17 | |||||
|
Italy |
58,451 |
6.24 |
--- |
--- |
--- | |||||
|
Belgium |
3,217 |
3.59 |
523 |
.57 |
16.26 | |||||
|
Germany |
112,364 |
--- |
11,405 |
--- |
10.15 | |||||
|
Austria |
171,601 |
--- |
17,399 |
--- |
10.14 | |||||
aSource of information: (1) Monthly sick and woundedreports of the Surgeon General, for the years 1914 to 1919, inclusive. (2)Official History of the War, Medical Services, Diseases of the War, vol. 1, p.11. (3) Dopter, M.: Les Maladies Infectieuses pendant la Guerre,Librairie Felix Alcan, Paris, 1921, p. 45. (4) Document on file in thehistorical division of the Surgeon General`s Office. (5) Document on file inthe historical division of the Surgeon General`s Office, (6) Handbuch derArztlichen Erfahrungen im Weltkriege, Band iii, Inner Medizin, Leipzig, 1921 87.(7) Document on file in the historical division of the Surgeon General`sOffice.
39
The interpretation of the data compiled in the table issomewhat complicated by the fact that the figures given for France and Italyinclude not only typhoid but also the paratyphoid fevers, while those for theremaining five nations are confined to typhoid. It may be assumed, however, thatthe vast majority of the cases occurring in both the French and Italian Armieswere typhoid. A further complication arises from the fact that Italy did not engagein hostilities until 1915 and the United States not until the spring of1917. It should be noted, however, that the statistics for the United StatesArmy include the cases occurring during 1919, while those for the armies of theother nations (except Italy and Germany) cover the period 1914-1918,inclusive.
It may safely be assumed that the armies of all the nationsconcerned were well acquainted with the generally accepted principles that formthe basis for the control and prevention of the enteric group of fevers, andthat all well-known general preventive measures were enforced in so far asmilitary necessity would permit. We will limit ourselves, therefore, to aninquiry as to the extent to which anti-typhoid-paratyphoid vaccines were used asa prophylactic measure by the armies of the various nations and the degree ofsuccess-prevention of typhoid fever-attending their use.
UNITED STATES ARMY
The United States Army was the only one of the seven underconsideration in which the policy, initiated several years previous to ourentrance into the World War, was continued and actually carried into effect, ofmaking mandatory the vaccination of all military personnel immediately aftertheir entry into the service and of using a triple vaccine-typhoid-paratyphoidA and paratyphoid B-for protective purposes.
Our admission (morbidity) rate per 1,000 for typhoid feverwas the lowest attained by the armies of any of the nations participating in theconflict.
40
Approximately one-fourth of the cases arose after thecessation of hostilities, and the assumption is justified that though anexceedingly high degree of protection was afforded our troops by this measurethe immunity was not a lasting one. It follows, therefore, that even thoughthree consecutive doses of vaccine are given for protective purposes therepetition of the series of inoculations may become necessary or desirable intime of war at less than three-year intervals. This procedure was actuallyadopted by our Army in the early months of 1919 and approximately 350,000 menwere revaccinated in France.
BRITISH ARMY
During the course of the war (1914-1918), amongapproximately 4,970,90228 British (excluding colonials) called to the colors,about 20,149 cases were recorded as having had the typhoid fevers.1 Leishman10reported 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 crossedthe channel, and that it was not long before the inoculation strength of theirtroops in France rose to a figure that fluctuated between 90 and 98 per cent.
The regulations of the British Army at the outbreak of thewar in 1914 provided for antityphoid inoculation for troops embarking forforeign service.29 In consequence of the existing emergency, thefirst expeditionary force of 100,000 troops dispatched to the Western Front hadbeen incompletely protected and soon after arrival in France typhoid fever beganto appear. In 1915 and thereafter approximately 90 per cent of the troopsdispatched for foreign service had received protective inoculations. Prior todeparture from home territory it was the custom to give two consecutive doses ofvaccine and repeat the series every two years. At no time was the use of thisprotective measure made mandatory for all troops. During 1914 and 1915 thevaccine consisted of typhoid bacilli alone, but the undue prevalence of theparatyphoid fevers A and B in troops in various theaters of activity madenecessary the addition of the paratyphoid organisms, and from the beginning of1916 to the end of the war the vaccine in use was a triple one (B. typhosus, andB. 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 inevery 1,000 had typhoid fever, by 1918 the rate had been reduced to 0.12 per1,000. This reduction coincided with an increasingly widespread use ofantityphoid vaccines as a preventive measure, and there is ample justificationfor the statement that the gradual elimination of typhoid fever from theBritish armies was attributable to protective inoculation.
FRENCH ARMY
Since no official figures from the French War Office relativeto the prevalence of typhoid and the paratyphoid fevers, or with reference tothe status of protective inoculations with typhoid-paratyphoid vaccines duringthe World War, are available, the data used herein were obtained from a reportmade by Dopter;30 the statistics include both typhoid and theparatyphoid fevers. During the course of the war approximately 8,410,00031 menwere called to active service by France, and during the same period of timeapproximately 125,000 cases of typhoid and the paratyphoid fevers occurred inthe
41
French Army30 (approximate rate per 1,000 for typhoid andthe paratyphoids for the period, 14.86).
Antityphoid vaccine as a prophylactic measure was used in theFrench Army to a certain extent at the outbreak of the war (1914) but was not acompulsory measure for all troops. On account of the existing emergency only asmall percentage of the military personnel was given protective inoculationsduring 1914, and as a consequence approximately 45,000 cases of typhoid andparatyphoid fevers occurred, most of which were typhoid.30 UntilSeptember, 1915, an antityphoid vaccine was used, but a large proportion of thetroops still were unprotected. It was noted in 1915 that, while some progresswas being made in the control of typhoid, the cases of paratyphoid fever wereincreasing rapidly. In consequence of this fact a triple vaccine containingtyphoid 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 soduring 1914, when a considerable proportion of the French military forces hadnot received protective inoculations of antityphoid vaccine, large numbers ofcases of typhoid occurred. Subsequent to September, 1915, however, when a triplevaccine was adopted and when military conditions permitted its more widespreaduse, both typhoid and the paratyphoid fevers were gradually brought undercontrol, 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, whereasduring the last two years the total was approximately 2,000 cases.
ITALIAN ARMY
During the World War approximately 5,615,000 Italian subjectswere called for active service with the Italian Army,31 and of thisnumber approximately 65,000 had typhoid or the paratyphoid fevers.32 (Approximaterate per 1,000 for typhoid and the paratyphoid fevers for the period 6.24.) Theuse of antityphoid vaccine as a preventive measure was technically obligatoryfor the Italian Army when Italy entered the war in 1915, but it was found tobe not feasible to carry it into effect during that year on account of therapidity and urgency of mobilization. During 1916 and 1917 somewhat similarconditions obtained and though some progress was made a large proportion of theforces still remained unprotected.32 During 1918 still greaterefforts were made to inoculate the new drafts and not until that year were theenteric fevers controlled to any marked extent. Though during 1915 the vaccineconsisted of the typhoid bacillus alone, from 1916 to the end of the war bothtyphoid and paratyphoid vaccines were used.
BELGIAN ARMY
During the course of hostilities approximately 267,000Belgian subjects were called to the colors with the army,31 and ofthis number approximately 3,200 had typhoid or paratyphoid fevers.33(Approximaterate per 1,000 for typhoid and paratyphoid for the period 13.1.) Approximately90 per cent of the cases were typhoid and 10 per cent paratyphoid.
Prophylactic vaccination was not carried out in the BelgianArmy prior to or at the beginning of the war in 1914, but was introduced in1915, and by the end of that year 10 per cent of the forces had been protected.33During 1914 and
42
1915 approximately 2,500 cases of typhoid and the paratyphoidfevers occurred. From 1916 onward to the end of the war about 96 per cent of thepersonnel was protected, and during this three-year period approximately 1,000cases 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 casesof typhoid fever occurred in the German Army.34 No information isavailable to us as to the extent to which prophylactic vaccines were used, thecontent of such vaccines, or the prevalence of the paratyphoid fevers in theGerman 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 1918approximately 171,000 cases of typhoid occurred35among the 7,800,000 menAustria mobilized for the war.31 The extent to which paratyphoidprevailed is not known nor is there available information concerning the extentto which prophylactic vaccination was practiced, or the type of vaccines used.
The data outlined above demonstrate most conclusively thevalue and importance of prophylactic vaccines (typhoid-paratyphoid) in theprevention of the enteric fevers and the very great importance of carrying thismeasure 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 inthe American Army for the control of typhoid fever and other communicablediseases are considered 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, itmay be said that instruction in hygiene was made a matter of routine and everyeffort was made to safeguard the environment in accordance with modernconceptions of disease prevention.36 To protect against theintestinal group of infections-typhoid, dysentery, and diarrhea-specialattention was directed to the proper disposal of excreta and to the supply ofpotable drinking water. In the field the pit latrine system with fly-proof boxseats was used generally, except in the battle areas. To each company or otherorganization of like nature was to be issued one or more canvaswater-sterilizing bags, capacity 30 gallons, for the storage and distribution ofdrinking water. Sealed ampules of calcium hypochlorite were available for use insterilizing supplies of water for drinking purposes. Investigation of outbreaksof typhoid and medical inspections of organizations frequently disclosed thefact that organizations either had no water-sterilizing bags or no calciumhypochlorite, or were provided with neither. Many company commanders apparentlyfailed to appreciate the importance of having water-sterilizing bags and tubesof calcium hypochlorite always with the organization. In France the generaldistribution of tubes of calcium hypochlorite was a difficult problem and veryunsatisfactorily solved until about the date of the signing of the armistice,when this item was issued as part of the ration. There
43
also was wide variation in the quantity of calciumhypochlorite in the tubes and the amount of available chlorine in the individualtubes varied within wide limits. Had all organizations in France hadwater-sterilizing bags and chlorine constantly available, together with goodwater discipline, and in addition, had it been possible to supply each soldierwith a sterilizing agent to be carried on the person and to be used inemergency for the sterilization of water in the canteen, it is extremelydoubtful if more than a hundred or so cases of typhoid would have occurred amongthe nearly 2,000,000 men in the American Expeditionary Forces.
The experiences of the Army with vaccines in the World Warhave their lessons for the future. The history of this subject may therefore bedivided into several periods. In this connection it should be remembered thatthis account relates only to the manufacture of vaccines and does not correspondexactly 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 duringthe Spanish-American War, the officers of the Medical Corps in charge of thebacteriological laboratories of the Army Medical School devoted much attentionto the problems of the prevention of the spread of typhoid. In 1908, Russell37took up the problem of typhoid vaccination on account of its soundtheoretical basis and because of partial success of the use of vaccines in theBritish and German Armies. He worked out the technique of the production of avaccine for subcutaneous injection, using the agglutinating power of rabbit`sserum as an index of immunity. The procedure finally decided upon was amodification 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 itat a minimum temperature of 53? C. for one hour. The organisms were suspendedin salt solution and 0.25 per cent tricresol was added to preventcontamination. This amount of antiseptic was found not to injure the antigenicproperties of the vaccine. The English strain "Rawlings," from a soldier ofthe Boer War, was selected from several strains as being most suitable forvaccine purposes.
The strength of the vaccine was 1,000 million bacilli percubic centimeter as determined by the Wright method of counting. The doses were0.5 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 wereexceptional, several cases of paratyphoid A and B occurred each year in troopsalong the Mexican border, and these cases seemed to indicate a lack of crossimmunity and the possible necessity of a mixed vaccine. In 1916 this problembecame more acute as a small epidemic of paratyphoid A infections occurred inthe Mexican expeditionary forces and also in the National Guard units stationedin Texas.38 Paratyphoid B infections also occurred, but were lessnumerous. Under these conditions, several cultures were sent from the Armylaboratories at Fort Sam Houston, Tex., and El Paso, Tex., to the Army MedicalSchool, where they
44
were tested for suitability as vaccine strains. Paratyphoid Avaccine No. 1 was made on September 10, 1916, 1,000 million per cubiccentimeter, for local use of our troops in Texas and Mexico. Six of the strainswere used at first in different proportions in different lots. The firstparatyphoid A and B mixed vaccine was made in 1916.37 Two hundred millionparatyphoid B organisms were added to the paratyphoid A vaccine. The reactionswere reported as severe and from January 20 to May 22, 1917, only a paratyphoidA vaccine was issued.
In the meantime, the British had been suffering fromparatyphoid infections in France for two years and had finally adopted a mixedvaccine. The cultures used were sent to the school by our observer with theBritish Army. "Mears" 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 offear 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 vaccine was 750 million per cubiccentimeter of each fraction, a total of 1,500 million per cubic centimeter. Theadministration of 6 doses of vaccine, 3 of monovalent typhoid, and 3 ofparatyphoid seriously complicated the training schedules and the possibility ofa mixed triple vaccine was again taken up. Such a vaccine, consisting of 1,000million typhoid and 750 million each A and B, a total of 2,500 million per cubiccentimeter, was made up and tested at Fort Leavenworth, Kans.39 Thereactions were not severe and the agglutination response was satisfactory. Thevaccine was made of "Rawlings" typhoid, "Rogers" and"Mears" A, and "Rowland" and "Cools" B. The firstlot was made on July 11, 1917, and this kind of vaccine constituted the bulk ofthe vaccine used in the war.
LIPOVACCINE (SEPTEMBER 30, 1918, TO MARCH 12, 1919)
In 1916 several French workers reported on the use of oils inthe place of salt solution as a medium for bacterial vaccines. The advantagesclaimed for this method were, slow absorption, larger dosage with less reaction,and especially the efficiency of a single dose. These claims attracted theattention of the director of laboratories at the Army Medical School,Washington, D. C., and he, with his assistants, in the spring of 1918, conductedpreliminary experiments in the manufacture and use of lipo-triple-typhoidvaccine.40 Their experience apparently confirmed the claims, and thesingle dose was an especially strong administrative argument in preparing theArmy quickly for action in France. In the fall of 1918 lipovaccine wasofficially adopted by the Surgeon General`s Office.41 The firstlot was made on May 23, 1918, of para B.
The technique, briefly, was to grow the organisms in theregular way in Kolle flasks; the growth was washed off in a minimum of saltsolution and centrifugalized to collect the bacteria. After November, 1918, aSharples centrifuge was used for this purpose, and the organisms were grown intryp-
45
broth. The centrifugate was collected and dried in a hot-airoven 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 driedorganisms. The dose was 1 c. c. Each cubic centimeter contained 0.3 mg. oftyphoid, para A and para B bacilli, representing a total of 7,500 millionorganisms. The plant at the school was greatly enlarged by a special apparatusfor this work.
After the armistice was signed, and there was enough leisureto study the subject more thoroughly at the school, it was found that to preparean entirely sterile product on a large scale was most difficult. Some of thetyphoid organisms were not killed, and contaminating organisms from the air weredifficult to exclude. It was also found that absorption was not slow; theorganisms were rapidly extracted from the oil by the body fluids. Even moreimportant, it developed that a single dose did not give the antibody responsethat follows the use of two and three injections.
On March 1, 1919, therefore, a return was made to salinevaccine, and the following circular letter was issued from the Surgeon General`sOffice:42
1. Beginning with date of receipt of this letter, salinetriple typhoid vaccine and saline pneumococcus vaccine, Types I, II, and III,will be used in place of the corresponding lipovaccines used to date.
2. Lipovaccincs were adopted as a war measure on accountof their obvious advantages and have served their purpose. The technique ofmanufacture, however, needs further improvement, and the duration of theirprotective power as compared with that of saline vaccines needs furtherinvestigation. Saline vaccines will therefore be used as a routine andlipovaccines will be reserved for emergencies.
* * * * * * *
LOCAL AND SYSTEMIC REACTION FOLLOWING PROPHYLATIC VACCINATION
There is nothing to indicate that any permanent disabilityfollowed the vaccination of troops during the war. Furthermore, the temporarydisability produced by the triple typhoid vaccine was not great. Of theapproximately 4,000,000 men who were mobilized for our war Army, all of whomwere inoculated with typhoid vaccine soon after enlistment, only 35,552 wereadmitted 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 alarge number of troops in that camp and reported as follows on the unusualreactions to typhoid and paratyphoid vaccination:43
The reaction which is usually experienced from prophylacticdoses of typhoid vaccines amounts only to a slight discomfort. At worst thesubject 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 thesymptoms. There seems to be a consensus of opinion, however, that vaccination withthe mixed typhoid-paratyphoid culture is not so apt to be passed unnoted asvaccination with the single typhoid strain. The symptoms commonly varyingsomewhat in degree, are slight fever, chilliness, muscular pains and backache;not so usual, but still relatively frequent, are severe headache, vomiting ordiarrhea, or both, epistaxis, and bronchitis, which last may continue for daysor even a couple of weeks. This list includes all the symptoms which occur inthe average cases, and from these deviations are not unusual. Occasionally, ofcourse, bizarre cases are noted due, perhaps, to some accident in technic.
46
Differentiated from the above-mentioned majority, of over40,000 vaccinated troops, was found a group of cases, admitted to the wards ofthe base hospital at Camp Meade on account of rather severe symptoms. Thesesymptoms at least suggested certain specific diseases. On account of thediseases simulated this group may be subdivided into meningeal, appendiceal,and purpuric types. These cases were sufficiently frequent to afford opportunityfor study, and because of the diagnostic embarrassment which we experienced inthe beginning no little attention was given to them. The reaction which boreresemblance to appendicitis was most common. At least 50 of these cases werestudied, and of the other types a somewhat smaller number.
The meningeal type of reaction is alarming because of theresemblance to meningitis. When, as happened with two cases, there were inaddition to other signs a few fine purpuric spots on the body, the resemblanceto an early stage of "spotted fever" was complete. The usual course ofevents with my cases was initiated by headache, commencing a few hours aftervaccination and gradually increasing to an almost unbearable intensity. Withsevere headache photophobia is the rule. There was pyrexia up to 102? F. andsometimes vomiting. When put in bed the patient assumes the meningitis posture-lyingon the side, knees up, and head thrown a little back. On examination one findsinvariably with these cases some stiffness of the neck, a positive Kernig sign,and a mild hyper?sthesia. In the absence of history, diagnosis can hardly bemade without lumbar puncture. When lumbar puncture is done the cerebro-spinalfluid is found under considerable increase of pressure, often dropping too fastto be counted. The fluid is clear and normal. There is no significant cellincrease. Withdrawing 10-15 c. c. of fluid almost invariably relieves theheadache. In brief, the condition is one of meningismus.
The appendicitis picture is definite enough as a clinicalpicture with localized pain and tenderness, slight fever, and some increase inthe leucocyte count (due to vaccine). A number of these cases were operatedupon. The appendices removed, however, did not present the conditions expected,and an agreement between the surgeon and the pathologist on this point wasimpressive. With this experience a conservative attitude developed and none ofthe 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 hadbecome interested in the surgical aspect of this problem but had come to adifferent conclusion in that with his cases the appendix did show more evidenceof acute inflammatory change. Colonel Martin`s cases gave a history suggestingrepeated attacks of appendicitis in the past, and it has been proposed inexplanation that the vaccination excited an acute process in an individual thuspredisposed. Neither the immediate practical question involved nor theunderlying one of scientific principle can be clarified by evidence nowavailable. It will be recalled that shortly after typhoid vaccination began tobe somewhat extensively used among our civil population in the cities thestatement was made and repeated that latent tuberculous foci in the lungs mightbe thus fanned into activity. Some scattered attempts were made to ascertain thetruth, but these studies bear analysis as badly as the statements to beexamined. At present there are opinions, but little evidence. Similar opinionsare current as to the effects of vaccination on latent chronic urethritis,arthritis, and some other conditions. The whole subject requires carefulreexamination. It is of interest in passing to recall that vaccines made fromtyphoid cultures have been advocated for the treatment of some of theseconditions-arthritis, urethritis-which we are now assured are aroused intoactivity by the same measure.
There is so much obscurity surrounding the etiology ofpurpura that the cases following vaccination had for me an especial interest.The first of these cases to receive recognition was admitted from a regimentalinfirmary on account of epistaxis. * * * On the morning of admission to hospitalhe had epistaxis, and for this reported at sick call. The epistaxis wasobstinate and required "packing." Examination showed a purpuriceruption covering the body. The spots were small and discrete, varying fromone-sixteenth inch to one-eighth inch, and purplish in color. There was nobleeding of the gums; no blood found in urine or feces. We had not at this timefacilities for exact measurement of clotting time, but no abnormality was notedby 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 toduty.
47
On inquiry, stimulated by this case, it was found that anumber of cases had been admitted to the otology service of the hospital becauseof epistaxis following vaccination, and it was recognized that many of these hadhematuria and a few had purpuric eruptions. A number of cases of varyingdegrees were studied subsequently in both these services. Epistaxis withtransient hematuria was not uncommon. Some of these showed also hemorrhages and purpuric rashes. In one case there was violent epistaxis, hematuria, melena,and extensive purpura and hemorrhage into some of the joints. The left elbowhad later to be opened and the clot removed. All of these cases made perfectrecoveries.
Since an understanding of this condition would be helpful foran understanding of purpura, examinations were made of blood in respect to theclotting and bleeding times, cell counts, and platelet counts. So much normalvariation was found in the platelets that no evidence could be recured inthis direction. The other estimations were normal, except a slight leucocytosisobserved in many cases after vaccination without special symptoms.
Statistical tables of the Surgeon General`s Office for theWorld War period show that five soldiers were discharged from the Army fordisability following triple typhoid vaccination. A further investigation of theclinical records of these cases, however, revealed an error in tabulation;although some temporary disability resulted from vaccination, a careful searchof the records failed to reveal any cases that terminated in permanentdisability or death.
The use of typhoid vaccine as a protective measure havingbeen a routine procedure in the United States for a number of years prior to theWorld War, the American military authorities appreciated the fact that thereactions following its administration not infrequently (approximately 10 percent) were moderately severe during a period of from 24 to 48 hours afterinoculation. For this reason it was the custom to recommend that all personnelbe excused from all duties, except the necessary roll calls, for a period of 24hours after vaccination. The experience gained in the vaccination of 4,000,000men during the World War further confirms the wisdom of carrying this procedureinto effect, and it is now required by Army Regulations.
FACTORS THAT MAY BE RESPONSIBLE FOR THE OCCURRENCE OF TYPHOID IN INDIVIDUALS PRESUMABLY PROTECTED BY VACCINATION
As noted, a large proportion of the cases of typhoid introops in the large mobilization camps in the United States occurred inindividuals who had not been protected by prophylactic vaccines. Approximately885 cases occurred in approximately 1,900,000 men serving in France, and it ishighly improbable that any appreciable number of these men were uninoculated.Vaughan,3 in a careful study of the records of 270 cases of proventyphoid in France, found that all had received prophylactic inoculations, andthat in 207 of the 270 cases there was a record of the dates of vaccination andtypes of vaccine used. Why did prophylactic vaccination occasionally fail toprotect against typhoid? Concerning this matter we have no definite information.Vaughan, who gave it considerable attention, made the following comments on thisphase of the problem:3
1. Absence of vaccination, either total or partial.-BythisI refer to failure not because of impotent vaccine but because of failure toreact in certain individuals. It is well known that after the same doses ofvaccine different persons form different amounts of agglutinins. But agglutinintiter is not a measure of immunity. We have no criterion that will tell
48
us when an individual is actually immunized, nor have we anymeans of determining the degree of immunity present.
2. New strains of the organisms against which the vaccinedoes not immunize.-Serologic and cultural determinations made in thevarious laboratories have not consistently produced anything to suggest such acondition.
3. Failure of proper inoculation.-Amongthe casesof true typhoid studied, vaccination had been performed in 50 different campsand posts in the United States. This fact, combined with the really excellentresults in most individuals vaccinated, renders such a possibility ratherremote.
4. An overwhelming dose of the infecting organism.-Absoluteimmunity to human disease does not exist in man. The highest immunity that canbe produced by artificial methods will protect against the antigenic virus onlyup to a certain limit. I am of the opinion that the greater number of cases oftyphoid and paratyphoid in France occurred as a result of massive infection witha dose great enough to overwhelm the forces of immunity. This, I presume, wasmost frequently associated also with the first cause enumerated, "absenceof vaccination, either total or partial," in that it occurred in thosepossessing a lower degree of immunity than their more fortunate comrades. AsBernard has so succinctly expressed it, vaccination raises against the typhoidbacillus a great barrier-high, but not insurmountable.
5. "Back-handed typhoid," "antibodyexhaustion," or "immunity exhaustion."-I include thesecond designation of this condition as being the most readily comprehensiblein view of the existing nomenclature and conceptions of immunity, while Iprefer the third as being more scientifically correct. I developed the firstterm as I recognized more and more of this type in the field, and it has theparticular advantage that it emphasizes the assumption that the successivestages of typhoid infection are therein, in a manner, reversed.
The present-day conception of typhoid is that itis ofprimary systemic infection. The organisms entering by way of thegastrointestinal tract are absorbed into the circulation and do not primarilygrow as saprophytes in the alimentary canal. After passing through thegastrointestinal mucosa, the organisms reach the liver through the portalcirculation, where they may be excreted through the bile; or some may passinto the general circulation, where they multiply and, after the usual period ofincubation, cause typhoid fever. The organism excreted in the bile may lodge inthe gall bladder and there, growing, produce the carrier condition, even thoughthe host has not had typhoid fever.
In a vaccinated person, the organisms entering the portalcirculation are either broken up and destroyed by the body ferments or excretedinto the bile, or both. In the gall bladder they may find lodgment and continueto grow, in reality outside the body organism, multiplying profusely eventhough the host be highly immune. The number of organisms that are continuallydischarged in the bile and resorbed through the intestinal mucosa call on theimmunity mechanism for constant and exhausting action. There may be superimposedon this local enteritis caused by one of the typhoid-colon group or any otherorganism, or even by the typhoid member of the group itself. This subacute orchronic condition rendering toxic absorption more facile, serves gradually toundermine the constitution. Finally, added to all this, are the hardships of warand army life-exposure, food not always well balanced, fatigue, and perhaps atlast some intercurrent infection-and all the conditions required to wear out abody immunity are then present.
It is this reversed process-a local infection or carrierstate followed by systemic disease instead of the usual typhoid followed by acarrier condition-that I have chosen to call "back-handed typhoid."Overwhelming doses of the infecting organism and this exhaustion reaction werein my opinion two of the chief causes of typhoid among our troops.
From the nature of the condition it has been impossible toobtain convincing experimental evidence of its presence in France; but acertain amount of indirect evidence appears to warrant our assuming itspresence. Our first case occurred in a colleague who, preceding his illness, hadbeen billeted with a French family and who had been drinking unchlorinated waterwhile at his billet. For two weeks or more he had been complaining of generalmalaise 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 oftyphoid developed, he became progressively worse, and he died within one weekfrom the onset of the exacerbation.
49
These cases present the usual clinical histories ofambulatory typhoid, with the definite addition of a local gastrointestinalpathologic condition and symptoms preceding the disease proper. Otherwise thereis nothing unusual about the symptomatology. Especially frequent was thissyndrome among the men who had seen active service at the front. From nearlyall, a history was obtained of having drunk whatever water they could get, evenfrom the stagnant mud of the shell holes.
To check up on the impression I had gained, I questioned 104patients as to previous history of chronic local gastrointestinal disturbance.All were straight typhoid cases. Forty-four denied attacks of diarrheaantedating the diarrhea of the disease itself. Thirty-nine admitted acontinuous preceding enteritis varying from one week to three months induration, and of these, 23 had it for over a month. Fifteen had had diarrhea forfrom one week to three months while at the front, which had subsided and fromwhich they had been free for from two to three months. Seven additionalpatients admitted having had a transient diarrhea of from one to five weeksduration in the two months preceding their disease.
Subacute diarrhea is not a necessary, or theusual,antecedent of typhoid fever. The disease begins frequently even withconstipation. I would compare the foregoing figures, in which more than 60 percent had been afflicted with enteritis, with the statements of the TyphoidCommission in the Spanish-American War, that in that epidemic "More than 90per cent of the men who developed typhoid fever had no preceding intestinaldisorder." I do not believe that the figure of 60 per cent wouldhold 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 hadbeen at the front.
There is no proof that these men were harboring the typhoidbacillus in their intestinal tract previous to coming down with the disease. Itis here that my hypothesis fails of absolute proof. Such proof would havenecessitated a survey of the stools of all members of a division, to be followedby weeks or months of watching to see whether the carriers discovered woulddevelop the disease. Moveover, had this been done, the carriers would have beenhospitalized and treated, thus defeating the object of the experiment. Butcorroborative evidence is not lacking. Several observers have reported thefinding of typhoid bacilli in the stools of patients a few days or more previousto the onset of the disease, while Battlehner has reported four cases in whoseexcreta the bacilli were discovered from 21 to 117 days before the onset of thedisease. These had been considered as healthy carriers. I have a record of onepatient who one and a half months previous to admission cared for a typhoidpatient and shortly thereafter developed diarrhea, which persisted for six weeksuntil the typical acute onset of typhoid. In the discussion of typhoid carriersI 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 oftyphoid and no diarrhea, who nine months previously, at Camp Dodge, had hadnegative stools for the typhoid group.
I have shown, then, that carriers have been produced inFrance; that diarrhea is often associated with the carrier condition; that among104 men, diarrhea preceded the disease in 60 per cent; that in one instanceexposure to the disease was followed by enteritis which persisted for six weeks,until the onset of typhoid. Before absolute proof of back-handed typhoid isproduced, I must show that all these facts find sequence in individual cases.
6. Unsatisfactory vaccine, either as regards antigenicproperties or number of doses administered.-Considerable experimentalevidence has accumulated to show that with increasing numbers of inoculationsthe immunity increases. Four inoculations confer a greater degree of immunitythan do three. One of the advantages of the method in use in the United StatesArmy is that the men nearly all receive the same vaccine in the same dosage andwith the same number of inoculations. Observers in other armies were sometimesforced to draw their conclusions from patients who had received different kindsof vaccine and all numbers of injections, from one to four or more. The factthat our vaccine did protect in the great majority of the cases demonstrates theefficiency of our preparation and of the dosage. It may not be ideal, but it isthoroughly practical.
50
CLINICAL COURSE OF TYPHOID FEVER IN THE VACCINATED INDIVIDUAL
The general impression prevailed at the outbreak of the WorldWar that the clinical manifestations of typhoid fever in the vaccinatedindividual differed from those found in the unvaccinated. The statement is madeby Gay44 that not only is the mortality rate decreased but the diseaseitself is found to undergo a very distinct modification when it occurs in thevaccinated individual, so much so, that it frequently is so mild as to offergreat difficulty in diagnosis. Vaughan, in a study of a series of 373 casesoccurring in vaccinated individuals in the American Expeditionary Forces,France,3 found that the most striking feature of the disease in theinoculated was its almost classical resemblance to the old typhoid fever as oneknew it in the unvaccinated individual. Not only was this resemblance noted inthe clinical history but also at the bedside. In the majority of cases in whichthe typhoid bacillus was isolated there was no difficulty in the clinicaldiagnosis. Typhoid facies, coated tongue, rose spots, palpable spleen, rigid andslightly tender abdomen, and dicrotic pulse were the rule rather than theexception; however, as in the uninoculated, all gradations of the disease werefound. One has long been acquainted with mild and ambulatory cases, withdifficulty in diagnosis on account of the mildness of the disease, and frequentabsence of many of the usual symptoms of typical typhoid fever. Many such casesprobably occurred among our troops in France and remained undiagnosed. It isfurther possible that the number of cases that would fall under this class hadbeen greatly increased by previous inoculation. But of those patients whom wehave seen sick in hospital there could be no doubt as to the clinical diagnosis.3
Leucopenia was not as marked as in the classical typhoidfever. The average white count on successive days was about 7,000. In a fewcases from 2,000 to 4,000 white cells per cubic millimeter were noted. The aboveaverage agrees with the report by Hawn, Hopkins, and Meader.14 Theaverage white count during hemorrhage was 4,500; in perforation, 6,000; in lobarpneumonia complicating the disease, 12,000, and in bronchopneumonia 9,000. Thesefigures, however, agree with those occurring in typhoid fever in theunvaccinated.3
What has been said relative to the white blood count appliesto the febrile course of the disease; that is, the type of fever in vaccinatedpatients did not differ remarkably from that in unvaccinated. The average day ofcessation of fever was 26.9; relapse occurred in 10 per cent of the cases andthe average date of onset was the 35th day. Death occurred in 11 per cent of 270of the cases studied and the 21st day was the average day of death.
The foregoing clinical findings are in accord with thosereported by other observers. Labb?45 remarks that the symptomatologyhas nothing characteristic and the same elements are present and appear in thesame order among vaccinated and unvaccinated individuals. The onset is notmarked by special symptoms and during the fastigium, diarrhea has the usualoccurrence. However, it may be that this symptom occurs somewhat less frequentlyin the vaccinated. Bernard and Paraf,46 in describing the clinicalsymptomatology among French troops, remarked that typhoid fever among thevaccinated has no particular characteristic which might indicate a modificationof the disease.
51
The different classical forms are seen with their usualcharacteristics. Campani and Gallotti47 reported that in a series ofcases of typhoid and paratyphoid fevers occurring in 144 nonvaccinated civiliansand 341 vaccinated soldiers on the Italian front the case mortality rate fromtyphoid fever in the vaccinated patients was 8.6 per cent and in the paratyphoidA and B cases 4.6 and 7.8 per cent, respectively. Among the unvaccinated thecase 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 febrileperiod 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 thefebrile curve instead of being irregular and low in the vaccinated, was high anddecidedly more regular than among the nonvaccinated. Splenomegaly and nervousphenomena were more frequent among the vaccinated. These workers concluded thatvaccination had lessened both the mortality and the severity of the disease.
Freund48 reported typhoid infection in the GermanArmy and concludes that among the vaccinated cases there were more remissionsand intermissions as well as a great number of mild cases. The fever was milderbut the total duration of the disease was not shortened. No change in thefrequency of the complications or relapses resulted on vaccination, andmortality given among the vaccinated was 8.3 per cent.
Hawn, Hopkins, and Meader,14 in describing the 38cases studied in an outbreak among American troops in England, found clinicalsymptoms similar to the cases described by Vaughan. The initial chill occurredin 16 per cent, diarrhea in 58 per cent, constipation in 21 per cent, abdominalpain in 6 per cent, and epistaxis in 2.6 per cent. Rose spots were described in19 cases, splenomegaly in 9 per cent. Blood cultures were positive in 12 casesand the mortality was 13.15 per cent.
There was a somewhat progressive increase in severity withlapse of time after inoculation in individuals to whom vaccine had beenadministered from one to six months before the patient was taken sick (11.6 percent severity). When from 13 to 18 months had elapsed, 15.9 per cent wereclassified as severe. It appeared that the average severity of the disease wasfairly constant throughout the first eight months following inoculation, afterwhich it gradually increased. The proportion with relapse did not appreciablydiffer.
COMPLICATIONS, SEQUEL?, AND CONCURRENT DISEASES
The complications and sequel? of typhoid fever during the warafforded nothing new from either a clinical or pathological point of view. Amongthe 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 myocardialinsufficiency, of which 2 resulted fatally. Important complications of therespiratory tract were 26 cases of bronchitis, with 6 deaths; 59 cases ofbronchopneumonia, with 39 deaths; 29 cases of pneumonia, of which 24 terminatedfatally; and 18 cases of pleurisy, with 6 deaths. Hemorrhage was recorded in 11instances, with 8 deaths; and diarrhea as a complication in 5 cases, of which 3terminated fatally. Enteritis and colitis occurred in 12 instances, with 2deaths; and peritonitis in 8, with 7 deaths. There were 2 deaths among the 4cases of acute
52
nephritis. Altogether 209 complications were deemed as beingof sufficient importance to be reported, with 151 deaths.
Typhoid fever was reported as concurrent with other diseasesin 368 instances. Of these, 60 terminated fatally, giving a casemortality of 16 per cent. The more important diseases with which it wasconcurrent are given in Table 8.
TABLE 8.-Typhoid Fever. Concurrent with otherdiseases, enlisted men, United States Army,serving in the United States and Europe, April 1, 1917, toDecember 31, 1919
|
|
Absolute numbers |
Deaths |
Case mortality |
Primary cause of admission |
Absolute numbers |
Deaths |
Case mortality |
|
Influenza |
162 |
33 |
20.37 |
Enteritis and colitis |
25 |
4 |
16.00 |
|
Tuberculosis of the lungs |
4 |
3 |
75.00 |
Intestines, other diseases of |
5 |
2 |
40.00 |
|
Bronchitis |
29 |
1 |
3.45 |
All others |
98 |
6 |
6.12 |
|
Pneumonia, broncho- |
29 |
6 |
20.69 |
Total associated |
368 |
60 |
16.30 |
|
Pneumonia, lobar |
16 |
5 |
31.25 |
CARRIERS
Nichols,49 who made a somewhat exhaustive study ofthe "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 anotherhas been variously estimated as being from 9 to 50 per cent, women constitutingthe majority, three-fourths of the carriers being of the intestinal type.
The bacteriological examination of the stools and urine offood handlers at stated intervals, and examination of convalescents from typhoidfor the carrier state prior to their discharge from hospital, was a matter ofroutine during the World War, and by means of this administrative procedure afew carriers were detected. According to Nichols, the results of examination ofabout 30,000 food handlers during the war demonstrated less than 0.1 per centcarriers among healthy males. Gay44 states that 7,500 carriers are beingadded to the civilian population in the United States each year. There were 64recorded carriers among the primary admissions to hospital during the war.
Instructions governing medical officers, A. E. F., in thedetermination 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 andfourth week of the disease, thecondition may persist throughout convalescence and not infrequently longer. Itis, therefore, important not to release the convalescent typhoid or paratyphoidfever patient until he ceases to excrete these bacilli.
Three negative cultures of the urine and feces at six-dayintervals should be required before release of patient, the first not earlierthan one week after temperature curve has become normal.
Some persons who have never had a clinical history of thedisease may excrete typhoid or paratyphoid bacilli. It is important to detectsuch carriers in any occupation, but especially among cooks and handlers offoodstuffs. In such a carrier survey, two examinations should be done on eachindividual.
53
No definite lesions were found in incubationary and contactcarriers. The liver and kidney showed lesions in convalescent carriers. Inintestinal carriers with lesions in the gall-bladder, bile-ducts, or both, theorganism was demonstrable in the stools. In urinary carriers the focus was foundin the kidney, especially in the pelvis.
According to Nichols,49 carrier strains did notdiffer from others and could not be differentiated by cultural or other tests.In determining the carrier state serological examinations were suggestive, asmore than 50 per cent gave positive agglutination tests. Such examinations,however, were of little value in the case of convalescents from the disease orin the recently vaccinated subject. The organism was found in the duodenalcontents or feces in the intestinal type of carriers and in the urine in urinarycarriers. It was the custom to require at least three consecutive examinationsof the feces and urine of convalescents from typhoid before dismissing thepossibility of an existing carrier state.
In the United States it was the policy to collect all chronictyphoid carriers in the Army at the Walter Reed General Hospital, Washington, D.C., for further observation and treatment.51At the time thearmistice went into effect arrangements also had been completed for theestablishment of a special hospital in France, near Dijon, for the treatment andstudy of chronic "carriers" of all types in the American ExpeditionaryForces.
An essential in the successful treatment of typhoid carrierswas location of the focus of infection which, though usually single, sometimeswas multiple. Where the focus was a single one, as for example, thegall-bladder, treatment by excision usually effected a cure. Where the foci weremultiple, as for example in the gall-bladder and in the bile-ducts, removal ofthe gall-bladder did not result in a cure.
Nichols, Simmons, and Stimmel52 reported on the surgicaltreatment of typhoid carriers at the Walter Reed General Hospital in 1919. Sevencases 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 theurinary carrier was cured by removal of the infected kidney. In two of theintestinal carriers failure was attributed to the gall-duct being infected asshown by cultures of the duodenal contents. Operation was not recommended for atleast six months after recovery from the primary disease, as in many instancesthe carrier state was of temporary duration. Henes53 reportedfavorably upon the surgical treatment of typhoid bacillus carriers at the UnitedStates Army General Hospital No. 12 during the war.
In spite of all known methods of treatment, some chroniccarriers continued to excrete bacilli. The commanding officer of the WalterReed General Hospital reported several such cases to the Surgeon General inApril, 1919.54 These cases had been operated upon, but foci of infectionremained. The procedure followed in such instances was to discharge theindividual from the Army, at the same time notifying the State board of healthhaving jurisdiction.55
54
DIAGNOSIS
For many years, particularly since prophylactic vaccinationwas made mandatory, the Medical Department of the Army has stressed theimportance of the scientific and early diagnosis of typhoid fever. Before weentered the World War it was required that the diagnosis be based on isolationof the organism and that a culture of the isolated organism be sent to the ArmyMedical School at Washington for confirmation. This practice was continuedduring the World War except that organisms isolated in France were sent forconfirmation to the central medical department laboratory at Dijon.
A prompt report of cases of enteric fevers was insisted uponby the chief surgeon, A. E. F.56 For purposes of classification adivision 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 circularletter relating to the typhoid and paratyphoid fevers. The following notes ondiagnosis were incorporated in this letter:50
In individuals previously vaccinated against typhoid but whohave completely lost their immunity, infection similar to that found in theunvaccinated occurs, giving rise to the symptom complex * * * characteristicof typhoid fever.
Infections occurring in the vaccinated individuals who stillpossess a certain degree of resistance to infection results in the appearance ofatypical clinical pictures, such as abortive types of typhoid and paratyphoid inwhich the constitutional symptoms are mild but with slight febrile reaction ofatypical type and few if any rose spots. The onset may be either insidious, withheadache, loss of appetite, and fatigue, or acute and associated with chills,vomiting, intestinal cramps, and diarrhea. Fever may be wholly absent orevanescent in character and determined only if observations are made within thefirst 48 to 72 hours. A low type of temperature, with daily fluctuations of from98.6? to 100.4?, suggestive of the presence of tuberculous disease, maypersist for a week or 10 days. It is in this class of cases that blood culturestaken early in the course of the disease, and repeated if negative, frequentlygive definite information concerning the nature of the infection. Ambulatorytypes of typhoid are not uncommon and the first indication of the existence ofthe disease may be furnished by the occurrence of intestinal hemorrhage orperforation.
The vaccinated individual protected against general systemicinfection may still act as a carrier of typhoid infection and frequently showsclinical manifestations of local disease of some portion of the gastrointestinaltract, while the characteristic symptom complex of typhoid fever due to generalinfection, namely, continued fever, rose spots, and enlarged spleen, may bewholly 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 appendicitis. (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. (f) In the above atypical modes of onset early blood cultures are of importances in differentiation. * * *
In the differential diagnosis influenza, acute miliarytuberculosis, sepsis, and malarial fevers must be differentiated. Local andunexplained gastrointestinal derangements, as
55
gastritis, diarrhea, dysentery, enteritis, appendicitis, andinflammation of the bile passages, occurring with or without fever should beregarded with suspicion when cases are admitted from commands in which casesof typhoid or paratyphoid fever have occurred.
Laboratory diagnosis of typhoid andparatyphoid fevers.
-Bacteriological procedures are of great value (1) for the certain and early diagnosis of suspected cases; (2) to determine carrier state in convalescent positive cases; (3) to detect carriers in otherwise normal individuals.
Blood cultures offer the most certain method for earlydiagnosis of undetermined fevers, and it should be kept in mind that the earlierin the disease the blood culture is taken the more likely is the result to bepositive; thus, in positive typhoid fever the chance of successful bloodculture declines from 90 per cent during the first week to 40 per cent duringthe third week. In paratyphoid A fever, because of the frequently short and mildfebrile period, the prompt and early blood culture is all the more necessary.Relapses are more common in paratyphoid than in typhoid, and taken at such atime, blood culture yields positive results in every case.
The following method of blood culture isrecommended asbeing 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 thefollowing day. Transplants are made to plain agar slants, or, better, Russell`sdouble sugar agar. In cases of development of Gram-negative motile bacilli onagar slants, emulsions should be made and agglutination tests done with immunesera for final identification.
Frequency of nonagglutinability of recently isolated typhoidcultures should be kept in mind. Negative blood culture in suspected typhoidfever means little. Repeat if clinical conditions indicate.
(a) If the blood culture specimen can not be takendirectly to the laboratory, filtered sterile ox bile is most useful, 5 c. c. ina tube. To such sterile ox bile 5 c. c. of blood is added, the tube closed witha sterile paraffin cork, carefully packed, and sent for examination to thenearest laboratory. Bile medium is furnished in chest No. 1, transportablelaboratory, United States Army, expeditionary force model. Additional supply ofthis medium may be obtained as needed from central Medical Departmentlaboratory, A. P. O. 721.
Bacteriological examination of feces is second only toblood culture as an important means of positive diagnosis. It is especiallyimportant 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 standardized 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 Vaughan,3 bloodcultures were made from 274 cases and typhoid or paratyphoid bacilli wereisolated in 180 cases, or 65.7 per cent. Of these 180 positive results, 143 werepositive on the first culture, 25 on the second culture, 3 on the third, 9 onthe fourth, and none on the fifth, showing the value of repeated culturing. Inthe case of the epidemic occurring in the Camp Cody replacement unit, 32 percent of the blood cultures taken in England were positive and 88 per cent ofthose taken at Cherbourg; in the Prauthoy epidemic 16 per cent were positive; inthe Curel epidemic 88 per cent; and in the Marseille epidemic 28 per cent werepositive. This is a
56
very wide range of positive cultures and indicates, in thelow percentages, either delay in resort to laboratory diagnosis or lack of skillon the part of the laboratory personnel. A blood culture is manifestly of muchgreater value than a stool or urine culture. In the Curel epidemic, which washandled promptly by a skilled laboratory force, the per cent of positive bloodcultures was high (88 per cent); consequently, it was necessary to resort tocultures of the urine and stools and there were reported only 14 per centpositive feces and 3 per cent positive urine. In the case of the Marseilleepidemic with a low percentage of positive blood cultures the gravity of thesituation was not at first appreciated. The local laboratory personnel wasreinforced and subsequently there were reported 53 per cent positive stool and14 per cent positive urine culture. Likewise in the Nevers epidemic and for thesame reason there were but 15 per cent positive blood and 38 per cent positivestool and 31 per cent positive urine cultures.
Marris,57 of the British Army, during the courseof an extended study of typhoid patients, developed the so-called atropindiagnostic test. He held that when the human body is so invaded by bacilli ofthe 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 ofthis toxin can be detected by observing the abnormal yet characteristicreactions of such hearts to a certain drug, notably atropin. This reactionconsists in the failure of acceleration of the pulse beat more than 15 beats perminute after the hypodermic injection of a large dose (one thirty-third gram) ofatropin. Marris based his observations on 111 cases of proved typhoid orparatyphoid. The test was positive in 92 per cent of cases in the first week ofthe disease; 89 per cent in the second week; 83.7 per cent in the third week; 88per cent in the fourth, and in the later stages the reaction was notcharacteristic. He found the test to be negative in the case of typhoid carriersand in a list of other diseases such as trench fever, meningitis, bronchitis,pneumonia, tuberculosis, dysentery, malaria, influenza, etc. The same resultswere noticed with amyl nitrate and adrenalin as with atropin.
In Vaughan`s3 series the atropin test was madein a small number of cases and was usually found to be positive, more markedlyso during the first week, when the pulse was slow. It was often negative afterthe pulse rate increased. In 38 cases reported from England14anacceleration of pulse rate occurred in 33 cases, a decrease of rate occurred in1, and no alteration in 2 cases. Of the 33 showing acceleration, 23 showed a positive reaction. Theearliest day on which the test was performed in this positive group of 23 caseswas the seventeenth day; the latest the thirty-first day. The positive reactionfor the group was 68 per cent. Of the 10 cases showing a negativereaction, the test was performed after the twenty-first day of the disease-sevenof them being after the thirtieth day of the disease. If the seven casesoccurring in the later stages of the disease, when the reaction is not supposedto be characteristic, are eliminated, the result would stand, as 81.5 per centpositive tests. Friedlander and McCord,58 at CampSherman, Ohio,tested the effect of atropin in other diseases than typhoid and found that in170 cases, 62, or 36.5 per cent, gave a positive reaction. Their list ofdiseases included measles, influenza, scarlet
57
fever, and pneumonia. These investigators are of the opinionthat a test which gives such a high percentage of positive results in otherdiseases than typhoid can not be depended on.
The statement is justified that the Widal reaction is ofsomewhat doubtful value in the diagnosis of typhoid fever in the recentlyvaccinated. This contention is supported by Hamilton59 and Fennel.60Dreyer, Walker and Gibson,61 and Davison62 presentarguments in support of their opinion that microscopic Widal tests, with astandardized agglutinable culture, made at intervals, to demonstratefluctuations upward or downward, in agglutinin content, have a definitediagnostic value. It may be stated that agglutination tests in the vaccinated,while suggestive of the presence or absence of specific infection, can notreplace in diagnostic value the recovery of the specific organism from theblood, urine, feces, or bile. The agglutination reactions performed in the Armyfollowed the Dreyer technique closely.63
In Vaughan`s3 series of 206 cases, in which thetentative or provisional diagnosis was noted, 120 bore a diagnosis ofrespiratory disease, while only 49 were diagnosed as gastrointestinal. This isin accordance with previous knowledge of the disease, the initial symptoms beingnot local but the general symptoms of acute infection frequently with aconcomitant bronchitis. The pandemic of influenza prevailing at the time alsotended to render difficult a proper diagnosis.
Vaughan`s report that the onset was generally gradual andmisleading is confirmed by a study of the period elapsing between onset andhospitalization. In the 123 cases occurring in the 77th Division, the cases werehospitalized on an average of 8.1 days after the onset of the disease, theextremes being 1 to 57 days. The laboratory diagnosis was made on an average of19.6 days after the onset, the extreme being 7 and 60 days. This gives anaverage of 11.5 days spent by a case in the hospital before a laboratorydiagnosis was made. In the 38 cases occurring in England (infected in the UnitedStates en route to England) the average date on which the cases werehospitalized was 13? days after initial symptoms; in the Prauthoy epidemic itwas 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 World 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 expeditionary 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 paratyphoid A vaccine. As paratyphoid fevers were being reported as of not uncommon 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 group of fevers was a negligible factor as a cause of illness in the United States Army, as is indicated in Table 9.
58
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
|
Country |
|
|
Para B | ||||||
|
|
Deaths |
Admissions |
Deaths | ||||||
|
|
Rate per 1,000 |
Absolute numbers |
Rate per 1,000 |
Absolute numbers |
Rate per 1,000 |
Absolute numbers |
Rate per 1,000 | ||
|
United States |
2,235,389 |
32 |
0.01 |
--- |
--- |
11 |
0 |
1 |
0 |
|
Europe |
1,665,796 |
95 |
.06 |
6 |
0 |
56 |
.03 |
4 |
0 |
|
Other countries |
227,294 |
7 |
.03 |
--- |
--- |
11 |
.05 |
--- |
--- |
|
Total primary cases |
4,128,479 |
134 |
.03 |
6 |
0 |
78 |
.02 |
5 |
0 |
|
Additional cases as associated diseases |
--- |
41 |
--- |
5 |
--- |
17 |
--- |
1 |
--- |
|
Grand total |
--- |
175 |
--- |
11 |
--- |
95 |
--- |
6 |
--- |
The death rate for cases occurring in the United States isthe more reliable one. Most, if not all, of the deaths from paratyphoid recordedfor troops in Europe actually were due to causes other than paratyphoid, butwere charged back to the paratyphoids for the reasons stated elsewhere (p. 15).
The clinical characteristics of the paratyphoid fevers asthey occurred in American troops during the World War can be summarized asfollows: On the whole, the disease followed a much milder course than didtyphoid. The individual case could not be distinguished from typhoid fever byclinical manifestations alone. Both diarrhea and initial constipation weresomewhat more common than in typhoid cases. No relapses were reported, and theduration of the febrile stage was approximately the same as for typhoid. Theonly certain method of differentiation was identification of the causativeorganism.
REFERENCES
(1) Official History of the War (British) Medical Services, Diseases of the War. His 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. The 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. D., 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. The 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.
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) Effler, 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 Rockefeller Institute for Medical Research No. 16, New York, May 10, 1922, 1.
(28) Statistical Report No. 169, Statistics Branch, General Staff, War Department, Washington, April 9, 1921.
(29) Official History of the War (British): Op. cit., 55.
(30) Dopter, M.: Les Maladies infectieuses pendant la Guerre, Librairie F?lix Alcan, Paris, 1921, 50.
(31) Military Casualties-Certain Countries-World War, Special Report No. 178. February 25, 1924. Statistics Branch, General Staff, War Department. On file, Historical 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 ?rztlichen Erfahrungen im Weltkriege. 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., 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 Association, 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) Labb?, Marcel: Les Infections Typhique et Paratyphiques chez lesVaccin?s. Annales de M?decine, Paris, 1916, iii, 13.
60
(46) Bernard, L., and Paraf, J.: Les Infections Typhoides chez Les Sujets Vaccin?s contre la Fi?vre Typhoide. Annales de M?decine, Paris, 1914, ii, 443.
(47) 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, 614.
(48) Freund, Ernst: Ueber den Verlauf des Bauchtyphus bei Schutzgeimphten. Wiener Klinische Wochenschrift, Wien, 1916, xxix, No. 39, 1232.
(49) Nichols, Henry J., Maj., M. C., U. S. A.: Carriers in Infectious Diseases. Williams & Wilkins Company, Baltimore, 1922, 45.
(50) Circular Letter, chief surgeon`s office, A. E. F., 1919.
(51) 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).
(52) Nichols, H. J.; Simmons, J. S.; and Stimmel, C. O.: The Surgical Treatment of Typhoid Carriers. The Journal of the American Medical Association, Chicago, 1919, lxxiii, No. 9, 680.
(53) Henes, Edwin, jr.: The Surgical Treatment of Typhoid Carriers. The Journal of the American Medical Association, Chicago, 1920, lxxv, No. 26, 1771.
(54) 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).
(55) 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).)
(56) Circular No. 69, Office of the Chief Surgeon, A. E. F., February 17, 1919. On file, Historical Division, S. G. O.
(57) 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.
(58) 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.
(59) Hamilton, C. D.: The Effect of Typhoid Vaccination on the WidalReaction. The Journal of the American Medical Association, Chicago, 1915, lxv, No. 22,1873.
(60) Fennel, E. A.: Agglutinin Response after Army Triple TyphoidVaccination. The Journal of the American Medical Association, Chicago, 1918, lxx, No. 25,1915.
(61) Dreyer, G.; Walker, E. W. A.; and Gibson, A. G.: Typhoid and Paratyphoid Infection in Relation to Antityphoid Inoculation. The Lancet, London, 1915, i, 324.
(62) Davison, W. C.: The Superiority of Inoculation with Mixed Triple Vaccine (B. Typhosus, B, Paratyphosus A, and B, Paratyphus B). The Archives of Internal Medicine, Chicago, 1918, xxi, No. 4, 437.
(63) 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.
