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Communicable Diseases, Table of Contents

CHAPTER IX

SMALLPOX

The most important fact disclosed by an investigation of therecords of occurrence of smallpox in the United States Army during the World Waris, as might be anticipated, the demonstration on a gigantic scale, of theimportance and value of vaccination as a preventive measure. Appreciation of thevalue of vaccine virus as a preventive agent presupposes a knowledge of thehistory of smallpox and the toll of human lives it took in prevaccination days,and, for that matter, in recent times, in populations not adequately protected.For example, history tells us that all the inhabitants of Greenland died duringthe course of one epidemic and the country was not repopulated for 300 years;that in 1707 one-third of Iceland's population of 50,000 succumbed to thedisease;1 that from 1701 to 1800 an average of 1 of every 12 persons dying inLondon each year died of smallpox;2 that in 1752 during an epidemic ofsmallpox in Boston, with a population of about 10,000 people not immune tosmallpox, about 2,000 were rendered immune by inoculation with smallpox, the only method of immunization then known, approximately 2,000 fled the city, and ofthe remaining 6,000 nonimmunes more than 5,500 suffered attacks of smallpox;3 andthat in two Indian (Moqui) villages in Arizona with a total population of 900individuals, smallpox in epidemic form attacked 590 and killed 184.4 These are afew of innumerable instances that will serve to illustrate the havoc thatsmallpox has wrought.

The history of military medicine of prevaccination days isreplete with reports of epidemics of smallpox comparable in nature and severitywith the examples cited for civil populations.

When Jenner, in 1798, gave to the world the method forcontrolling and preventing this disease-vaccination-this measure graduallywas adopted by all civilized countries. With the passage of time and withadditions to scientific knowledge, it has been possible constantly to improvethe methods of preparation of the vaccine virus and to develop better and moresatisfactory methods of administration, with the result that to-day theprocurement of a potent, purified virus is, as compared with 30 years ago, asimple matter in all civilized communities.

In so far as military medicine is concerned the prevalence ofsmallpox in the French forces as compared with the German forces during theFranco-Prussian War (1870-71) offers very striking evidence of the value ofvaccination. Perhaps the most conservative and most reliable statistics of thereactive prevalence of the disease in the opposing military forces are thoserecorded in the official German Medical History of the War of 1870-71. Thesefigures are as follows:

 


Total cases

Rate per 1,000 strength

Total deaths

French Army

14,173

540

1,963

German Army

4,835

61

278

aUnless otherwise stated, all figures for the World War periodare derived from sick and wounded reports sent to the Surgeon General.-Ed.

358

General vaccination of the military forces was a matter ofcustom in the German Army at that time,5 whereas in the French Armysuch was not the case.

During the Russo-Japanese War the Japanese forces were wellvaccinated and of the million men engaged in that conflict only 362 contractedsmallpox (4 per 10,000 of strength), of which number only 35 died.6

OCCURRENCE IN THE ARMY PRIOR TO THE WORLD WAR

A brief reference to the trend of the smallpox rates in theUnited States Army during the past few decades and a comparison of itsprevalence during war periods are considered desirable and will bring moreclearly into relief the very excellent results obtained through the applicationof protective measures during the World War. The admission and death rates forwhite enlisted personnel, United States Army, 1840 to 1919, inclusive, are givenin Table 54 and shown graphically in Chart XLI.

TABLE 54.-Smallpox-Admissions and deaths, whiteenlisted men, United States Army,1840 to 1919-Rates per 1,000 of strength

Year

Admissions

Deaths


Years

Admissions

Deaths

Years

Admissions

Deaths

Years

Admissions

Deaths

1840

0.40

0

1862

4.68

1.36

1882

0.48

0.05

1901

1.27

0.30

1841

0

0

1863

4.71

1.44

1883

.14

.05

1902

1.02

.17

1842

1.70

.20

1864

8.08

3.21

1884

0

0

1903

.50

.05

1843

.30

0

1865

4.62

1.75

1885

0

0

1904

.32

.05

1844

.12

0

1866

3.37

.70

1886

.23

0

1905

.11

0

1845

.12

0

1867

1.07

.17

1887

.05

0

1906

.17

.02

1846

.55

0

1868

.84

.05

1888

.22

.04

1907

.10

0

1849a

7.22

.87

1869

1.02

.10

1889

.13

0

1908

.19

0

1850

2.23

0

1870

.93

.07

1890

.05

0

1909

.01

0

1851

1.19

.43

1871

.56

.07

1891

.33

.10

1910

.18

.01

1852

1.20

.22

1872

1.65

.25

1892

.05

0

1911

.07

0

1853

1.31

0

1873

1.58

.36

1893

.09

0

1912

.08

0

1854

2.59

0

1874

.16

.04

1894

.04

0

1913

.11

.03

1855

3.74

0

1875

.51

.05

1895

0

0

1914

.09

.01

1856

.21

.07

1876

.22

0

1896

0

0

1915

.05

0

1857

.63

0

1877

.83

.28

1897

0

0

1916

.06

0

1858

1.10

0

1878

.28

0

1898

.66

.16

1917

.21

0

1859

.90

0

1879

.78

.05

1899

3.38

.85

1918

.20

0

1860

0

0

1880

.28

0

1900

1.91

.79

1919

.07

.01

1861

3.36

.15

1881

.24

.05

 

 

 

 

 

 

aNo record for the years 1847 and 1848.

The interesting points shown in Chart XLI are two in number:First, the highest admission and death rates since 1840 occurred in 1864 duringthe Civil War, since which time the general trend of the smallpox admission anddeath rates in the Army have been downward, except for the period of theSpanish-American War and the Philippine insurrection. Second, prior to the WorldWar the Army had always experienced a sharp increase in smallpox admission anddeath rates during war periods, whereas during the World War the admission ratewas but little higher than for the years immediately preceding, and the deathrates for smallpox were essentially the same.

A somewhat more detailed analysis of the admission and deathrates during war periods discloses information of importance. The comparativeadmission and death rates for the Civil War, Spanish-American War and Philippineinsurrection, and for the World War are incorporated in Table 55.

359

CHART XLI

TABLE 55.-Smallpox-Admissions and deaths, United States Army in the Civil War, Spanish-American War, and Philippine insurrection, and the World War-Absolute numbers and ratios per 10,000

 

Total mean annual strengths


Admissions

Deaths

Case mortality


Absolute numbers

Ratios per 10,000

Absolute numbers

Ratios per 10,000 strength


CIVIL WAR

 

 

 

 

 

 

White troops May 1, 1861, to June 30, 1866

2,193,427

12,236

55.8

4,417

19.5

36.10

Colored troops July 1, 1863, to June 30, 1866

183,395

6,716

366.2

2,341

122.1

34.85


SPANISH-AMERICAN WAR AND PHILIPPINE INSURRECTION

 

 

 

 

 

 

Total Army, white and colored, 1898-1901

446,221

825

18.5

258

5.8

31.27

Army in United States, 1898-1901

212,658

126

5.9

4

.2

3.17

Army in Cuba and Porto Rico, 1898-1900

48,686

20

4.1

4

.8

20.00

Army in Philippine Islands, 1898-1901

177,542

674

38.0

249

14.0

36.94


WORLD WAR
(Apr. 1, 1917, to Dec. 31, 1919)

 

 

 

 

 

 

Entire Army

4,128,479

853

2.1

14

.03

1.64

Army in United States

2,235,389

780

3.5

1

.005

.13

Army in Europe

1,665,796

24

.1

5

.03

20.83

Army in Philippinesb

21,451

11

5.1

3

1.4

27.27

Army in other countriesc

22,620

10

4.4

3

2.1

30.00

Transports

108,033

4

.4

2

.2

50.00

Native troops, Philippine Islands

18,576

23

12.4

---

---

---

Native troops, Porto Rico

11,831

1

.8

---

---

---

aSource of information: (1) Medical and Surgical History of the War of theRebellion, Part First, Medical Volume, pp. 640 and 710. (2) Annual reports ofthe Surgeon General, 1899, 1900, 1901, 1902. (3) Statistical tables, Office ofthe Surgeon General, 1917-1919.
bIncludes troops in China. 
cNot including Hawaii, Panama, and native Hawaiians; including 8,388 officers.

360

The rates in Table 55 are based on the total of the meanannual strengths for the periods covered. The table shows a marked decrease inrates for each war period as compared with the immediately preceding war period.Based on a rate per 10,000 of strength for each war period, the rates were asfollows: Civil War (white troops) 56, Spanish-American War, 19; WorldWar, 2. During the Civil War vaccination as a protective measure was not wellcarried out for a number of reasons; and while no epidemics occurred, there wasa considerable number of sporadic cases.7 The colored enlisted menincorporated in the Union Army during the Civil War were protected only in smallmeasure by protective vaccination, with the result that the rate per 10,000 ofstrength for colored enlisted men during the period was 366 as compared with arate of 56 for white enlisted men in the same army.7

An examination into the geographical distribution of thecases of smallpox that occurred during the Spanish-American War and Philippineinsurrection is illuminating. Table 55 shows that whereas there was a total of825 admissions for smallpox during the period referred to, 674 of these casesoccurred in troops on duty in the Philippine Islands. The comparative rates per10,000 of strength were as follows: Total Army, 19; troops on duty in UnitedStates, 6; troops on duty in the Philippine Islands, 38. The high rates in thePhilippines caused the comparatively high rate for the Army as a whole duringthis period, and the high rates in the Philippine Islands were due to lack ofprotection by vaccination and inability to secure a potent vaccine virus fortroops on duty in those islands during the first year or more of the occupation.8

The first expeditionary forces sent to the Philippine Islandsduring the Spanish-American War were dispatched hurriedly, and our presentknowledge of the keeping qualities of vaccine warrants the statement that manyof the individuals when called to active service were vaccinated with an inertvirus. On arrival in the Philippines, these forces immediately came in contactwith virulent smallpox in epidemic form. It is a matter of record that under theSpanish r?gime and for a few years subsequent to American occupation more than40,000 Filipinos died each year of smallpox.9 American troopsgradually came to occupy many small and large towns throughout the islands, withconsequent intimate exposure to virulent smallpox. There was the furthercomplication that there were no adequate provisions for the production of thevirus in the Philippines, and supplies brought from the United States frequentlywere not adequately protected by cold storage en route, with the result thatthey proved to be inert when used. There was the still further complication thateven when a potent vaccine became available in Manila itself, no ice wasavailable in which to pack it for shipment to military garrisons in theProvinces. These were the factors that account for the high rate of incidence inthe early days of our occupation of the Philippines. The principal factormilitating against the protection of our forces, the nonavailablility of potentvaccine

361

virus, soon was overcome by the establishment of alaboratory, under Government supervision, for the production of the vaccinevirus. When and as such a vaccine became available the admission ratesimmediately dropped, as is shown in Chart XLI. When locally produced vaccinevirus became available steps were taken to protect the civil population, withthe result that the disease in epidemic form disappeared in the wake of thevaccinating squads. As an example of the striking influence of this protectivemeasure may be cited the fact that the deaths from smallpox in the nativepopulation in the Provinces adjacent to Manila were reduced from 6,000 annuallyto zero and in Manila itself not 1 death from smallpox was recorded for the 7years prior to 1914.9

Subsequent to 1914, as a result of relaxation inadministrative control and inefficiency and incompetency on the part ofsubordinate Filipino health officers charged with the administration of smallpoxvaccine, a large unprotected population-young children-came into being. Theresult was that in 1918 and 1919 the population of the Philippine Islandssuffered the greatest smallpox catastrophe of modern times.9 Incompletestatistics show that more than 60,000 persons died of smallpox during thisperiod and more than 90 per cent of the deaths occurred in unvaccinatedchildren.10

Notwithstanding the fact that smallpox in widespread virulentepidemic form attacked the Filipino population during the period of the WorldWar, the military forces (American and Filipino) on duty in the Philippinesduring the same period were singularly free. In a military force ofapproximately 40,000 men only 3 deaths from smallpox occurred. Reduced toapproximately comparable figures, the statement is justified that the ratio ofrecorded deaths from smallpox during the epidemic in the native population ascompared with that in the military population was as 40 is to 1. The seniorwriter of this chapter has been informed by those conversant with the situationthat, as a matter of fact, it may conservatively be estimated that 100,000Filipinos died during the course of the 1918-19 epidemic, in which case thecomparative ratio would be about 80 to 1, rather than 40 to 1.

The actual results accomplished in the prevention of smallpoxin the American military forces during the past 75 years probably can best beexpressed in the statement that for every 1 case of smallpox occurringduring the World War, 9 occurred during the Spanish-American War and Philippineinsurrection and 28 occurred during the Civil War (white enlisted men only). Thecase fatality rate during the Civil War was 39 per cent; during theSpanish-American War and Philippine insurrection, 31 per cent; and during theWorld War it dropped to the extraordinarily low figure of 1.6 per cent. (SeeTable 55.) This low mortality rate is probably accounted for in minor degree bythe fact that the type of smallpox prevailing in the United States during theWorld War was of low virulence; however, the principal factor responsible forthe low death rate was the high degree of protection afforded by vaccination.

362

TABLE 56.-Smallpox-Admissions and deaths, by countries of occurrence,officers and enlisted men, United States Army, April 1, 1917, to December 31,1919-Absolute numbers and ratios per 1,000

 

 

Total mean annual strengths


Admissions

Deaths

 


Absolute numbers

Ratios per 1,000 strength

Absolute numbers

Ratios per 1,000 strength

Total officers and enlisted men including native troops

4,128,479

853

0.21

14

0

Total officers and enlisted men American troops

4,092,457

829

.20

14

0

Total officers

206,382

11

.05

1

0

Total enlisted American troops:

 

 

 

 

 

    

White

3,599,527

612

.17

9

0

    

Colored

286,548

204

.71

2

.01

    

Color not stated

---

2

---

2

---

         

Total

3,886,075

818

.21

13

0

Total native troops enlisted

36,022

24

.67

---

---

Total Army in the United States including Alaska:

 

 

 

 

 

    

Officers

124,266

9

.07

---

---

    

White enlisted

1,965,297

573

.29

1

0

    

Colored enlisted

145,826

198

1.36

---

---

         

Total enlisted

2,111,123

771

.37

1

0

         

Total officers and men

2,235,389

780

.35

1

0

U.S. Army in Europe, excluding Russia:

 

 

 

 

 

    

Officers

73,728

1

.01

1

.01

    

White enlisted

1,469,656

16

.01

2

0

    

Colored enlisted

122,412

5

.04

---

---

    

Color not stated

---

2

---

2

---

         

Total enlisted

1,592,068

23

.01

4

0

         

Total officers and men

1,665,796

24

.01

5

0

Officers, other countries

8,388

1

.12

---

---

U.S. Army in Philippine Islands:

 

 

 

 

 

    

White enlisted

16,995

11

.65

3

.18

    

Colored enlisted

4,456

---

---

---

---

         

Total enlisted

21,451

11

.51

3

.14

U.S. Army in Hawaii:

 

 

 

 

 

    

White enlisted

16,161

---

---

---

---

    

Colored enlisted

3,319

---

---

---

---

         

Total enlisted

19,480

---

---

---

---

U.S. Army in Panama: White enlisted

19,688

---

---

---

---

U.S. Army in other countries not stated:

 

 

 

 

 

    

White enlisted

---

9

---

3

---

    

Colored enlisted

---

---

---

---

---

    

Color not stated

---

---

---

---

---

         

Total

14,232

9

.63

3

.21

Transports:

 

 

 

 

 

    

White enlisted

97,498

3

.03

---

---

    

Colored enlisted

10,535

1

.09

2

.19

    

Color not stated

---

---

---

---

---

         

Total

108,033

4

.04

2

.02

Native troops enlisted:

 

 

 

 

 

    

Philippine Scouts

18,576

23

1.24

---

---

    

Hawaiians

5,615

---

---

---

---

    

Porto Ricans

11,831

1

.08

---

---

OCCURRENCE DURING THE WORLD WAR

As stated above, smallpox played a very minor part as a cause of sickness anddeath in the United States Army during the World War. The total mean annualstrength of the Army for the period April 1, 1917, to December 31, 1919,

363

was 4,128,479, and during this period only 853 cases ofsmallpox were recorded as primary admissions. The admission rate per 1,000 ofstrength for the period was therefore 0.2, or 2 men in every 10,000. Of thosewho had the disease only 1.6 per cent died (14 deaths), and the death rateexpressed in terms of strength was only 3 deaths in every 1,000,000 men. It willbe noted that the expression "primary admissions" is used inreferring to the total number of cases. In all the basic tables presented inthis chapter the absolute numbers used will be primary admissions unlessotherwise specified. Only one disease was used in statistical tabulations, andthis was the primary admission. It occasionally happened that an individualadmitted for one disease (primary admission) contracted some other disease-forexample, smallpox-before release from hospital. This concurrent disease, orcomplication, was tabulated separately, and the tables of concurrent diseasesshow that in addition to the primary admissions (853) a total of 126 cases ofsmallpox were concurrent with other diseases, making a grand total of 979 cases(.24 per 1,000 of strength).

GEOGRAPHICAL DISTRIBUTION

The geographical distribution of smallpox during the WorldWar is shown in Table 56.

Briefly, the facts of interest disclosed by this table are asfollows, the admission ratios per 1,000 being converted into ratios per 100,000of strength that they may be expressed in whole numbers:

 

 


Admissions

Deaths

 


Absolute numbers

Ratios per 100,000

Absolute numbers

Ratios per 100,000

United States (including Alaska), American troops, commissioned and enlisted

780

35

1

0

Europe (excluding Russia), commissioned and enlisted

24

1

5

0

Philippine Islands, American troops, enlisted

11

51

3

14

Philippine Islands, Filipino troops

23

124

0

0

Hawaii, American troops, enlisted

0

0

0

0

Hawaii, Hawaiian troops

0

0

0

0

Porto Rican troops

1

8

0

0

Panama, American, enlisted

0

0

0

0

In order of importance the occurrence geographically was thePhilippine Islands, United States, Porto Rico, and Europe. As will be explainedbelow, a large proportion of the 780 cases encountered in troops in the UnitedStates occurred in nonprotected individuals reporting for duty at mobilizationcamps in the incubationary stages of the disease.

IN THE UNITED STATES

Mobilization of the military man power of the United Statesfor the World War was accomplished in large mobilization camps and theoccurrence of smallpox in 39 of the larger of these camps is tabulated in Table57. The rates per 1,000 of strength are based on the total mean annual strengthfor the period.

364

TABLE 57.-Smallpox. Admissions by camps of occurrence, white and coloredenlisted men, United States Army, April 1, 1917, to December 31, 1919. Absolutenumbers and ratios per 1,000

Camp

Total mean annual strengths


White admissions

Colored admissions

Total admissions


Absolute numbers

Ratios per 1,000 strength

Absolute numbers

Ratios per 1,000 strength

Absolute numbers

Ratios per 1,000 strength

Beauregard, La.

20,625

3

0.15

1

2.37

4

0.19

Bowie, Tex.

26,193

13

.52

---

---

13

.50

Cody, N. Mex.

22,636

3

.13

---

---

3

.13

Custer, Mich.

37,631

12

.33

6

4.43

18

.48

Devens, Mass.

47,921

1

.02

---

---

1

.02

Dix, N. J.

49,786

3

.07

1

.21

4

.08

Dodge, Iowa

39,032

39

1.17

28

4.82

67

1.72

Doniphan, Okla.

26,747

32

1.20

---

---

32

1.20

Fremont, Calif.

15,414

2

.13

---

---

2

.13

Funston, Kans.

56,222

69

1.38

20

3.24

89

1.58

Gordon, Ga.

44,871

7

.18

8

1.17

15

.33

Grant, Ill.

49,256

12

.28

14

2.02

26

.53

Greene, N. C.

29,710

6

.23

1

.28

7

.24

Greenleaf, Ga.

11,959

1

.08

---

---

1

.08

Hancock, Ga.

37,994

3

.08

---

---

3

.08

Jackson, S.C.

42,011

5

.14

---

---

5

.12

Kearny, Calif.

25,472

1

.04

---

---

1

.04

Lee, Va.

57,635

13

.25

8

1.21

21

.36

Lewis, Wash.

47,792

12

.25

---

---

12

.25

Logan, Tex.

27,734

4

.15

2

1.87

6

.22

McArthur, Tex.

25,271

10

.41

1

1.05

11

.44

McClellan, Ala.

28,664

3

.11

3

1.41

6

.21

Meade, Md.

50,033

---

---

2

.25

2

.04

Mills, N. Y.

24,197

5

.22

5

3.98

10

.41

Pike, Ark.

49,587

6

.15

44

5.05

50

1.01

Sevier, S. C.

27,786

9

.34

1

.62

10

.36

Shelby, Miss.

30,432

1

.03

6

3.63

7

.23

Sheridan, Ala.

26,507

1

.04

---

---

1

.04

Sherman, Ohio

42,750

2

.05

6

1.04

8

.19

Taylor, Ky.

46,962

19

.45

4

.91

23

.49

Travis, Tex.

44,264

19

.51

7

1.06

26

.59

Upton, N.Y.

44,871

4

.10

4

.86

8

.18

Wadsworth, S.C.

31,809

3

.10

---

---

3

.09

Wheeler, Ga.

25,726

1

.04

1

.55

2

.08

Others

339

---

---

1

2.95

1

2.95


     Total (all camps in U.S.)

1,270,068

324

.28

174

1.57

498

.39

Examination of Table 57 shows that in only four of the camps-CampsDodge, Iowa; Doniphan, Okla; Funston, Kans.; and Pike, Ark.-did the rates ofoccurrence exceed one case per 1,000 of strength. In only 10 of the remaining 35camps did the admission rate exceed 0.25 per 1,000 of strength. It is evident,therefore, that smallpox occurred only sporadically during the mobilization ofour forces. Furthermore, the historical records of the various camps andhospitals on file in the Surgeon General's Office indicate that a largeproportion of the cases arising in the camps occurred in individuals already inthe incubationary or acute stage of the disease on arrival at camp and to aconsiderable extent in individuals soon after the arrival at camp and beforeprotection could have been afforded by vaccination. The following evidence insupport of this statement has been epitomized from these historical records:

CAMP BOWIE, TEX.

Of the 13 cases occurring in this camp, no evidence could be adduced thatcontact played any part. Three recruits reported at camp in the prodromal stagesof the disease and one case was contracted through exposure while on furlough.11

365

CAMP DEVENS, MASS.

Only one case occurred at this camp and he contracted thedisease prior to induction into active service.12 The low rate atthis camp as well as at all other camps located in the northeastern section ofthe United States is a reflection of the thoroughness with which protectivevaccination is carried out in the civil communities of the States concerned.

CAMP DODGE, IOWA

A total of 67 cases occurred at this camp.13Insix instances the disease occurred in one organization and was attributed tocontact. Twenty of the cases were admitted to hospital within a period of 14days after arrival in camp, most of them having acquired the disease prior toarrival, and in 30 other instances the disease developed within less than amonth after arrival. Smallpox is known to have been unduly prevalent in theStates-Iowa, Minnesota, and Illinois-from which this camp drew its quota fortraining, and the prevalence of smallpox at Camp Dodge was merely a reflectionof the prevailing conditions in civil communities.

CAMP FUNSTON, KANS.

A total of 89 cases occurred at this camp, and the troops intraining in this camp were drawn from an area in which smallpox was known to beuncommonly prevalent in the civilian population.14

CAMP PIKE, ARK.

Of the 50 cases arising at this camp, 29 were admitted tohospital within 14 days of their arrival at camp and 1 individual reported atcamp in the eruptive stage of the disease.15The training quota forthis camp was drawn from the States of Alabama, Arkansas, Louisiana, andMississippi, and the occurrence of smallpox at Camp Pike was a reflection of theundue prevalence of smallpox in some of those States.

CAMP TAYLOR, KY.

Of the 23 cases at this camp, it is stated that 13 were inthe incubationary stage of the disease at the time of arrival at camp.16

From what has been said in preceding pages, the inference maybe drawn that the greater prevalence of smallpox in some mobilization camps, ascompared with others, was attributable to the more extensive prevalence of thedisease in certain States or groups of States than in others. In support of thisstatement a statistical analysis is offered in Table 58.

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TABLE 58.-Smallpox. Numbers of admissions and ratios per 1,000 enlistedmen (white and colored), United States Army, by States and groups of States, and comparableratios per 1,000 among the civilian population of these States and groups, April 1, 1917, toDecember 31,1919a

aSource of information: (1) Sick and wounded reportsmade to the Surgeon General, U.S. Army. (2) Public Health Reports-NotifiableDiseases, Prevalence in States, 1917, 1918, 1919. Government Printing Office,Washington, D. C.

The data in Table 58 are assembled by groups of States inconformity with the grouping adopted by the United States Bureau of the Census.It will be noted in the statistics covering the civilian population that certainStates have been omitted. The principal reason for this is that such States hadnot been admitted to the registration area and authoritative figures were notavailable. It should also be explained that the rate in the civilian populationfor each group of States is an average of those rates available for the Statescomprising the group rather than for all States comprising the group; forexample, the rates for the New England group are based on the rates for fourStates rather than six.

Analysis of this table lends adequate support to thestatement that the rate of occurrence of smallpox in military personnel inmobilization camps during the World War was dependent on its rate of occurrencein the civilian population in near-by States and was a reflection thereof. Thiscan best be appreciated by inspection of Chart XLII.

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CHART XLII.-Smallpox in the United States Armyandcivil population, April 1, 1917, to December 31, 1919. Occurrence by groups of States. Ratios per 1,000 of population

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Leake and Force,17 who reviewed the prevalence ofsmallpox in the United States during recent years (1915-1920), found that thedisease is markedly increasing in certain sections. In general, it may be saidthat the increase is occurring in the southern and central groups of States andin practically all States west of the Mississippi River. In the New England andMiddle Atlantic groups the rates are very low and have remained so for years. Inthe Pacific group, the rates are increasing rapidly. A correct interpretation ofthis condition presupposes a knowledge of the laws and customs governingpreventive vaccination in the United States. There are no Federal laws governingthis matter, the formulation and enforcement of protective measures of thisnature being left to each State. The result is that in some States the laws areeffective and well administered and there is practically no smallpox, whereas inothers they are loosely drawn or inefficiently administered, or both, with theinevitable result-increased occurrence of the disease. In New York State, forexample, the law provides that vaccination against smallpox shall constitute acondition requisite for school attendance in cities of the first and secondclass, and for other children residing in the State when smallpox is declaredepidemic by the State commissioner of health. The public health organization ofthe State is a strong one and vaccination is efficiently administered. It is notsurprising, therefore, that during the period, April, 1917, to December, 1919,the reported incidence rate for smallpox was only 14 cases in every 100,000 ofpopulation. On the contrary, the vaccination laws in the State of Kansas aremost ineffective, and it occasions no surprise to learn that the reported rateof incidence for that State for the same period (April, 1917, to December,1919), was 158 cases in every 100,000 of population. In the State of Indiana,for example, it is lawful for health officers to order compulsory vaccination ofschool children upon pain of exclusion from school for noncompliance. TheIndiana State Board of Health, however, advises its health officers to be verychary in issuing such orders on account of the opposition exhibited by thecitizens of the State. The reported smallpox morbidity rate for Indiana for theperiod under discussion (April, 1917, to December, 1919), was 40 per 100,000population.18

IN EUROPE (RUSSIA EXCEPTED)

During the period, April, 1917, to December, 1919, there were24 primary admissions for smallpox in the American forces in Europe, with 5deaths. The admission rate was 1 in every 100,000 of strength. The cases were ofsporadic occurrence except for 5 cases arising in January and February, 1919, inBase Hospital No. 103, at Dijon, France.19 The original of this smallgroup of cases was an enlisted man of Company K, 52d Infantry, admitted tohospital with what at first appeared to be chicken-pox. A correct diagnosis wasnot arrived at until a short time prior to the death of the individual, when aconfluent hemorrhagic eruption appeared. As a result of contact with theoriginal case, a nurse and three attendants developed smallpox. The nurse hadthe disease in highly virulent form and died; the three enlisted attendantsrecovered. As soon as the true condition was recognized, all military personnelin Dijon were revaccinated with a fresh "green" vaccine virus obtainedfrom Paris, and no further cases arose. In the interim between admission of thecase to

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hospital and final diagnosis of smallpox no revaccinationswere carried out, and the three individuals who later contracted the diseasethrough exposure had not therefore been revaccinated. The important lesson to bededuced is that in all cases suggestive of a diagnosis of smallpox it is wise toconsider them as such, at least administratively, and to revaccinate all personsexposed.

IN THE PHILIPPINE ISLANDS

The comparatively high admission rate in the PhilippineIslands, as has been explained in previous pages, coincided with a devastatingepidemic of virulent smallpox in the native population of the PhilippineIslands. Though 34 cases of smallpox occurred in approximately 40,000 Americanand Filipino troops in the Philippine Islands, the influence of protectivevaccination is evidenced in the fact that only 3 of these cases resulted indeath.

IN OTHER COUNTRIES WHERE OUR TROOPS SERVED

No cases occurred in Hawaii. Among the Porto Rican troops, 1case occurred and the individual recovered. In Panama, there were no cases. InSiberia, 9 cases, with 3 deaths, occurred among our expeditionary forces there.

IN THE ALLIED ARMIES AND IN THE MILITARY FORCES OF GERMANY AND AUSTRO-HUNGARY

An effort was made to secure information as to the occurrenceof smallpox in the military forces of all the European nations (Russia excepted)engaged in the World War. Though incomplete, the information obtained is ofsufficient importance to warrant its inclusion here.

FRENCH ARMY

During the four years of the war only 28 cases of smallpoxoccurred in the French Army, and among French colonial troops 44 cases werereported, with 4 deaths.20 Vaccination was a compulsory measure inthe French Army and it is understood that a "green," rather than a"ripe," glycerinated vaccine was used. Vaccines of the"green" type, though containing more pyogenic organisms, areundoubtedly more potent, and this doubtless accounts for the exceptional freedomof the French forces from smallpox.

BRITISH ARMY

British forces serving in France were exceptionally free ofsmallpox.21 During 1914 and 1915 no cases were reported; during 1916,4 cases; 1917, 2 cases; and in 1918, 6 cases, with 3 deaths. Prior to 1914, theBritish Army was well protected by vaccination. In January, 1916, the ArmyCouncil issued instructions authorizing the enlistment of men who refusedvaccination ("conscientious objectors"). The promulgation of theseinstructions resulted in the dissemination of a considerable number of these"conscientious objectors" throughout various commands in thedifferent theaters of war. These nonimmunes created no trouble in France, as allthe armies operating on the Western Front were well protected, as was also thecase with the population of France

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in general. In the Near East, however, conditions were quitedifferent, smallpox prevailed in the civil populations, supplies of potentvaccine were difficult to obtain, and very considerable numbers of nonimmunemilitary personnel were incorporated in the various commands. It is notsurprising, therefore, that difficulty was encountered with smallpox. Thedisease appeared in the forces in Mesopotamia, and gradually spread, with theresult that 1,908 cases were reported between December, 1916, and October, 1918.Great difficulty was encountered in stamping out the disease because of theconsiderable numbers of military nonimmunes, the impossibility of makingvaccination compulsory, the widespread prevalence of smallpox in the civilpopulation, and the inability to secure adequate supplies of a potent vaccinevirus. As a matter of fact, the epidemic was only finally brought under controlby the establishment of a vaccine-producing laboratory on the ground. In tworegiments with a combined strength of 1,749 men there were 204 men unprotectedby vaccination. In the unprotected group 25 cases of smallpox (123 per 1,000)occurred, with 5 deaths (20 per cent), whereas in the remaining protected groupthere were only 5 cases (3 per 1,000), with no deaths. During the period March31, 1918, to March 29, 1919, 1,068 cases were reported in Mesopotamia with thefollowing death rates:21

 


Admissions

Deaths

Mortality (per cent)

British troops

516

86

17

Indian

552

56

10

The records of protective vaccination in these groupsindicate that the admission and death rate in the unprotected group was fargreater than in the protected group. The matter is summed up in the followingwords:21

The lessons taught by the war on the subject of smallpoxstand out clearly. If compulsory vaccination is not permitted, and menunprotected from smallpox by vaccination are sent to a war area where thedisease is endemic, a sharp epidemic may flare up, as happened in the FrenchArmy during 1870-71. It was unfortunate that in Mesopotamia the one greatessential in combating smallpox was denied to the medical services, namely,compulsory vaccination. If similar conditions should occur in future campaigns,the authorities concerned should realize how great a source of weakness must bepresent in the event of a smallpox endemic area becoming a theater of war.Attention should be devoted to the training of all medical officers in thediagnosis of the disease and the operation of vaccination. Further research inlymph suitable for a hot country is required. Careful plans for the properdistribution of lymph are essential, and the medical arrangements of a forcewill not be complete without adequate means for distributing the lymph inthermos flasks or other suitable containers. If resistance is to be offeredagainst a severe outbreak, well-equipped isolation hospitals with modern andeffective methods for disinfection will also be necessary.

BELGIAN ARMY

No cases were reported in the Belgian Army.22

ITALIAN ARMY

In the Italian Army 695 cases of smallpox were reported(1915, 79 cases; 1916, 148 cases; 1917, 139 cases; 1918, 329 cases).23 Militaryregulations provided for compulsory vaccination. No information is available asto the

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thoroughness with which the regulations were complied withnor as to distribution of cases with respect to the vaccinated and thenonvaccinated status of the personnel.

GERMAN ARMY

During the four years of the European war there were reportedin the German military forces 434 cases of smallpox, with a case mortality rateof approximately 5 per cent.5 This speaks well for the thoroughnesswith which vaccination was carried out in the German Army, as their forces wereexposed to smallpox both on the Russian front and in the Balkan States.

AUSTRO-HUNGARIAN ARMY

Vaccination was not effectively carried out in theAustro-Hungarian Army, particularly as regards those forces serving in Galicia;as a consequence 25,000 cases had been reported by the end of 1915, and during1916 an additional 18,000 cases were reported.24 DoctorMorawetz,Vienna, who was in charge of a large smallpox hospital during the war, in apersonal communication, has furnished the following information relative tosmallpox in the Austro-Hungarian Army:24

Smallpox was a rare disease in the army before the war, andwas only occasionally seen among civilians in Vienna. Although in the absence ofepidemics, vaccination was not strictly compulsory, it was customary amongcivilians, and a high percentage of immunes were thus created. However, thiswas not universally true in Galicia, where vaccination was not carried out tothe same degree and many persons were susceptible to the disease. During thewar, vaccination became careless and many children were not protected. It wascompulsory in the army, but as time went on the supply of lymph becameinadequate on account of the scarcity of animals, and it was not uncommon tofind many men in the service without vaccination scars. There are no statisticsavailable to show occurrence of smallpox, either in the army or in the countryas a whole. Such records have been misplaced or destroyed. However, for Vienna,the first case was reported in October, 1914, a soldier returning from thebattle fields of Russia, where smallpox was prevalent. This case was followed bythree others among soldiers. From that time, there was a rapid increase in thenumber of cases, and during the last three months of 1914, 112 cases wererecorded. During the following year, 1915, 1,566 cases were reported, afterwhich there was a decrease. In 1914, 7.4 per cent of the cases reported wereamong the military population; in 1915, 4.2 per cent; in 1916, 39.9 per cent;and in 1917, 64 per cent. In the civil population, the occurrence was chieflyamong babies or children under the school age. The disease was brought undercontrol by compulsory vaccination; but following the conclusion of hostilities,there was an increase due largely to fugitives from Poland.

RACIAL DISTRIBUTION, AMERICAN TROOPS (WHITE AND COLORED)

The detailed statistics showing prevalence of smallpox in ourwhite and colored enlisted men are in Table 56. The rate for colored enlistedmen was considerably higher than for white enlisted men, both in the UnitedStates and in Europe; admission rates for the Army as a whole having been 17cases per 100,000 of strength for white, as compared with 71 per 100,000 forcolored enlisted men. Vaccination for the colored population of the UnitedStates is not so complete as for the white population, and this accounts for thecomparatively high rates in the colored group.

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RELATIONSHIP OF SMALLPOX TO LENGTH OF SERVICE AND TO PREVIOUS VACCINATION

In previous pages it has been stated that a large proportionof the smallpox occurring in mobilization camps in the United States was notchargeable to the Army, but was traceable rather to exposure in civilcommunities just prior to reporting at camps.

Prior to the World War, Army Regulations provided thatcertain data relative to all cases of smallpox in military personnel were to bereported to the Surgeon General of the Army, and these regulations werecontinued in force during the war. The data to be reported are shown on thefollowing form:

INFORMATION DESIRED BY OFFICE OF THE SURGEON GENERAL IN CASESOF SMALLPOX AND SUSPECTED SMALLPOX

1. Name of patient:
2. Rank and organization:
3. Date of enlistment:                            Where mustered in:
4. Age:
5. Last station and date of joining present station:
6. Date taken sick:                                Where:
7. Date admitted to sick report:             Where:
    By whom:
8. Has patient been vaccinated against smallpox? If so, givedates and names of places where administered (from records available, consultservice record); also the result-i. e., immune reaction, vaccinoid, vaccinia,or unsuccessful. (See F. 81 M. D.: "The immune reaction appears as anareola after 24 hours and disappears in 72 hours. In a case of vaccinoid thereis a small pustule which appears and disappears more quickly than in vaccinia.These reactions are evidence of protection. The term "protected" willnot be used.)
9. Soldier's statement regarding vaccination, whereobtainable:
10. Medical history of present attack (to accompany onregular form):
11. Whether cases of smallpox exist in the post orneighborhood among soldiers or civilians:
12. Diagnosis:
13. Remarks:
Date - - - - - - - - - - - - - - - - - - -
Station - - - - - - - - - - - - - - - - - -

Signed - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

It was possible to analyze 422 of these reports pertaining tothe World War, from the viewpoint of the interval between the date of reportingat camps and the appearance of symptoms of smallpox, the following informationbeing obtained:

 


Interval between date of reporting at camps and appearance of symptoms of smallpox


Number of cases


Per cent of total

 

Active smallpox on arrival at camp

 

2

1

 

1 to 3 days after inoculation

 

69

16

 

4 to 14 days after inoculation

 

82

19

 

15 to 30 days after inoculation

 

88

21

 

1 to 3 months after inoculation 

 

50

12

 

3 to 12 months after inoculation

 

93

22

 

More than 1 year after inoculation

 

6

1

Time interval unknown

32

 

8

 

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In this analysis of the special reports on smallpox it willbe noted that two of the cases arrived at camp with smallpox. These specialreports, however, cover only about one-half of the cases that occurred duringthe World War, and unfortunately include only a small percentage of such cases,for the historical records of the various camps of mobilization indicate that avery considerable number of men had smallpox on arrival at camp. Thus atJefferson Barracks there were 4; Camp Pike, 14; Columbus Barracks, 5; CampFunston, 9; Camp Dodge, 14; Camp Lee, 31; Camp Taylor, 13; Camp Sherman, 2; CampTravis, 3; Fort Thomas, 15; Camp Upton, 2.

Since the incubation period of smallpox is usually 14 days,and 153, or 36 per cent, of the above group of 422 cases came down with smallpoxwithin 14 days of their arrival at mobilization camps, it may be stated verydefinitely that somewhat more than one-third of the individuals of the groupcontracted the disease prior to their entry into the service. Only sixindividuals (1 per cent of the total in this group) with more than one year ofservice contracted smallpox. More adequate protection, as a result ofrevaccinations, accounts for the freedom from smallpox of the group ofindividuals with service in excess of one year. Three per cent of the casesoccurred in Medical Department personnel nursing cases of smallpox.

PREVENTIVE MEASURES

VACCINATION

Needless to say, the principal, and for practical purposesthe only, measure on which the United States Army has relied for the preventionof smallpox is vaccination.

For many years prior to the World War a considerable numberof manufacturers of biological products were engaged in the manufacture ofvaccine virus, the methods of manufacture being regulated by and under thesupervision of the United States Public Health Service. The United States Armyhas never produced its vaccine virus, but has obtained all such products fromfirms accredited by the United States Public Health Service.

The following regulations governed the administration ofvaccine virus to military personnel during the World War:25

34. Smallpox.-Any case of smallpox occurringamong persons subject to military control will be isolated, and contacts notprotected by recent successful vaccination will be revaccinated.

35. Vaccination.-Vaccination being recognized as aneffective means of preventing smallpox, all recruits upon enlistment and allsoldiers upon reenlistment will be vaccinated. When the first vaccination of arecruit is ineffective, it will be repeated at the end of eight days.

All the personnel of a military command, station, ortransport, including civilians connected therewith, will be vaccinated when inthe opinion of the medical officers responsible for sanitation it is necessaryas a means of protection against smallpox. Civilians refusing to be vaccinatedwhen so directed by proper authority may be excluded from the militaryreservation or station.

Officers should be vaccinated at least once in a period ofseven years. Troops under orders to perform overseas journeys or field servicewill be inspected by the responsible medical officer with respect to theirprotection against smallpox, and those who in his opinion require it will bevaccinated.

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Technique.-The skin of the selected site must be clean.Washing with warm water, followed by alcohol, is usually sufficient, the alcoholbeing permitted to evaporate before proceeding. Scrubbing with soap and water isnecessary for a dirty skin, but needless irritation of the skin is to beavoided.

The procedure, described as follows, is preferable to"scarification," which will no longer be used:

Incision is the method of choice, and should be made with thepoint of a sterile needle, producing a "scratch." A sterile scalpelmay be used, but is more likely to cause bleeding. The incision or scratchshould preferably not draw blood. There should be at least two incisions,three-quarters of an inch long and one inch apart; after exposure to smallpoxfour incisions will be made. The virus is then placed upon the abraded surfaceand gently rubbed in, unnecessary irritation being avoided.

The wound is allowed to dry thoroughly and can be leftwithout dressing, though several layers of gauze may be applied with adhesiveplaster. Any dressing that retains heat and moisture is bad. Shields will nolonger be issued.

A number of different methods of administering vaccine viruswere subjected to trial by individual medical officers during the World War,the purpose being to develop a more satisfactory technique, to increase thepercentage of positive reactions, and to reduce complicating pyogenicinfections.

Two of the most promising methods subjected to trial andresults obtained are summarized below.

De Lanney,26 at Fort Crook, Nebr., reported as follows on amultiple puncture technique used by him in vaccinating 508 soldiers.

I have maintained for a number of years that the Americanmethod of vaccination was defective in its technique because of the variety oflocal results, some of which are very severe. Nor could they all be due toindividual susceptibility, because bad arms often occurred in thosepreviously vaccinated; neither could they be blamed to the operator because, no matter how careful he was, bad arms were sure to follow. Shields andprotectors were often to blame, but bad arms would occur where nothing in theway of protection had been used. What, then, was the cause of those large,sloughing, painful sores with their necrotic cores and sharply defined edges,which later filled up with redundant granulation and still later became glazedover instead of covered with normal epithelium?

During a smallpox epidemic, I had, as city physician to anindustrial city, to have about 4,000 laborers vaccinated. The best virusprocurable was used and the strictest precaution was practiced, but, in spite ofall, a large number of very sore arms developed, with resultant suffering andloss of time to laboring men who could least afford it.

It was noticed that a large number of men of foreign birthhad well-formed scars on their arms, and it was learned from them that theynearly all had been vaccinated from scabs removed from another person's arm,as is still the practice in some communities. It was also noticed that when"scab vaccination" had been used, a larger number of places on thearms had been vaccinated, often as many as five or six to each arm. The questionthen came up: Does not the number of vaccination incisions play animportant part in determining the severity of the local reaction? Followingthese observations, I then proceeded to experiment with multiple vaccination,but the epidemic having been controlled and nearly every one being vaccinated,no large number of unvaccinated could be gotten together for vaccination,observation, and tabulation of results; but from the few that we were able toobserve it seemed that the reaction was very much less severe, and that fewersore arms resulted from the multiple vaccination than in the single ones.

During the mobilization of the National Guardin 1916, Itried again to confirm what had then become a conviction, but the hurry,incident to rapid mobilization, did not permit of statistical report.

In the February 10, 1917, British Medical Journal, Capt.H. W. Hill, D. P. H., described a method of vaccination by the subdermal method,and an opportunity to try it out came when 520 truck company personnel came toFort Crook, to be equipped and prepared for

375

oversea service. I then had an opportunity to try out thespeed with which this method could be used, an essential point when a largenumber has to be vaccinated, also the percentage of primary and secondary"takes" and the results, both local and systemic. These results aretabulated below, and justified statistically our previous conviction, thatmultiple affords far less local reaction than single vaccination and that thediffusion of the area of inflammatory reaction prevents local death of tissue.


Number of men vaccinated

Not previously vaccinated

Previously vaccinated

Number of men vaccinated

Not previously vaccinated

Previously vaccinated

508

116

387

Successful, per cent

85

28

Successful

99

109

Unsuccessful, per cent

15

72

Unsuccessful

17

278

Number of dressings required

1

0

Had smallpox

3

2

 

The time actually consumed in vaccinating each man was about15seconds; there was no time lost in waiting for arms to dry, no aftertreatment, and in no case was any man excused from duty for more than threedays. The method was practically that described by Hill, which I here copy:

(1) The sleeve is rolled up. (2) Orderly 1 washesthe arm with soap and water. (3) Orderly 2 washes the arm with rectified spirit.(4) Orderly 3 washes the arm with ether. (5) Orderly 4 breaks the capillary tube of glycerinizedvaccine, and sets the rubber bulb or other method of expelling contents, handingit to orderly 5. (6) Orderly 5 expels the vaccine at three or four points on thearm in a triangle or square having not less than 2 inches between the points.(7) Orderly 6 sterilizes an ordinary sewing needle, and hands it to the medicalofficer. (8) Medicial officer punctures the arm through the drops of vaccine;six tiny punctures, drawing no blood, are made through each drop, each set ofsix occupying a space of not more than one-sixth inch square; the needle isheld almost parallel to the surface; not over one one-thousandth of an inchenters the epithelial layer, a peculiar little "snick" being felt asthe needle goes in. (9) Orderly 7 wipes the vaccine. (10) The sleeve is pulleddown.

The only difference in the technique I used was, that allthe needles were mounted on a handle, either a hemostat or pushed intopenholders, to facilitate handling. This was found a great help, for when theneedle was held in the fingers alone they became very tired and the needle hardto hold.

Of the 508 men vaccinated, not one had a bad arm. There wasredness and swelling, differing in degree with each case, but no suppuration orlarge scabs or large area of necrosis. One case had to be dressed once becauseof multipustular vaccinia around the points of vaccination. These pustulesresembled confluent smallpox, and covered the outer surface of about half thearm, but they soon dried without bad results. In previously vaccinated cases atypical local reaction resembling a von Pirquet reaction appeared at the side ofpuncture, usually accompanied by itching which subsided in a few hours; this wasnot an indication that the vaccination was or was not going to "take."

That which is hard to explain is the great variation inthenumber of successful points of vaccination in different arms; in some cases allfour took, in others three, two, or one- this in both primary and secondarycases. It was noticed, however, that the relative number increased in theunvaccinated, while in those with only one "take" it was always a veryweak "pock," with very little systemic reaction, as though theindividual had a relative high degree of immunity.

The vaccinial "pocks" were typically umbilicated,and dried up in 15 to 20 days in the form of hard black buttons which readilydropped off, leaving a typically vaccinial scar.

*    *    *   *     *    *    *

It would seem from observation of this series thatthemethod described by Hill has many advantages: (1) It protects the arm fromexternal infection, for as soon as the arm is wiped off the punctures arepractically sealed; this also obviates the necessity of waiting for the arm todry or to be dressed. (2) The numerous vaccination points diffuse the area ofinflammation over a large surface, thus preventing the formation of a necroticcenter, as in the single method, at the same time increasing the percentage of"takes." (3) It is painless and

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bloodless. (4) It is rapid enough for any requirement. Thesaving in suffering, time, bandages, and dressing by this method will beappreciated by those who have had an opportunity to compare this with othermethods now used, or who have had to spend whole mornings dressing suppuratingarms.

The puncture method of vaccination used by De Lanney anddescribed by Hill27 was tested on 500 individuals at the Army MedicalSchool, Washington, D. C., during the fall of 1917, and the medical officersmaking the test were very favorably impressed with the results obtained.28 Theprincipal advantages were that the vaccination could be more expeditiously donethan by the method of linear incision (routine Army method) and the further factthat no dressings or after treatment of any nature were necessary.

The intradermal method of vaccination gave most excellentresults as carried out by Wright,29 at Camp Upton, N. Y. He reportedon this method, in part, as follows:

Importance of successful vaccination -To-daytheimportance of the successful vaccination and revaccination of troops isappreciated by the medical officers of all armies. In the 367th Infantry, withwhich regiment I am serving, the regimental medical officers found large numbersof men on whom repeated revaccinations, and in many cases primary vaccinations,by the prescribed incision method gave negative results. The questionimmediately arose as to whether or not these men were immune to smallpox.According to their histories, very few of them had ever had smallpox, while armexaminations for vaccination scars showed that the majority of them had beensuccessfully vaccinated in civil life-in most cases from 10 to 15 yearspreviously. Some were found who had never been successfully vaccinatedagainst smallpox and had never been through an attack of the disease. Therefore,it seemed reasonably clear that most of them were not immune, and that thosewho were immune possessed only partial immunity. At the same time it wasevident that their failure to give "takes" was not due to the virusused, because with it we were daily getting a large number of"takes" on other men. Then it occurred to me that intracutaneousinjections of vaccine virus might prove to be a more satisfactory method ofvirus transference than the one that we were using; therefore it was forthe purpose of reducing to a minimum the number of unsuccessful vaccinations inthe regiment that this work was undertaken.

The method used was as follows: Virus treated with aglycerol-phenol solution was used. The composition of the glycerol-phenolsolution was: Phenol (carbolic acid), 1 part; glycerin, 49 parts; and water, 50parts. The virus was diluted with equal parts of sterile distilled waterimmediately before using, although in a few of the first cases undiluted viruswas used. Dilution of the virus was made solely to avoid waste, because I soondiscovered that the diluted virus gave just as good results as the undiluted;and sterile distilled water was used for dilution instead of glycerin because itwas feared that further dilution with glycerin might cause too muchattenuation of the virus. One-tenth cubic centimeter of the diluted virus wasinjected intradermally by means of a sterile tuberculin syringe and a relativelyfine needle, which was also sterile. I used needles size 26 according to theEnglish standard wire gauge No. 189. The site of injection was the skin areacovering the insertion of the deltoid muscle. In some of the cases only oneinsertions was made, but in most of the cases two injections were made, onebeing separated from the other by a distance of about 1 inch. Two injections arepreferred because of the larger area of vesicle formation that results, therebyaffording one a better sense of protection, if not actual protection. Controlvaccinations by the incision method, as described above, were made on all menvaccinated by the intradermal method; they were made on the same arm, on thesame day, and the same virus was used in the two methods. Control injections ofthe virus-free glycerol-phenol solution, of exactly the same percentagecomposition as the fluid medium in which the virus was preserved and as shownabove, were made on 60 of the men who volunteered. Two-tenths cubic centimeterof this solution was used for each injection, which was also made intradermally.

Results.-Intradermal vaccinations and controls by theincision method were carried out on a total of 227 men. All of these men duringthe preceding four months had been

377

unsuccessfully vaccinated by the incision method a number oftimes, the number varying from two to eight. ''Takes'' were obtained in160, or 70.48 per cent of the cases by the intradermal method, whereas"takes" were obtained in only 19, or 8.3 per cent of the same cases bythe incision method. All of the 19 cases that showed a "take" by theincision method also showed a "take" by the intradermal method. Therewere 67 cases that failed to show a "take" by the intradermal method;in all but 4 of these cases, however, the vaccination site showed either an"immunity reaction" or "vaccinoid." The "immunityreaction" occurred in most instances. The 208 cases that did notgive a "take" by the incision method exhibited "immunityreactions" and "vaccinoids" in but few instances.

In Table 1 the number of unsuccessful vaccinations by theincision method during the past four months is detailed as well as the resultsobtained by myself with both methods.

TABLE 1.-Unsuccessful vaccinations by incision method, and results with incision and intradermal methods

Number of times unsuccessfully vaccinated in Army


Total number vaccinated

"Takes,"
 intradermal method

"Takes," incision method

Unsuccessful intradermal method

Unsuccessful incision method

1

6

6

0

0

6

2

34

23

2

11

32

3

68

51

8

17

60

4

44

31

3

13

41

5

44

29

3

15

41

6

17

12

1

5

16

7

12

7

1

5

11

8

2

1

1

1

1

     


     Total

227

160

19

67

208

Table 2 shows the results obtained in the case ofmen whohad never been successfully vaccinated in their lives, as compared with theresults obtained on men who had been successfully vaccinated at some time priorto their entry into the military service.

TABLE 2.-Results according to success of previousvaccinations

 

Total


Intradermal "takes"

Incision "takes"

Intradermal unsuccessful

Incision unsuccessful

Men never successfully vaccinated before

50

44

9

8

43

Men successfully vaccinated before

175

116

10

59

165

Of the 8 men who had never been successfully vaccinated, andwhose results by the intradermal method were unsuccessful, it was found byinquiry into their histories that 7 had had smallpox, 3 of them having had itfive years before, 1 one year before, 1 four years before, 1 eight yearsbefore, and 1 eighteen years before. Of the 59 unsuccessful cases by theincision method in this same group, a history of smallpox was obtained in onlyseven instances.

The course of the eruption as it occurs in primaryvaccination by the intradermal method is similar in every way to the course asit occurs by all other methods except for the arrangement of the vesicles, whichform a circle around the site of virus deposition. The vesicles appear, as arule, on the sixth day and become pustules on the seventh or eighth day. Thevesicles are multicolor. The center of the circle of vesicles is depressed andshows early scab formation. On the eighth or ninth day the circle reaches itsmaximum diameter, at which time it measures from 0.5 to 1.4 centimeters. Afterthe ninth or tenth day the vesicles begin to dry up, and at the end of from 12 to 14days the vaccinated area is marked by a dark brown scabthat is sharply circular in outline. This scab falls off in from 18 to 24 daysand leaves a sharply circumscribed reddish, circular depressed scar, which mayor may not show foveation.

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In revaccination "takes" by the intradermal methodthe vesicles become pustules on the sixth or seventh day, and the size of thecircle of vesicles is smaller-their maximum diameters measuring from 0.4 to0.9 centimeter-than the size circles obtained in the primary vaccinationcases.

One circle of vesicles surrounds each site of virusinjection.

It is seen that the circular arrangement of the vesiclesaround the site of virus injection is a constant and characteristic feature ofthe method, and is the only difference to be noted. The virus produced evidenceof its activity by vesicle formation only at points where the skin layers werebut slightly separated, which explains the circular arrangement of the vesicles;the actual site of virus deposition is marked by the dark depressedcentral scab, which is due to the local necrosis produced by the mechanical andchemical injury to the skin at that point.

In none of these cases did any infection occur, and the localreactions in the severest cases were relatively mild as compared with the severereactions that so often follow vaccination by the incision method.

In the cases of primary vaccination with no history ofsmallpox, the circle of vesicles was the same size in practically all of thecases, measuring approximately 1 centimeter in diameter. In the cases with ahistory of smallpox, and also in the revaccination cases, the size of the circleor area of vesiculation varied in a most remarkable way according to the timethat had elapsed since the attack of smallpox or the previous vaccination; themore recent the smallpox attack or revaccination, the smaller the circle ofvesicles-a result that is not at all surprising because in all of these casesexactly the same amount of virus was introduced, and it seems only reasonablethat the size of the area of vesiculation should vary in direct proportion tothe immunity against smallpox that the person vaccinated possesses.

With this method it is possible to deposit a definite amountof virus of known strength in each instance; and after having observedthat a definite relationship exists between the size of the reaction area andthe immunity to smallpox the injected person possesses as shown by hishistory, I am convinced that intradermal injections of vaccine virus will proveto be a most satisfactory and reliable method for the estimation of the relativeimmunity of individuals to smallpox, if a sufficient number of observations aremade.

The arms of the 60 men on whom control injections of 0.2cubic centimeter of the glycerol-phenol solution were made showed at the end of24 hours a small area of erythema, measuring about 2 millimeters in diameter;while at the end of 48 hours all traces had disappeared. It isapparently clear, therefore, that the results obtained were due not to theirritant action of the glycerol-phenol solution on the skin, but rather to theactivity of the virus itself, and also that pressure necrosis is not to beconsidered a factor in their production.

The amount of time required for vaccinating a large number ofmen by this method is slightly less than the amount required for vaccinating thesame number by the incision.

The only disadvantage of the method is the relatively largeamountof virus used in comparison with other methods. With 1 cubic centimeter ofvirus it is possible to vaccinate from 16 to 20 persons, while by most othermethods 1 cubic centimeter is a sufficient amount of virus for 40 or 50vaccinations.

It is evident that Wright attributed a large proportion offailures, or unsuccessful vaccinations, to the routine technique used throughoutthe Army. There is, however, ample justification for the statement that in sofar as the Army as a whole was concerned many of the failures were attributableto other factors, the most important of which doubtless was nonpotent, or weaklypotent, virus. The virus routinely used in the Army was a "ripe"glycerinated virus, and whereas such virus will retain its potency for aconsiderable length of time if kept in cold storage at low temperatures, itloses it more or less rapidly when exposed to the high atmospheric temperaturesthat prevail in this country during the summer months. Producers of vaccinevirus will not guarantee the potency of their glycerinated products if exposedfor any length of time to atmospheric temperatures during the hot summer months.The methods of

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handling and storing vaccine virus at mobilization campsduring the World War were not always ideal; there is no doubt, therefore, thatmuch of the vaccine virus was nonpotent, or only slightly potent, at the timeit was actually used. This factor accounts to a considerable extent for thefailures obtained.

That the linear incision technique of itself fails to accountfor a considerable proportion of unsuccessful vaccinations was clearly shownduring the course of a small outbreak of smallpox at Dijon, France, in Januaryand February, 1919, referred to above. The technique followed in revaccinationwas the linear incision method described on page 374. Notwithstanding the factthat all personnel presumably had been protected by vaccination or revaccinationprior to departure from the United States, a large percentage of the personnelrevaccinated gave positive reactions (vaccinia or vaccinoid). A few hours afterrevaccination a considerable number of the vaccinated individuals noted a mildinflammatory reaction apparently due to a staphylococcus infection. Thissubsided and the virus reaction appeared on the fourth to sixth day.Bacteriological examination of the vaccine showed numerous staphylococci, and alaboratory specialist was sent to Paris to inspect the institute from which thevaccine was being obtained. The following pertinent information is abstractedfrom the report of the inspecting officer:30

The smallpox vaccine purchased in France for use by theAmerican Army is prepared at the Institute de Vaccine Animale, 8 Rue Ballu,Paris. * * *

The Institute de Vaccine Animale is over 50 years old andvaccinia virus is its sole product. This institute is at present the only oneof its kind in Paris, though there are several other laboratories for theproduction of the virus in France.

The institute was strikingly clean in all particulars. On theground floor, in addition to offices and reception room, there is an open courtfor receiving animals and supplies. This court was in excellentcondition. Off to one side from the court was the stable with eight cows. Thestables are well lighted by natural and artificial light. The construction wassuch as to permit complete and thorough flushing of the walls and floor. Theanimals were clean. They had been inoculated and only the belly of each wasused. The inoculated areas of the animals were excellently protected from dustand dirt.

Only animals free from tuberculosis, as proved by rigidtuberculin tests, are brought to the institute. They are also quarantined toassure the absence of other diseases. After collection of the virus, theanimals are kept for some days to insure the absence of any other disease,then killed and a careful post-mortem examination made.

The second floor of the institute is the laboratory proper,and here grinding of the pulp is done. The apparatus for this purpose is such asto exclude air during the process. A 50 per cent glycerin is used with such anamount of pulp as to give a final dilution of about 40 per cent glycerin in thevirus ready for use. Great reliance is placed on the germicidal properties ofglycerin, as proved by tests. As a routine, no bacteriological examinations aremade, for the absence of dangerous organisms is accepted, as shown by numeroustests in the past.

The vaccine is ready for use after the following tests:First, the autopsy; second, the test on rabbits for virulence, by inoculation ofthe entire shaven backs with a dilution of 1 to 1,000 dilution of the virus.This inoculation must give a confluent cowpox; third, tests on the uninoculatedhuman must give 100 per cent of "takes." No attempt is made to rid thevaccine of all but spore-bearing bacteria. It is accepted that bacteria arepresent in large quantities in the pustules of cowpox, and the director insiststhat an attempt to ripen the vaccine to such a point would render the vaccinevirus itself relatively inactive, and to such a degree as to make the vaccine oflittle value.

The vaccine, therefore, is not a "ripe virus." Onthe other hand, inasmuch as glycerin is used, it is not a green virus.It may be described as partially ripened by the addition of glycerin.

380

The director of the institute lays great stress on the actualresults, on the complete absence of accidents in the vaccination of millions ofFrench soldiers and civilians, on the fact that 40 per cent of vaccinations inthe French Army during the great war resulted in "takes," and,finally, on the fact that only 10 cases of smallpox occurred during the sameperiod and these of a mild type.

The following figures on the vaccination of 108 individualsat the central Medical Department laboratory are recorded: The figures aresmall, but these individuals had all been vaccinated within the past two yearsand none with positive results. Out of these 108 vaccinations, 18.5 per centgave a normal positive "take" (vaccinia); 26 per cent additional gavea modified positive "take" (vaccinoid).

Vaccination against smallpox as practiced in the UnitedStates Army during the World War was highly successful as a preventive measure,as has been pointed out in preceding pages.

We should not be content, however, with the extraordinarilygood results obtained but should strive rather to eliminate the diseasealtogether. In so far as the military service is concerned an approach to thisideal is contingent primarily on two factors: The development of a vaccine virusthat will retain its potency for a considerable length of time after exposure tocontinuously high atmospheric temperature, and perfection of a vaccinationtechnique that will assure a higher percentage of positive results.

DISCHARGES FOR DISABILITY RESULTING FROM VACCINATION

The basic tables in the statistical volume of this history(Vol. XV, Part II, Table 50, p. 166) indicate that four men were discharged as aresult of vaccination against smallpox. The clinical records of these caseshave been reviewed and the following pertinent information is made of record toprevent misrepresentation. Of the four individuals presumably discharged onaccount of disability resulting from vaccination, one was discharged in Europeand three in the United States. One of the four cases was complicated byerysipelas, the end result of which was a peripheral nerve paralysis, and it wasfor the latter condition that discharge was effected. Two other cases tabulatedas being discharged as a result of vaccination were actually discharged fordefects that had existed prior to their enlistment and their vaccination had nobearing. The reason for the discharge of the fourth and last case was not madea matter of record.

GENERAL MEASURES

No special hospitals were provided for the care of smallpoxcases. These cases were segregated in special wards or separate rooms in thesections of hospitals allotted for the care of acute infectious diseases.Medical personnel (attendants and nurses) caring for such cases were vaccinatedat frequent intervals.

On the occurrence of a case of smallpox in a command,regulations provided for immediate vaccination of the command or such parts ofit as might be considered necessary by the medical authorities. Revaccination oflarge groups and the establishment of a so-called working quarantine(confinement to the limits of the area occupied by the group for a period of 14days) occasionally were practiced when secondary cases arose.

381

Usually, however, the command had been vaccinated recently,and the cases were of sporadic occurrence without secondary infection. Undersuch conditions no attention was paid to the matter except revaccination ofcontacts who recently had not been vaccinated successfully.

Individuals with smallpox were held in isolation untilscaling was complete. The average duration of hospitalization of cases ofsmallpox during the World War was 29 days.

ETIOLOGY

No contributions were made to the elucidation of the etiologyof smallpox by Army medical investigators during the World War.

SYMPTOMS

In general, the cases occurring in the United States weremild, in Siberia the infections were usually severe (hemorrhagic and confluenttypes), and in the Philippines and in France the disease was more severe than inthe United States, but not so severe as in Siberia. Of 236 cases concerningwhich clinical histories are available for study, 166 (70 per cent) wereadmitted to hospital after the eruption was established. In a few instancespatients with headache and fever remained in barracks for several days beforesmallpox was suspected. Headache was recorded in practically all cases. In 19instances the records show that at no time did the patient feel ill. Backachewas recorded in 42 per cent, and pains in the bones and joints in 33 per cent.Chills were noted in 32 per cent, nausea and vomiting in 21 per cent, andvertigo in 8 per cent. Abdominal pains were complained of in 22 cases (7 percent), and in 2 of these the pain was located in the right inguinal region, wasaccompanied by rigidity of the abdominal muscles, and simulated appendicitis.Chest pains occurred in 3 per cent, and bronchitis frequently was noted. Threecases presented marked nervous symptoms, positive Kernig's sign and Babinski'sreflex, stiffness of the neck muscles, diplopia, and convulsions. These cases sostrongly simulated meningitis that lumbar puncture was performed. Pharyngitiswas present in 91 cases (27 per cent).

In but two cases was a prodromal rash noted. This was amorbilliform eruption simulating measles. Distribution of the smallpox rash wasthat usually seen; i. e., more commonly on exposed surfaces of the body,especially the forehead, palms of the hands, and soles of the feet. The usualinduration or "shotty" feel to the papules was recorded in nearly allcases. Scarring was noted in but one case, which occurred in Siberia.

Elevation of temperature was not of constant occurrence. Areview of 139 clinical histories shows the temperature during the first week inhospital to have been afebrile in 50 cases (36 per cent); it ranged between 99?F. and 100? F. in 28 (20 per cent), and exceeded 100? F. in 61 cases (44 percent).

In 87 cases, in which the eruption was more or less fullydeveloped on admission to the hospital, 6 cases were in the macular; 4,maculopapular; 28, papular; 15, papulovesicular; 10, vesicular; 15,vesiculopustular; 22, pustular stage. It will be seen from the above statementsthat patients were admitted to hospital during all stages of the disease exceptincrustation. This apparent delay in sending cases to hospital was dueprincipally to the fact that

382

many arrived in camp in the eruptive stage. This was notconfined to camps in any one locality, but was common throughout the UnitedStates.

Secondary rise of temperature was practically always absent.Itching frequently was noted and often manifested itself early in the course ofthe disease. Albumin and casts in the urine were of frequent occurrence butevidently cleared up, as a diagnosis of nephritis was but rarely made.

The following extracts from clinical histories serve toillustrate some of the more important phases of the disease.31

A. H. R. (white), Pvt., Company 1, V. T. S., Camp Lee, Va.Length of service, three months. Vaccinated three times unsuccessfully in Julyand August, 1918. November 1, 1918, without prodromal symptoms, the eruptionappeared on the forehead. Lesions so few in number that it was not until theybecame scattered all over the body, on November 5, that the patient was sent tohospital. Even then he did not feel ill. Temperature and pulse were normalduring the evolution and decline of the eruption. Diagnosis: Smallpox. OnNovember 25, headache, backache, slight cough, and elevation of temperature werenoted. Following these prodromes an eruption appeared which was diagnosed aschicken pox. Neither disease was severe and the patient was returned to dutyafter 41 days in hospital.

G. K. (white), Pvt., B. H., Camp Dodge, Iowa. Length ofservice, three months. Successfully vaccinated February 28, 1918. On duty inisolation ward with smallpox cases. March 18, 1918, with prodromes, an eruptionappeared on face, body, and extremities, thickest on forehead. When entered onsick report two days later (March 20) the eruption was described as "anumber of small pustules on indurated bases." Temperature 104.4? F., butreturned to normal on March 22, and 19 days after admission, desiccation beingcomplete, the patient was discharged from the hospital to resume his duties asattendant in the smallpox ward.

A. L. H. (white), recruit unassigned, 163 D. B., Camp Dodge,Iowa. Length of service, one day. Never vaccinated. Several days before comingto camp the patient noticed an eruption on the forehead. He did not feel sick atthe time. Smallpox was present in his home town. He was admitted to hospital onthe day of his arrival in camp, May 28, 1918, because of a pustular eruption allover his body. He did not feel sick. On June 3 the pustules were dry and scalinghad commenced. By June 8 scaling was complete, and the patient returned to dutyon the 10th without any elevation of temperature during his stay in hospital.

C. R. (colored), recruit unassigned, Camp Lee, Va. Length ofservice, one day. No record of previous vaccination. There was one case ofsmallpox in his home town at the time of his departure. He was taken sick April10, 1918, while at home, with a severe headache and backache. There was ahistory of some fever, in bed four days, sore throat, and a few"bumps" on his face, April 15. He arrived at camp April 17, and wasadmitted to hospital with normal temperature and a discrete, shotlike, pustulareruption over the face, chest, abdomen, back, arms, and legs. There were a fewpustules in the palms of hand and on the soles of feet; also slightumbilication. The eruption was diagnosed as smallpox, and the patient wasdischarged from hospital after 25 days.

The case histories summarized above are typical of many casesoccuring in the United States. One relates to a patient repeatedly vaccinated,with negative results; another to a patient recently successfully vaccinated;the third to a patient who had never been vaccinated; and the fourth to apatient concerning whom there was no record of vaccination status. The firstcase shows both smallpox and chicken-pox, the disease which is most commonlyconfused with mild smallpox. In the second case, the question might arise as towhether the case was one of a generalized vaccinia. The belief held by manyobservers is that generalized vaccinia is a rare disease. The fact that manycases came into camp with active lesions of smallpox and others gave a

383

history of contact while at home and arrived in camp withinthe incubation period, throws the weight of evidence in favor of a diagnosis ofmild smallpox rather than vaccinia. This was the consensus of opinion amongmedical officers stationed in the larger hospitals. The mild character of thedisease is evidenced by the fact that 22 per cent of the cases were diagnosedvarioloid.

DIAGNOSIS

The diagnosis of smallpox is neither simple nor certain priorto the appearance of the eruption. Even then it may offer considerabledifficulty if the number of lesions is small. In mild cases, occurringsporadically, the difficulty is increased. This was the experience of the Armyduring the World War. With universal vaccination in effect, the cases generallywere mild, as is shown by the very low case-fatality rate. In but few instances,for example, at Dijon, was it possible to trace the source of infection topersons in the military service, and it but seldom was feasible personally toverify histories of exposure to civilian contacts. The general symptom-complexof a more or less sudden onset, generalized pains, headache, backache, chills,fever, nausea, and vomiting, is not peculiar to smallpox. Most of the eruptivediseases, as well as influenza, present such signs and symptoms in varyingdegrees of intensity. It was a matter of differential diagnosis and each stage,from the prodromal to the well-marked pustular or scab stage, offered newdifficulties. During the prodromal stage the following symptoms were mostcommon, and in the order named: Headache, backache, pains in bones and joints,fever, chills, nausea and vomiting, vertigo, and chest pains. This syndromenecessitated consideration of a diagnosis of influenza, meningitis, and thepneumonias. The differential diagnosis between smallpox and influenza wasdifficult and sometimes impossible until appearance of the eruption. If noeruption was present by the fourth day, a diagnosis of influenza was consideredsafe. There were 30 cases in which a tentative diagnosis of influenza was laterchanged to smallpox. In several instances the resemblance to meningitis led tolumbar puncture. Pneumonia and bronchitis were not uncommon complications,especially among severe cases; pneumonia was reported in five of the more severecases. These cases were admitted to hospital as pneumonia and the diagnosis ofsmallpox subsequently was made. In such instances there is a question whetherthe pneumonia was a complication or whether smallpox was merely a concurrentdisease. The clinical records of World War cases do not indicate that typhus orthe typhoid fevers caused any particular concern in differentiation fromsmallpox, though several cases were under observation for typhoid fever over aperiod of several days before the final diagnosis of smallpox was made.

Since the prodromal rash may be either morbilliform orscarlatinaform, measles, German measles, and scarlet fever were of necessitygiven consideration. There were 6 admissions to hospital with an originaldiagnosis of measles, 1 of German measles, and 5 of scarlet fever in which thediagnosis was changed to smallpox after further observation.

Measles was of very common occurrence, and it is notsurprising that some confusion was encountered in differentiating it fromsmallpox. There were 5 cases of smallpox in which measles was diagnosed as aconcurrent disease and 6

384

of measles where an additional diagnosis of smallpox wasmade. There were 8 cases, with 1 death, in which scarlet fever was a concurrentdisease. The case in which death resulted was one of hemorrhagic smallpoxcontracted in Siberia. It ended fatally after eight days in hospital.

The angina commonly seen in smallpox occasionally led to theconsideration of diphtheria. As a concurrent disease, diphtheria was recorded inone case, and, in addition, the clinical records not uncommonly showed theresults of repeated cultural and bacteriological examinations for theKlebs-Loeffler baccilus. Drug rash occasionally presented difficulty indiagnosis. This was especially true for iodide and copaiba rashes. The formerdrug is in common use in the Army and the records show one case sent to hospitalas "drug rash" (iodide) in which the final diagnosis was smallpox.

During the vesicular and pustular stages differentialdiagnosis ordinarily offers no great difficulty to persons conversant withsmallpox when the rash is typical. But few medical officers in the Army wereclinically conversant with smallpox in atypical form as noted during the WorldWar and there was difficulty in diagnosis.

The clinical records show that cases of smallpox in theUnited States usually were afebrile unless accompanied by some condition otherthan smallpox that could account for the elevation of temperature. During thevesicular and pustular stages, syphilis and chicken-pox caused the greatestconcern in differential diagnosis. The former was common in the Army. Wherediscrete lesions occurred, irrespective of type, especially when of recent onsetand accompanied by fever, there was a tendency to make a presumptive diagnosisof syphilis. The clinical records indicate that not infrequently consultantsfrom the venereal services were called in before a final diagnosis of smallpoxwas made. The Wassermann test, consultation, study of vaccination status,general signs and symptoms, especially of the skin and mouth, with observation,were the methods used in arriving at a diagnosis. Even after the use of allavailable methods in large base hospitals, several cases were sent to duty andrecorded as smallpox in which doubt is expressed in the records as to the truediagnosis.

It was with chicken-pox, especially, that difficulty wasencountered in differential diagnosis. An analysis of 100 clinical records ofsmallpox cases shows that 47 per cent were admitted to hospital during thevesicular or pustular stage, and that 9 per cent were thought to be chicken-pox.There were two cases of chicken-pox in which smallpox was diagnosed as aconcurrent disease and three cases of smallpox in which chicken-pox was recordedas an additional disease. One case was discharged from hospital after 23 days inisolation, during which time both diagnoses had been considered and no decisionwas reached as to what the real diagnosis was.

COMPLICATIONS AND SEQUEL?

The complications and sequel? of smallpox are usually due tosecondary pyogenic infection, and are dependent on the severity of the skinlesions. As the type of disease occurring in military personnel was mild, exceptin Siberia and in the Philippines, it is not surprising that the complicationsand sequel? were also mild in character.

385

Among the diseases recorded as secondary or concurrent diseases were:Erysipelas, carbuncle, furunculosis, abscesses, and impetigo. There were fourcases of erysipelas and two of impetigo. One case with multiple abscesses andone with impetigo ended fatally. Eye and ear complications were uncommon.

The most important complications were those of the respiratory tract, whichincluded 12 cases of bronchitis with recovery, 2 of bronchopneumonia with 1death, and 4 of lobar pneumonia with 1 death.

Of the 780 primary admissions in the United States, only 1 ended fatally, andthat case was complicated with scarlet fever.

Among the total primary admissions, 126 complications and associated diseaseswere recorded, with 8 deaths. The remaining deaths, 6 in number, show no otherdiagnosis than smallpox or toxemia. There were no cases of tetanus followingvaccination or associated with smallpox.

REFERENCES

(1) Spalding, Heman: Smallpox (Variola) and its Prevention. The Chicago Medical Recorder, Chicago, 1917, xxxix, No. 11, 490.

(2) Macaulay, History of England, Vol. IV, 53.

(3) Rosenau, M. J.: Preventive Medicine and Hygiene. D. Appleton & Co., New York and London, 1927, fifth edition, 28.

(4) Annual report of the Surgeon General, U. S. Army, 1899, 250.

(5) Handbuch der ?rztlichen Erfahrungen im Weltkriege, Band iii, Innere Medizin, Leipzig, Johann Ambrosius Barth, 1921, 265.

(6) Osler, Sir William: The Principles and Practice of Medicine. D. Appleton & Co., New York and London, 1914, eighth edition, 315.

(7) Medical and Surgical History of the War of the Rebellion, Part third, Volume I, Medical History, Washington, Government Printing Office, 1888, 625.

(8) Annual Report of the Surgeon General, U. S. Army, 1899, 207.

(9) Heiser, V. C., and Leach, C. N.: Vaccination in the Philippines Still Effective. Journal of the American Medical Association, Chicago, 1922, lxxix, No. 1, 40.

(10) Philippine Islands, Health Service Annual Reports, 1918, 1919.

(11) History of Medical Department activities, Camp Bowie, Tex., prepared under the direction of the camp surgeon. On file, Historical Division, S. G. O.

(12) History of Medical Department activities, Camp Devens, Mass., prepared under the direction of the camp surgeon. On file, Historical Division, S. G. O.

(13) History of Medical Department activities, Camp Dodge, Iowa, prepared under the direction of the camp surgeon. On file, Historical Division, S. G. O.

(14) History of Medical Department activities, Camp Funston, Kans., prepared under the direction of the camp surgeon. On file, Historical Division, S. G. O.

(15) History of Medical Department activities, Camp Pike, Ark., prepared under the direction of the camp surgeon. On file, Historical Division, S. G. O.

(16) History of Medical Department activities, Camp Taylor, Ky., prepared under the direction of the camp surgeon. On file, Historical Division, S. G. O.

(17) Leake, J. P., and Force, J. N.: The Essentials of Smallpox Vaccination. Smallpox in Twenty States, 1915-1920. Weekly Public Health Reports, U. S. Public Health Service, Government Printing Office, Washington, August 19, 1921, xxxvi, Part 2, No. 33, 1975, 1979.

(18) Public Health Reports, U. S. Public Health Service, Government Printing Office (The Notifiable Diseases, Prevalence in States in 1917, 1918, 1919). Reprints Nos. 505, February, 1919, 551, August, 1919, and 643, February, 1921.

(19) Letter from the director of laboratories, A. E. F., to the commanding officer of troops stationed at Dijon, February 5, 1919. Subject: Smallpox. Copy on file, A. G. O., World War Division, chief surgeon's files, 710-Smallpox.

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(20) Dopter, M.: Les Maladies Infectieuses pendant la Guerre. Librarie F?lix Alcan, Paris, 1921, 163.

(21) History of the Great War, Based on Official Documents, Medical Services, Hygiene of the War. His Majesty's Stationery Office, London, 1923, Vol. II, 438.

(22) Health Statistics for the Belgian Army. On file, Historical Division, S. G. O.

(23) Health Statistics of the Italian Army. On file, Historical Division, S. G. O.

(24) Morawetz, G.: Die Blattern wahrend des Krieges 1914-1918 in Oesterreich. On file, Historical Division, S. G. O.

(25) Special Regulations No. 28, W. D., August 10, 1917.

(26) Delanney, E. L.: The Army Method of Vaccination. The Military Surgeon, Washington, 1918, xlii, No. 1, 84.

(27) Hill, H. W.: Acupuncture the Best Method of Vaccination Against Smallpox. The Canadian Medical Association Journal, Montreal, vi, March, 1916, n. s., 193.

(28) Letter from the commandant, Army Medical School, to the Surgeon General, U. S. Army, dated December 21, 1917. Subject: Smallpox Vaccination by Puncture. On file, Historical Division, S. G. O.

(29) Wright, Louis T.: Intradermal Vaccination Against Smallpox. The Journal of the American Medical Association, Chicago, 1918, lxxi, No. 8, 654.

(30) Report from Major P. A. Schule, M. C., to the Director of Laboratories, A. E. F. Subject: Preparation of Vaccines and Sera in Paris Laboratories, February 25, 1919. On file, Historical Division, S. G. O.

(31) Case records on file in the Office of the Surgeon General, U. S. Army.

 

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