A HISTORY OF PREVENTIVE MEDICINE IN THE EUROPEAN THEATER OF OPERATIONS UNITED STATES ARMY 19a - 19a VOLUME II by Colonel John E, Gordon, M.C. Chief of the Division of Preventive Medicine Office of the Chief Surgeon, ETC This monograph is being made available in manuscript form pending the.completion of the official History of the Medical Department in World War II, and must be considered as a draft subject to final editing and revision. Persons finding errors in facts or important omissions should communicate with the Historical Division, Army Medical Library, Washington 25, D0 C. It is emphasized that all statistical data in this monograph are tentative and subject to revision when tabulation of individual sick and wounded report cards has been completed. This document is reproduced from unedited, unreviewed material on file in the Historical Division, SGO, and statements of opinion, any comments, or criticisms contained herein do not necessarily represent the views of The Surgeon General, Department of the Army, or official policy or doctrine. Therefore, this document is not to he reproduced in any part or in its entirety. A HISTORY OF PREVENTIVE MEDICINE IN THE EUROPEAN THEATER OF OPERATIONS UNITED STATES ARMY 1941 - 1945 VOLUME I Part I The Progression of Events in Preventive Medicine, ETO. Part II Organization of Preventive Medicine Service in ETO. Part III Epidemiology Section 1 Introduction Section 2 Intestinal Infections Number 1 The Diarrheas and Dysenteries Number 2 Food Poisoning ' Number 3 Typhoid and Paratyphoid Fevers Control of Intestinal Infections Section 3 Acute Respiratory Infections Number 1 Common Upper Respiratory Infection Number 2 Influenza Number 3 The Pneumonias Section 4 Infections Transmitted by Discharges from the Respiratory Tract Section 5 Arthropod Borne Diseases Number 1 Typhus Fever Number 2 Malaria and Others VOLUME II Section 6 Miscellaneous Infections / Section 7 Specific Immunization Section 8 Foreign Quarantine Part IV Nutrition Part V Venereal Disease Control Part VI Medical Intelligence Part VII Laboratory Service Part VIII Gas Casualties Part IX Sanitation Part X Military Occupational Hygiene Part XI Integration of Preventive Medicine into Military Medical Practice Part XII The Health of the Command A HISTORY OF PREVENTIVE MEDICINE IN THE EUROPEAN THEATER OF OPERATIONS UNITED STATES ARMY 1941 - 1945 PART III - Epidemiology Section 6 - Miscellaneous Infections by Colonel John E* Gordon, M0C* Chief of the Division of Preventive Medicine Office of The Chief Surgeon, ETO TABLE OF CONTENTS PART III - Epidemiology Section 6 - Miscellaneous Infections Page Acute Infectious Jaundice. ... ..... 1 Primary Infectious Jaundice 1 Weil’s Disease ..... 2 Yellow Fever ........... ..... 2 Epidemic Hepatitis ...... 2 Infectious Jaundice in the European Theater , 2 Annual Incidence of Infectious Jaundice, ETOUSA, ..... 3 Comparative Incidence, United Kingdom and Continent. , . 5 Jaundice in Various Theaters of Operation. ... $ Special Epidemiologic Problems. ............ . 6 Leptospirosis Icterohaemorrhaglca (Weil's Disease), ..... 6 Epidemic Hepatitis ..................... 7 Nomenclature 8 The Clinical Disease ................... 9 Incidence in the European Theater. ............ 10 Jaundice Among Troops He turning from Africa and Sicily . , 10 2nd Armored Division .................. 11 82nd Airborne Division ................. 11 9th Infantry Division. ................. 11 1st Infantry Division. ............ 12 General Epidemiologic Considerations .......... 13 Page Epidemic Jaundice in an Air Force Unit Jaundice Among the Armies on the Continent 16 Epidemic Hepatitis in the Seventh Army. . . ; 17 Mode of Transmission. 22 105th Infantry Division . 23 9th Evacuation Hospital . 23 i 6th Armored Division, ........ 23 104th Infantry Division ..... 23 26th Infantry Division. 24 AAF Station 120 24 27th Evacuation Hospital. 24 86th Chemical Battalion 25 463rd AA (AW) Battalion 25 Communicability Among Hospital Employees 25 Control Measures. 25 Post-Arsphenamine Jaundice. - 25 Homologous Serum Jaundice ........ 26 Field Studies .......... .... 28 Experimental Studies. 30 Source of Infection ..... 30 Program of Study. 32 The Clinical Disease. . 33 Clinical Course 33 Convalescence ........ 35 Page Identity of the Disease.. • 35 The Course of the Epidemic „ , . . . . , , .. , . . . . , » o 35 Geographic Distribution. ... 0 . 35 Mortality in the European Theater. , 0 . . , . , . . , , , . 37 Incidence of Jaundice by Lot Number of Yellow Fever Vaccine. 38 Scatter of Lot Numbers , „ . . ... ... . . . .... . 38 Lot Numbers of Vaccine Associated with Jaundice. , , . . , 39 Clinical Reaction According to Lot Number. • 40 Relationship of Date of Inoculation to Incidence of JaUndICe ooooooooobooooooooooooooo 4l Incubation Period According to Lot of Vaccine. . . . , . , 41 Effect of Other Immunizing Agents on the Incubation Period. -41 Interval Between Yellow Fever Inoculation and Jaundice . , 42 Epidemic Jaundice Among Troops Not Immunized Against Yellow Fever o.ooooooooooo.ooooooooo 42 Comparative Attack Rates between Inoculated and Uninocu- lated TrOOpS 0000000000.000000000000 44 Communicability of the Disease , ... ... « . « , , . , 0 44 Jaundice Following Accidental Inoculation, . , , , . , , , « 45 Recommended Preventive Measures „ , . . . , . » 46 Homologous Serun Jaundice After Transfusion , » • . . , • • , 47 Summary of Acute Infectious Jaundice. , . . . . . . . . . . , 49 Neurotropic Virus Diseases , . . . . , . , , . . , , , , , , , 30 Poliomyelitis, 000,000000000000,0000.0 5C Encephalitis oooooo.oo.. .0000000,00.0 5C Rabie s. ©o ooo.o.. 000000.0.00.00000 51 Page Tetanus, . Other Theaters of Operation 53 Scabies Anthrax » Leprosy. Undulant Fever 55 List of Figures List of Tables List of Epidemiologic Case Eeports PART III = Epidemiology Section 6 - Miscellaneous Infections ACUTE INFECTIOUS JADMDICSJi The days are long since past when all fevers with jaundice were collectively called the bilious fevers; and yet the more modern term of acute infectious jaundice contributes little toward better differentiation of jaundice due to Infection from the other and multiple causes of this striking clinical sign. It is often applied just as loosely to include several acute infections, some specific and some non-specific; or with equal fault as a synonym for one of the group, leptospirosis icterohaemorrhaglca or Weil’s disease. The more important consideration is the frequent failure to distinguish among the various kinds of infectious Jaundice a communicable disease which is by far the most common of the lot. It is as independent and distinct a disease as mumps or measles, has a world distribution and indeed is the only one that currently appears in frank epidemics. Reference is made to the disease variously known as simple Jaundice, common infective Jaundice, non-spirochetal infectious Jaundice, epidemic catarrhal Jaundice, infective hepatic Jaundice and epidemic hepatitis0 The inadequate understanding of the epidemiological behavior of epidemic hepatitis and to a lesser extent of its clinical nature, and the divided opinion about what is and is not to be included within this disease entity is well brought out by the interpretation given the condition in standard texts of the world; and yet this is no newly recognized disease « it has been knovra. for hundreds of years0 Its existence as an entity was appreciated even in the days before bacteriological methods had made any headway in separating the several kinds of infectious Jaundice„ In the course of years this conception has been reinforced by modern clinical study and by well-controlled epidemiological observations0 Primary Infectious Jaundice Primary Infectious jaundice Includes those specific communicable diseases having a more or less direct action on the liver parenchyma with production of jaundice as the leading symptom. The three well-known examples of primary infectious jaundice are Weil’s disease, yellow fever and epidemic hepatitis. Distinct from those are a number of infectious processes, some specific and some non-specific, which lead secondarily and irregularly to jaundice as a complication. The more common specific diseases include relapsing fever, malaria and typhoid fever. Jaundice may follow pneumococcus pneumonia, also erysipelas and scarlet fever among hemolytic streptococcus infections. Typical of non-specific infections leading secondarily to jaundice are general sepsis of varying origin, and ascending infection of the bile tracts following gastroduodenitis. This discussion is not concerned with the above group although problems of clinical differentiation are more frequent than commonly appreciated. Weil’s Disease,—The detailed clinical descriptions of Well in 1866 served to differentiate the first of the three primary forms of infectious jaundice from other types. Because Weil’s disease has a wide geographic distribution and also because epidemic hepatitis is frequently and erroneously considered a milder form of the same process, the general clinical characteristics are briefly stated. They differ materially from those of epidemic hepatitis. Well's disease has a sudden onset with profound prostration, aching muscular pains and a high fever characteristically followed by jaundice, evidences of renal failure and a hemorrhagic diathesis. The case fatality is about 30$, The usual distribution is sporadic, commonly in small occupational groups, involving miners, butchers, fish cleaners or sewerage workers; and never in the extensive epidemics so characteristic of the other two kinds of primary infectious jaundice. The epidemiology of Weil's disease and its clinical nature have been the subject of extensive review. The disease was rare in the European Theater, although existing both in Britain and on the Continent, Yellow Fever,—Yellow fever is just as firmly established as\a disease entity, clinical recognition having long antedated that of Weil's disease although the specific flltrable virus was not discovered until 1928, No cases of yellow fever occurred among troops of the European Theater nor Indeed among any troops of the United States Army in any theater of the world. Epidemic Hepatitis,—The third specific infectious disease having jaundice as the principal symptom is epidemic hepatitis, a benign condition in comparison with leptospirosis or yellow fever, of far reaching geographical distribution and with a definitely greater incidence„ Infectious Jaundice in the European Theater The records of the theater include 22,223 cases of acute infectious hepatitis for the four years of military operations. The reported cases probably Include a collection of diverse condi- tions, Those of the first year were principally instances of an 2 acute disease having a low degree of communicability, if actually it was communicable at all. The Illness was the result of previous immunization of soldiers against yellow fever with an antigen which contained an icterogenic substance, presumably of viral nature. The principal element contributing to this group of cases was representative of a specific infectious disease, with well-marked ability to pass from person to person and known as epidemic hepatitis. That some infections of this nature were also Included in the reports of 1942 is certain, It became the predominant form of Infectious Jaundice as increased numbers of cases occurred in each succeeding year. The third type of acute Illness characterized by appearance of jaundice was a condition occurring as an aftermath of treatment for syphilis with arsenicals. Its relation to epidemic hepatitis remained undetermined. A form of acute liver disease was noted with increasing frequency to follow treatment of patients by transfusion with whole blood or by parenteral injection of serum, plasma or other blood fractions0 The condition was definitely akin to the Jaundice which followed yellow fever vaccine and the two were commonly termed homologous serum Jaundice„ Finally and of relatively rare occurrence were scattered cases of leptospirosis„ The broad distributions of acute infectious Jaundice among troops of the European Theater will first be presented, together with a coroparison of the incidence in Great Britain and that which occurred on the Continent during the time operations took place in both areas. The experience of the European Theater will be compared with that of other theaters of operation during the period of the / war„ . / Annual Incidence of Infectious Jaundice. ETCXJSA Acute Jaundice among American troops in 19-42 was almost wholly related to homologous serum Jaundice arising from the treat- ment of soldiers about three months previously with vaccine against yellow fever which contained an icterogenic substance. The outbreak was short lived and extended only through August 1942. Some instances of epidemic hepatitis were assuredly included within the reported cases of May to August of that year, but the majority of the 1395 cases listed in those months were a part of that incident0 (Table 1) Cases of infectious hepatitis reported in the course of the next year were neither numerous nor significant „ They were clinically typical of epidemic hepatitis and distributed to considerable 3 extent as Isolated cases, although, occasional small groupings occurred among units of the command corresponding to the limited outbreaks which are so characteristic of that disease under endemic conditionso Epidemic hepatitis had been a commonly observed disease in Great Britain for many years, apparently of somewhat greater frequency than in the United States, and consequently it was to have been anticipated that the rates for American troops would be greater than had characterized American military practice under peacetime conditions in continental United States,, Some few cases within this period were probably of the homologous serum jaundice type arising through use of blood derivatives, but casualties were few and jaundice infections of this type likely minimal, although records and indeed medical appreciation of the problem were then generally lacking„ Epidemic hepatitis took on a distinctly added importance in October 1943 when American troops returned to the United Kingdom from Africa0 It had been a prevalent disease in that region, one of the most important of medical conditions. When four divisions of infantry and the First Engineer Special Brigade returned to Britain they brought the disease with them, as they did malariac The attack rate for November 1943 was 1209 per 1000 per year and for individual units of the command was of course much greater, for jaundice in the theater.was at that time largely a problem of these troops0 The usual seasonal decline was noted in the early spring of 1944, although the data fail to give a true indication of the trend because of the excessive dilution of the troops principally effected through the continued arrival of new divisions in preparation for the forthcoming operations on the Continent. The final year of the war was marked by an extreme prevalence of acute infectious jaundice. The seasonal increase ordinarily evident in late summer and early autumn, was in this instance delayed until October. Thereafter the monthly Incidence was progressively greater each month and reached a maximum of 16.9 in April 1943. The rates were still excessive in June, namely 6.5 per 1000 per year, which is definitely high for that time of the year. The general epidemic situation in the Theater, which had arisen through seeding of troops by units returning to make up the First Army, was again exaggerated by the introduction into the theater in November of three divisions of infantry and attached troops which made up the Seventh Army. The three divisions had suffered severely from epidemic hepatitis in Italy and as had happened in Britain, they brought the disease with them. The Seventh Army was likewise greatly augmented by the inclusion In forces of that command of a 4 number of newly arrived divisions from America made up essentially of susceptibles to hepatitis. These troops were included with the divisions already affected, in such a way that infection readily spread to the fresh units. Comparative Incidence. United Kingdom and Continent.— Infectious hepatitis was much more frequently observed in 1954 than in any previous year of the theater. Individual records for the troops stationed in the United Kingdom and those concerned with operations on the Continent showed an Increased incidence of acute jaundice in both locations, but much more marked on the Continent than In Great Britain, (Table 2) For the period September 1944 to June 1945, the rate in Great Britain was 5.6 and for the Continent, 9,0. The preponderance of the disease on the Continent was wholly a matter of the later months of that period. The behavior of epidemic hepatitis among continental troops in the autumn of 1944 conformed with preceding experience and indeed the rates were measurably lower than in the United Kingdom, The first notable increase was in December at which the continental rate was still one-half that of the United Kingdom. Thereafter the rates for continental troops increased each month to reach a maximum of 18.7 in April, Jaundice in Various Theaters of Operation For the Array as a whole infectious jaundice was one of the most frequent of all communicable diseases. For the period of the war from January 1942 to June 19-45, the number of cases reported was 1-42,636. Most of these occurred among troops stationed overseas; the rate for troops of continental United States was 2.61, compared with 13.3 for troops of all theaters of operation. The Mediterranean Theater maintained a consistently hlgji rate. During the early days of the theater in late autumn of 1942 the number of cases was negligible, but Jaundice soon became evident in epidemic proportions. The frequency in 1943 was 36.8 per 1000 strength per annum and the rate did not decrease in succeeding years; rate for 1944 was 22.7, and that for 1945 was 25.8 The disease was next most frequent in the Southwest Pacific area, with a rate for the entire war experience of 25.9, Well-marked variations in frequency occurred from year to year in contrast to the more consistent behavior of the disease in the Mediterranean, in that for the first year of 19-42 the rate was 23.0, it dropped in 19-43 to a very favorable level of 2.8, but again increased to give the highest rate for any theater of any year of 61,9 per 1000 per year in 19-45. Troops of the Alaskan Theater occupied third place, largely because of the high incidence of homologous serum Jaundice experienced in the first year of operations. Epidemic hepatitis was apparently 5 a rare disease in that locality since rates in succeeding years were negligible. The European Theater occupied sixth place among the nine theaters of operation with a rate for the entire period of activities of 7,0. The 19-42 level of 21,5 was directly attributable to homolo- gous serum jaundice. The disease existed at a low level of frequency in 1943, 6,8; and was still less common in 1944 when the rate was 2.6. The 1945 upsweep was material and decided, for it reached 10.9 per 1000 per year for the first six months of 1945. (Table 3) Special Epidemiologic Problems Individual consideration will now be given to the five particular problems associated with acute disease characterized by rapidly developing Jaundice. Comment will be restricted to events which occurred among American troops of the Theater, although acute infectious Jaundice was widely spread the British civilian population, and was a matter of concern among British troops. The studies and contributions of Joint committees and commissions as well as those of individual British investigators will be drawn on to the extent that they bear on the problems of American troops. LEPTOSPIROSIS ICTEROHAEMOBHHAGICA (WEIL'S DISEASE) Weil's disease was neither the first nor the most Important problem in primary acute infectious Jaundice to be presented to medical authorities of the European Theater. Since It is perhaps the best known of these conditions to American physicians, and because it frequently confused the interpretation of existing epidemiologic phenomena, its relative place among these conditions is briefly defined, principally to emphasize its lack of importance and to clarify the situation. Leptospirosis was not recognized among United States troops until operations started in Continental Europe, and no more than ten cases were included in the entire medical record of the theater, With the exception of a single case in Great Britain, all originated from troops serving on the Continent-—seven in late 1944 and two in 1945, The following case report is illustrative of the disease. EPIDEMIOLOGIC CASE REPORT NO, 1 - Two weeks before admission to hospital the patient fell into a small pool of stagnant water on the Brest Peninsula, where French women frequently washed clothing. He suffered a small laceration of the left wrist which was not treated until the following day. One week later he developed coryza, a mild non-productive anorexia, and had a slight chill. Physical examination at the time of admission to hospital was essentially negative 6 except for moderate injection of the pharynx and coarse rales in the right lower lung field. The diagnosis was early pneumonia and sulfadiazine was administered. The temperature continued at 101°F to 103 F for three days, Roentgen examination of the chest demonstrated no abnormalities. Subsequently the patient complained of severe pain in the calves of both legs, headache was present and injection and lack of luster of the conjunctlvae were noted. During the next two days an Intense icterus of rapid evolution and a peculiar orange color became evident. An eplstaxls was of such moment as to require nasal packs, and spontaneous purpura of the skin were noted. Vomiting was severe, and fluid and food intake by mouth was Impossible. Leptospira were observed in the urine. The liver and spleen were barely palpable. The patient showed definite improvement after treatment for three days with penicillin. An agglutination test performed at the Pasteur Institute was reported positive for leptosplra icterohaemorrhagica. Urine and blood cultures proved negative, A guinea pig inoculated with blood from the patient, failed to develop the disease. Complete recovery followed and an agglutination test performed four weeks after the onset of the disease was positive in a titer of 1 to 1,000,000 for leptosplra icterohaemorrhagica. Because of the extensive and continued presence of an outbreak of epidemic hepatitis among troops of the European Theater, the diagnosis of Weil’s disease was made with considerable frequency In most Instances the evidence failed to support the diagnosis, and it is believed that even the small number of reported cases is in excess of the number that actually occurred. For the entire United States Army during the war period, 18 cases of leptospirosis were reported; 17 among troops serving in overseas theaters of operation. Other than the European Theater, the greatest number was noted in the Southwest Pacific area with six, and a single case came from the Africa-Middle East Theater. (Table 4) EPIDEMIC HEPATITIS Epidemic hepatitis was easily the most Important ox the fevers associated with jaundice„ The disease appeared rather promptly after the first American troops landed in North Ireland, it continued to be a significant problem during the entire stay in the United Kingdom, and it became truly epidemic during the year of operations on the Continent, Proper understanding of what is to be included within the clinical limits of the condition and the appreciation of its existence as a specific infectious disease, have been inhibited as much as anything by the variety of names that have been applied to the disease. 7 Nomenclature Early renorts speak of the disease as “epidemic Jaundice11 which is a good enough name since it stresses the principal symptom and the epidemic nature. However, in 186-4, Virchow reported what subsequent experience has shown to be a rare sporadic form of Infectious Jaundice, and called it “acute catarrhal Jaundice”. At autopsy a plug of mucus developing from an acute gastroenteritis was found to have lodged in the common bile duct and produced an obstructive Jaundice, Unfortunately this pathogenetic mechanism was accepted for years as the pattern for all mild sporadic Jaundice of infectious nature. It soon was evident that a clinically indistinguishable condition occurred in frank epidemics and so the term epidemic catarrhal Jaundice was introduced. There is no evidence that catarrhal Jaundice as described by Virchow has ever occurred in epidemics, A variety of evidence—clinical, pathological had epidemiological—gradually gave proof that tnis disease was not a local Infection of the gastrointestinal raucous membrane, but a general infection with primary localization of the infectious agent in the liver parenchyma; and that it was furthermore a specific communicable disease with a well-defined epidemiological behavior. As a result of this changing concept, a variety of names were intro- duced to define the epidemic disease. The disadvantages of the terra infectious Jaundice have "been mentioned,. The French usage of benign Jaundice or of simple icterus scarcely gave emphasis to the epidemic nature of the condition, "Jaunisse des camps" was a favored war time name in 19180 British writers used "common infective Jaundice" or "non-spirochetal infective Jaundice", In 1919, Lingstedt suggested “epidemic hepatitis” as most suitable, in analogy with epidemic parotitis for mumps. This name emphasizes the primary pathology of the disease, its ability to occur in epidemics and its specific nature. It has the advantage over epidemic Jaundice of cutting sharply away from any confusion with catarrhal Jaundice, What is more important, the numerous atypical infections occurring in epidemics and not proceeding to Jaundice can be included logically within a term like epidemic hepatitis. Used almost universally in the Scandinavian countries where much attention lias been given this disease, it is preferred by most German and continental workers. In England, Findlay and others speak of “infective hepatitis”. More general use of the term “epidemic hepatitis” would conceivably lead to better appreciation of the true nature of the disease. For purposes of clarifying further epidemiologic discussion it is deemed desirable to present the characteristic clinical features 8 of eoidemic hepatitis as manifested in clearly recognized epidemics, accepting this as the classical type of the disease. For the moment attention will deviate from any possible common relationship with the many clinically similar sporadic cases of jaundice that have occurred so frequently in recent years. The jaundice in association with arsphenamlne treatment of syphilis will be disregarded, as will the more serious condition of acute yellow atrophy of the liver, and the disease known as homologous serum jaundice. The aim here is to define a clinical type. The Clinical Disease The clinical course of epidemic hepatitis has two well- defined stages, a situation not always appreciated because so commonly patients first come under medical care after jaundice has appeared, With opnortunity for full observation, the two stages are distinct. The first presents all the appearances of a general Infection with fever, gastrointestinal symptoms, but without jaundice, while the second is introduced by the appearance of jaundice and ordinarily is free from fever. The infection developes progressively and a sudden onset is rare* The patient is irritable and experiences loss of appetite; there is vomiting, and very regularly pain or at least a sense of fullness in the region of the liver. Headache is fairly common, sometimes dizziness, and rather frequently a sense of tiredness and weakness of the extremities. Headache is to be expected. At this time much variation is encountered in respect to localizing symptoms. Sometimes only evidences of systemic Infection are present, while some epidemics are characterized by an initial upper respiratory infection. More commonly, early symptoms are associated with dis- turbances of the gastrointestinal tract, constipation or mild diarrhea. The fever is low grade, ordinarily about 101°F but some- times as much as 104°F, Early observation of the illness may be necessary to determine the presence of fever, with some reason to believe that it is more constant in children than in adults. Under all circumstances, the temperature tends to return promptly to normal limits so that the course is afebrile when jaundice appears. As the infection progresses, the disturbances referable to the liver become lore pronounced and shortly before jaundice develops are sometimes so marked as to produce a colic-like pain of sufficient severity to lead to confusion with appendicitis or cholelithiasis. The spleen is occassionally enlarged, but by no means regularly. The duration of the first stage is variable, ordinarily three to ten days, A day or so in advance of jaundice the urine becomes darker and the stools lighter, although complete acholia Is uncommon. Jaundice is the outstanding sign of the second or icteric stage of epidemic hepatitis. The sclerae are affected first and 9 sometimes no more than the sclerae, The usual sequence is progres- sive yellowing of the face, neck, body and limbs* Perhaps ten percent of patients complain of itching, adults more commonly than children* The jaundice lasts ordinarily for a week or two, sometimes persists over four weeks and rarely a month, with recorded instances of eight weeks duration* Once jaundice appears the patient promotly . feels better, the appetite returns and gastrointestinal symptoms disappear. Herpes labialIs is a rare accompaniment in contrast to. feil!s disease. The general course of the illness is mild, although generally admitted to be more severe in respect to adults. Compli- cations are seldom introduced and convalescence is brief, about 2 to 4 weeks. A striking uniformity in clinical behavior has been observed from descriptions of various epidemics in the course of this experience, and in many parts of the world over many years, giving weight to the belief that epidemic hepatitis is an entity and therefore due to a specific infectious agent, Naturally variations from the clinical course are encountered during a given epidemic, but these are largely a matter of degree. The first stage may be indefinite or absent, with jaundice the first evidence of the condition. By contrast, the infection may not progress beyond the initial stage, with jaundice remaining absent or limited to the slightest yellowing of the sclerae. Recognition of such abortive infection depends upon clinical evidence and association with outspoken epidemics, since the infectious agent has not been demonstrated. Despite the usually good prognosis, patients with this disease sometimes develop the manifestations of acute or sub-acute yellow atrophy with a fatal outcome. Incidence in the European Theater Epidemic hepatitis was one of the earliest reported communicable diseases among American troops in the European Theater, Members of the 151st Field Artillery Battalion- of the 34th Division contracted the disease in Worth Ireland in April 1942 and the illness led to confusion with the outbreak of homologous serum jaundice then so prevalent in that locality. The disease continued to occur in North Ireland among both British and American troops, as well as in the civilian population. It was consistently and regularly present in Great Britain from the time that troops were stationed there, although the incidence was not great until troops arrived from Africa and Sicily, aundice Among Troops Returning from Africa and Sicll; In contrast to malaria which was common in all four divisions of infantry and the 1st Engineer Special Brigade which 10 returned to Great Britain from Africa in November 194-3, only the 1st Infantry Division had a serious problem in respect to infectious hepatitis. Prior to their arrival in Great Britain epidemic hepatitis had appeared in all five units which were to furnish the nucleus for the First United States Army, but never to an extent comparable to that for the 1st Division. The Introduction of the disease in epidemic proportions among troops of Great Britain served to initiate an increasing incidence of this communicable disease, which-eventually involved troops of the theater generally. It is not to be assumed that the well-marked epidemic which became evident in the spring of 1945 arose wholly from this source. The disease among troops from Africa merely gave impetus to the situation. Epidemic hepatitis was repeatedly introduced by Air Force units returning from Africa and Sicily, and the arrival of troops of the Seventh Army in the autumn of 1944 contributed a further extensive focus of infection. The existing endemic prevalence of the disease in both Great Britain and on the Continent added other reservoirs of infection. 2nd Armored Division..~~The Second Armored Division had experienced a measurable amount of epidemic hepatitis in Sicily in the period immediately preceding deployment in Great Britain„ The disease first made its appearance in August, 19-43. In the immediately succeeding months about 7$ patients were sent to hospital. The Division Surgeon was of the opinion that an appreciable number of others with outspoken but mild jaundice did not report ill, end that a number of mild cases without icterus remained undetermined» During the first week that the division was in England * 3 December 19-43* seven cases were reported and In the next two succeeding weeks two cases and five cases came to record, but thereafter the division was essentially free from epidemic hepatitis except for sporadic attacks rarely involving more than a single patient during a given week. Throughout operations in France, the division experienced little difficulty 0 82nd Airborne_ Divisi on o~~The 82nd Airborne Division parti- cipated in operations in North Africa and in Sicily and was stationed for an appreciable period of time in Naples. Epidemic hepatitis was particularly prevalent in the division while in Italy, with 370 reported cases in 1943. The epidemic had essentially passed by the time the 82nd Division arrived in Great Britain in the week of 10 December 1943, since only four cases were observed that week. No outspoken problem was ever again noted although a source of infection evidently existed, for most weeks of the succeeding year and a half found at least one reported case. Weeks with two or three cases were frequent and occasionally as many as five occurred. The rates were consistently those of a continued endemic prevalence. 9th Infantry Division.—Jaundice had never been a principal consideration of the Ninth Infantry Division during the campaign in 11 Africa or in Sicily, for the regular reports of the division failed to mention the disease. The unit would appear to have been exposed to the infection shortly before departure from Palermo, as had the 1st Infantry Division, for during the first week in Britain, 3 December 1943, 16 cases of hepatitis were reported, 19 more the next week, and 11 in the week thereafter. The disease continued to be relatively prevalent during January but in the period of the assault on Normandy and in the European campaign, the history of the division was characterized by no more than an ordinary endemic prevalence. 1st Infantry Division .—The 1st Infantry Division had the most serious problem in respect to epidemic hepatitis. Throughout the Tunisian campaign, the period of organization and regrouping in Algiers, and the operations in Sicily, the division had no hepatitis other than a single isolated case early in the Tunisian phase. The disease first appeared while troops of the division were in bivouac in the Palma Di Monti area in South Sicily after the conclusion of the campaign. A striking increase in reported cases took place from the week of 27 August. The peak of the out- break occurred on board ship in transit to Great Britain in the week of 22 October, and the outbreak continued in the United Kingdom through December and January. Not until the first week in February 1944, was a stable situation reached, with epidemic hepatitis again at a reasonable endemic level. Thereafter the division experienced relatively little concern over the disease, although the rate of Incidence did increase slightly during the general excess prevalence of the spring of 1945. The men of the First Division began to develop jaundice directly the campaign, in Sicily was over. Thus a sergeant in the Counter Intelligence Corps, in a unit consisting of only five enlisted men and one officer, stated that one of the four men developed jaundice on August 21 and another on September 1. The sergeant became jaundiced on 22 October, having shared a room with the other two men. Prom a number of accounts, it would appear that patients with jaundice were frequently kept in quarters in Sicily rather than hospitalized. About one-half of the 52 patients interviewed when the division landed in Great Britain stated that one to nine members of their company had jaundice in either September or October prior to embarking. All agreed that jaundice was thoroughly prevalent in the camps at Licata and Palma; for example, one man stated that nine others of his unit developed jaundice at about the same time that he did on 1 October, that none went to the hospital, but all remained in quarters. Another patient stated that six of his company had had jaundice in September. Altogether, thirty-six men developed jaundice while in transit in England. A battalion medical officer who made it a practice to observe fevers for several days before instituting treatment for 12 malaria stated that a small number of men came in with temperatures of 103°F or 104°F which fell to normal within a few days, and were subsequently followed by jaundice. The actual incidence of jaundice in the 1st Division at the peak of the outbreak cannot be satisfactorily determined. Between 15 October and 15 November, 190 cases were reported. Many of the men, but more especially the officers, preferred to continue on a duty status although jaundiced. Medical officers of the division estimated that approximately one-fifth of cases were of this nature and consequently not reported, and that 300 cases for the division up to the time it arrived in Britain would be a conservative figure. This estimate gives no consideration to cases without demonstrable icterus. Based on the strength of the division, the number attacked was about two percent of the total command. Separate figures for the 18th Regiment of the 1st Division indicated that 173 cases of jaundice were reported for that unit, which had a total strength of 2903. The attack rate was thus close to six percent. The 1st Battalion of the 18th Regiment had 63 cases or an incidence of 8.6 percent among 731 men. Of 46 officers of the 1st Battalion, 8 or 22% became jaundiced. An excessive rate for officers was also true of other battalions; the 3rd Battalion for example had 12 patients with jaundice, 4 of whom were officers, and the Provisional Battalion had 30 officers, 6 of whom developed jaundice. No reasonable explanation could be determined for the high rates in the 1st Battalion, which apparently bivouac I under similar conditions to the others. It was the only battalion of the regiment to go on a recreational convoy to Palermo in early October. \ General Epidemiologic Considerations.—The-outbreak of v/ epidemic 'hepatitis among troops returning from Africa. andTTtaiy' nS unusual features, and indeed was much like the out- breaks described among German and British troops in that area. The diagnosis was substantiated by a number of considerations. The seasonal incidence in the late summer and early autumn, the slowly rising epidemic curve and the clinical features were all characteristic of epidemic hepatitis. Furthermore, hepatitis had been reported as epidemic in the civilian population of Sicily. The troops has been through a campaign where they were subjected to severe physical exhaustion, unappetizing and inadequate rations, and loss of weight„ After the campaign, they camped in an area where malaria and sandfly fever were highly endemic. The food was only slightly better than before and diarrhea was prevalent, conditions similar to those associated with outbreaks of epidemic hepatitis among British troops0 13 The association of jaundice and malaria was confusing. Many medical officers apparently treated most significant fevers as malaria since a definite diagnosis of malaria was frequently impossible under field conditions0 A proved association between the two diseases would appear unsubstantiated0 While the troops were crowded on transports, the oppor- tunities for contact infection were at a maximum. The effect is probably to be observed in the secondary rise which took place after troops landed in Great Britain, and in the prolonged course of the epidemic beyond the usual expectancy for this condition0 The secondary peak of the outbreak was about one month after the original height of the epidemic. (Figure 1) The greater frequency of epidemic hepatitis among officers as compared with enlisted men had been a frequent and consistent observation among British troops where similar epidemics had occurred. Interviews with officers of the 18th Infantry Regiment indicated that jaundice was also measurably more frequent for officers than for enlisted men. Officers even with marked jaundice were particularly prone to remain on a duty status. The existence of such cases was only detected by Interviews with unit medical officers, for they were not entered officially on division records. A review of the 216 cases of jaundice reported by the 1st Division from their arrival in the theater through the week ending 3 December 19-43> showed that 17 were officers and 199 were enlisted men. The distribution was essentially the same as that for the theater during 19-42 and the first five months of 19-43. Three authenticated instances of relapse of jaundice were noted among patients admitted to hospital. Prodromal symptoms did net precede the second attack; patients noted only that they again became heavily jaundiced and that they were more readily fatigued. There were no deaths among patients of this outbreak. The disease occurred with apparently equal readiness during active fighting, under field conditions in bivouac, with relative rest in houses in Sicily, on board ship and under training conditions in requisitioned houses and billets in England. Obser- vation of this epidemic led to the distinct impression that once introduced into a unit, the infection continued to spread through three or four more monthly generations. That troops from the Mediterranean area served as the source of infection for other units of the European Theater was clearly demonstrated by the follow- ing experience. A bakery unit of 4 officers and 160 men left the United States on 13 October 19-43, landed in Glasgow on 19 October and immediately moved to Kettering. The unit was divided on 18 November with the 3013th Company going to one location and the 3031st Company to Dorchester, where 77 men were housed in Liberty 14 Figure 1. Epidemic hepatitis in the First Infantry Division, European Theater of' Operations, U.S. Array, number of by weeks, 16 July 1943 to 26 May 1944, inclusive. Hall, They slept in three-tier hunks and ate at a mess which also served troops recently returned from the Mediterranean Theater. Jaundice appeared among members of the 3031st Bakery Company -41 days after the first contact with troops from Sicily, Nine cases of jaundice corresponding to 12 percent of the command occurred within a space of 9 days in well-nourished and rested troops recently arrived from America, The 3013th Bakery Company remained free of jaundice. \ Epidemic Jaundice in an Air Force Unit The circumstances associated with the 113th AAF Station in April 1944 served to demonstrate some of the factors associated with the spread of epidemic hepatitis. This station was used as a final training center for Eighth Air Force replacements and new units. The average length of stay was only a few weeks and large numbers of men passed through the station. Approximately 20 units had been assigned for varying periods during March 1944, of whom at least nine had been transferred prior to an investigation brought about by the appearance of jaundice on 25 March 1944, The onset of subsequent cases of clinically definite epidemic hepatitis is shown in Table 5, In addition to the 31 patients with hepatitis at AAF Station 113, other air force stations were found to have sent an additional AS patients to nearby hospitals, of whom 38 had been at AAF Station 113 sometime during March, Since the usual incubation period for epidemic hepatitis is about four weeks, and since the disease was not unduly prevalent at other air force stations than AAF Station 113, the outbreak at that location appeared to be the likely source of infection. Only enlisted men were involved. The 69 cases of hepati- tis were determined to be distributed geographically at the probable time of infection among all living sites of the station with the exception of the officers* site, and among all working sites with the exception of the hospital, With two exceptions, the patients Included only men employed in ground duty in strictly Air Force organizations. A common factor to all was the consolidated enlisted men’s mess which at the probable time of infection was feeding 2600 men at each meal. The facilities were greatly overtaxed according to the statement of the mess officer and the mess kit laundry was Inadequate, The first patient with jaundice worked on the permanent night Kitchen Police detail at the mess until sent to hospital. The epidemic would appear to have arisen as the result of direct or indirect contact infection with the original patient 15 during the pre-Icteric stage of the disease. The median onset for all patients, excluding the first ca.se, was 19 April; and this was exactly 2$ days after the first patient went to hospital or approximately 28 days since the beginning of the pre-lcterlc stage of his illness. Accepting that period as being from 19 March to 23 March, every one of the 38 patients who subsequently became ill elsewhere with epidemic hepatitis had been at AAF Station 113 at that time. Jaundice Among the Armies on the Continent The outbreak of jaundice of 1943-19-4-4 among American forces in Britain was essentially an imported epidemic from the Mediterranean Theater. It largely Involved the returned units but extended to others of the area in the United Kingdom to give a sizeable outbreaks In extent and significance, it failed to approach the epidemic of hepatitis that developed in the following year of 194.4—45o The outbreak of the first year followed the usual seasonal curve and had largely subsided by the end of February 1944, The rates for the Army in Europe compared very favorably during the summer with those of the summer of 1943, which may be taken as an ordinary year of endemic prevalence. The rates for 1942 had little to do with epidemic hepatitis, for the jaundice then prevalent was almost entirely homologous serum jaundice. The epidemic of 19*44-1945 was a feature of Ground Force troops, (Table 6) Epidemic hepatitis continued to be present in the United Kingdom and the incidence there was somewhat above normal expectancy, but the real epidemic phenomenon was manifested on the Continent, Little or no connection would appear to exist between the outbreaks of the two years. An understanding of the battle line in Western Europe is essential to proper interpretation of the course of the epidemic. The Third Array was in the line next to the Seventh, and the First was on the other flank of the Third, The Ninth Army held the opposite end of the line in Holland, Interchange of units was most common between the Third and Seventh, less so with the First and almost non-existent with the Ninth Army, It has been demonstrated that jaundice among elements of the First United States Army in Britain had largely burned itself out by the spring of 1944, when those troops went to the Continent, Jaundice continued to be present in that organization, indicating that reservoirs of infection were maintained, but their significance was not great. The First Army had relatively little jaundice during 1945 until March when the rate increased to 6 per thousand per year. The peak of incidence came in April with a rate of 12,4 and the disease continued at a level of about 8 per thousand during May, 16 The rates for the Third Army were much the same as those of the First Army. A gradually Increased frequency of the disease became evident in January and reached a peak of 42 per thousand in April, The rate still continued high in May with 10 per thousand. In general the experience of the Third Army was somewhat more serious than that of the First. The Ninth Army had relatively little jaundice at any time and while Increased rates in the late spring of 1945 were also noted in this organization, the maximum prevalence in April did not exceed 5 per thousand per year. The real problem and the center of the epidemic in Continental Europe lay with the Seventh United States Army. Epidemic Hepatitis in the Seventh ArmyAll divisions of the Fifth Army in Italy had a serious experience with epidemic hepatitis, and the Mediterranean Theater as a whole had much more jaundice than any other theater of operations. Epidemic hepatitis apparently involved the several divisions promptly after their entrance into Italy, and rates for the disease were maintained at a high level throughout their operation in the field.. Three divisions of the Fifth Army were of special significance to the European Theater because they formed the nucleus of the Seventh United States Army which invaded Southern France in August 19-44. These three divisions constituted the source of infection for the extensive epidemic of hepatitis that developed among troops of the European Theater the following winter and spring. Detailed information on the frequency of epidemic hepatitis in the 36th Division, the 3rd Division and the 45th Division of Infantry are available from late September 1943. They demonstrate the extent to which Jaundice was prevalent in these units during the time they served in Italy. (Figure 2, Table 7) Epidemic hepatitis gained an early start in 1943, Judged by the usual seasonal distribution of the disease, for Jaundice was already a commonly existing disease in September in two of the divisions, the 3rd Infantry Division and the 45th Infantry Division. It became manifest about a month later in the 36th Division. The 3rd Division was the first and the most heavily infected. Although the epidemic tended to subside in all three divisions in March and April, excessive rates were nevertheless maintained throughout the summer, so that Jaundice was a commonly existing disease when the three divisions landed in Southern France on 15 August 1944. The entrance into an active campaign in the field was coincident with the usually anticipated seasonal exacerbation of epidemic hepatitis0 The conditions encountered probably contributed to a greater incidence of the disease than would otherwise have occurred. The heavy reinforcement of all three divisions during succeeding months provided a continuous flow of susceptible into an Infected medium 17 Jaundice was maintained at a high level throughout the autumn, When the three divisions were incorporated into the European Theater on 1 November 1944, the rates of the Third Division were 30 per thousand per year, those for the 36th Division were at the same level and the existing attack rate for the 45th Division was 33 per thousand per year. This was greatly in excess of theater experience, which at that time was 2,1 per thousand per year. The situation remained essentially unchanged in all three divisions in succeeding months of 1944, hut January saw a greatly increased frequency with a maximum rate of 73*4 eventually attained hy the 43th Division in the week of 26 January 1943, Replacements appeared to have been continually infected with the virus of the disease by their close association with the older members of the divisions., The epidemic in the Seventh Army as a whole took a decided upward swing as new divisions unaffected by jaundice were added to the troops of the three veteran divisions« 100th Infantry Division,—The 100th Infantry Division arrived in Marseilles from the Zone of the Interior in September 19-44-, with a previous history of essential freedom of epidemic hepatitis. The Communications Zone troops of Delta Base Section with whom they first had contact were likewise from Italy, but Jaundice was never as prevalent in Service Forces as among Ground Forces of that command. Furthermore, intimacy of contact was relatively low grade, for the 100th Infantry Division, like most units of the line engaged in training and in preparation for combat, functioned as an independent unit with no more than the usual contacts in the course of leave and pass. Such cases of epidemic hepatitis as appeared during the autumn corresponded to no more than a low grade endemicity. On 1 November 19-44 the 100th Infantry saw its first action, and on 9 November relieved the 45th Division. The 100th Division was at that time a considerable distance from any of the old divisions, being located on the left flank of the 103rd Division, also new, which in turn was on the left flank of the 36th Division„ During the week of 24 November 1944 the 3rd Division was moved between the 100th and 103rd, The first week of December two regiments of the 100th Division attached ith elements of the 3rd Division, while one regiment was attached to a regiment of the 43th Division, About the middle of December the 100th Division was moved to the left flank of the 43th Division and was now between the 44th, a new division, and the 43th, This position was maintained throughout the winter and until the week of 9 March, Sporadic cases of hepatitis were reported in the 100th Division from 24 November until 26 January, During the week of 26 January 1943, 14 cases of hepatitis occurred and the rate constantly increased from that time until 6 April, Judged by accepted incubation periods the source of the 18 Figure 2. Epidemic hepatitis in Divisions of the Seventh Ariry, European Theater of Operations U.S. Army, rates per 1000 strength per annum, by weeks, 2a September 19-43 to 27 April 194A, inclusive. infection would apnear to have been the 45th Division which at the time of contact was experiencing a rate of 21 per thousand per year. Contact with the Third Division had also been close. The epidemic that followed was the most severe of any- experienced by a unit of comparable size in the European Theater, with a maximum level of 437 per tnousand per year for the week ending 23 March 194$, The epidemic lasted for several weeks „ The last week in April, immediately prior to cessation of hostilities, the rate was still 146 end the enidemic had not spent its force by July 194$. (Table 7) 103rd Infantry Division: Like the 100th Division, the 103rd Infantry Division entered the European Theater through the port of Marseilles in September of 1944. During the early part of its operations in the theater it was subjected to similar conditions in the south of Prance. There was little or no jaundice. The division was committed to combat during the week of 17 November, taking up a station between the 100th and 36th Divisions. It was thus located on the left flank of one of the old divisions. This position was maintained until the week of 8 December at which time the 45th Division was placed in the line on the left flank of the 103rd, putting the 103rd between two of the old divisions. During this time two regiments of the 103rd were almost constantly inter- mingled with two regiments of the 45th. The 103rd Division was then moved to the extreme left flank of the entire Seventh Army fronts with its closest neighbor the 44th Division immediately to its right. This position was maintained until the week of 19 January, when the 103rd was again moved to the center of the line, on the right flank of the 45th and again very intimately associated with that division. This position was maintained until the 45th Division was relieved on 16 March. As in the case of the 100th Division sporadic cases of hepatitis were reported from the first week the division went into the line, but cases did not appear in serious numbers until the week of 5 January which was four weeks after the division had been placed between two of the original divisions from the Mediterranean area. As will be seen from Figure 2, the rates for epidemic nepatitis increased very rapidly until the week of 6 April at which time the first decrease was registered. 44th Infantry Division.—The 44th Division came into the theater through Cherbourg, and was not exposed to any division or any troops previously in the Mediterranean area until committed to the Seventh Army. Jaundice had been practically unknown in the division. The unit went into action during the week of 17 November on the extreme left flank of the Seventh Army. Its nearest neighbor was the 100th Division, with little or no opportunity for exposure to any of the older divisions 19 s During the week of 1 December, the 157th Regiment of the 45th Division was attached to the 44th Division where it served with the 71st and ll4th Regiments of that organization. During the week of 29 December the 103rd Division which had previously been with the 45th and 36th Divisions was deployed very close on the left flank of the 45th so that it was possible for members of the 44th Division to be exposed to soldiers of the 103rd during the time when the rate of the 103rd Division for epidemic hepatitis was increasing rapidly. For the week of 19 January the 103rd Division was moved again so that exposure of the 44th could only have taken place during the three-week period. During the week of 2 February elements of the 63rd Division were assigned to the left flank of the 44th and this position was maintained until the 44th Division was relieved during the week of 16 March. The first cases of hepatitis were reported in the 44th Division during the week of 9 February, six weeks after the 103rd had been deployed closely on its left flank. The epidemic that followed was relatively severe and extended over the course of many weeks. 42nd Infantry Division.—The 42nd Division was first committed to the Seventh Army during the week of 16 February 1945, at which time the 22nd Regiment of the Division was in the line with the 157th Regiment of the 45th Division. Thus the 42nd Division was deployed between the 100th and 103rd which were the first divisions to experience hepatitis among those not previously in Italy. Comparison of the attached tables will show that the 100th and 103rd Divisions were suffering an increased frequency in hepatitis at the time the 42nd Division was placed between them. The 42nd Division remained between the 100th and 103rd until the breakthrough at Saarguemines on 21 March. The first cases of hepatitis were reported from this division during the week of 30 March which is again six weeks after the first regiment could have possibly been exposed to older divisions. The division first went into action in December 1944 under the Seventh Army on the right flank at Saarbrucken, serving as an emergency task force plugging gaps and weak points in the line. In January the Seventh Army was holding along the'two-army front while the Third Army helped to fight back the Nazi bulge on the First Army front. The following month the Seventh Army was readied for renewal of attack and it was in this month the 42nd Division was announced as a part of the Seventh Army. 63rd Infantry Division..—The 63rd Division arrived in the ETO in December 1944. Some of the units saw action on 22 December 1944 but the Division was not committed as a unit until 8 February 1945, At this time the 63rd was announced as a division under the Seventh Army in Alsace. Two regiments were committed during the week of 2 February on the left flank of the 44th Division, This is the week previous 20 to any cases of hepatitis being reported from the 44th Division,, These two regiments attacked with elements of the 44th Division from this period until the week ending 2 March at which time the 63rd Division moved somewhat further to the left« At the same time the tv/o regiments of the 63rd were attached to the 44th Division, One regiment of the 63rd was attached to the 3rd Division and remained with this Division for a period of three weeks, after which it migrated to the 100th Division and the 44th Division before rejoining the other two regiments to form an entire division. Only one regiment of this division was ever exposed to elements of the 3rd, 45th or 36th Divisions but all regiments were closely allied to the 44th Division during the time that the 44th Division rates were Increasing, The first cases of hepatitis were reported from this division during the week of 2 March which is five weeks after its first commitment in the Seventh Army, 70th Infantry Division,—The 70th Infantry Division arrived in the theater in December 1944, and reached the Seventh Army area in the latter days of that month. It was first committed during the week of 19 January at which time one regiment was attached to the 45th Division, During the next two weeks the other two regiments were not committed but were in an assembly area close to the 63rd Division, During the week of 9 February the regiment which had pre- viously been attached to the 45th Division was attached to the 63rd Division and fought between two of its regiments. The following week the entire 70th Division was committed on the left flank of the 63rd Division where it remained until the breakthrough on 21 March at which time both the 63rd and 70th were taken out of the line. The first cases of hepatitis reported in the 70th Division were during the week of 2 March, six weeks after one regiment had been attached to the 45th Division and five weeks after the remaining two regiments had been in an assembly area close to the headquarters of the 44th Division, 14th Armored Division,—The Division came overseas in October 1944 and spent three weeks in rear areas of the Seventh Army during which time it was impossible, to estimate contacts with epidemic hepatitis. Elements of the 14th Armored were first com- mitted during the week of 15 December at which time the division was assigned to support the 103rd and 79th Divisions and had battalions attached to both of the above infantry divisions. This position was maintained for two weeks at which time the entire 14th Armored Division was withdrawn from the line and was not com- mitted again until the week of 19 January, when it was in close support of the 100th Division, This position was maintained for two weeks, after which the division was again shifted and was in very close support of the 36th Division and in less close support of the 79th and 101st Airborne Divisions. During the week of 23 March the 36th Division was withdrawn from the line and the 14th 21 Armored attacked on the right flank of the 103rd Infantry Division. The 36th then came in the line to support and for the next two weeks the 14th Armored had elements closely intermingled with both the 36th and 103rd Divisions. This position was maintained until the breakthrough at wnich time the 14th Armored was far in advance of any infantry division. The first cases of hepatitis in this division were reported during the week of 2 February, six weeks after the division had first been put in support of the 103rd Division. The repeated appearance of jaundice in susceptible divisions with no previous history of the disease rather promptly after the accepted incubation time, and following contact with divisions suffering with the disease, speaks strongly for a contact type of spread,, Outbreaks of jaundice did not occur under cir- cumstances of combat messing, incidence of diarrheal disease and insect distribution which were much the same, when contact was with army units where jaundice was not a particular problem,, Mode of Transmission A mass of evidence has accumulated, although not readily available in any single source, to indicate that the usual method of transmission of epidemic hepatitis is by secretions of the upper respiratory tract. The behavior of the disease in 194-3 in the Seventh Army would suggest that route as the usual method. Epidemic hepatitis has been transmitted experimentally by the gastrointestinal route as well as by the respiratory tract, and the epidemiologic evidence from some outbreaks would support that means of transmission despite the weight of evidence being for a respiratory mechanism, Much stress is often placed on the association of outbreaks of epidemic hepatitis and of diarrhea and dysentery in military practice, without sufficient regard for the chance frequency with which both may occur in a unit at a given time,, The most important consideration is perhaps the epidemiologic pattern of the two conditions, in that diarrhea and dysentery epidemics tend to be of abrupt onset involve many men and are relatively short lived, while those of epidemic hepatitis extend for months and sometimes two or three years unlike the epidemiologic behavior of diseases spread by the way of the intestinal tract, The epidemic in the United States Army in 1945 was primarily among the field forces at a time when existing rates for intestinal disease were particularly favorable and when opportunity for transmission of disease by intestinal means was limited by the conditions under which men were living. Messing was more an in- dividual than a community matter. The suggestion that epidemic hepatitis may be insect borne lias received little support. No particular insect has ever been 22 specially involved nor has the disease been transmitted experimentally through the agency of arthropods, The broad extent of the disease in most countries of the world and in all sorts of climates and environment would appear of itself to eliminate that consideration. The seasonal distribution with the principal incidence in winter and early spring would also discount the likelihood of that mode of transmission. The observation of a number of surgeons of field units are submitted as they bear on the general epidemiologic behavior of the disease and on the mole of transmission. 105th Infantry Division.,-*--It is interesting to note that in not a single unit of the division did the rates for epidemic hepatitis bear any resemblance to the rates for the diarrheas and dysenteries. In the epidemic of acute diarrhea of 15 December to 1 January all units of the division were affected in proportionately equal extent. The epidemic of hepatitis did not affect all units proportionately and indeed the curve of this disease bore a striking similarity to the curve of upper respiratory disease in all units. Numerous reinforcements not subjected to the epidemic of diarrhea developed hepatitis. The concensus of opinion of medical officers of the division was that hepatitis is a contact disease of upper respiratory origin. 9th Evacuation hepatitis, which gained epidemic proportions in this command during January and February apparently subsided as quickly as it started for no new or recurrent cases occurred during March 1945. The frequency with which tne onset was preceded by a sharp attack of diarrhea indicated that the portal of entry was most often through the gastrointestinal tract. However, occasional cases began with initial symptoms of a mild upper respiratory infection. Whether or not this might be an alternate portal of entry was a matter of conjecture. The command was not exposed to mosquito or other insect bites, and an insect vector was definitely excluded. 6th Armored Division.—The 48 patients evacuated to hospital during March with mild "hepatitis of undetermined origin usually developed the illness subsequent to a mild or a moderate upper respiratory Infection. 104th Infantry Division.—The 104th Infantry Division had 56 cases of jaundice between 5 January and 16 February. Ten occurred in the 413th Infantry Regiment, 32 in the 4l4th and 11 in the 4l5th Infantry Regiment with the remainder in three attached units. The cases occurred Sporadically, both in respect to time and to units involvedJ No more than four cases were noted in any one day and no more than seven cases in any one company. At about the same time three similar cases are known to have occurred among VII Corps troops and six cases in another nearby division, although complete reports for other units were not available due to changes in corps jurisdiction 23 There had been no concomitant rise in the general rate of respiratory or digestive disturbances; on the contrary and since December 19-4-4, there had been a definite increase in both rates. The division had occupied the same general area for many months, although various units of the division had rotated within the area at various times. Spread by way of the respiratory tract was deemed most nearly compatible with the epidemiological facts. The distribution of cases by units and by time for the 104th Infantry Division, Table 8, illustrates the characteristic behavior of epidemic hepatitis in Ground Force units. 26th Infantry Division,—The rate per thousand per annum of epidemic hepatitis for the 26th Infantry Division for the week ending 2 March 19-45 was 137,9. One hundred eight cases with icterus had been reported since 2 February 19-45, with the distribution by weeks ending 9 February, 8 cases; 16 February, 9 cases; 23 February, 27 cases; 2 March, 42. cases; and during the -4-day period ending 7 March, 22 cases. Of the 108 cases hospitalized for observation and study, approximately one-half had an onset associated with upper respiratory prodromata, while the other half had gastrointestinal prodromata with not infrequent association of the two. The onset of the current epidemic of hepatitis followed by 6 to 8 weeks an upswing in the frequency of respiratory diseases within the division. Cases of hepatitis were not confined to any single organization, and the majority were among headquarters personnel of the various divisional units. Infections were mild and patients returned to duty in two to three weeks. A common causative factor or a direct link between cases was rarely determined. When Company M of the 101st Infantry Regi- ment reported six cases of epidemic hepatitis in February 19-45, inquiry brought information of a single original infection in that unit on 25 January 19-45. A physical inspection of all men of the unit after appearance of the six cases showed five other men to have ambulant disease not previously reported at sick call. AAF Station 120Ten patients with jaundice were treated during the six weeks preceding 1 March 19-45. Infection was believed to have arisen within the unit, as few cases had been reported in surrounding towns. Prodromal symptoms were uniformly those of a severe nasopharyngitis preceding the appearance of jaundice. 27 th Evacuation Hospitalo—Numerous patients were seen at the 27th Evacuation Hospital in which a diagnosis of epidemic hepati- tis without Jaundice was warranted0 For the most part they had some degree of anorexia, vomiting, abdominal cramps, tenderness over the right upper quadrant usually more marked to the right of the mid-line and in the upper gastric area, and a palpable liver, The illness was usually of sufficient degree to require evacuation to a General Hospital, 24 86th Chemical Battalion.—Thirteen men of the 86th Chemical Battalion developed jaundice during the week of 12 February 194$0 Three patients admitted to hospital on February 8, 9 and 10 had previously been in hospital for acute upper respiratory infection between February 1 and 3o They were discharged as the symptoms cleared, only to be readmitted several days later when jaundice became evident. This succession of symptoms was characteristic of patients from the respiratory symptoms suggest the respiratory tract as the portal of entry. 463rd AA (AW) Battalion.—During a period of nine days, 1$ cases of jaundice 463rd AA (AW) Battalion attached to the 79th Infantry Division, The first case was on 22 July, another on 23 July and several in succeeding days, with the last two on 29 July and on 30 July, The patients were from the various batteries of the unit, which were separated tactically and not in contact with each other. Communicability Among Hospital Employees A survey of acute epidemic hepatitis among hospital personnel engaged in the care of patients with the disease gave information on 31 hospital units of which personnel exposed to risk of contracting the disease included 20$ medical officers, $64 nurses and 849 enlisted men. The duration of exposure incident to the care of patients with hepatitis was from one day to two years but in most instances was less than two months„ Personnel contracting epidemic hepatitis included four medical officers, 23 nurses and 22 enlisted men, to give attack rates of 2$ for medical officers, 4% for nurses and 206% for enlisted men. Control Measures Since the mode of transmission of epidemic hepatitis remained undetermined, Army Regulations directed that the general measures against intestinal, respiratory and insect-home diseases were to he employed „ Principal stress in the European Theater was placed on the procedures designed for control of infections trans- mitted hy secretions of the upper respiratory tractc Judged hy the progress of the disease in most units attacked, little result was derived from any of the measures employed0 POST-ARSPHENAMINE JAUNDICE This third general problem among acute diseases associated with jaundice was of no great moment in the European Theater, The substitution of penicillin for the previous regimen of the arsphena- mines served to eliminate interest in the jaundice that developed 25 among patients under treatment for syphilis, despite Its continuing infrequent occurrence. The cause of the jaundice among patients under treatment for syphilis is open to a variety of interpretations. Toxic action of the arsenicals is a ready explanation but the dominant opinion has developed that in most instances the disease follows ordinary exposure to epidemic hepatitis. The frequency of such Instances is observed to be greatest when the epidemic disease is prevalent. That the action of the arsenicals on the liver may exert a contributing influence appears reasonable. EPIDEMIOLOGIC CASE REPORT NO. 2 - A soldier receiving anti-luetic treatment for primary syphilis developed jaundice of a non-obstructive type in February 1945. The icteric index was 30. In the course of treatment up to the time jaundice appeared he had received 1.47 grams of mapharsen. Epidemic hepatitis was epidemic at the time. The oustanding contribution on pathogenesis of the con- dition arising from experience of the war was the demonstration in British experience of transmission of jaundice by contaminated syringes, A number of clinics commonly used a single syringe in the treat- ment of a number of patients and it developed that enough blood entered a syringe in the course of intravenous injections to serve as a medium for the transmission of jaundice. Post-arsphenamine jaundice in the recent military ex- perience in England was seemingly more frequent in British than in American practice. Such infections would appear in part to have been representative of homologous serum jaundice with the mechanism of infection through syringes; and in part, and perhaps most commonly, to usual infection with the agent of epidemic hepatitis. Added susceptibility to infection as a result of action of the arsphenamines is probable but unproved, That any great proportion of cases of jaundice in this group was directly and solely due to toxic effects seems unlikely, x iDMOKXKXIS SERUM JAUM)ICE The epidemic of homologous serum jaundice following the administration of yellow fever vaccine was the most outstanding event of its kind in the European Theater. Isolated instances of this form of infective jaundice occurred throughout the period of operations, largely due to the effect of transfusion of blood or blood products, but the 1942 experience was the single outspoken epidemic. It was part of a general phenomenon involving troops of the United States Army stationed in many parts of the world, a fact unknown at the time the first cases were encountered in Europe, The problem was that of an unfamiliar disease and a completely unknown kind of epidemic. The methods of study that were employed and the epidemiologic attack were on that basis. 26 The first Information that jaundice had occurred on hoard American troop ships came through a message from the Department of Health for Scotland on 13 May 1942, advising that 26 patients with jaundice were included among a large complement of troops just arrived in Glasgow, On the assumption that the disease was probably Infectious but not epidemic, the patients had. been per- mitted by the Scottish health authorities to proceed to their destination in Northern Ireland, Field investigations in the Northern Ireland area were undertaken 20 May by members of the American Red Cross-Harvard Field Hospital Unit. Practically all of the patients with jaundice had been admitted to the 5th General Hospital, then stationed near Belfast, It was immediately apparent that the outbreak was of more serious proportions than originally reported, since 83 patients with jaundice had by that time been admitted to the hospital wards. This of itself was unprecedented. Outbreaks of ordinary eoidemlc hepatitis are characterized by a slow and orderly development of the epidemic process, with the result that the number of patients at any one time is relatively few even in the course of an extensive outbreak. A ward of 83 patients with manifestations of acute jaundice was beyond any ordinary clinical or epidemiological experience. Ward rounds were promptly made with the purpose of determining the general clinical nature of the condition at hand. General Inquiry drought evidence that the disease was prevalent among American troops, that the outbreak had started in America, that numerous infections had developed aboard ship, and that subse- quent to arrival a great many more had been determined. Although the presence of an excessive frequency of jaundice in America was unknown to military authorities in the British Isles, it soon be- came evident from conversation with physicians accompanying the newly arrived troops that jaundice had been decidely prevalent within recent months among the United States armed forces in America, Definite information about rates was not obtained nor was information available about deaths, although individuals knew of three and sometimes five fatal cases. Clinical observation of patients then in hospital did not serve to determine the nature of the existing condition. It was certainly not Weilss disease. The signs and symptoms were compatible with the usual behavior of epidemic hepatitis. The condition could conceivably have been the result of Infection by modified yellow fever virus, but if so it was certainly a most atypical yellow fever. Laboratory and field studies were evidently needed to supple- ment the primary clinical observations. Description of the Area.-“About 20,000 men arrived in North Ireland after having transshipped from Glasgow on 13 May 27 1942, They were housed in a variety of cantonments in the south and east of North Ireland, the forces being distributed in groups varying from 500 to 1,000 men0 One of the principal units came originally from Fort Knox, Kentucky. The troops proceeded from there to Camp Dix, New Jersey and embarked for the European Theater at the port of New York, Jaundice had first made its appearance at Fort Knox about the middle of March0 More cases occurred at Camp Dix in late April and during their days at sea from April 30 to May 1-4 still more had been reported. The patients belonged for the most part to the 1st Armored Division, The second group came from Fort Sheridan, Illinois, travelled from there to Indiantown Gap, Pennsylvania, and subse- quently reported to Camp Dix where they embarked in the same convoy with the first group. Jaundice did not appear in the second group until about the tenth day at sea which was about 15 days after contact with troops of the first group where Jaundice was already present. That the second group was Infected by the first did not appear likely, because the accepted incubation period of epidemic hepatitis is about 30 days. Furthermore, essentially all members of both groups had been inoculated against yellow fever. Those of the Camp Knox group received the vaccine in the early days of January while the Camp Sheridan group were inoculated about the middle of March, If a connection existed between the vaccine and the development of Jaundice, then both groups had developed the condition about two months subsequent to its administration. In the days immediately following debarkation many new cases appeared in both groups. The epidemic passed its peak at the end of May but nevertheless continued with scattered cases through June, Field Studies,—'The decided clinical variation among patients seen in hospital and the presence of many mild Infections led to the assumption that subclinical disease was probably common. Furthermore interviews with ship and camp surgeons made it evident that in all probability many more cases of Jaundice existed among the troops than was Indicated by the number of patients referred to hospital. Field surveys were undertaken in order to determine the actual prevalence of the disease and to ascertain the general level of severity in the military population at large. Forms were prepared which incorporated questions concerning the principal clinical features of the disease? whether the onset had been in America, on board ship or in Ireland? identification data? and space for recording the results of physical examinations. The men examined were placed in one of four categories? patients with Jaundice sent to hospital, 28 patients with jaundice not hospitalized and noted as ambulant, persons with subclinical jaundice, and those not affected. Five different military organizations, each of about 150 men and known to have suffered recently from epidemic jaundice were surveyed within the period 23 May to 26 May 194-2, The actual groups were selected by the division surgeon and were stated to Include one group with a relatively high incidence of jaundice, another that had relatively little jaundice, and three thought to be about general average. The Incidence of jaundice in the several commands studied varied from 10 per cent to 39 per cent of total strength. A control group with a history of freedom from jaundice within recent months gave no indication of the presence of the disease, except for one individual with questionable subclinical jaundice. The ratio of ambulant cases to hospital patients within the same organization was in the proportion of about four to one, so that an estimate of total cases for the whole command on the basis of 250 patients in hospital was about 1250. Correlation was next determined between the lot number of the yellow fever vaccine and the presence or absence of Jaundice. In summary, Jaundice was not associated with the administration of all lots of vaccineo In some instances the number of patients related to a given lot was so small as to Justify no conclusions. Some 32 persons had not been vaccinated against yellow fever and none had Jaundice. The majority of patients with Jaundice had been inoculated with yellow fever vaccine from Lots Nos. 338, 351, and 368 and they had a relatively high attack rate of Jaundice. Other sizeable groups of persons received yellow fever vaccine from lots such as Noo 327, 3-40 and 423 and no individual within these groups had become ill. The attack rates in the three large groups that received vaccine of Lot Numbers 338, 351, and 368 were respectively 33%, 18% and 14%. This variation conceivably might be either a function of the vaccine itself or these groups may have been subjected to circumstances favorable to the spread of an epidemic agent having an origin Independent of the vaccine Itself. If the latter were true, then a variable attack rate would be expected among different groups of men receiving the same lot of yellow fever vaccine. The best proof that the attack rate was a function of certain lots of vaccine was in respect to Lot Number 368, which had been administered to at least three groups of men represented in the study. Virtually similar attack rates for jaundice were observed in all three instances In summary, certain lots of vaccine were associated with a higher attack rate for jaundice than others. There was indication that for one lot, Number 368, the attack rate was the same when given 29 to three different groups of persons having little or no contact with each other0 Experimental Studies A number of studies were undertaken at the laboratories of the Wellcome Research Institution in London through the interest and cooperation of the institution staff. Attempts were made to isolate a flltrable virus from the blood of patients by inoculation of monkeys and mice. Suspended cell cultures of chick embryo tissue and tyrode solution were inoculated with serum and clot suspensions. Developing chick embryos were inoculated with serum and clot suspension. The result of these experiments was essentially negative in that neither yellow fever virus nor any other infectious agent was isolated from the material. The serum of 25 patients were tested for yellow fever neutralizing antibodies by the intraperitoneal mouse protection test using six week old Swiss mice. Serums from English soldiers inoculated with yellow fever vaccine during the past year were used as controls. There was no significant difference in the neutralizing power of the serums of the men of the two groups. The Inoculation of animals with tissues from a fatal human case was completely negative. Inoculation of ferrets with duodenal fluid from infected patients was likewise without result. Source of Infection Practically the whole military population concerned in the outbreak had been vaccinated recently against yellow fever. The vaccine contained no yellow fever immune serum but was made from a seed virus propagated in tissue culture using a medium which contained a small amount of normal human serum. The virus used had undergone long artificial culture and was so greatly attenuated that partial neutralization with immune serum was no longer practiced nor deemed necessary. Five possible theories by which the disease might have developed were hypothesized. The yellow fever virus in the vaccine was a living virus known to have been greatly attenuated, but always with the potentiality of acquiring enhanced pathogenic properties „ Such an occurrence could conceivably have led to a mild disease associated with jaundice, distinct from classical yellow fever. The prevalent Jaundice might have "been due to the hypothetical virus of ordinary epidemic hepatitis incorporated in the seed virus by way of the supposedly normal human serum used in its propagation, despite the usual precaution of inactivation., The second virus - of epidemic hepatitis - would then he carried along 30 with the yellow fever virus in tissue culture„ If this was the case, successive lots of yellow fever vaccine prepared over a given period would expectedly be contaminated with the agent of epidemic hepatitis and virtually all would lead to cases of jaundice when administered to susceptible persons. In the preparation of the vaccine, chick embryo tissue containing the attenuated yellow fever virus was diluted with normal inactivated human serum in the proportion of one part embryo tissue to nine parts of serum. Some of the supposedly normal human serum used as a diluent might have come for a patient or a person having an early or subclinlcal Infection of epidemic hepatitis or which an indenendent virus of similar nature, thus contaminating the particular lot or lots of vaccine in which it was used* In this instance some lots of vaccine would be expected to produce Jaundice and others would not, since probably not all pools of diluting serum would be involved. The epidemic of Jaundice might be due to a fortuitous circumstance whereby jpidemlc hepatitis appeared among the population recently vaccinated against yellow fever, the epidemic having no relation to the vaccine itself* The disease could be of purely toxic origin due to a chemical poisoning and bearing no relation to an Infectious agent* That the condition was of toxic origin was doubtful. There was no evidence that food or other environmental factors had intruded at this time* Moreover the apparently long incubation period in the disorder was against a chemical poisoning* There was no presumption of a poisonous chemical fraction in the vaccine* That the outbreak was simply coincidental with the vaccination for yellow fever was doubtful. There was no evidence that epidemic hepatitis existed in appreciable numbers in the particular geographic areas from which these troops came in America, hepatitis furthermore had been a relatively rare infection in the United States since 1922, Moreover the epidemiological curve lacked the periodic monthly aggregation of cases, so typical of spontaneous outbreaks of epidemic hepatitis. The average attack rate of the spontaneous disease was about 7 per cent compared with the observed rate of 21,9 per cent among the four major groups of the present outbreak. Clinically, the existing disease was not suggestive of yellow fever even in its mildest conceivable form0 Urinary changes were largely absent, as were hemorrhage and cardiac involvement* There was no evidence of chemical poisoning. 31 Behavior of the outbreak epidemiologlcally was not like that of ordinary epidemic hepatitis of spontaneous origin, The seasonal distribution was wholly different, the incubation period was much longer0 On the available evidence the cause would seem to lie within the vaccine. The long period over which some lots of vaccine had been known to produce jaundice would suggest contamination of the seed virus with a jaundice producing agent. More Information was needed about the constitution and size of the pools of normal serum used for dilution. Further field studies were projected to develop knowledge about the regularity with which certain lots were involved and whether or not they occurred in series, irregularly, or if all vaccine lots were concerned. The jaundice producing agent would seem, to have been added to the vaccine through normal human serum used in its preparation, but whether through culture mediums used in cultivation of seed virus or through serum diluents could probably be decided by field studies of the types projected. The long incubation period in this outbreak was not explained., Ordinarily the incubation period for epidemic hepatitis is 30 daySo In this instance it was commonly 3 to U months or longero This suggested the presence of another flltrable virus distinct from that of ordinary epidemic hepatitis. The long incu- bation period was a regular occurrence in jaundice after immunization processes, both active immunization as related to yellow fever protection in past experience, and with passive immunization against measles and more recently with mumps. Jaundice after immunization appeared furthermore to be less communicable than ordinary epidemic hepatitis. No spontaneous outbreaks with such a long incubation period had ever been noted0 Program of Study It appeared that the working quarantine which had been put into effect on arrival of these troops could be raised with safety and certainly after a month had elapsed since their arrival. Plans were made for the collection of data on the prevalence of jaundice in all units of the command, to be correlated with the lot number of the vaccine used. Additional surveys were proposed for troops who had received the lots of vaccine associated with high attack rates for jaundice, especially Lot Number 338, Because of the extent of liver damage determined by clinical studies of the 3th General Hospital, an adequate program of convalescence was recom- mended, Periodic survey of affected individuals was believed essential to determine residual permanent liver damage. 32 The results that came from these proposed clinical, field and laboratory observations constitute the balance of this report. The general features of the clinical disease will be first discussed. This will be followed by a general presentation of the epidemic situation. The details of epidemiologic studies contributing to the solution of the problem follow thereafter. The Clinical Disease The clinical picture presented by the patients with inocu- lation hepatitis was remarkably stereotyped., The outstanding dif- ferences were of degree rather than klnd0 The onset of the disease was rarely abrupt but in the majority of cases could be accurately dated. Typically, it was marked by the development of gastrointestinal disturbances and the coincident appearance of dark urine. There- after the patients almost uniformly experienced a feeling of lassitude and became readily fatigued on exertion. The most characteristic feature of the indigestion was a rather complete loss of appetite, or if the appetite was preserved, a few mouthfuls of food sufficed In most instances the ingestion of food, especially beef, was followed by a burning gastric distress, nausea, and for about one-fourth of patients by vomiting. Constipation was common and likewise occurred in about one-fourth of cases. Icterus usually appeared within two or three days after dark urine was first noted. The onset of systemic disturbances occasionally preceded the icterus by two or three weeks. During the first week or two, as the icterus became more intense and the symptoms developed in severity, the patients commonly experienced generalized aches and pains, muscular weakness, chilly sensations in the absence of fever, itching, photophobia, and epigastric or right upper quad- rant pains on pressure or on movement of the trunk. All but about 8 per cent of patients experienced indigestion in one form or another. A small number, less than 4 per cent, had no constitutional symptoms whatever throughout their illness. The severity of symptoms as might by anticipated was roughly proportional to the depth of icterus, its duration and the depression of liver function. So far as physical signs were concerned, those most commonly encountered were icterus of the sclerae and skin, and a demonstrably enlarged and tender liver, A small percent of cases developed transient splenomegaly, Chemosis, conjunctivitis and occasionally petechlae were observed in association with marked icterus. Clinical Course0—In the majority of cases jaundice deepened and symptoms became progressively more marked over a period of from one to three weeks before improvement set in. Symptomatic 33 improvement not infrequently preceded the maximum development of icterus. In most instances this improvement occurred coincidentally with hospitalization or shortly thereafter. Similarly symptomatic improvement was almost invariably well established some days or weeks before the Jaundice had entirely cleared. The height of the illness, defined as the period of maximum icterus, appeared to be somewhat dependent on the time of hospitali- zation with reference to the onset of the disease. Thus, of patients hospitalized within one week of the appearance of the Initial symptoms 80% began to improve within two weeks of the onset. Of patients hospitalized more than two weeks after their first symptoms, 30% experienced the height of their illness after the fourth week, as contrasted with 5% of the early hospitalized cases. Jaundice disappeared within three weeks in about one-third of cases and within six weeks in over two-thirds. In a small number, approximately 4%, jaundice persisted for three months or longer. The depth of icterus appeared to reflect with reasonable preciseness the degree of liver damage, and held some prognostic significance with respect to the ensuing course of the disease, especially in regard to the anticipated duration of jaundice and depression of liver function. Hepatomegaly was not demonstrable ordinarily until the second or third week of the disease, although the finding of upper right quadrant tenderness or tenderness on deep percussion over the liver area was the rule in the early stages 0 Liver enlargement eventually developed in over two-thirds of patients, although ordinarily not extending more than two finger-breadths. Hepatomegaly persisted for an average of 3 to 6 weeks and its disappearance in most instances was preceded by the disappearance of jaundice. The liver failed to enlarge in over half of the mildest cases, whereas hepatomegaly appeared in all but very few of the extremely icteric patients. In those with marked jaundice, failure of the liver to enlarge was associated with marked delay in recovery and the appearance of a large liver came to be regarded a.s a welcome sign. Liver enlargement beyond two finger-breadths Was most commonly encountered in individuals wnose icterus was particularly pronounced. The spleen became demonstrably enlarged in 7% of cases. In almost all instances, splenomegaly was associated with liver enlargement and had no peculiar prognostic significance so far as severity or duration of the illness was concerned. That prognosis of the disease was somewhat Influenced by the age of the patient was suggested by the observation that approximately one-third of individuals over 40 years of age had severe hepatitis, on the basis of an icteric index over 100 and a 34 duration of jaundice exceeding three months. On the other hand, less than one-twentieth of patients under UO ran comparable courses. There was nothing to Indicate that patients presenting a past history of jaundice reacted in any unusual fashion to post- inoculation hepatitis. Convalescence,—Convalescence for the hepatitis patient was a slow and arduous process more akin to convalescence from tuberculosis than other types of jaundice, A long duration with physical weak- ness and all its associated signs marked in many cases a stormy return to health without the patient ever being seriously ill0 The eventual convalescent program emerged after early misconceptions of the duration of the disease. It was a rehabilitation program carefully outlined and supervised with progressive exercises arranged according to the clinical improvement and ability to undertake an increasing load of physical exertion. The response to this exercise program proved a most satisfactory method of determining disposition to duty or return to the Zone of the Interior, Identity of the Disease.-°Qn the basis of clinical observation leptospiral jaundice was readily ruled out. The differential diagnosis between ordinary epidemic hepatitis, homologous serum jaundice and jaundice due to a chemical poison or toxin could not be established on a clinical basis alone. The Course of the Epidemic Infectious jaundice of all forms had been absent from records of the theater during the first few months of 1942. The onset of the epidemic was sharply defined and coincided with the arrival in the middle of May of about 20,000 troops in Northern Ireland. Many were jaundiced on debarkation. By the end of September 1942, which may be taken as the end of the epidemic, 1462 cases had been sent to hospital or quarters as determined from the official 86ab reports. Field surveys indicated that the actual number of cases was considerably greater since numerous patients with minimal signs and symptoms were treated on active duty, and many on the basis of adequate sampling were shown to have remained wholly unrecognized. The admission rate for jaundice for the theater was 186 per thousand strength per annum for the month of May, and for the week ending 22 May 1942, it was 354. From this date, admissions declined until 18 September 1942, after which a level of approximately three per thousand persisted for the following 12 months. The greatest number of cases was reported for the week ending 22 May. The distribution by months through the course of the outbreak as shown by 86ab reports is presented in Table 1. Geographic Distribution.—The epidemic was essentially one of the North Ireland area for the reason that most troops of the theater were stationed there at the time. 35 The only satisfactory information on the number and distribution of patients included within the outbreak comes from a series of individual and special field surveys made at the time,, Infectious jaundice was not reported on the Statistical Health Report until 22 May 194-2„ In some instances, cases of the disease were entered on that part of the form provided for special conditions, but in general reporting before the date mentioned was unsatisfactory. Subsequently, many duplications were encountered. It was found necessary to make surveys and obtain data directly from the in- dividual units Concerned and the computation which is presented in Figure 3, Table 9 is derived from that source. The responsi- bility for these studies rested with special investigators of the Division of Preventive Medicine0 If the end of the outbreak be accepted as the month of September, the number of cases of Infectious hepatitis from the beginning of activities in the theater in late January through the week of 25 September 1942 is 1915 as determined by these special studies. The number of cases that occurred in North Ireland was 1591 and 324 were noted for Great Britain, Because of the great differences in military strength in the two areas, the rates were essentially the same. Cases noted within a given week are by day of onset of the disease and not day of report, as is true of the series of 86ab reports Included in Table 1, Enough information is available to assure that not all cases were representative of homologous serum jaundice, since a basic residium of ordinary epidemic hepatitis occurred in both areas. The latter number cannot be determined with preciseness but a satisfactory idea can be obtained by comparison with the endemic prevalence which persisted after termination of cases due to administration of yellow fever vaccine. While Iceland was a part of the European Theater of Operations, medical problems of that area were never an intimate feature of the work of the theater. Reports on the incidence of disease were sent directly to the Office of The Surgeon General in Washington, The summary of the epidemic of jaundice presented in this discussion excludes Iceland and relates only to cases which occurred in the United Kingdom, Information became available to indicate that the condition was as prevalent in Iceland as it was in the United Kingdom. As of 1 September 1942, 1320 patients with jaundice were known to have been hospitalized and about 200 more had not been sent to hospital. With a few exceptions the cases were mild and no fatalities occurred. Most instances of the disease were among troops of echelons arriving in Iceland in March and April, and most of the troops had been immunized against yellow fever in February 1942, with yellow fever vaccine of Lot No, 368, The exception Included one patient who received Lot No, 367, one of No, 353, one 350, and eleven who had been immunized with Lot No, 369, The 11th Infantry Regiment and the 36 Figure 3, Homologous serum jaundice of origin from yellow fever vaccine, cases by week of onset, special study survey, February to September 1942. 2nd Infantry Hegiment were the units with the greatest number of patients, having 636 and 140 infections respectively. The remaining cases had occurred in other divisional units and a few among non- division troopso f Mortality in the European Theater Two of the 191$ patients died of homologous serum jaundice to give a case fatality rate of 0ol%> a raEe which'Xs lower than that ordinarily experienced with epidemic hepatitis. It was less than the general rate ior the army as a whole in respect to cases following administration of yellow fever vaccine. The first patient died in the first week of illness. The clinical course had been progressively retrogressive with deepening jaundice. There was never any liver or splenic enlargement and death was preceded by coma. Post mortem examination showed red atrophy with atypical regeneration and severe icterus with wide- spread small hemorrhagic changes through most of the organs. The liver was small, 935 grams, with raised irregular nodules up to 0.$ cm in diameter over the right lobe. The left lobe was small, finely wrinkled and the cut surface was purplish red in color. Microscopic examination of the right lobe showed zones of varying size in which liver cells were entirely absent, with only stroma, vessels and bile ducts remaining. Irregular patches of liver cells surrounding central veins and without identifiable central vessels were present and represented islets of regeneration. The left lobe showed complete destruction of all liver cells, with only slight proliferation of bile ducts in portal zones. Other organs were essentially normal, both grossly and microscopically. This single death among cases in North Ireland occurred $ June 1942. The second fatal case was that of a member of the Air Forces stationed in Great Britain, The onset of Illness was on 10 August 1942, and death occurred on 12 September 1942. The liver was very small and the capsule was wrinkled. Large nodular areas were present, having a firmer consistency than the rest of the liver The liver surface was bright yellow on surfaces made by cutting, and mottled with fine red dots. The bile ducts were very prominent, the liver substance considerably firmer than normal liver and generally fibrous. A third patient apparently recovering from hepatitis died of miliary tuberculosis in the fourteenth week of icterus, 13 October 19-42. The gross pathological examination also showed red atrophy with regeneration of the liver, similar but more extensive than that of the first case noted. The microscopic changes were less pronounced than in the other cases. All lobes of the liver were similarly affected and miliary tubercles were superimposed on the basic changes due to Hepatitis. Other organs of the body 37 presented only the pathologic changes of tuberculosis, with no organ free from miliary tubercles0 Incidence of Jaundice by Lot Number of Yellow Fever Vaccine Data were obtained for all troops of the North Ireland Command in respect to the number of cases of Jaundice that had occurred in each military organization, according to the lot number of yellow fever vaccine administered. The field investigation form required the listing of each lot of yellow fever vaccine used in protection of the organization; the number of men who received each particular lot; the number according to lot number who developed Jaundice, this information being subdivided into those patients who were sent to hospital and those who remained ambulant; and finally special attention and information about men of the various commands who did not receive yellow fever vaccine and the frequency of Jaundice among them. Information was obtained for the period dating from the first immunization against yellow fever in the particular organisation and extending through 31 May 1942, Scatter of Lot NumbersInformation was sought from these data on whether or not Jaundice occurred more or less regularly over a given period of time and through a continuous series of lot numbers. In the event that this were true, it would indicate that the seed virus used in preparation of the vaccine was most likely involved0 This might conceivably be the yellow fever virus Itself or an extraneousiy introduced virus„ On the other hand, if groupings of certain lot numbers could be determined in respect to the occurrence of jaundice, with intermediate lot numbers unlnvolved, such evidence would indicate that the trouble more likely was in relation to the serum diluent rather than to the seed virus itself. If an indiscriminate scatter were observed, attention would necessarily be attracted to factors of contact with outside sources of infection, or to some other origin in explanation of the outbreak, (Table 10), Inspection of the data shore four rather well defined groups, Included in the first group are Lot Numbers 317 to 320 inclusive, The second group includes Lot Numbers 333 to 338; and the third includes only a single lot of vaccine, No, 351; while the fourth grouping is of two lots, Numbers 367 and 3680 These groupings of certain lots of yellow fever vaccine whose administration was associated with a definite frequency pf jaundice, and the existence of intermediate lots where no jaundice occurred, suggested strongly the activity of the serum diluent used in preparation of certain lots of vaccine as the probable source of infection. 38 Lot Numbers of Vaccine Associated with Jaundice . —The data of the preceding table, augmented by information from subsequent field investigations, identified all lot numbers of yellow fever vaccine used in inoculation of troops where jaundice later appeared., Among all of the troops here concerned, 93 different lots of vaccine were employed and 19 were associated with the occur - rence of jaundice; in the proportion of 20%. The lot numbers in- volved and the attack rates per hundred, are presented in Table 11. A high correlation is shown between the incidence of jaundice and the administration of certain lot numbers of yellow fever vaccine* A great proportion of cases were associated with two particular lots, No* 338 and No* 368* A significantly high rate was associated with certain others, which include Lot Numbers 319, 333, 333, 331 and 367. Only a few scattered cases of jaundice were related to other lot numbers and the significance of these occurrences has yet to be determined. In the first place, too few persons were Involved in respect to at least two lots to warrant any evaluation, these being Numbers 308 and 334° Secondly, the number of cases of jaundice associated with certain others was so small as to sug- gest accidental infection from some other source or a questionable diagnosis of the cases involved. This applies especially to Lot Numbers 346, 333 and to the large group in which the lot number is unknown. Finally, three other lot numbers, Nos* 317, 320 and 330, while Involving a relatively limited number of persons, nevertheless fall into a series which has been heavily involved, as noted in the preceding section* The relationship of these lots may or may not be significant* The table lists all lot numbers with watch jaundice was associated and for each the number of persons inoculated., the number of cases of jaundice and the number of those hospitalized, and the attack rate per one hundred persons. The lots without associated jaundice are lumped together under the heading of others. The Individual attack rate for lots associated with more than one or two cases varies from 2.1 to 13c6 per hundred, while the similar rates for the entire group (936 cases out of 31,351 individuals inoculated) is 3ol. Approximately three-fourths of the patients were hospitalized. A field survey of the 814 th Engineer Battalion showed this organization which was stationed in England to have received for the most part different yellow fever vaccine lots from the troops in Northern Ireland* The lots associated with jaundice in that battalion and not included in the above large series were as follows! Table 12* 39 In addition to the 31,351 persons receiving yellow fever vaccine, data were also obtained on 4,073 soldiers who were not inoculatedo Among this group were 13 cases of jaundice (0.3 per one hundred). A detailed investigation of 8 of the cases is subsequently described. The conclusion to be drawn is that the well defined grouping of certain lot numbers suggests the serum diluent as the factor through which the unknown virus was introduced into the yellow fever vaccine Clinical Reaction According to Lot Number. —Correlation was also made between the lot number of the yellow fever vaccine received by individuals, the presence or absence of jaundice, and the extent to which jaundice was present. Of 1594 persons surveyed, 1531 had received yellow fever vaccine from one or other of 21 different lots including 238 persons for whom the lot number was unknown. Some 48 persons had not been vaccinated against yellow fever and records were lacking for 15„ The majority had been inoculated with vaccine from Lot Nos. 338, 351 and 368„ Groups inoculated from these lots had a relatively high attack rate of jaundice,. Other sizeable groups of persons received yellow fever vaccine from Lots No„ 327, 340, 347, 353 and 423 and no individual within these groups became ill., Again five cases of jaundice occurred among nine persons inoculated with Lot No. 317 and 15 cases occurred among 90 persons vaccinated with Lot No0 319. Several lots among them, No. 350, 352 and 345 were used for one person only with no jaundice resulting. One lot, No, 367, was used for 5 persons none of whom became infected. Forty-eight persons surveyed had received no yellow fever vaccine and showed two clinical cases of jaundice although drawn from a population inhere the attack rate was 14$. (Table 13)» Distinct variation is to be seen in the frequency of jaundice resulting from administration of various lots of vaccines * In some instances, the proportion of those affected was as great as 56%, in others such as Number 362, it was decidedly minimal „ It is further evident that a relatively small proportion of patients were severely enough affected to have been sent to hospitals,, Among the 228, the proportion was 34 per cent. By far the greater number were ambulant, 66% and 13,5 others were only determined to have sub- clinical Infections as the result of field investigation.. The attack rates of the three large groups who received vaccine of Lot Numbers 338, 331 and 368 were respectively 25%, 13% and 15%o This variation was conceivably either a function of the vaccine itself or that those groups were subjected to circumstances favorable to the spread of an epidemic hepatitis having an origin independent of the vaccine. If the latter were true, then a variable attack rate would be expected among different groups of men receiving 40 the same lot of yellow fever vaccine. The best proof that the attack rate was a function of certain lots of vaccine was in respect to Lot No. 368, which was administered to at least three groups of men represented in this study. Virtually similar attack rates for jaundice were observed in all three. In summary, certain lots of vaccine were associated with a higher attack rate for Jaundice than others* There was indication that for one lot, hoc 368, the attack rate was the same when given to three different groups having little or no contact with each otherc This was determined to be a regular observation. Relationship of Date of Inoculation to Incidence of Jaundice. In an attempt to determine whether there was any relationship between the date of inoculation and incidence of jaundice, the two lot numbers associated with the largest numbers of cases, No. 338 and 368, were selected for study and the Incidence of jaundice determined for each according to the time of administration, using half month periods. The results of this analysis in Table 14 show no apparent relationship between these two factors. The incidence of jaundice irrespective of the time of the year or the troops to which it was given, regularly led to about the same frequency of clinical disease. Incubation Period According to Lot of Vaccine0—The field survey methods were not believed to have given sufficiently accurate dates of onset to warrant computation of Incubation periods or more properly the elapsed time from the date of yellow fever inoculation to the onset of symptoms. Reports were available for 298 cases in which the onset of symptoms was determined by the medical officer caring for the patient with Jaundice„ Table 15„ Only four lots of vaccine were concerned with sufficient numbers of cases to warrant analysis* The scatter of incubation periods by weeks for each gave no evidence of a characteristic incubation period for any given lot, except that lot No* 338 generally gave evidence of greater delayed reaction* Figure A illustrates the time distribution for the 298 cases of Jaundice0 Effect of Other Immunizing Agents on the Incubation Period.- Most of the troops inoculated with yellow fever vaccine had also been immunized against typhoid, small pox and tetanus. The question arose as to whether inoculation with one or more of these immunizing agents at or near the time of yellow fever vaccination had any effect on the incidence of jaundice. Unfortunately, the immunization records in respect to the three other agents were not available except for reports submitted by Surgeons of various commands in the British Isles. Of 298 cases on which reports were received, 169 had been immunized with yellow fever vaccine Lot No. 368 and this group was therefore selected for further study. No incidence rates could be computed since all the individuals had developed jaundice, so incubation time was decided upon as the next best 41 criteria for determining the possible influence of other immunizations. The period at or near the date of yellow fever immunization was arbitrarily defined as comprising 20 days before or after that date. The results of the analysis are given in the accompanying table. The cases were divided into those receiving no other immunization during the specified AO day period and those receiving any one immunization, any combination of two, or all three, making in all eight categories. Each of these was further subdivided by length of incubation period (from yellow fever inoculation to onset of symptoms) in ten day groupings. The incubation period for each classification would ssem to be fairly symmetrically arranged about the 81 to 100 day period Inoculation with other immunizing agents at or near the time of yellow fever vaccination would appear to have had little or no effect upon the incubation period, Table 16« Interval Between Yellow Fever Inoculation and Jaundice,— The interval in weeks that elapsed between the administration of yellow fever vaccine and the development of jaundice is illustrated in Figure 5 from survey reports. It is to be observed that the most common period was in the fourteenth week and that arrangement about that point was representative of a symmetrical distribution.. The data Include all patients developing jaundice within the year 1942-43 who had ever received yellow fever vaccine „ The particular purpose in arranging this material was to determine the possible existence of secondary or tertiary waves of jaundice, this interest relating to communicability of the condition., If the usual incubation period is accepted as about 14 weeks, then a secondary rise should be evident about 28 to 30 weeks. There was a slight increase o A third wave would be apparent somewhere around the 40th week, and is again manifesto A fourth wave would appear about the 55th week, and again a slight indication of such a phenomenon appears in the diagram„ This is the only evidence Indicating a possible communicability of the condition., Epidemic Jaundice Among Troops Not Immunized Against Yellow Fever.—The preliminary field investigation among recently arrived American troops in Northern Ireland gave information of 32 soldiers who had not received yellow fever vaccine. Ail others of the 1045 investigated at that time had been Inoculated with the vaccine. The number of non-immunized persons was subsequently increased to 39. No jaundice occurred among these soldiers despite the fact that they belonged to various military units in which the attack rate for jaundice was about 14$. This circumstance was considered to bear importantly on the origin of the condition. In consequence, more than usual attention was given to a report from the 10th Station Hospital, Londonderry, that 8 patients with jaundice of varying degrees of severity had been admitted and A2 Figure 4. Incubation periods of 298 cases of jaundice, North Ireland Force, European Theater of Operations, U.S. Army, Number of weeks between inoculation and onset of symptoms, February to May 19-42. Interval in weeks between yellow fever inoculation and onset of Jaundice, European Iheater of Operations, 0,3. Army, February to May 1942, inclusive. Figure 5. had received no previous yellow fever vaccine, The etlologr of the condition was obscure. All presented the usual objective and subjective symptoms of epidemic hepatitis, none were seriously ill and none of the patients had died. The eight natients belonged to the 151st Field Artillery; one to Battery A, four to Battery B and one to Battery C, one from the Service Battalion, and one from the Headquarters Battalion, The cases from Headquarters Battalion, Battery A and the Service Battatlon were all officers who had been more or less in contact with each other. The significant feature of this group of eight patients with Jaundice was that none of the men had "been vaccinated against yellow fever., While this information could not be substantiated by actual inspection of their immunization records, it seemed definite from medical histories obtained from the patients and from the word of one of their officers, himself a patient„ In respect to the officer, his immunization record was produced and contained no mention of yellow fever inoculation., In general, the troops to which these patients belonged had not been immunized and there seemed no reason to doubt the history glven„ The medical officer of the unit confirmed the absence of administration of yellow fever vaccine• Furthermore, the period betv/een any possible exposure to American troops arriving in May and the date of onset of these eight cases made contact through that channel Impossible. If an extraneous source of Infection for this group could not be determined, doubt would necessarily exist about the relation- ship of the currently prevalent jaundice to inoculation with yellow fever vaccine. The best assumption seemed to be that these soldiers had been exposed to ordinary epidemic hepatitis in Ireland and that the disease from which they were suffering was of altogether different origin from that among the newly arrived American troops whose jaundice could be traced to America, The camp of the 151st Field Artillery had been located for several months since January 1942 near the village of Ballyrena. From the local health officer it was learned that ordinary epidemic hepatitis had appeared in August 1941 in Ballyrena, with a considerable number of cases that frequently involved two or three children in the same family. Further cases had occurred during December 1941 and thereafter the outbreak spread up and down the coast, Involving a number of villages including Port Rush, McGilligan Point and others. A goodly number 8f cases still existed in April and the disease was prevalent at McGilllgan Point which was the area in which the camp of the 151st Field Artillery was located. The lady health officer recalled the existence of jaundice among 3 or 4 children during the week of April 8, She spoke particularly of an outbreak involving the Quigley family who lived directly opposite 43 the entrance of the arny camp. Essentially one month later, the usual incubation period for tfyls infection, on May 4, the first case of Jaundice appeared in an American soldier. All subsequent cases developed within that month. The explanation of Jaundice among non-inoculated members of United States forces in Northern Ireland seemed therefore to depend on contact infection from a thoroughly widespread outbreak of epidemic hepatitis in the region in which they were stationed. Local doctors volunteered that contact between soldiers and civilians was close, and that American soldiers were highly esteemed in the community. Added evidence in respect to the prevalence of ordinary epidemic hepatitis in the region was furnished by the outbreak among British soldiers stationed at Coleraine, about 12 miles distant. This occurred in August and September 19-41. Comparative Attack Rates between Inoculated and Uninoculated TroopsIn further elaboration of the relationship between inoculation with yellow fever vaccine and the occurrence of Jaundice among American troops, information was gathered from medical officers in charge of troops in Northern Ireland, concerning soldiers who had not received yellow fever vaccine„ The outbreak of Jaundice had involved particularly the troops arriving about 12 May. Almost all had been inoculated with yellow fever vaccine and the attack rate was relatively great, 17%. Some 316 soldiers of this contingent for one reason or another had not received yellow fever vaccine. No Jaundice occurred in the group. This was also true of a smaller group of 12 men whose time of arrival was irregular since they reported as casuals, but who arrived in the theater during the same general period. Table 17. A division of United States soldiers had arrived in Northern Ireland on January 26, preceding the main contingent by about 3 1/2 months. Many had not been inoculated with yellow fever vaccine prior to their departure, in all 3379 individuals, Eight cases of Jaundice had occurred in this group. The 8 cases constituted the outbreak Just described. Aside from this localized outbreak related to Irish sources, the remaining 3371 men had been unaffected by Jaundice. The attack rate for Jaundice among all ye How fever immunized troops of the May 12 group was about 17%. The attack rate for Jaundice among the non-immunized troops of the January 26 group was 0.24%, about the usual attack rate for sporadic epidemic hepatitis. Communicability of the .Disease A number of field observations contributed evidence bearing on the communicability of homologous serum Jaundice. It is 44 well known that ordinary epidemic hepatitis is infectious and trans- missahle, and that the usual attack rate amongst attendants of such patients is relatively high0 Consequently evidence on the communi- cability of the Jaundice that followed immunization with yellow fever vaccine was sought from the study of the reactions of contacts to patients with the disease. The Medical Detachment of the 5th General Hospital included some 260 persons, physicians, nurses and enlisted.men. They were responsible for the care of most of the patients with jaundice during the epidemic. No case of jaundice with the possible exception of one subclinlcal infection was determined by survey of this group in May. A further examination by direct survey at the end of June and again in November 19-42 showed a single case of jaundice to have occurred after the original examination. This was the case of accidental inoculation jaundice described separately below. Do contact or other infections occurred. Troops among whom Jaundice was occurring were in some instances billeted in close contact with civilian populations known hy Inquiry to have been previously free from Infectious Jaundice. Inquiry made at the end of four months showed no transfer of the condition to civilians„ Opportunity was further presented to determine the possi- bility of transmission by contact between military organizations. Much jaundice had occurred among the troops of the 13th Armored Regiment. The 106th Coast Artillery was stationed in close contact with that organization. The Artillery unit had not been immunized against yellow fever, and subsequently over a period of four months showed no cases of jaundice. Jaundice Following Accidental Inoculation Evidence of another sort indicated that the disease could he transmitted hy accidental inoculation of hlood or serum from persons suffering from the condition0 In June 1942, in the course of caring for patients who developed hepatitis with jaundice after vaccination with yellow fever vaccine, a ward surgeon of the 5th General Hospital jammed a hypodermic needle into his finger after taking blood from a patient relatively early in the course of the disease. The needle was in- troduced far enough into the finger to hang suspended without sup- port. It was promptly removed and the finger encouraged to bleed freely. Four months later, about 1 October, the surgeon developed symptoms characteristic of the hepatitis which followed administra- tion of yellow fever vaccine. The onset was insidious, with vague gastrointestinal complaints over a period of two weeks. The urine was dark, gave a positive test for bile and had an Increased con- centration of urobilinogen. Jaundice of the sclerae soon became 4-5 apparent„ There was no fever; the liver was enlarged and tender0 The initial phase of the Illness was accompanied by a skin eruption most marked over the buttocks0 The Jaundice was moderate and the usual symptoms were present for three to four weeks„ Improvement was extremely slow, the liver did not return to normal for eight weeks, and In December the patient had not recovered his full strength. While no specific test could determine the nature of the illness, the disease was indistinguishable from the hepatitis following yellow fever vaccine., There had been no epidemic hepatitis in the command, although patients had been admitted with this disease. It was assumed that the ward surgeon Inoculated himself with an infectious agent which had been the cause of the outbreak of Jaundice following vaccinations with yellow fever vaccine. The incubation period was most suggestive. He had received yellow fever vaccine of Lot No, 327 or 342 in January 1942, neither of which were incriminated in the outbreak of Jaundice, and the elap- sed time also served to eliminate that source of infection. Case 20 A woman technician who had never been vaccinated against yellow fever developed Jaundice, From June until H0vember 1942 she determined over a thousand icteric indices in cases of acute hepatitis of yellow fever vaccine origin. She remembers suck- ing serum into her mouth on two occasions, in August or September 1942, On 17 October she had loss of appetite and mild pain in the upper right quadrant of the abdomen; on 20 October nausea and vomiting. The following day the white cell count of the blood was 3,000, On 27 October the urine became dark red, followed two days later by icterus of the sclerae. Recommended Preventive Measures Unit commanders were instructed to examine immunization registers in order to determine those officers and men who had been inoculated with lots of yellow fever vaccine brought under suspicion by the survey findings0 These lots were Nos„ 317, 319, 320, 333, 333, 338, 331, 360, 367, 36B0 For such individuals a high carbohydrate diet was advised for six months after inoculation, avoiding or at least greatly decreasing fried foods and particularly greasy foods. Arrangements were made to provide wherever practical an increased candy ration for this group and also increased amounts of other carbohydrate foods such as molasses, honey, syrup, preserves and Jam, It was further advised insofar as compatible with military requirements that these individuals avoid severe or long continued mental or physical exertion, and exposure to unfavorable environmental conditions, 46 Unit surgeons were instructed to be on the lookout for change of bowel habits, undue fatigue, biliousness and dark urine, and to encourage troops to report promptly the occurrence of any of these symptoms. HOMOLOGOUS SERUM JAUNDICE AFTER TRANSFUSION The outbreak of jaundice following yellow fever vaccination and that associated with passive protection against mumps by con- valescent serum naturally directed attention in 1942 to the pertinent possibility that similar events were occurring as a result of transfusion of blood, and the intravenous use of such blood fractions, as plasma and serum for the treatment of shock after wounds e Early studies by the British Ministry of Health and by the Jaundice Committee of the Medical Research Council readily established that this was soc The Ministry of Health collected records of 456 British soldiers convalescent from wounds in Emergency Medical Service hospitals in Great Britain, All had received plasma or blood and had been in hospital 100 days or more. Thirty six developed jaundice, in the proportion of 79 per thousand trans- fused men, and the mortality rate was 20 per thousanoOnly 3 cases of jaundice occurred among 1741 wounded men who had not oeen trans- fused, but were in hospital at the same time and under the same con- ditions, / Similar suggestive Instances were noted in American practice but the number was small, the cases were isolated and there was always the question of the infection being related to naturally acquired epidemic hepatitis. Not until the number of casualties increased with the opening of the continental campaign, and trans- fusion of blood or blood products became more common, was it evident that jaundice due to an icterogenlc agent in blood plasma or serum was a matter of equal concern to the U, S, Army, The incubation period of this condition, which is another form of homologous serum jaundice, is about three months. Con- sequently reports of American experience first became available in any considerable numbers in the autumn of 1944, the first coming from the 7th General Hospital, A series of 14 cases of jaundice was observed among surgical patients convalescent from wounds, who had received plasma some months previous to the development of jaundice. Several had received blood as well, The infections were relatively severe and several had ended fatally. Epidemic hepatitis was an uncommon disease in Great Britain at that time. That and the localization of cases among surgical patients made it probable that the condition was homologous serum jaundice. 47 Corroborative evidence soon came from the 297th General Hospital where 30 patients with jaundice had been observed among 6,000 admissions, about evenly distributed between the medical and surgical services. Fifteen cases were considered in all probability to have been homologous serum jaundice. The disease was of a fulminating variety and three patients had died0 Inquiries were Instituted among general and station hospitals in Britain where the majority of wounded retained in the theater were in hospital 0 From reports received in the course of the next several months, up to 1 March 194$, from 49 hospitals in the United Kingdom, only nine hospitals gave a negative report. The remaining 40 reported 281 cases of jaundice among surgical patients occurring 4$ to 100 days after transfusion of plasma o’r blood. Twenty one of the patients had died. Information on 143 patients of the series was sufficiently detailed to permit further analysis. Patients who received plasma alone numbered 47, an additional 11 had been transfused with blood and the remainder had received both. Deaths among the 143 cases numbered 14, of which $ had been treated with plasma alone and 2 with blood only* The illnesses were described by attending phy- sicians as generally mild or moderate. When death took place it was almost invariably before the tenth day. Some patients died within four or five days of the onset of jaundice, the disease taking a violently unfavorable turn with disorientation rapidly followed by coma. The conspicuous feature of post mortem examina- tions was an almost total disappearance of liver cells. During the period covered by this study, from late summer of 1944 to 1 March 194$, admissions to hospital in the United Kingdom for epidemic hepatitis were consistently low and deaths from this cause were decidedly few. The incidence of jaundice among patients who had been transfused was notably greater than that for persons who had not received blood fractions. These data were collected from a variety of hospitals and in general depended upon the memory of physicians who treated the patients. Some few cases of epidemic hepatitis may well have been included but would appear to be more than balanced by un- recognized cases of homologous serum jaundice. Patients recovered from wounds were ordinarily returned to one of the large reinforcement centers for convalescence. A sur- vey of the 10th Reinforcement Depot revealed that during the months of August to November 1944 only 20 cases of jaundice had been noted among 34,-478 battle casualties processed at the depot. In general these men represented the more mildly wounded who had not so commonly received blood transfusion. 48 Plasma would appear to be a more common source of homologous serum jaundice after transfusion than blood. The pools were larger. The ordinary unit of plasma represented contributions from at least eight donors and the number was sometimes as great as 25. The chances of an icterogenic agent being admitted would be in about that order for the two products. SUMMARY OF ACUTE INFECTIOUS JAUNDICE The preceding discussion has demonstrated that the problems of acute Infectious Jaundice in the European Theater were continuous, diverse and often confusing in nature. Epidemiologically two separate kinds of Jaundice could be distinguished. The first was a specific disease entity as separate and individual as measles or mumps. This was epidemic hepatitis. It was present among troops of the United States Army from the early days of the theater until the close of operations. Truly epidemic proportions were reached in the spring of 19-45, particularly among Ground Force units of the 7th Army which brought the infection with them from Italy where epidemic hepatitis had been consistently at a nigh epidemic potential. The mode of transmission remained unsettled, except that the experience in the European Theater served rather definitely to eliminate insects as a consideration. The weight of evidence suggests that spread of the infection was chiefly by secretions from the upper resplratorv tract, which was the common opinion among surgeons of units where the disease was prevalent. Certain outbreaks were suggestive of an origin from water, or from food, or otherwise by way of the intestinal tract. That such means constituted the ordinary and usual route would not appear likely in view of the broad epidemiologic behavior of the disease, which is much muic like that of an infection transmitted by secretions of the respiratory tract than by the intestinal route. The causative agent remains undemonstrated, although the accumulated evidence continued to support a probable flltrable virus. Homologous serum jaundice appeared to be a separate condition, the chief evidence in support being the outstandingly different incubation period and the lack of communicability„ The icterogenic agent was rather commonly present in the blood serum of apparently normal human beings* The two epidemiologic mani- festations of the condition, the outbreak of jaundice after yellow fever vaccine and that which followed transfusion, appeared to be representative of the same phenomenon* Jaundice after treatment for syphilis by arsphenamines was a minor consideration. The origin was mixed, in some instances arising by the same mechanism responsible for homologous serum Jaundice and in others corresponding to a normal infection of the 49 nature of epidemic hepatitis„ It is not to he considered an individual problem, but related to one or other of the tv/o principal forms of jaundice* ■ Leptospirosis or Weil9 s disease was the most unimportant among problems of acutely developing jaundice* The disease was rarely observed* miROTHOPIC VIHJS DISEASES The neurotropic virus diseases were never of great concern in the European Theater* Lymphocytic choriomeningitis was not a reportable condition and its frequency among disease conditions is not known* Discussion will be limited to poliomyelitis and encephalitis of the group transmitted by secretions of the upper respiratory tract with brief consideration of the preventive measures employed against rabies, of which no case occurred. Poliomyelitis Poliomyelitis was a most uncommon disease in the European Theater* Four oases occurred in 1942 and the same number in 1943* The year of greatest prevalence was 1944 with 36 patients among the theater population* The data for 194$ are for the first six months of the year and the 24 cases therefore represent a rather decided excess prevalence, in that all occurred before the time of usual seasonal prevalence* The average annual rate of incidence during the period of operations was 0*02 per thousand strength per annum, which compares very favorably with the rate among soldiers stationed in continental United States which was 0*03? and for total troops in overseas areas where the rate was 0*07* (Table 18) The China-Burma-India Theater had the greatest frequency of poliomyelitis with a rate of 0*23 and the Southwest Pacific was next* No cases were reported in the Alaskan Theater* The data include polioencephalitis as well as poliomyelitis* Encephalitis Encephalitis in the European Theater was a rarely recognized condition. One case is included in the medical records of 1944 and two came to report in 194$* Most cases of encephalitis came from the theaters in the far eastern area* The Chlna-Burma-India Theater had the greatest number with 18, followed closely by the Pacific Ocean Area and the Southwest Pacific* The incidence in these areas was largely related to the outbreak of Japanese B encephalitis on the island of Okinawa* The records for the other theaters of operation were much the same as those in the European Theater. 50 The greatest number of cases by far, 320, came from troops stationed in continental United States., (Table 19) Rabies Despite the far flung activities of the United States Army during the course of the war just passed, not a single case of rabies occurred among troops serving in any of the theaters of operation. Two cases were reported from continental United States, It was a novel sensation in the experience of most American physicians to be able to look with complete equanimity on the occurrence of a dog bite among patients of their practice. Rabies had been so long absent from Great Britain by reason of the stringent quarantine practiced in that country that no need existed for administration of anti-rabic vaccine after bites by dogs or other animals, The last rabies in Great Britain occurred at the time of World War I, A small stock of anti-rabic vaccine was maintained at theater headquarters in Great Britain to care for unusual situations but was rarely drawn upon. In only one instance did the need exist. An officer of the Air Corps freshly arrived from the Zone of the Interior had been bitten by a dog previous to his departure. On arrival in the United Kingdom, word awaited him that the dog had died. Anti-rabic vaccine was not immediately available at the port of debarkation, and a civilian source of supply could not be located. Without more ado the officer took the next plane back to America for preventive treatment. The rabies situation in France was almost as favorable. The records of the Instltut Pasteur contained no definite case of rabies in animals for some years, and no human had died from rabies in France for 16 years. Rabies was reported in Berlin in 194-5 and occasional in- fections among animals were recognized in northwest European countries. Most American medical officers consequently returned to traditional practice in the management of dog bites. Such in- stances were not frequent and stocks of anti-rabic vaccine were not maintained in theater depots generally. Vaccine was obtained promptly by requisition on the Supply Division of the Medical Department at theater headquarters through arrangements made with the Instltut Pasteur by which that organization furnished all anti~rabic vaccine required by American trooos. JMo serious program of prevention was under taken. The principal effort was directed toward inclusion with the provisions 51 relating to sanitary control of air traffic, of prohibition on importing dogs and other pets into the theater areau The enforce- ment of this regulation brought a number of troublesome situations, but the American forces had a distinct obligation to prevent introduction of this transmlssable disease. Previous to shipping military guard dogs to operational areas in France, they were immunized against rabies. TETANUS No more astounding example can be cited in support of the progress made by preventive medicine in recent years than the circumstance that in a war of three and a half years duration, with battle casualties that numbered 395.A88, a single case report constitutes the record for tetanus. The measures employed for the prevention of the disease have been set forth in the section on specific Immunization. The single case that occurred in the European Theater of Operations terminated fatally. EPIDEMIOLOGIC CASE REPORT NO. 3 - A private first class of Company B, 30th Infantry Division, 119th Infantry, received a perforating gun shot wound of the right foot as tne result of enemy action in an unknown locality in Prance, 1700 hours, 27 August 1944. Emergency treatment including 1 cc. of tetanus toxoid was administered at the battalion aid station four hours after the injury. The wound was debrided and a boot cast applied at 0310 hours, 29 August at the 77th Evacuation Hospital. The patient was evacuated to the 128th General Hospital in Great Britain on 31 August and his condition was good when he arrived. At 1800 hours the next day he noted a stiffening of the jaw while eating his evening meal, and at 2100 hours he experienced a definite spasm of the masseter muscles. During the next four days he received 3B0.000 units of tetanus antitoxin, liberal doses of penicillin, blood plasma, sulfadiazine and a minimum of 2,000 cc of five percent dextrose saline solution. The patient died of strangulation at 1400 hours on 5 September 1944- in spite of an emergency tracheotomy and after previous apparent improvement. Tetanus toxoid had been administered in January 1944 as an original series and a stimulating dose was given on 28 August 194-4, approximately four hours after injury. The situation was not so satisfactory in regard to German prisoners of war, but does give excellent indication of the number and kinds of casualties which would have been experienced by the United States Army in the absence of the methods of prevention that were employed,, Hie German Army did not use tetanus toxoid. 52 Only Incomplete information is available but it is known, for example, that during the period 17 September to 2 October 19-44, no less than 53 German prisoners of war were received in hospitals in the United Kingdom with tetanus, of whom 16 died„ A further record of tetanus among German prisoners of war is obtained from the records of the Advance Section of the Communications Zone, where from September 1944 to June 1945, 70 cases of tetanus were observed among German prisoners. The number of deaths that occurred in this group is not known, but for the period 1 May to 15 June 1944 there were 13 deaths from tetanus among prisoners of war. Other Thfeaters of Operation,—The experience of the European Theater was by no means unique. For all theaters of war there were only 3 cases of tetanus; 1 in the China-Burma-India Theater and one in the Mediterranean Theater in addition to that just described for the European area. It is a most peculiar circumstance that in those areas where the war was fought there were 3 cases of tetanus; while in continental United States among troops in training the number was 10. (Table 20) SCABIES Both on the Continent and in the United Kingdom, the troops of the European Theater were situated among a civilian population where scabies was prevalent. The frequency of the disease was measurably enhanced in all countries of the war zone and continued so throughout the duration of hostilities. Conditions on the Con- tinent were worse than in the United Kingdom, The rates that pre- vailed in the American Army are judged satisfactory compared with those experienced by British troops. Figure 6 The disease was most common in 1943 with an average annual rate of 9,02, (Table 21), That most of the cases were con- tracted in Europe was demonstrated by repeated surveys of recently arrived troops which showed almost universal freedom from tills skin disease. This was in agreement with usual American experience, in that scabies was no problem in camps of continental America, Judged by the single year of operations on both the Continent and the United Kingdom, no great difference existed between the frequency of scabies in the two areas. The rates were almost identical. (Table 22) Among Theaters of Operation of the United States Army, the rates for scabies in the European Theater were relatively great, since the theater occupied second place, being exceeded in the frequency of this condition only by the Mediterranean Theater, The rates for the theater were essentially twice those of Continental United States, (Table 23) 53 ANTHRAX In Great Britain no question ever arose of anthrax in- fection among civilians associated with American troops, nor among troops themselves„ Prance hy contrast is traditionally the seat of small localized endemic foci, principally on the Brittany peninsula. The first report of this disease from American occupied regions on the continent .came on 8 August 1944. Two butchers and a farmer at Briec near Quimber in Brittany had slaughtered a cow and developed cutaneous"anthrax. The bizarre nature of the disease and the lack of familiarity on the part of American physicians led to more than usual activity when the report of the outbreak was received. Investigation showed that in addition to the three human cases, some 30 instances of anthrax Infection among animals had occurred within recent weeks on seven farms. Veterinary offi- cers of the Civil Affairs Division aided local authorities in instituting control measures and in obtaining supplies of anti- anthrax serum, A special investigation by the Preventive Medicine authorities led to certain assurance that no significant health problems in relation to American soldiers was likely to arise from the circumstance. A number of suspected cases of anthrax continued to be reported in the succeeding autumn months but the next confirmed case of the disease of which record exists was on 2 June 19-43, This was a single infection in man. No instance of anthrax infection was ever suggested in an American soldier. The numbers stationed in endemic regions were always small. LEPROSY Two cases of leprosy were reported in .the theater during the course of operations in Prance, The onset of both antedated military service. The first case was recognized during the week ending 22 December 19-44, The patient, a soldier aged 39 years, white, and a native to Texas, had had a tour of duty in the Philippines and China from 1933 to 1937, Later he spent a year in Panama, in 1939. The first cutaneous manifestation of leprosy apparently developed there, for a diagnosis of erythema multiforme was made. When first seen in Prance he had deeply pigmented anesthetic areas generally distributed over the body. There were nodular lesions on the face. Mycobacterium leprae was recovered from smears from the nose and the organism was particularly numerous in biopsy tissue. In view of the recovery of the bacterium from the nose, the Infection was considered an open case of the maculo-anestnetlc type. 54 Figure 6. Scabies, iimerican and British Annies in the United Kingdom, rates per 1000 strength per annum, February 1942 to January 1944, inclusive. The patient had had the characteristic leonine expression for approximately a year. After service in the United States Army until 1933, he returned to his home in San Antonio, Texas where he remained until he re-enlisted in 19370 He served tours of duty at posts in Louisiana, Southern Texas and in the Canal Zone, all endemic areas of leprosy0 The first manifestation of the disease was the appearance of annular lesions on the chest and abdomen in 19-43 while in the Canal Zone. Although some of the lesions were known to be anesthetic, the diagnosis of erythema multi- forme was maintained until admission to hospital in 19-44. The second patient was a Puerto Rican born in San Turce, Puerto Rico where he had. lived until he was inducted into the Army. He reported to Fort Dlx in 19-43 where he spent five months, tie was transferred to England and subsequently to France and Belgium, while in England in October 19-44 he reported a lesion on his face, was it was merely an eruption and to go back to duty. On 8 February 1945 he again reported to the dispensary and was admitted to a General hospital. Examination of a nodule of the forehead demonstrated the leprosy bacillus. There was no family history of leprosy or of exposure to patients with leprosy. It is not believed that he had been exposed while in the military service The disease was manifested by nodules on the face with some deform- ities, some crusting of the lesions and anesthesia of the little fingers of both hands. Smears from the nose were positive. Of the 20 cases of leprosy originating among troops of the entire Army during the period of the war, January 1942 to June 19-45, twelve were recognized in Continental United States and eight in overseas Theaters of Operation It is to be noted that the official records of the Medical Statistics Division credit the European Theater with one case, but actually there were two0 The most common source of leprosy outside of the United orates was the Pacific Ocean Area with six cases, and one each came from the Mediterranean Area and the Africa-Middle East Theater„ (Table 24) UNDULANT FEVER Undulant fever, including cases reported as Malta fever, occurred among troops of the United States Army to the extent of 485 cases. The troops of continental United States showed by far the greatest frequency with 338 and only about one-'third that number were recognized in theaters of operation. The Medi- terranean had the greatest number, 70 cases, and the Pacific Ocean Area was next with 20. All theaters of operation were represented, but the Alaska Theater had only a single case. Of the 12 cases reported in the European Theater, six occurred in 1944 and all were from Great Britain. Three of the six cases in 1945 were from that area and three originated on the Continent of Europe. (Table 25) 55 „_Tatal . I 1942 _ . 1942 194 -4 i. 1945 Month Cases Rat© Cases Rate Cases Rate Cases Rate Cases Rate January 1726 6,4 59 5,4 414 6,7 1253 6,4 February 1990 7,0 0 0 35 4,1 198 2,8 1757 8,5 March 4573 12 o 1 0 0 38 4,6 225 2C2 4310 16,3 April 3974 12 o 3 0 0 37 3,5 236 2,5 3701 16,9 May 2998 9,0 396 186,0 21 2,2 317 3,2 2264 10,2 June 2453 6,0 499 140,5 26 2,1 219 1,7 1709 6,5 July 648 4,8 380 59,4 70 3,7 198 1,8 August 365 2,4 120 13,7 46 2,4 199 1,6 September 368 1,3 67 5,3 54 2,3 247 1,5 October 419 2,2 28 1,7 105 2,9 286 2,1 November 958 4,7 56 3,2 527 12,9 395 2,6 December 1751 5,8 37 4,0 771 11,9 943 4,2 Total 7,0 1563 21751 1789 6,8 3877 2o6 ' 14994 10,9 Sources Division of Medical Statistics*? Office of The Surgeon General.? War Washington*, D, C, Infectious Hepatitis European Theater of Operations*) U« S0 Army Cases and Rates per 1000 strength per annum* by months February 1942 to June 1945* Inclusive Table 1 Table 2 Infectious Hepatitis United Kingdom and Continent European Theater of Operations® U»‘ So Army Cases and Rates per 1000 strength per annum by months September 1944 to June 1945® Inclusive Total United Kingdom Continent Month Cases Rate Cases Rate Cases Rate 1944 September 247 , lo5 178 2©7 69 «7 October 286 2ol 187 4o5 99 1.0 November 395 2o6 243 5o9 • 152 1.4 December 943 4«2 334 5o6 609 3©7 1945 January 1253 6o4 286 5«8 967 6©6 February 1757 8o5 322 6o8 1435 9.0 March 4310 16„3 377 7©5 3933 1804 April 3701 16o9 312 8el 3389 18© 7 May 2264 10© 2 247 8©3 2017 10© 5 June 1709 6©5 172 3«,7 1537 7© 1 Total 16865 | 8©f ““2658 5©6 14267 9©0 Sources Division of Medical Statistics/, Office The Surgeon Generals War Departments Washingtons Do Co of - 1 Theater Total 1942 1943 1944 1945 Cases Rate l~———— Cases Rate Cases Rat© Cases Rate Cases Rate ‘ 1 —■ Total Army 142678 6o7 38588 12©65 24284 3©60 30010 4© 00 49796 12© 8 Continental U© S© 54557 2 3 61 26029 10© 26 3005 ©59 2881 ©72 2642 1©8 Total Overseas 108121 13 9 5 12559 24© 5 21279 13© 4 27129 7©8 47154 19©4 Mediterranean 37077 27o4 35 1©5 15865 36© 8 14980 22©7 6199 25© 8 South West Pacific 31202 25<>9 1514 23© 0 550 2©8 6025 9©1 24113 61©9 Alaska 3119 11 o 5 2959 58©91 50 ©44 25 ©30 85 3©6 China- Burma- India 3102 9©3 108 19©0 443 9© 6 1928 12© 1 625 5© 1 Pacific Ocean Area 9049 8© 7 6056 34e5 2248 7©6 812 2ol 953 4© 5 European 22223 7©0 1565 21© 5 1789 6©8 3877 2©6 14994 10© 9 Africa-Middle East 762 5© 8 81 14© 1 257 4© 8 294 6© 2 150 5©4 North America 573 3© 4 | 555 13©65 4 ©06 7 ©17 9 ©6 Latin America 1014 2©9 692 6© 73 73 ©60 181 2©1 68 1©7 Sources Division of M< War Department sdical Statist! Washington-, cSfl Office of T D* C© he Surge >on General© Infectious Hepatitis Total Army*, Continental United States and Theaters of Operationsa U« S0 Army Cases and Rates per 1000 strength per annum January 1942 to June 1945* Inclusive Table 3 Table 4 Weil’s Disease Total Army, Continental United States and Theaters of Operations, U* S* Army- Number of Cases* January 1942 to June 1945, Inclusive Theater Cases Total Amy 18 Continental U»S* 1 Overseas 17 European 10 South West Pacific Area 6 Africa-Middle East 1 Alaska 0 China-Burma-India 0 Latin America 0 Mediterranean 0 North America 0 Pacific Ocean Area 0 Sources Division of Medical Statistics* Office of The Surgeon General* War Department* Washington* D« C* Table 5 Infectious Hepatitis AAF Station 113p 8th Air Force European Theater of U»S» Army- Distribution of Cases by Date of Onset ,25 March to 26 April 1944 Date Total Cases at AAF Station 113 Cases at other AAF Stations March 25 1 1 0 April 10 1 1 0 13 1 1 0 14 2 2 0 15 6 1 5 16 3 2 1 17 11 2 9 18 9 6 3 19 6 3 3 20 6 1 5 21 6 2 4 22 7 4 3 23 8 5 3 24 1 0 1 26 1 0 1 Total 69 31 38 Sources Subject 1< 3tier* Investig Ration of Epidemic Hepatitis 3 8th AAF* to? Chief Surgeon* Hq ETOUSA* from Division* Preventive Medicine* Office of the Chief Surgeon* ETOUSA* dated 13 May 1944* Table 6 Epidemic Hepatitis by Armies European Theater of Operations» U*S® Army Cases and Rates per 1000 strength per annum* by weeks 1 September 1944 to 29 June 1946* Inclusive Week ending- First Third Seventh Ninth Cases Rate Cases Rate Cases Rate Cases Rate 1944 September 1 3 .6 1 .2 27 10.9 0 0 8 - 1 .2 23 9.2 0 0 15 4 • 8 2 .5 20 8.5 0 0 22 2 o 4 1 .2 33 14.5 0 0 29 - mm 3 .6 36 13.9 1 .3 October 6 4 • 7 2 .5 51 21.8 2 ,5 13 2 .4 1 .2 40 17.2 0 0 20 6 lei 0 0 53 22.3 0 0 27 4 *7 2 .4 82 36.3 0 0 November 3 8 1.4 2 ® 4 82 37.0 5 1.5 10 4 .7 2 .4 73 29.0 1 • 3 17 4 .6 4 .9 48 17.0 3 .9 24 7 1.1 2 » 4 22 6.4 2 .5 December 1 7 1.1 2 • 4 26 ' 6.7 1 . 3 8 6 1.0 3 .6 23 5.9 4 1.1 15 8 1.2 3 .6 29 7.3 7 2.0 22 9 1.3 5 1.0 32 7.7 3 .8 29 6 1.0 3 .5 39 9.3 2 .6 1945 J anuary 5 11 1.8 11 1.7 44 10.0 7 2.1 12 15 2.4 18 2.8 62 13.6 3 .9 19 13 2.1 11 1.6 73 15.5 11 3.1 26 14 2.2 22 3.2 96 18.5 20 5.8 February 2 9 1.6 19 3.0 in 19.4 32 5.7 9 1 12 2.5 21 3.6 130 21.6 19 3.8 16 39 6.9 19 3.5 99 18.7 21 3.6 23 17 2.8 40 7.0 124 23.9 26 4.5 March 2 10 1.6 57 10.3 206 38.5 18 3.0 9 37 6.1 78 13.3 203 39.2 18 3.0 16 25 4.1 67 11.3 234 39.1 40 6,5 23 30 4.9 97 15.6 319 $5*1 55 8.9 30 37 6.0 100 17.2 307 51.2 56 d«« April 6 49 7.6 86 14.4 170 30.2 31 4.8 13 42 5.9 92 15.1 181 32.7 52 5.1 20 43 6.0 123 21.7 159 25.1 32 5.1 27 81 12.4 138 19.0 132 22.9 51 5.1 Table 6 (contM) Week ending” First Third Seventh Ninth ✓ Cases Rate Cases Rate Cases Rate Cases Rate May 4 60 9,3 102 15,7 203 35,7 18 2,6 11 35 6,5 32 4,2 112 17,5 19 2,8 18 29 3,5 106 17,5 71 6,0 25 61 7,3 126 20,5 101 9,0 June 1 53 6,3 93 15,5 55 4,8 8 41 4,8 40 5,2 28 3,5 15 55 5*0 42 3,7 0 0 22 47 4,0 9 ,9 0 0 29 59 5,5 16 1,8 0 0 Total 663 3,0 1517 6,5 4116 19,3 775 3,8 Source: Division of Medical Statistics* Office of The Surgeon General* War Department * Washington* D, Co 3rd Infantry* 36th Infantry* 46th Infantry* 100th Infantry 103rd Infantry 44th Infan- try 14th Arm- ored 70th Enfan- ..VX . 63rd Infan- try 42nd Infan- try 1943 ■ September 24 72 18 October 1 138 3 75 8 260 3 46 15 291 6 57 22 377 10 67 29 515 0 93 November 5 201 20 83 12 246 76 132 19 149 55 210 26 138 86 171 De6ember 5 1*83 80 133 10 128 69 86 17 142 74 67 24 127 130 59 31 113 127 65 Not in Theater 1944 J anuary 7 212 70 71 - 14 126 159 48 21 52 141 70 28 109 123 14 \ February 4 93 95 54 ■> 11 74 •98 31 18 48 59 43 25 37 53 23 Table 7 Epidemic Hepatitis in the Seventh Army by Divisions, European Theater of Operations, U» S» Army, Rates per 1000 Strength per Annum, by Weeks September 1943 to April 1945 Infantry* 36th Infantry* ’ 45th Infantry* — 100th Infantry L _ — Infantry 44 th Infan- try 14th Arm- ored 70th Infan- try 63rd Infan- try 42nd Infan- try 1944 March S 49 60 18 10 44 35 9 17 54 46 9 24 39 44 15 \ 31 49 28 27 April 7 9 10 26 14 21 25 5 21 42 6 7 28 38 12 5 May 5 8 12 7 12 8 6 7 19 13 0 0 . * V 26 8 6 9 June 2 17 12 12 9 10 5 6 16 15 2 0 23 11 9 0 30 o 3 14 July 7 8 0 0 14 0 19 14 21 14 3 9 28 10 0 12 Not in Thea- ;er August 4 3 16 3 11 6 0 0 18 3 0 3 25 18 14 3 September 1 22 11 3 8 16 4 12 15 6 4 0 * 22 16 7 6 29 28 14 3 » October 6 10 10 9 13 10 11 24 20 29 29 18 27 30 30 33 Table 7 (Continued) Epidemic Hepatitis in the Seventh Army by Divisions 3rd Infantry 36th Infantry 45th Infantry l60th ’ Infantry " 'I'oSrd Infantry 44th Infan- try 14th Arm- ored “76th Infan- try 1 63rd Infan- try 42nd Infan- try November 3 40 9 9 10 22 9 20 ** *♦ 17 14 15 21 11 ** 24 14 14 14 8 Qrl December 1 25 14 16 8 4 8 22 0 31 1 CM 15 36 4 15 4 8 ** 22 36 11 21 tsn nca 3 4 *=•«=» 29 37 11 31 4 15 1945 January 5 41 38 9 «« 34 aa 12 60 22 r is 3 44 a<=( KJa 19 30 14 37 84 6 26 28 41 75 53 94 February 2 56 34 69 106 58 «ae» 20 ao ♦♦ 9 83 45 52 110 97 18 4 16 48 28 31 90 77 28 a=ttr* 23 44 40 34 85 123 27 14 QO March 2 59 95 33 311 83 26 23 3 51 9 25 62 65 259 132 62 23 30 48 16 64 33 30 295 146 63 23 40 48 23 86 34 61 437 149 119 14 67 62 50 42 31 63 404 223 88 35 67 75 23 April 6 45 8 49 164 131 49 9 21 49 4 13 34 22 21 235 92 35 45 50 104 15 20 15 11 21 186 69 20 73 97 59 17 27 37 17 31 146 53 33 44 110 62 3 ♦ With Fifth Army* Mediterranean Theater until 9 June 1944® Landed Southern France 15 August 1944® ** Date committed to combat® Sources Division of Preventive Medicine* Office of the Chief Surgeon* European Theater of Operations* U® S « Army Table 7 (Continued) Epidemic Hepatitis in the Seventh Army by Divisions 329 413th Infantry 414th Infantry 415th Infantry 692 Med Companies § Hq® Companies § Hq® Companies s ToD< Bn Div® Date Hq C E G L AT 2Bn Total Hq A C D H I M AT SV IBn 3Bn Med Total Hq B D F K Med Total sa CoC Total Jan 5 1 1 1 9 1 1 1 10 1 1 1 1 1 1 3 13 1 1 1 15 1 1 1 16 1 1 1 18 1 1 1 3 3 19 1 1 i 1 20 1 1 1 21 1 1 2 1 1 3 22 1 1 1 23 1 1 1 1 2 3 24 1 1 2 2 25 1 1 2 2 27 1 1 1 1 2 3 28 1 1 1 29 1 2 3 30 11 1 3 3 31 1 1 1 1 2 Feb 1 1 1 3 1 1 2 1 3 5 1 1 2 1 1 3 6 1 1 2 1 1 1 1 4 7 1 1 1 9 2 2 2 10 ; 1 1 13 1 1 1 14 1 1 1 15 1 1 16 1 1 2 c Total TlTTl 2 £ 10 | 6 7 1 4 4 2 2 2 111 ~ 1 32 “ 13 2 11 3 11 2 1 56 Source ; Subject* Jaundice 104th Division* to Surgeon* First U® So Army* from 10th Medical Laboratory* 19 February 1945® Epidemic Hepatitis in 104th Infantry Division European Theater of UoS„ Army Distribution of Cases by Companies and Date of Onset 5 January to 16 February 1945 xcuTxb o Table 9 Homologous Serum Jaundice of Origin fron* Yellow Fever Vaccine Cases by Week of Onset® Special Study Survey® North Ireland and England® European Theater of Operations® U®S« Army January to September® 4942 Week Ending Total North Ireland England 19-42 January 6«21 4 4 February 7 14 21 2 2 2 ra 2 ' , 28 3 3 March 7 5 5 14 5 4 1 21 12 10 2 28 17 16 1 April 5 56 55 1 10 75 75 17 89 89 e» 24 101 100 1 May 1 109 104 5 8 85 85 0 15 116 112 4 22 127 125 2 29 92 89 3 June 5 127 112 15 12 115 95 18 19 126 103 • 23 ' 26 69 55 14 July S 110 89 21 10 110 61 49 17 77 56 21 24 59 35 24 31 48 32 16 August 7 50 26 24 14 32 17 15 21 31 18 13 28 27 9 18 September 4 14 4 10 11 18 10 8 < 18 16 6 10 25 8 3 5 Total 1915 1591 324 Sources Final report. Homologous Serum Jaundice arising from use of Yellow Fever Vaccine, Office of the Chief Surgeon, European Theater of Operations, UeSo Army, 1942* Table 10 Incidence of Jaundice* North Ireland Forces European Theater of Operations* UaS* Army- Cases and Attack Rates by Lot Numbers of Yellow Fever Vaccine January to May 1942 Lot No® No® Persons Vaccinated No® Cases Jaundice Attack Rate (per 100) Unknown 5018 1 0®05 1 Special Issue 56 35 1 42 5 74 50 140 1 142 79 2X7 5 253 1 242 7 249 1 253 26 500 1 301 1 308 1 1 - 309 5 310 . 5 317 94 1 1.1 318 6 319 508 24 4® 7 320 18 1 5®6 324 4 325 1 327 91 329 1 550 194 ■ 332 101 335 91 8 8.8 334 2 1 355 206 23 11«2 537 2 *• 338 3058 287 9.4 340 1873 340®1/2 341 991 342 2733 345 178 344 10 345 70 346 | 1625 1 1 0.06 347 45 348 159 Table 10 (cont*d) No* Persohs No* Cases Attack Rate Lot No* Vaccinated Jaundice (per.100) 360 102 351 1093 33 5*0 352 57 355 3119 1 Q*03 . 355 2 ' 35? 2 • 358 627 359 155 360 919 3 0.3 361 20 362 46 363 2 364 29 365 31 366 1 367 155 14 9*2 368 1752 186 10.6 369 13 370 3 571 19 372 49 375 503 375 4 379 2 380 70 381 5 382 20 385 2 584 1 386 99 5 387 74 388 18 391 3 392 22 396 5 397 2 409 20 423 29 460 1 551 112 888 1 Total 24,249 585 2*4 Source: Interim report number 9* Homologous Serum Jaundice arising from use of Yellow Ferer Vaccine, Office of the Chief Surgeon, European Theater of Operations, U*S* Army, 1942* Table II Incidence of Jaundice by Yellow Fever Vaccine Lots North Ireland Forces European Theater of Operations* U«S<, Army January to May 1942 ✓ , No® Persons No® Gases No® Cases Attack Rate Lot No® Vaccinated Jaundice Hospitalized per 100 508 1 1 1 317 102 1 1 1®0 319 1106 45 57 4®1 320 141 12 4 8® S 327 92 1 1 1®1 333 158 8 4 5®1 534 3 1 1 355 359 33 25 9«2 336 1 1 1 338 5512 519 593 9»4 346 1425 1 0 0«07 351 2550 68 37 2®7 353 3375 1 0 0»03 360 892 2 2 0«2 362 96 2 1 2® 1 364 254 1 1 0®4 367 342 27 23 7®9 368 2181 235 170 10® 8 388 22 3 3 13®6 Others* 9628 0 0 0 Unknown 3311 1 1 0®03 Total 51551 963 706 3®1 * Includes all vaccine lots with which Jaundice was not associated® They are as followss 33* 42 * 65* 74* 104* 142* 216, 217 * 232, 233* 237® 242* 251* 252* 268® 30C * 301* 304* 309* 310* 315* 316* 318* 321* 324* 325* 326* 329® 350* 532 * 337* 339* 340* 341* 342* 343* 344* 345* 347* 348* 349* 350* 352* 355 * 35% 558* 359* 561* 363* 565* 366* 369* 370* 371* 372* 373* 375* 380 * 381* 382* 383* 384* 585, 386* 387* 391* 592* 396* 397* 404* 423* 551 * 643* 888® Source: Interim report number 19* Homologous Serum Jaundice arising from use of Yellow Fever Vaccine* Office of the Chief Surgeon* European Theater of Operations* U®S® Army* 1942® Table 12 Additional Yellow Fever Vaccine Lots Found to be Associated with Jaundice in the 814th Engineer Battalion, England European Theater of Operations, U#S0 Army 23 May to 7 August 1942 Lot* No* No* Inoc* Jaundice Cases 91 9 2 331 . 195 15 340 17 1 369 5 1 370 59 1 Source: Interim Report Number 19, Homologous Serum Jaundice arising from use of yellow fever vac- cine. Office of the Chief Surgeon, European Theater of Operations, U* S, Army, 1942, Table 13 Correlation of Yellow Ferer Lots and Incidence of. Jaundice European Theater of Operations* U*S« Army- Cases and Percent of Clinical Jaundice by Lot Numbers January to May 1942 North Ireland Force Vaccine Lot Number Number Surveyed Hospi- talized Jaun- dice Jaundice not Hospital- ized Sub- clini- cal in- fection Not effected Percent including Clinical Jaundice 317 9 5 4 55.6 319 90 4 11 16 59 16® 7 327 11 11 333 1 1 •Et 538 361 35 55 34 237 24® 9 339 1 1 ♦ 340 '42 42 m 342 5 1 4 345 1 1 «a 347 16 2 14 350 1 - 1 351 326 6 35 21 264 12®6 552 1 1 mm 555 11 11 C-> 361 1 1 - 562 6 2 1 3 55® 3 367 5 S 3 mm 368 383 , 20 36 • 51 276 14® 6 382 1 1 • - 388 1 1 ♦ 425 20 20 - Total reo?g know lots 1295 h 66 145 129 955 16«3 Unknown lots 238 5 4 5 224 3® 8 Not inoculate^ 48 1 1 46 4® 2 No record i5 ; ... _5 ....... 1 1 8 40.0 Total 1594 I 135 1231 14.3 ♦ Percent not significant® Sources Preliminary report and Interim report number 15* Homologous Serum Jaundice arising from use of Yellow Fever Vaccine* Office of the Chief Surgeon* European theater of Operations* U«S® Army* 1942® Table 14 Correlation Between Date.of Inoculation and Incidence of Jaundice North Ireland Force European Theater of Operations, U. S. Army Jdnuary to May 1945 Lot Humber 358 Lot Number 568 Dates of Inocu- No* No. Rate No. No. Rate lations IELO-Sa Ca&ea.. ,j,er -1Q0,. Ia00i gaaftfl— per 100 January 1-15 3596 344 9.6 * 395 38 9.7 January 16 - 31 1046 106 10.1 48 3 • 6.3 February 1-15 14 mtmmmtam February 16 - 28 159 22 15.8 275 21 7.6 March 1-15 3 mmtmrn* —— 185 23 12.4 March 16 - 31 6 nwri —— 502 23 7.6 April 1-15 1 — —- 89 4 4.5 April 16 « 30 12 1 —-- May 1-15 13 3 —— Inoculation dates unknown 687 47 —— 864 ‘ 119 —— Total 5512 5l9 9.4 'Sl'sl' 235 16.8 H, Sources Interim report number 20, Homologous Serum Jaundice arising from use of Yellow Ferer Vaccine , Office of the Chief Surgeon, European Theater of Operations, U.S. Army 1942. Table 15 Incubation Period of 298 Cases of Jaundice Yellow Fever Vaccine Lots North Ireland Force European Theater of Operations* UoSe Army Number of weeks between inoculation and onset of symptoms February to May 1942 Incubation Period in Weeks Vaccine Lots 317 319 320 338 342 351 357 367 368 369 Total 5th 1 1 6th 7th 2 2 8th 1 3 4 9th 7 1 5 14 “Toth , 1 1 9 11 11th 1 1 19 21 12th 1 3 4 31 39 13th 1 1 5 25 30 14th 9 5 29 43 15th 1 i 5 6 ~Ss 55 16th 1 3 5 1 2 11 23 17th 1 3 2 4 7 17 18th 1 1 5 1 4 2 14 19th 1 1 3 5 Toth r“ 2 2 .5 . i 10 21st 4 4 8 22nd 3 3 23rd 2 3 5 24th 2 2 i 5 “T&fcH 26th 27 th 4 i 5 28th i 1 29th 30th 31st 1 ! 1 32nd 1 T Total T" -JLJ 1 53 1 32 16i9 & 298 Sources Interim report number 22* Homologous Sei rum Ja undice arising from use of Yellow Ferer Vaccine, Office of the Chief Surgeon, European Theater of Operations„ U® So Army, 1942e Immunizations Within 20 Days Before or After Yel= low Fever Inoculation 50 & Under 51= 60 61- 70 71- 80 81- 90 91- 100 101- 110 111- 120 121- 130 131- 140 141- 150 151- 160 161= 170 171- 180 181- over Total Smallpox only 1 2 2 3 1 9 Typhoid only 3 2 2 7 Tetanus only 1 1 1 3 4 4 2 4 1 21 Typhoid & Tetanus 1 3 .1 5 Smallpox & Tetanus - - - - - - - - - - 0 Typhoid & Smallpox 1 1 2 All Three: Typhoid-, Tetanus & Smallpox 2 1 3 No Other Immunizations 2. . 8 20 30 32 16 10 1 1 2 122 Total 1 6 11 ISO 46 41 19. 14 3 1 0 0 1 2 169 Sources Interim Report Number 21, Homologous Serum Jaundice arising ft*om use Df Yellow Fever Vaoc: Lne, Office of the Chief Surgeon, European Iheater of Operations, u*s > Army, 1942* Table 16 Effect of Other Immunizing Agents on Incubation Period of Jaundice in Cases IVho Received Yellow Fever Vaccine #368 Number of Days between Immunization and Onset of Symptoms North Ireland Force European Theater of OperationsU«S« Amy January to May 1942 Vaccinated Unvaccinated Totals Dates of Arrival Number No a with Jaundice Number Noo with Jaundice Number No* with Jaundice Jan 26 May 12 Casuals 7*533 16*256 1*388 1 556 0 o01 3«42 0 3*379 316 12 8 0 0 0*24 0 0 10*912 16*572 1*400 9 556 0 ©08 3*36 0 Totals 25*177 557 2 o 21 3*707 8 0*22 28*884 565 lcS6 Source s Interim report number 7* I Fever Vaccine* Office of i UoS, Army* 1942# iomo logons Serum Jaundice arising fro 3he Chief Surgeon* European Theater o • m use of Yellow f Operations* Jaundice Among Vaccinated and Unvaccinated Troops European Theater of Operations, Army Number of Cases by date of arrival in Northern Ireland January to May 1942 Table 17 Total 1942 1943 1944 1945 Theater Cases Rate Cases Rat© cases Rate Cases Rate Cases Rate Total Army 967 ©05 48 O 259 © 04 350 ©05 330 ©09 Continental U© S© 420 ©03 36 o O 167 ©03 162 ©04 56 o o Total Overseas 547 ©07 12 ©02 72 ©05 188 ©05 275 ©11 Burma*- India 7? ©23 3 ©53 14 ©30 35 ©22 25 ©21 South West Pacific 209 ©17 0 ©0 0 ©0 39 ©07 170 ©44 East 20 ©15 0 ©0 14 ©26 5 ©11 1 ©04 Mediterranean 131 ©10 0 ©0 32 ©07 61 ©09 38 ©16 Latin America 16 ©05 4 ©04 4 ©03 5 ©06 3 ©08 Pacific Ocean Area 23 ©02 0 ©0 4 ©01 6 ©02 13 ©06 North America 3 ©02 1 ©02 0 ©0 1 ©02 1 ©06 European 68 ©02 4 ©06 4 ©02 36 ©02 24 ©02 Alaska 0 ©0 0 ©0 0 ©0 0 ©0 0 ©0 Sources Division of Medical Washington*, D© G© Statist ;ics,9 Office of The Surgeon General*, War Department0 Poliomyelitis Total Amy® Continental United States and Theaters of Operationsa Uo Sd Army Cases and rates per 1000 strength per annum January 1942 to June 1945 Inclusive Table 18 Table 19 Encephalitis Total Army, Continental United States and Theaters of Operationst U« S« Army Number of Cases January 1942 to June 1945 Inclusive Theater Cases Total Army 387 Continental TJ* Sa 320 Overseas 67 China*Burma-India 18 Pacific Ocean Area 17 South West Pacific 16 Me diterranean 6 Africa-Middle East 4 European 3 North America 2 Latin America 1 Alaska 0 Source: Division of Medical Office of The Surgeon General, War Department, Washington, D« CB Table 20 Tetanus Total Array® Continental United States and Theaters of Operations# U* Se Array Number of Cases January 1942 to June 1945 Indus ire Theater Cases Total Army 13 Continental IT* S© 10 Overseas 3 China~Burma=>India 1 European 1 Mediterranean 1 Africa~Middle East 0 Alaska 0 Latin America 0 North America 0 Pacific Ocean Area 0 South West Pacific 0 Sources Division of Medical Statistics, Office of The Surgeon General, War Department, Washington, D® C® Month , - 1 19< IS. ' If 144 _ If 3.45 Cases Rate Gases Rate Cases Rate |Cases W..TOTrrtvr* Rate Cases Rate J anuary February March April May June' July August September October November December 1461 1647 2283 1663 1633 1739 428 465 502 612 819 1334 5,44 5,78 6,06 : 5,14 4,89 4,28 3,16 3,00 2,51 3,18 4, 00 4,43 16 16 9 5 8 23 41 20 36 26 40 51,88 20,24 10,26 2,35 2,25 3,59 4,67 1,58 2,15 2.33 4, 2S 103 149 191 141 255 119 216 221 186 244 223 335 ' 9,41 17,62 23,05 13,34 23,85 9,81 11,30 11,42 7,97 6,66 5,44 5,15 383 435 525 354 305 260 189 203 296 . 332 570 959 6.23 6,19 5,09 3.81 3,05 2,04 1.74 1,80 1.81 2,39 5.74 4.23 975 1047 1551 1159 1068 1352 4,98 5,08 5,86 5,30 4,82 5,13 Total 14586 4,59 S40j 3,30 1*3831 9,02 \ 4811 3,27 7152T*1 5,22 Sources Division of Me Washington® D, dioal Si C, >" ■" ■ ■"— ■ - ■■" —-> — batistics® Office of The Surgeon General® War p*——— —— Department® European Theater of Operations* UoS© Army- Cases and Rates per 1000 strength per annum* by months February 1942 to June 1945* Inclusive Table 21 Scabies Table 22 Scabies United Kingdom and Continent European Theater of Operationsa UoS© Army Cases and Rates per 1000 strength*, per annum by months September 1944 to June 1945* Inclusive Total United Kingdom Continent Month Cases Rate Cases Rate Gases Rate 1944 September 296 1*81 98 1©00 198 2©99 October 332 2039 156 1©60 176 4©23 November 570 3©74 372 3©34 198 4© 83 December 959 4© 23 688 4*13 271 4© 51 1945 January 975 4© 98 702 4©79 273 5© 54 February 1047 5© 08 787 4© 96 260 5»50 March 1551 5© 86 1257 5©87 294 5© 82 April 1159 5© 30 992 5©5I 167 4© 31 May 1068 4© 82 934 4©87 134 4© 48 June 1352 5©13 ♦ * ♦ ♦ Total 9569 4© 53 |5986** T97Tm 4o$4** ♦Data not ava: .lableo ♦♦June 1945* not included** Sources Division of Medical Statistics* Office of The Surgeon General o War Departments Washingtons Do C*> Theater Total 1942 1943 1944 1945 Gases Cases Rate Oases Rate - Gases Rate Total Army Continental U,S, Overseas Mediterranean European South America North America Africa-Middle East South West Pacific China-Burma-India Pacific Ocean Area Alaska 65379 38498 26881 73§3 14586 822 365 240 2079 444 838 154 3,09 2,93 5o34 5,45 4, 59 2,36 2,15 1,84 1,72 1,34 ,80 ,57 5532 4627 905 62 240 60 46 18 324 0 112 43 1,81 1,82 1,76 20 91 3,30 ,58 1c 14 3,14 4,83 0 ,76 ,86 16754 11625 4129 646 2383 211 101 79 496 24 146 43 2,34 2,26 2,59 1,50 3,02 1,74 1,41 1,48 2,54 . ,52 ,49 ,37 24388 13686 10702 3821 4811 365 112 58 891 224 389 31 3,25 3,41 3*06 5,79 3,27 4,24 2,66 1,22 1,60 1,40 ,99 ,37 — 19705 8560 11145 2824 7152 186 106 85 368 196 191 37 5,08 5, 92 4.58 11,73 5,22 4,77 6,85 3,56 ,94 1,62 ,92 1.58 Sources Division of Medical Statistics/, Office ol Washington* D» C, > The Surgeon Gc sacral* War Depa rtment* Total Armyc Continental United States and Theaters of Operations* UeS„ Army Cases and Rates per 1000 strength per annum January 1942 to June 1945* Indue ire Table 23 Scabies Table 24 Leprosy- Total Army* Continental United States and Theaters of Operations, U*S* Army Number of Cases, January 1942 to June 1945, Inclusive Theater Cases. Total Army 20 Continental U0S0 12 Overseas 8 Pacific Ocean Area 6 • European 1 Mediterranean 1 Africa-Middle East 0 Alaska 0 China-Burma-India 0 Latin America 0 North America 0 South West Pacific Area 0 Sources Division of Medical Sta fcistics* Office of The Surgeon General* Washington* DoC® War Department* Table 25 Undulant and Malta Fevers Total Army, Continental United States and Theaters of Operations, U»S«. Army- Number of Cases, Jaunary 1942 to June 1945, Indus ire Ihoator Cases Total Army 485 Continental U»S« 358 Overseas 127 Mediterranean 70 Pacific Ocean Area 20 European 12 South West Pacific 7 Africa-Middle East 6 China-* Burma- India 6 North America 3 Latin America 2 Alaska 1 Sources Division of Medical Statistics, Office of The Surgeon General, War Department, Washington, D„C« FIGtJRES 1, Epidemic hepatitis in the First Infantry Division, European Theater of Operations, U. S, Army, number of cases by weeks, 16 July 1943 to 26 May 1944, inclusive, 2, Epidemic hepatitis. Divisions of the Seventh Army, European Theater of Operations, U. S, Army, rates per 1000 strength per annum by weeks, 24. September 1943 to 27 April 1945, in- clusive. 3, Homologous serum jaundice of origin from yellow fever vaccine, cases by week of onset, special study survey, January to Sep- tember 1942. 4.. Incubation periods of 298 cases of jaundice, North Ireland Force, European Theater of Operations, U. S, Army, number of weeks between inoculation and onset of symptoms, February to May 1942. 5* Interval in weeks between yellow fever inoculation and onset of jaundice, European Theater of Operations, U, S. Army, February to May 1942, inclusive. 6, Scabies, American and British Armies in the United Kingdom, rates per 1000 strength per annum, February 1942 to January 1944., inclusive. TABLES lo Infectious Hepatitis, European Theater of Operations, UQ Sc Array, cases and rates per 1000 strength per annum, by months, February 19-42 to June 194-5, inclusive. 20 Infectious Hepatitis, United Kingdom and Continent, European Theater of Operations, U0 S0 Army, cases and rates per 1000 strength per annum by months, September 1944- to June 1945, inclusiveo 3o Infectious Hepatitis, Total Army, Continental United States and Theaters of Operations, UQ SQ Army, cases and rates per 1000 strength per annum, January 1942 to June 1945, inclusivec 4o Weil’s Disease, Total Army, Continental United States and Theaters of Operations, Uc SQ Army, number of cases, January 1942 to June 1945, inclusiveo 5o Infectious Hepatitis, AAF Station 113, 8th Air Force, Euro- pean Theater of Operations, Uo So Army, distribution of cases by date of onset, 25 March to 26 April 1944<> 60 Epidemic Hepatitis by Armies, European Theater of Operations, Uo So Army, cases and rates per 1000 strength per annum, by weeks, 1 September 1944 to 29 June 1945, inclusive0 7c Epidemic Hepatitis in the Seventh Army by Divisions, European Theater of Operations, Uu SQ Army, rates per 1000 strength per annum, by weeks, September 1943 to April 1945, inclusive0 80 Epidemic Hepatitis in 104th Infantry Division, European Theater of Operations, Uo So Army, distribution of cases by companies and date of onset, 5 January to 16 February 1945. 9o Homologous Serum Jaundice of Origin from Yellow Fever Vaccine, North Ireland and England, European Theater of Operations, Uo So Army, cases by week of onset, special study survey, January to September 19420 10o Incidence of Jaundice, Worth Ireland Forces, European Theater of Operations, U0 So Army, cases and attack rates by lot numbers of yellow fever vaccine, January to May 1942o 11o Incidence of Jaundice by yellow fever vaccine lots, North Ire- land Forces, European Theater of Operations, U0 S* Army, January to May 1942o / 12o Additional yellow fever vaccine lots found to be associated with jaundice in the 814th Engineer Battalion England, European Theater of Operations, Uo S0 Army, 23 May to 7 August 1942 c 13o Correlation of yellow fever lots and incidence of jaundice, North Ireland Force, European Theater of Operations, U0 S0 Army, cases and percent of clinical jaundice by lot numbers, January to May 1942c 14o Correlation between date of inoculation and incidence of jaundice, North Ireland Force, European Theater of Operations, Uo So Army, January to May 1942* 15o Incubation period of 298 cases of jaundice, by yellow fever vaccine lots, North Ireland Force, European Theater of Opera- tions, Uo So Army, number of weeks between inoculation and onset of symptoms, February to May 1942c 16„ Effect of other immunizing agents on incubation period of jaundice in cases who received yellow fever vaccine #368, number of days between immunization and onset of symptoms, North Ireland Force, European Theater of Operations, Uc So Array, January to May 19420 17. Jaundice among vaccinated and unvaccinated troops, European Theater of Operations, UQ S. Army, number of cases by date of arrival in Northern Ireland, January to May 1942« 18. Poliomyelitis, Total Army, Continental United States and Theaters of Operations, U0 So Array, cases and rates per 1000 strength per annum, January 1942 to June 1945, inclusivee 19. Encephalitis, Total Army, Continental United States and Theaters of Operations, U0 So Army, number of cases January 1942 to June 1945, inclusive0 20o Tetanus, Total Army, Continental United States and Theaters of Operations, Uc So Army, number of cases, January 1942 to June 1945, inclusivee 210 Scabies, European Theater of Operations, UQ S0 Army, cases and rates per 1000 strength per annum, by months, February 1942 to June 1945, Indus ivec 22, Scabies, United Kingdom and Continent, European Theater of Operations, UQ SQ Army, cases and rates per 1000 strength per annum by months, September 1944 to June 1945, inclusive„ 23o Scabies, Total Army, Continental United States and Theaters of Operations, U0 S0 Army, cases and rates per 1000 strength per annum, January 1942 to June 1945, inclusive0 24o Leprosy, Total Army, Continental United States and Theaters of Operations, U0 SQ Army, number of cases, January 1942 to June 1945, inclusive0 25o Undulant and Malta Fevers, Total Army, Continental United States and Theaters of Operations, U0 SQ Army, number of cases, January 1942 to June 1945, inclusive. EPIDEMIOLOGIC CASE REPORTS 1. Mumps introduced into units by replacements, 2. Jaundice following anti-leutic treatment. 3. The single case of tetanus in the European Theater of Operations. A HISTORY OF PREVENTIVE MEDICINE IN TEE EUROPEAN THEATER OF OPERATIONS UNITED STATES ARMI " 19^6 Part III - Epidemiology- Section 7 ” Specific Immunization ■by Colonel John E0 Gordon, M0C0 Chief of the Division of Preventive Medicine Office of the Chief Surgeon, ETO TABLE OF CONTENTS PART III Epidemiology Section 7 - Specific Lmminization Page ✓ Immunization Activities in the European Theater 0 . „ . 0 „ 1 Preparation for Operation TORCH 0 e 0 -0 ,0 e „ 0 0 0 0 , , c 2 Periodic Survey of Immunization Status # „ 0 0 0 0 , . , „ 4 Immunization Order of 1943 - Routine and Special Procedures 5 ♦ Preparation for the Invasion of Normandy 0 » » 0 o » 0 . „ 5 Immunization Practices on the Continent 0 0 0 „ o ■» o • „ 5 Immunization during Redeployment u 0 0 0 0 0 . „ , 0 6 , 0 6 Smallpox Vaccination u. e » » » »..••••• o«.*. » 7 Typhoid Fever Immunization 0 0 » , » „ , 0 . „ 0 o o • . 0 7 Immunization against Typhus Fever 0 a 0 0 0 0 0 „ „ „ 0 0 0 7 Immunization against Tetanus 0 „ „ 0 0 0 e o » . o . » o <, 8 Yellow Fever Immunization c 0 0 0 0 „ „ c 0 0 0 » . <, o » • 9 Cholera Vaccination 0 0 0 „ „ c 0 c „ „ 0 „ 0 « • . o e . 0 10 Diphtheria Immunization „ „ 0 0 0 . . . . , » o . . . . . « 10 Plague Immunization „ 0 0 e , u 0 0 c c » • • . • . . * , 0 10 Reactions to Immunising Agents „ „ 0 0 » . . 0 <. « * . « • 11 Supplies of Immunizing Agents «. «.•«•' «»...«.• 12 Results of the Immunization Program 12 List of Figures List of Tables PART III Epidemiology Section 7 - Specific Immunization The program of immunization for troops of the United States Array was prescribed by the War Department Theaters of Operation had the obligation to execute these instructions in accordance with defined policy, making such alterations in schedule and method as were permitted by regulation in order to meet special situations,, Immunization procedures were divided for administrative purposes into two classes, those termed routine immunizations and the special immunizations0 Troops arriving in the European Theater had in general received the four specified routine immunizations in advance of departure, since early published instructions directed that this be accomplished so far as time permitted,, In many instances a number of the procedures were initiated or completed during trans- Atlantic transit, but a few had to be completed after the arrival of troops in the theater0 Such special immunizations as were required of troops destined for Europe had almost invariably been completed before arrival„ A principal feature of the work of the Theater in immunization had to do with the development of an adequate system of survey and report on newly arrived units, to assure that primary immunization had been practiced in accordance with reg- ulations o The work of the day was concerned with maintaining the status of immunity by reimmunization at the prescribed intervals 0 I From time to time, one or the other of the special types of immunization was required, ordinarily in connection with de- parture of troops for other theaters0 Local situations occasion- ally required applications of such measures as immunization against diphtheria in selected groups„ General theater wide sur- veys of the status of immunity of troops were undertaken under special circumstances, ordinarily associated with the mounting of a major military operation,, i Immunization Activities in the European Theater0°»The first directive on immunization was issued by the theater in May 194-2. as a publication of the United States Army Forces in the British Isles0 , It supplemented the regulations of the War 1 Department which had governed from the time the Theater was es- tablished o Smallpox vaccination was prescribed for all officers and enlisted men who had not been protected within one year prior to leaving the Zcme of the Interior for duty in the theater0 A full course of typhoid paratyphoid inoculations was required under the same circumstances0 Personnel who had completed the initial immuniza- tion for tetanus more than six months previous to departure for the theater were reimmunized by administration of one cubic centimeter of tetanus toxoid0 The three doses of the initial inoculation were re- quired for those having no record of previous treatmento In early July the War Department prescribed typhus vac- cinations for all military personnel stationed in or traveling through the British Isles© The existing requirements of the War Department in respect to tetanus were stated in detail in one of the initial orders of the newly established European of Operations, published in July of 194-20 Reimmunization at a six month interval was required as in the previous order„ Preparation for Operation TORCH0— The departure of an ex- peditionary force from the European Theater to North Africa, desig- nated Operation TORCH, led to the publication of the first comprehen- sive immunization order of the theater„ In preparation for that event, unit commanders were directed in early September 1942 to assure that military personnel of their commands were properly protected against typhus, typhoid and paratyphoid fevers, smallpox and tetanus0 A series of weekly reports was required of all units, noting the current progress attained in bringing the status of members of the command to complete protection„ Indicative of the difficulties in communications and in the circulation of orders that existed at that time, separate instructions were issued to troops of the Services of Supply; and to medical organ- izations of the command from the Office of the Chief Surgeon, in ad- dition to the general theater order0 The important consideration was that troops departing for Africa be assured of full protectiono For security reasons it was considered unwise to check only on the status of immunization of those units intended for active op- erations in the immediate future, since a clear indication of the strength to be employed could thereby be determined0 Complete immuni- zation of all troops was under any circumstances a desirable objective0 A theater wide effort was consequently put into effecto 2 Troops having no record of the complete and initial im- munization against typhus fever received three injections of typhus vaccine at weekly intervals• Those who had completed the initial series of three doses one year or more previously received a stimu- lating does of one cubic centimeter of typhus vaccine* In respect to typhoid and paratyphoid fevers, persons having no record of a completed initial immunization within three years received three injections at weekly intervals* Those who had completed the initial series one year but not more than three years previously received a stimulating dose of 0*5cc of typhoid-paraty- phoid vaccineo Personnel having no record of a completed initial immuni- zation against tetanus received three doses at tri-weekly intervals0 Those who had completed the initial immunization or received a stim- ulating dose more than four months previously received an additional stimulating dose of one cubic centimeter of tetanus toxoid* Troops were revaccinated where no record was available of successful vaccination against smallpox within one year* North Africa had a well earned record for outbreaks of smallpox and revac- cination within a one year period was deemed desirable* The directions in respect to typhus fever and typhoid- para typhoid fevers were in accordance with standard practice* The additional requirement in respect to tetanus was prescribed because the troops were entering a combat area* The assurance of the effi- cacy of active immunization against tetanus which came with later ex- perience did not exist at this time, and every reasonable precaution was deemed advisable* The action taken was in line with the policy of reimmunizing troops against the disease just prior to departure from the Zone of the Interior for a theater of operations* The troops were leaving one theater for another* The first weekly report required by this program gave indication of the extent to which troops of the theater were properly immunized* For a representative sample of the theater population, protection against typhus existed in the proportion of 84*3$; for typhoid and paratyphoid fevers, B9<.2$; for tetanus 80*9$; and for smallpox 89o3$» Subsequent weeks saw measurable progress in the approach to complete immunization* Special letters were sent in October to units that were particularly delinquent* By the end of the year when this special effort was concluded the extent of im- munization against typhus had reached 97$, against typhoid and paratyphoid 99$, for tetanus 96$, and for smallpox 98$* Individual 3 unit reports gave information that the level of accomplishment for the Ground Forces was better than that for the theater as a whole0 Very few individuals of the task force left for duty in North Africa with- out adequate arid complete protection against the diseases of that area for which specific immunization procedures existed<> Periodic Jjyrvey of Immunization Status „—Having met the special circumstances associated with the departure of the task force for Africa, theater regulations in respect to immunization against tetanus were promptly altered to require that those who had completed the initial immunization series, were henceforth to receive a stimu- lating dose of one cubic centimeter at the end of each twelve-month periodo When somewhat more than six months had elapsed after the energetic immunization effort of late 1942, the attention of com- manding generals of all major commands was brought to.the very satisfactory situation which had existed at that time, together with a statement that the need continued and that maintenance of a proper immunization status of the army was as essential as primary immuniza- tion,, A periodic check was ordered to assure compliance with theater requirementso Meanwhile in the Zone of the Interior greater effort was extended to assure that troops arrived in the theater completely immunizedo That conditions had measurably improved since the early days of the theater was shown by a special field survey instituted in April 1943 of ten newly arrived Air Force and Services of Supply unitso Actual inspection of immunization records, including those of a group of officers,, showed the prescribed immunization against smallpox; typhoid fever and tetanus to have been completed with few exceptions before embarkation, and that immunization against typhus had in general been completed enroute0 Immunization of very few men remained to be done after arrival in the theater0 A further investigation two months after arrival showed the same ten organ- izations which included 130$ officers and men, to be completely immunized in accordance with theater requirements against typhoid fever, tetanus and typhus fever, and only one man was not immunized against smallpox. The 3rd Armored Diyision was selected for similar studies„ Shortly after debarkation in September, 1943, the immunization rec- ords of 1,032 men were examinedo All were completely immunized against tetanua and smallpox0 One lacked typhoid fever protection and two were deficient in respect to typhus fever, altogether an enviable record„ 4 Immunization Order of 1943 - Routine and Special Pro- cedures 0-"Various procedures relating to immunization such as the recording of injections against tetanus on identification tags and other alterations which had been made since publication of the original immunization circular in September 1942, were brought together in a new publication in September 1943o The requirements for the four routine immunizations were re-stated, together with the special requirements for persons en- tering particular geographic areas and for the protection of members of the command under special circumstances® This included the measures for specific immunization against yellow fever, chol- era, plague and diphtheria® Preparations for the Invasion of Normandy®—Just as had been done in connection with the mounting of Operation TORCH in Africa, plans were made and early action taken in the course of mounting Operation Overlord in Normandy, to make certain that the troops sent were thoroughly protected against the communicable diseases for which protective measures were necessary® 0 Accordingly, a special letter was published by theater headquarters under date of 7 February 1944, directing that all officers and men who had not been Immunized or reimmunized against tetanus since 1 February 1944 would receive a stimulating dose; and that all who had been vaccinated or revaccinated against typhus fever, typhoid-paratyphoid fever, and smallpox prior to 1 July 1943 would similarly be reimmunized® This program served to bring about a situation where members of the command entering Normandy in June were protected against the last three diseases within one year and against tetanus by an immunization no more distant than six months® The results that were attained, as judged by a special survey and report, matched those of the previous experience in preparation for Operation TORCH® The status of immunization was nearly perfect® Immunization Practices on the Continent®—Among the significant changes incorporated in the next revision of immuni- zation requirements, which again came after about a year, was a change in the requirements governing vaccination against small- pox® The interval between revaccination was increased from one year to three years® Altered requirements for yellow fever vaccination which had been stated already in a special ortter were incorporated into the new general order in somewhat greater detail® For the first time provision was made for im- munization of prisoners of war® Vaccination against smallpox 5 and*the typhoid-paratyphoid fevers as prescribed for forces of the United States Array, was made mandatory except when documentary proof in the form of official records showed previous compliance0 By the following January of 194-5 the War in Europe had advanced to what gave good evidence of being its final stages <, No great number of new troops was being received from the Zone of the Interior0 The form of the European Theater had settled down to the semblance of a fixed force well on the way to the accomplishment of its missiono It was therefore believed reasonable to relax some of the previously existing requirements for specific protection against the communicable diseases0 The principal change was in re- spect to administration of tetanus toxoid0 The requirements of an annual revaccination were liberalized to the extent of requiring only the original series, revaccination after the first year and thereafter a stimulating injection only in case of battle wounds or in the other specially prescribed situations which had always governed*« Immunization during RedeploymentThe final revision of practices in specific protection was brought into force in Mjry of 194-5, largely to meet new situations which had developed after the war and to provide for new problems in connection with re- deployment,, Persons traveling to the United States were required to meet theater provisions for protection against the four routine diseases, (smallpox, typhoid-paratyphoid fevers, typhus fever and tetanus) and for yellow fever when the returning travel to the Zone of the Interior Involved passage through the prescribed yellow fever zoneo For military personnel preceding to other theaters, smallpox vaccination within one year of departure from the theater was obligatoryo A single stimulating dose of typhoid-paratyphoid fever vaccine was required within one year of departure and like- wise a stimulating dose of tetanus toxoid when no previous stimu- lating dose had been received0 Reimmunization against typhus fever must have been within one year0 The usual regulations applied in respect to yellow fever„ In addition all persons traveling to or through any part of Asia or the Pacific Ocean area were immunized against cholera„ The particular features relating to protection against the individual communicable diseases for which specific immunization is available, are summarized in Table 1, as represented by Theater procedure in 194-5o The changing practices which occurred in the 6 course of operations in respect to the individual diseases will now be briefly outlined„ Smallpox Vaccination,,—For the first two and a half years of theater activity, annual revaccination against smallpox was practicedo Operations were mounted in the autumn of 194-2 and in the spring of 1944-0 It was deemed advisable to send troops into action with immunization against this disease no more than one year remote„ Specific troop commitments could never be determined with certainty and consequently the practice was made universale When operations on the European continent were finally under way, the requirement was relaxed through return to the standard prac- tice of revaccination at intervals of three years0 Troops arriv- ing from the Zone of the Interior could be depended upon to have been revaccinated within one year0 Typhoid Fever Immunization,,— Annual revaccination against the typhoid and paratyphoid fevers was a continually maintained policy of the theater„ The practice in vogue in the Army for many years of requiring a complete series of typhoid-paratyphoid vaccine every three years continued to hold through the early months of the theatero Subsequent to September 194-3, a single initial series of three doses met all requirements, whenever given, and annual re- immunization was accomplished by administration of 0„5cc of vac- cine o The only exception came in preparation for the Normandy invasion, when the immunization requirements for that operation were arranged in such a way that every man entering the European campaign would have been immunized against typhoid fever not less than one year previously0 To accomplish this and at the same time fit the immunization program into the mounting plans for the oper- ation, the interval in some instance was then as short as six months0 Immunization Against Typhus Fever0—Specific immunization against typhus fever was first directed by the War Department for the European Theater in the summer of 19420 (Figure 1) The prac- tice was incorporated in theater directives issued in September of that year0 Originally the series of primary injections in- volved three successive doses, which continued to be the required procedure until 7 January 1945, when improvements in the antigenic quality of the immunizing agent made possible a change to a series Of tWOo Annual reimmunization with 1 ca* was continuously in practice until the special requirement© o# February 1944 in prep- aration for the continental campaign,, This led in some instances to reimmunization at as short an interval as six months0 7 The demonstrated presence of typhus fever on the European continent and the prospect of greatly Increased numbers of cases among the civilian population as troops approached Germany, gave rise to a special problem in late 1944 <> The requirements of the War Department were that immunization should be practiced in November and again in February for troops operating in a typhus infested region* In the autumn of 1944, troops of the theater were not operating in a typhus infested region* There was no typhus fever in France* Troops of the armies would almost certainly be in a typhus region by late winter or early spring* Decision was taken to administer typhus vaccine about the middle of December, in the hope that a single dose given then would suffice for the epidemic season* The program was completed by 20 December 1944o In the event of a serious typhus situation in Europe, a second general immunization was to be brought about in March or April* Provided the situation continued favorable, no further reiramunization with typhus vaccine was to be done* March came, and it was decided not to proceed with further immunization* No cases of typhus fever had occurred among American soldiers* The Army was operating in a typhus infested region but control measures were proving efficient in limiting the spread of the disease* Individual units such as those responsible for control measures against typhus fever in civilian populations, and others exposed to special hazard were reimmunized every 3 months; but no general immunization of troops of the theater was undertaken* The record of only three cases of typhus fever among American soldiers, two of them among recently reimmunized persons engaged in the control of the disease, served to support this decision* Immunization Against Tetanus *—The primary immunizing series against tetanus always included three subcutaneous injec- tions of 1 cc* of tetanus toxoid at three-week intervals* An emergency stimulating dose of 1 cc* was administered as soon as possible after injury to individuals receiving wounds or severe burns, or when deemed advisable by the responsible medical officer, to those undergoing secondary operations or manipulations of old wounds * 8 Figure 1. Immunization of combat troops against typhus fever, Germany, December 1944. Reimraunization underwent periodic changes in practice„ In preparation for operation TORCH reimmunization within the pre- ceding four months was required0 Reimmunization in connection with operation OVERLORD was so timed that all troops of the command had received a stimulating dose of tetanus toxoid within approx- imately six months of D-Day <> Other than for those two special events, annual reimmunization was practiced until 7 January 194-5o A single stimulating dose following the original series after one year, was thereafter the only requirement,. In view of experience which demonstrated so certainly the efficacy of active immuniza- tion against tetanus, less frequent reimraunization would have sufficed, and in all probability have given a record of protection equally good0 In the conduct of medical affairs in the European Theater American soldiers were frequently admitted to British hospitals and British soldiers to American installations0 The United States Army was committed to a program of prevention of tetanus through the use of tetanus toxoid0 In the event of wounds or other need for im- mediate protection, a stimulating injection of toxoid was admin- istered o Tetanus anti toxin was not used* The British services placed reliance on tetanus anti toxin in the prevention of tetanus infections„ Because of a lack of primary stimulus on the part of British soldiers, immediate and certain protection could not be afforded by administration of toxoido On the other hand, it was not desirable that American soldiers receive tetanus anti toxin when admitted to British hos- pitals » Because no common program was possible, an order was published directing that British soldiers admitted to American hospitals were to be treated by the British method for prevention of tetanus, and that American soldiers admitted to British hos- pitals were to have American style prevention,. Yellow Fever Immunization„—Immunization against yellow fever was required of all military personnel, and all civilian employees subject to field service with the army, and all others authorized to travel by United States water and air transport before entering or passing through areas in Africa between 18° south latitude and the northern border of French West Africa, French Equatorial Africa and the Anglo-Egyptian Sudan, including the immediately adjacent islands„ Areas in South America in- cluded those between 13° north latitude and 30° south latitude9 including the islands immediately adjacent, and Panama, including the Canal Zone,, Yellow fever vaccination was not required when entry into the Canal Zone was only for transit through the zone0 9 Immunization had to be completed not less than 10 days and not more than four years before entry into the areas defined,, Air transport command, port and immigration authorities required evidence of completed immunization against yellow fever from in- dividuals traveling through the areas specifiedo A properly ex- ecuted War Department MD Form 81 or a certified true copy was judged to satisfy this requirement0 The initial immunization consisted of the administration of 0o5ccoof yellow fever vaccine, and stimulating doses were re- quired at intervals of four years0 Cholera Vaccination,,— Immunization against cholera was required of individuals traveling through or stationed in Asia, including the Middle East, the Southwest Pacific Area and the East Indieso Two subcutaneous injections of 0o5cc<, and 1 cc0 of vaccine respectively, constituted the initial series of immunizations when given at weekly intervals0 A stimulating dose of 1 cc3 was re- quired at A to 6 month intervals in the presence of danger of cholerao Diphtheria Immunization0--The immunizing agent for this disease was plain diphtheria toxoid0 No routine program of im- munization was practiced in the theater0 The use of the immuniz- ing agent was authorized when the occurrence of diphtheria among troops was of such nature as to give indication of likely spread0 It was recommended that large scale administration of diphtheria toxoid should be undertaken only in the presence of sound epid- emiologic evidenceo Large scale Schick test surveys for the de- termination of susceptibility to diphtheria were not considered practicableo A preliminary reaction test dose of 0ol cc„ of plain toxoid administered subcutaneously was advised0 Individuals who demonstrated no untoward response within AS hours were started on the regular immunization schedule„ The initial series of immun- izations thus consisted of individual doses of 0ol cc0, 0o$ cce and two doses of I cc„, with a period of AS hours between the first and second doses and 3 to 4 weeks for the others0 Subsequent stim- ulating injections were not ordinarily givenQ The frequency of diphtheria in the European Theater during the course of active operations was so slight that relatively little active immuniza- tion against this disease was practiced0 It was used by some few hospital unitso The best available records indicate that diph- theria immunization was never used by Air Force or Ground Force troops o Plague Immunization;,— Provision existed for protection of soldiers against plague0 The vaccine was never used for 10 troops stationed in the theater because plague never appeared0 Persons departing for other theaters, particularly to the Far East, were in some instances immunized against plague before de- parture but in general it was recommended that this measure be postponed until arrival in the theater to which personnel were dis- patched o The indication for plague vaccine was stated as a serious threat of exposure to epidemics of that disease0 Primary immuniz- ing series consisted of two subcutaneous injections of 0o5 cc* and 1 cco respectively, at weekly intervals0 Stimulating doses were necessary for continued protection against plague, and ordinarily 1 cubic centimeter at six month intervals was deemed to suffice in the presence of danger from that disease0 Reactions to Immunizing Agents The theater was singularly free of any serious reactions to the immunizing agents administered, either routinely or for special purposes„ The usual reactions that follow administration of these agents occurred in about the usual expectancy0 Untoward results associated with administration of tet- anus toxoid involved a group of 219 men who received stimulating doses in January 1943« Thirty-six of the men experienced reactions of an allergic nature, including varying degrees of local edema, asthma, localized and generalized urticaria, fever, headaches, nausea, and vomitingo The identity of these symptoms, as well as the combination of two or more symptoms, varied widely in individual cases and hospitalization was required for only six0 The symptoms appeared five to nine days after reinjection and were readily re- lieved by administration of epinephrine„ The initial series for most of the men had been completed 4 to 6 months previously0 The difficulty came with the first reimmunization0 The absence of local suppuration and cellulitis precluded laxity in surgical technic0 The only other instance of reported reactions to tetanus toxoid involved a different type of clinical manifestation, namely an immediate effect0 A majority of the men developed an immediate local reaction but not all; no delayed reactions occurred0 A primary irritant, either the toxoid itself or some preservative, was suspectedo The severity of the reactions which followed administra- tion of diphtheria toxoid in the adult population of the army were usually of such degree as not to encourage extensive use of the agento The widespread incidence of homologous serum jaundice following administration of yellow fever vaccine which occurred 11 during the early days of the theater, is discussed separately and in connection with epidemic hepatitis0 Supplies of Immunizing Agents0"-With two exceptions, biologic products of American origin were used entirely in accomplishing the program of immunization in the European theater0 Throughout the course of operations smallpox vaccine pre- pared by the Government Lymph Establishment of the United Kingdom was employed in the protection of American troops0 Arrangements were made with the Ministry of Health to supply the materials0 Requisi- tion was made through American installations but the vaccine was shipped directly to units by the Government Lymph Establishment0 This arrangement provided an admirable solution to the difficult problem of maintaining a constant and satisfactory immunizing agent for theater needs0 Results of the Immunization Program0— No better index can be obtained of the satisfactory accomplishments of specific protective immunization than by consideration of the frequency of the four prin- cipal diseases toward which the program was directed• No case of smallpox occurred in the theater0 Only three soldiers contracted typhus fever, of whom two were subjected to special risk through duties involved in the care of patients0 Tetanus was a remarkably rare disease, out of all proportion and comparison with the exper- ience of previous wars0 Typhoid and paratyphoid rates set an all time record for the United States Array0 The results are shown in Table 20 12 Table 1 IMMUNIZATION PROCEDURE IN THE EUROPEAN THEATER OF OPERATIONS May 194-5 Routine Immunizations (All Personnel) Disease & Agent Initial Immunization Stimulating Dose Smallpox (vaccine) Vaccination on entry Vaccination every 3 years Typhoid-paratyphoid fevers (triple vaccine) 3 subcutaneous injec- tions of 0,5 cc, 1 cc and 1 cc, respectively, at weekly intervals 0o5 cc yearly Typhus fever 2 subcutaneous injec- tions of 1 cc, each, at weekly intervals 1 cc yearly, preferably about 1 Dec0* Tetanus (plain toxoid) 3 subcutaneous injec- tions of 1 cc, each, at 3 week intervals 1 cc one year initial series** Soecial Immunizations - Reauired for c lertain areas Disease & Agent Indication Initial Immunization Stimulating Dose Cholera (vaccine) Travel or station in Asia (including Middle East), the Southwest Pacific area, and East Indies 2 subcutaneous injections of 0o5 cc and 1 cc, respect- ively, at weekly inter- vals. 1 cc at U - 6 months intervals in the presence of danger of cholera Yellow fever (vaccine) Before entry into or passage through, yellow fever zones. 0o5 cc Every 4 years Table 1 (cont’d) Indicated in the Presence of Definite Disease Hazards Disease & Agent Indication Initial Immunization Stimulating Dose Plague (vaccine)*** Upon serious threat of ex- posure to epidemic 2 subcutaneous injections of 0o5 cc and 1 cc, respect- ively at week- ly intervals 1 cc at 6 month intervals, in the presence of danger of plague Diphtheria (plain toxoid)*** Occurrence of disease among troops, with indications of liklihood of spread Ool cc, 0o5 cc, 1 cc & 1 cc| A8 hours between 1st & 2nd dosesj 3 to U weeks for re- raainder Usually none l , * An additional dose of 1 cc of typhus vaccine should be ad~ ministered every 3 - 6 months in the presence of serious danger of infectiono ** An emergency stimulating dose of 1 cc of tetanus toxoid will be administered, as soon as possible after injury, to individuals receiving wounds or severe burns, and, when deemed advisable by the responsible medical officer, to those undergoing secondary operations or manipulations of old wounds0 -V y y A A A Large scale administration of diphtheria toxoid or plague vaccine should be undertaken only in the presence of sound epidemiological evidence therefore Source: Circular No0 68, Hq, European Theater of Operations» 25 May 19A5o Table 2 SPECIFIC PREVENTION OF INFECTIOUS DISEASES BY IMMUNIZATION European Theater of Operations, U„ S„ Army Cases per 1000 strength, per annum February 194.2 to June 194-5, Inclusive DISEASE TOTAL - 1942 1943 1?44 1945 Smallpox 0 0 0 0 0 Typhoid and Paratyphoid 62 1 2 27 32 Tetanus 1 0 0 1 0 Typhus* 5 0 0 0 5 TOTAL 68 1 2 28 37 Source: Division of Preventive M edicine, Office of the Chief Surgeon, European Theater of Operations * *Includes two American RAMPS (Recovered Allied Military Personnel)0 FIGURE !• Immunization of combat troops against typhus fever, Germany, December 19^4^4-* TABLSS 1, Immunization procedure in the European Theater of Operations, May • 2. Specific prevention of infectious diseases by immunization, European Theater of Operations, U. S» Army, Cases per 1000 strength per annum, February 19i+2 to June 19U5» inclusive. A HISTORY OF PREVENTIVE MEDICINE IN THE EUROPEAN THEATER OF OPERATIONS UNITED STATES ARMY 19hl - I9I+5 Part III - Epidemiology Section 8 - Foreign Quarantine *7 Colonel John E„ Gordon, M„ C* Chief of the Division of Preventive Medicine Office of the Chief Surgeon, ETO TABLE OF CONTENTS PART III Epidemiology- Section 8 - Foreign Quarantine Page Foreign Quarantine . 1 Sanitary Control of Ports , . 1 Joint British and American Agreement on Port Control , . . , 3 Sanitary Control of Ports in the United Kingdom 5 Sanitary Control of Ports of Continental Europe , 8 Sanitary Control of Airports 10 International Traffic by Combat Planes , 11 International Traffic by Transport Planes 0 • 11 Development of a Program for Sanitary Control Q 12 Regulations for the Sanitary Control of Airports , 13 Quarantine of Aircraft and Air»Borne Personnel , . . 0 . . . 16 Procedures for Aircraft to Overseas Airdromes ....... 18 Quarantine of Plantsf AnimalsJ and their Products 20 Procedures for the Reception of Incoming Aircraft 22 List of Figures PART III Epidemiology Section 8 - Foreign Quarantine Foreign Quarantine,—Foreign quarantine in military prac- tice in the European Theater involved the protection of outgoing and incoming passengers. The great proportion of movements in international traffic naturally involved personnel of the United States Arny but some of the most complex problems were associated with others who travelled under United States military auspices. Prominent among these were members of the American Red Cross, technicians of various kinds but mainly those employed by the air forces, technical experts, scientific advisers, diplomats and members of the Allied armed forces. As the war developed there were obligations relating to the transport of other nationals, the French, Belgians and Dutch, and at times the movement of large bodies of allied troops as when the 1st French Army came from North Africa, As the war ended, the flow of traffic was reversed; and there was need to protect the Zone of the Interior and other areas of redeployment from Importation of diseases from the theater. The principal effort previously had been to assure protection of the theater. While the work was essentially that of foreign and port quarantine as ordinarily understood, it was much broader in its interests and outlook, for all of the features of sanitation and health as related to overseas troop movements and the management of ports came into consideration. Sanitary Control of the time operations be- gan in the United Kingdom, the control of sea traffic entering British ports was a function of the local British Port Authority at the various ports of entry, British quarantine procedure dif- fered from that in America where the control of maritime traffic is at the Federal level and actual practice is by the United States Public Health Service, The Ministry of Health in Great Britain a*cts in an advisory capacity and promulgates certain general poli- cies, but the actual management of quarantine and other sanitary practices in ports is a direct obligation and function of the par- ticular local port authority. Port battalions of the United States Army Transportation Corps were early established in all of the principal ports of the United Kingdom to which American ships came. They served in* facilitating the receptior &f United States troops as they arrived in Great Britain and dealt 'with matters concerning the United States War Shipping Administration and the merchant marine under United States flag. A port., surgeon was a part of the organization. Under the arrangements in effect during the early months of the theater the management of quarantine and the inspection o&* ships and newly arrived troops followed the usual procedure of Brit- ish ports, in that the local British Medical Port Authority exercis- ed control and jurisdiction. Port surgeons of the United States Army had neither duties nor responsibilities associated with quar- antine or medical reception. Since the personnel of British Port Authorities had suf- fered the usual depletions and shortages in staff that characterized most organizations in time of war, American port surgeons were grad- ually delegated authority by a number of British Port Authorities. Although the latter continued to retain primary responsibility in health and other matters, a working arrangement commonly evolved whereby duties relating to American troop transports and much of that of cargo ships of American registry or control, was done by the American Port Surgeon acting for his British counterpart. The sanitary practices of the several ports of embarkation varied considerably because each port functioned under an independ- ent and separate local authority, and because the individual arrange- ments made between British and American port surgeons of a given port were different. Nevertheless the system worked fairly satis- factorily. The sanitary difficulties in connection with a series of outbreaks of diarrheal disease on incoming transports in September 194-3 (see page 23> Part III, section 2, number 1), led to a general reconsideration and evaluation of port practices and sanitary con- trol of troop movements on both sides of the Atlantic. The measures taken in the Zone of the Interior have been described. The theater made a comprehensive survey of port practices at the receiving end. With due allowances for the variations in practice which made each port an individual problem, a general pat- tern of procedure characterized practices at the 4th, 5th, 11th, 12th, and 14-th Ports of Embarkation. When a transport of American registry came into a port in the United Kingdom, the ship surgeon or transport surgeon clear- ed the vessel through quarantine in company with the civilian medical officer of health of the port. In the event that patients with 2 infectious disease were aboard ship, the civilian port medical officer took complete control where necessary and sent the patients to British civilian fever hospitals. The American port surgeon arranged f or evacuation and hospitalization of soldiers requiring cam for other than a communicable disease. The arrangements by both British and American port sur- geons were made on the basis of information provided by the trans- port surgeon. There was no inspection or examination of arriving troops. According to statements obtained from commanding officers of recently arrived units, no examination and no inspection was ordinarily held aboard ships in transit; and in the opinion of port surgeons such inspections were rarely if ever held. The statements of unit surgeons arriving in the theater indicated that the pre-em- barkation physical inspection in ports of the Zone of the Interior was likewise decidedly cursory. On the basis of these observations, .steps were taken to more clearly define the duties of Port Surgeons in United States ports of embarkation in the United Kingdom, and to bring them into agreement with the provisions of existing army regulations. The practice of sending United States soldiers to civilian fever hos- pitals was a matter of necessity in the early days of the theater but adequate U.3. Army hospitals were later located near all prin- cipal ports. Loose practices had developed in respect to naval gun crews and merchant seamen. They were often allowed shore leave with communicable disease, particularly a venereal disease, a prac- tice which had given rise to informal inquiry and comment by Brit- ish health authorities. Other than the Medical Department of the United States Army, four other organizations within the theater area were con- cerned with an attempted stabilization and organization of sanitary practices in ports. First of all was the British Ministry of Health and the several British Port Health Authorities having local jurisdiction. The United States Navy was definitely concerned, A great proportion of port activities related to the American Merchant Marine, and the War Shipping Administration. The definite manage- ment of port activities as they related to American interests was the obligation of the Transportation Corps of the United States Army, Joint British and American Agreement on Port Control.— Since the control of maritime traffic in British ports was wholly a function of British authority and the United States Army'" to all intent and purpose was a guest user of these facilities, the first thing to do in any proposed development control of Amer- ican port activities was to obtain sanction of British authorities 3 to that proposal. The British Ministry of Health proved most sym- pathetic and indeed welcomed American aid in the work of inspection and control. The Ministry wrote all local port authorities concerned, recommending that sanitary control of American shipping be delegat- ed to American port authorities who would act for the local port health authority, although the latter would continue to maintain primary responsibility. The willingness of United States port con- trol organizations to accept this obligation was assured. Without exception all local port authorities agreed to the suggested arrange- ment and expressed appreciation of the technical additions to port control facilities which would follow. The possibility of such an arrangement having been assur- ed, the Transportation Corps of the United States Army gave ready agreement to the projected system, believing that it would improve practices and facilitate the work of ports. A letter was sent by the Chief of Transportation to all Port Battalions of the United States forces in Great Britain asking for a statement of existing practices and duties of port surgeons. On the basis of the replies received, a protocol of port procedure was prepared by the Division of Prevention Medicine of the Office of the Chief Surgeon, based on existing common and de- sirable practices and including the necessary alterations to elim- inate undersirable features demonstrated by the original survey. The authority of port surgeons and their relations with British port authorities were defined. A conference of United States port surgeons served to bring into line with the practical aspects of ship inspection and the sanitary control of ports the desired objectives and the tenta- tive provisions of the proposed regulations. On the basis of this preliminary planning and the working arrangement which had been effected through the help of the Ministry of Health, a draft of provisional procedure was prepared and submitted for consideration of the United States Navy, The Navy was particularly interested in that most trans- ports carried naval gun crews. Naval surgeons were not stationed in all ports used by American transports. Furthermore, a single inspection of a ship and its personnel had advantage over a dup- licating inspection by both Army and Navy port surgeons in expe- diting the clearance of vessels. The Army agreed to accept entire responsibility and that arrangement was finally agreed upon for all transports carrying United States Army personnel, the Navy naturally continuing to exercise full responsibility over purely naval vessels. The arrangement with the American Merchant Marine produc- ed greater difficulty. In general, previous practice had been looser and less satisfactory for cargo ships than for transports. It was agreed that the Army would be responsible for certification of health conditions of all transports carrying troops. Many cargo vessels carried small numbers of military personnel, sometimes only three or four, and it was necessary to define just what a transport wes , whether it was any vessel carrying a member of the United States Army or whether certain numb***** of persons should determine the decision. It was finally the international defini- tion of a passenger vessel should govern, namely that the presence on board a ship of more than 16 passengers should determine its na- ture as a troop transport. The Army Medical Department in initiating these discus- sions had offered to provide the same services of inspection and sanitary control for cargo vessels of American registry or control, as for transports carrying United States troops. This arrangement was declined by the Merchant Marine, since the less rigorous in- spection of the domestic civilian port authority was believed to be the only workable procedure. Sanitary Control of Ports in the United Kingdom.—Eventual- ly the varying interests of the several military and civilian orga- nizations of both British and American origin were correlated and a directive on the sanitary control of ports was issued with the indorsement of all concerned. The responsibility for granting pratique to all ships entering ports in Great Britain and Northern Ireland was stated to rest with the civilian port health authority, who through mutual arrangement might delegate this responsibility to the United States Port Surgeon. The conditions under, which this was to be accomplished were set forth in detail. The closest liaison and cooperation was directed to be exercised at all times by United States port surgeons v/ith civilian port medical authorities. Certain terms pertaining to maritime traffic were defined. A transport was to be considered as any vessel carrying in overseas movement 17 or more military personnel as passengers. A cargo ship was any other vessel in overseas traffic, except hospital ships and naval vessels. Hospital ships were to be considered as those carry- ing principally sick and wounded military personnel. An official list of communicable diseases was set forth which included all of the venereal diseases. Quarantinable diseases were stated to be those recognized by the International Sanitary Con- vention, to include typhus, yellow fever, small pox, plague and chlorea. 5 The definition of military personnel was to be understood as including all members of the United States Armed Forces and others such as American Red Cross employees and civilian technicians travel- ing protein under military control. Regulations were first prescribed for procedures to be followed in the reception of troop transports* The passenger branch of the operations division of the Port Battalion was to notify the port surgeon in writing of the expected date and hour of arrival of each transport bearing United States military personnel, regardless of flag of registry, as soon as the information was available. The port surgeon or his representative was required to board each incom- ing transport most expeditiously0 Upon boarding the transport, the port surgeon or his repre- sentative reported to the transport commander or his designated rep- resentative. He received from the transport surgeon a list of the sick and wounded aboard, by name, army serial number, organization, provisional diagnosis and recommended disposition. He received the voyage report of the transport surgeon and a certificate of the immunization status of troops aboard. The transport surgeon also provided a copy of the ship’s roster endorsed with the statement that except for certain individuals specifically noted: the ship's company, including troops, crew, and United States naval gun crew, was free from vermin and communicable disease. In the event the transport surgeon was being relieved from duty on completion of the voyage, a record of alcohol and narcotic receipts and expenditures was audited. The port surgeon initialed each page of the roster certi- fying to the health of the ship9 s company and their proper physi- cal examination. If no physical examination of troops and ship's company had been made during the voyage, the port surgeon caused such an examination to be made without delay. If the physical inspection had not been done within 4-8 hours of debarkation, he made or caused to be made such examination or inspection as he deemed necessary. Only those members of the shipfs crew or naval gun crew or other military personnel whose names were certified on the roster were permitted to disembark. Immediately a transport carrying United States military personnel had docked, the port surgeon made a sanitary inspection of the ship with particular reference to the care of the sick, hospital accommodations, medical supplies, available sleeping and latrine facilities, messing accommodations, mess sanitation and the quality of rations provided. 6 The surgeon arranged for the reception and care of mili- tary personnel unfit to travel and for the hospitalization in the most convenient United States military hospital of those who were sick and injured, except that members of the ship's crew with un- complicated venereal disease were allowed to remain aboard but not to disembark. The port surgeon quarantined on the duly delegated authority of the civilian port Medical Officer of Health and pur- suant to the procedure established by the International Sanitary Convention any ship bearing aboard a diagnosed or reasonably sus- pected case of typhus, yellow fever, smallpox, plague, or cholera and promptly notified the Chief Surgeon of the European Theater. Quarantine, fumigation, or other procedures which might delay the movement of the vessel were not practiced for other communicable diseases except on specific order of the Chief Surgeon, ETOUSA. Upon receipt of prisoners of war or of military person- nel from an area in which typhus fever was prevalent, the port surgeon carried out the necessary desinfestation procedures and certified that proper disinfestation had been accomplished. In the event of the reception of a ship bearing cere- brospinal fever, diphtheria, acute poliomyelitis, scarlet fever, measles, mumps, typhoid fever, jaundice, or having experienced an explosive epidemic of any communicable disease,the port surgeon informed certain prescribed health authorities of the theater by the most expeditious method available. These included the Chief Surgeon, the Surgeons of base sections to which troops were as- signed and the commanding officers of all posts and stations to which troops were traveling. Finally the port surgeon was required to issue to arriv- ing units that portion of their unit medical equipment prescribed by theater regulation, to accept dhd give receipts for medical supplies carried by ships with no transport surgeon, and to ex- pedite to the nearest United States Army Medical Depot the requisi tions of transport surgeons for such medical supplies as were needed for the next anticipated vbyage. The procedures for the reception of transports of for- eign registry bearing United States troops, were precisely the same as those prescribed for ships of United States registry, ex- cept that responsibility for clearance of the ship and the ship’s crew was not assumed by the port surgeon or his representative unless specifically so requested by the civilian port surgeon under written designation as his representative. 7 The procedures outlined for transports were employed for hospital ships carrying United States troops with such modifications as were made necessary by the status of the military personnel. The procedures for the reception of cargo ships of United States registry provided that the Operations Division of the port notify the port surgeon in writing of the expected date and time of arrival of all cargo vessels of United States registry* As soon as such information was available, the port surgeon boarded each in- coming vessel in such good time as to prevent delay of the movement of the vessel by the procedures which he was required to complete. Upon boarding the vessel, the port surgeon reported to the master or his designated representative. The port surgeon then furnished information regarding the local United States Army facilities for hospitalization and for medical care of the ambula- tory sick and at the request of the master, arranged for hospitali- zation in the most convenient United States hospital of members of the crew for whom hospital care was deemed necessary, provided that the ship had been previously cleared by the local civilian port medical officer. The port surgeon inspected all United States military personnel aboard for communicable disease and for vermin and they were not allowed to disembark until this inspection had been com- pleted. He arranged for hospitalization in the most convenient United States military hospital, of United States military person- nel who were ill or who were suspected of having a communicable dis- ease in an incubationary stage. No inspection of the ship’s crew nor of the ship itself was made by the port surgeon. Clearance of the ship and crew was brought about by the local civilian port medical officer. Sanitary Control of Ports of Continental Europe.—When operations were initiated on the continent, the regulations already applying in Great Britain became operative in respect to ports in France; except that in the early phases of operation, all ports used by United States forces were necessarily under their direction and complete control. In late 1944- a number of regulations were issued by the War Department concerning the control of international traffic by sea and by air. These included a new Army regulation on foreign quarantine, and two circulars elaborating quarantine procedures. The United States Army Quarantine Liaison Officer visited the theater in February of 1945» reviewed the existing port and airport regulations of the theater and made minor recommendations 8 designed to bring the practices of the European Theater in the control of sea traffic into agreement with those in force in theaters of operation of the United States Army generally. The value of uniform prodedures was apparent, A revised circular on the sanitary control of ports incorporated these recommendations, clarified certain administra- tive procedures involving reports, and brought the previous regu- lations into agreement with altered conditions and new situations encountered in the course of operations on the continent. The responsibility for granting pratique to ships bearing United States personnel or cargo on entry into conti- nental ports used exclusively by the United States armed forces rested solely with the United States military port authorities operating the port. In continental ports used for both United States military and European civilian purposes, specific areas of the port were designated as the responsibility of the United States Army and others that of the civilian port authority. This arrangement placed the sanitary control of continental ports on a basis of those being used by the United States Army being com- pletely under their control, and those used wholly by the French or other nationals in military or civilian operations under their individual control. Separate areas under individual control of the nations using the facility were provided where two countries made use of the same port. The clearance of all cargo ships of United States regis- try entering continental ports was made an obligation of the Port Surgeon of the United States Army. (Figure 1). The previous con- dition of clearance by the civilian port medical officer was main- tained in the United Kingdom, The transport commander of each departing troop transport furnished a statement certifying that all military and civilian personnel who were embarked had satisfied theater immunization re- quirements, were free from quarantinable disease and were free from vermin. Exceptions were permitted only in the case of immunization requirements and these were specifically noted in order that de- ficiencies might be corrected enroute. The latter change was significant in that for the first time it provided for clearance on departure, a necessary measure in connection with redeployment of troops. (Figure (2) Other than min- or changes in respect to records and reports, the remaining provis- ions of the new order were the same as in the previously published directiveo 9 Sanitary Control of Airports.—A well-developed organi- zation for the control of traffic by sea had developed over the course of many years in most countries of the world. Even those with health organizations which by modern standards failed to reach a very high order of accomplishment, had systems of port control and quarantine which served more or less adequately to limit the spread of the quarantinable diseases. In Great Britain, and in the continental countries within the scope of military operations of the European theater, sanitary port control had been at a high level for many years0 The United States army in the course of its military planning had established Port Battalions and port organizations. Systems of procedure had been defined to deal with the health prob- lems of sea ports. The system in respect to air traffic and the sanitary control of airports was less firmly established and had attained a less secure level of organization. International air traffic was relatively newc It had just been getting under way on a commercial basis before the war. The onset of military opera- tions brought a tremendous increase in volume and a complexity magnified many fold. Sea traffic entered Great Britain at a few well-defined ports, with systems of port control that had existed for many years. Enlargement and refinement of control measures were often required, but there was a good foundation upon which to build. Separation existed between combat and ordinary military traffic, in that certain ports were set aside primarily for the use of the Navy and others were designated for the reception of transports and the usual military movements by sea. Airports were commonly war time developments, newly con- structed and newly organized, with relatively little tradition or experience in the health measures required to assure safe movement of international traffic. The same airport commonly served both combat planes and those engaged in the ordinary traffic of war, the movement of troops and of urgently needed supplies, air traffic into the theater was furthermore predominantly related to combat activity, in contrast to sea operations which had to do in the European Theater primarily with the movement of troops and supplies. The number of airports was infinite in comparison with sea ports. They were scattered all over the theater in contrast to seaports which were located along the fringes of the operational area. The volume of intra-theater air traffic was much greater than that of sea traffic. Planes arrived after having called in all manner of airports, which gave rise to the possibility of transmission of communicable diseases from Africa, the Near East, 10 Figure 1 The dock area of the Port of Marseilles, France. Ships in the outer harbor await clearance. October 1944. Figure 2 The first soldiers to be discharged under the point system and liberated prisoners of war mount the gang plank of a ship back to the United States, May 1946. South America, and even from the Far East. The great bulk of sea traffic was representative of an uninterrupted passage from rela- tively safe points of departure in the Zone of the Interior. The extent of the problem of adequate sanitary control was much greater for airports than for seaports, and decidedly more complicated. Shortly after action had been taken in 194-3 to formalize the health measures related to maritime traffic, inquiries were made on the nature of existing procedures concerning air traffic. Several kinds of travel by air were involved. International Traffic by Combfct Planes.—Combat planes ate first considerSd. A great volume of movement was involved in missionsrover Europe, originating from the United Kingdom but with departure and return both related to the home air port where bomb- ers were stationed. The opening of the continental campaign in- creased these activities, and in addition the Ninth Air Force be- came operational on the continent. Spotter and other planes attache ed to armies still further increased air traffic. The shuttle operations to Russia, to Italy and to Africa introduced the problems of international traffic and far more pertinent health problems. Intra-theater traffic was always measureably great. It increased tremendously when operations extended into Germany. Long distance international traffic came into important consideration. Large numbers of combat planes were flown to Europe from the Zone of the Interior to be put into operations in the thea- ter, Sometimes they flew non-stop from the Zone of the Interior by the relatively direct northern route. In many instances, and at particular times of the year, the longer southern route was used, with numerous stops in tropical and sub-tropical regions. (Figure U) International Traffic by Transport Planes.—Transport planes presented the major health consideration. The traffic was primarily between the theater and the Zone of the Interior, The conditions of travel were like those of combat planes in course of delivery, with varying degrees of risk dependent on the route traveled; whether it was the relatively direct northern route or the longer, more potentially hazardous southern route. Inter- theater traffic between Europe, Africa and Italy was no inconsider- able feature. Truly international traffic involved scheduled runs between the theater and Iceland, later to the Scandanavian countries, to Russia and even to the Far East, particularly in the latter days of operations. 11 Intra-theater movements were numerous, especially after the onset of operations in Europe because of the relatively great distances involved and the necessity for maintaining contact be- tween France, Germany and Britain, Development of a Program for Sanitary Control.—The problem of sanitary control of airports was approached in much the same man- ner as in respect to seaports, Numerous airports were used jointly by the British and American forces particularly in the early days of the theater, but in no instance was British control exercised over health considerations at such airports. Whether the airport was primarily operational, in the sense of being concerned only with combat activities, or whether it had to do with transports and similar military movement, British and American authorities were individually responsible for sanitary control measures. Airports which were wholly American were under American control for sani- tation and quarantine. It was deemed desirable that the principles of sanitary control should rest on common grounds and that so far as feasible uniform and coordinated practices should govern British and American movements by air. The British sanitary laws covering traffic to and from the United Kingdom were being circumvented by American forces, commonly without intent, through lack of proper British or American control at airports in the United Kingdom and at airports of departure for the United Kingdom in other regions. Infractions of regulations were sufficiently frequent to constitute a serious health threat. The British had stringent and efficient laws governing sanitary control of traffic to and from the United Kingdom. For the application of these laws they had adequate administrative procedur- es at seaports. A committee composed of the British Ministry of Health, and representatives of the three British military forces had been working on the problem for approximately two years, looking toward divlsing as simple a procedure and staff as was feasible for the application of existing laws to air traffic. Their investigations indicated that currently it was impossible to set up the necessary staff or administrative proce- dures to apply the sanitary laws to airports in the same manner in which they were applied to seaports. In looking toward this devel- opment certain administrative procedures had been developed by the committee which were in substantial agreement with the proposals made by the Chief Surgeon of the European Theater for the control of air movement, British authorities gave specific endorsement to the proposed plan. 12 Figure 3 A plane of* the 1st Infantry Division lands on a newly acquired section of the Autobahn superhighway- in Germany, March 1945. Figure 4 A Plying Fortress arrives from the Zone of the Interior at an American Airdrome in England. The Air Transport Command was more intimately concerned with these problems than any other unit of the air forces in Europe, A field survey of the principal airports maintained by that organization was accomplished as a joint activity of the Division of Preventive Medicine of the Office of the Chief Surgeon and of the Surgeon of the air Transport Command. Practices in san- itary control and in quarantine at the several air forces were bas- ed on existing regulations of the service. While a certain uni- formity of pattern existed, in no two airports were practices alike and individual differences were sometimes great. With all other information at hand a thorough review and discussion was held with the Surgeons of the Eighth and Ninth Air Forces, air traffic under control of these two organizations in- cluded the majority of activities within the Theater, They were principally concerned. Together a draft of regulations was prepar- ed and submitted for publication as a command directive of the theater. / Regulations for the Sanitary Control of Airports.—The V purposes of these newly defined regulations were to prevent the transportation and spread of communicable or quarantinable diseases, through examination of crew members and passengers upon arrival in the United Kingdom for evidence of these diseases and for vermin; to effect disinsection in accordance with air force directives; and to prohibit animals from being carried or imported into the theater from other countries by air craft. (Figure $) The communicable diseases were defined in precisely the same manner as for seaports and likewise the quarantinable diseases. An endemic area south of 54° north latitude and ‘north of 45° south latitude, excluding territories included within the United States, Canada, and the British Isles. Procedures for the reception of incoming aircraft provided that the Operations Division of each air base in the United Kingdom notify the Base Surgeon of the estimated time of arrival of aircraft from airports outside the United Kingdom, in order that the surgeon or his representative might be on the field to meet such incoming aircraft. All passengers and crew members proceeded to the medical clearance room where each crew member and passenger was examined for communicable disease and vermin, unless such examination had been made within 43 hours of arrival,, The surgeon of the airdrome quar- antined all passengers and crew members of aircraft carrying a diagnosed or reasonably suspected case of typhus, yellow fever, smallpox, plague, or cholera; and the aircraft was disinfected. 13 In the event of the arrival of personnel having cerebro- spinal fever, diphtheria, acute poliomyelitis, scarlet fever, measles, mumps, typhoid fever or jaundice, the patient was hospita- lized in the most convenient United States military hospital and the Surgeon of the airdrome by the most expeditious method available notified the Chief Surgeon of the theather, the Surgeon of the air command concerned and the commanding officers of all commands to which the military personnel aboard were assigned. Each passenger and crew member who arrived from areas of endemic insect-borne disease, from areas where a quarantinable disease was known or suspected to exist, or on aircraft bearing a communicable disease were given a prescribed form card. The card informed the passenger that while on board the aircraft he might have been in contact, without knowing it, with some dangerous epi- demic disease prevalent in other countries. He was therefore ad- vised that if he felt ill during subsequent days that he should consult his medical officer or doctor immediately and give him the card, which bore notice to the physician of essentially the same import and requested that in the event of significant clinical observations that notice should promptly be given to the Chief Sur- geon of the European Theater0 The immunization register of each military passenger or crew member was inspected,, The commanding officer of each air base in the United Kingdom caused the following measures to be accomplished for air- craft arriving from endemic areas of insect-borne disease. The pilot furnished a certificate according to a prescribed form', showing compliance with the provisions of air force regulations before mem- bers of the crew or passengers were permitted to disembark. Cer- tificates of disinsectization for all such aircraft were forward- ed weekly to the Surgeons of the air commands concerned. The base Surgeon made frequent inspections of aircraft to determine that disinsectization was properly performed. Aircraft arriving from an area in which typhus was preva- lent, and on which passengers or crew members showed evidence of louse infestation or gave history of exposure to the disease were disinfested in accordance with existing regulations of the Chief of Transportation, War Department. Animals, including mammals, birds, fish, reptiles and insects, were not carried or imported from other countries by air- planes except that animals transmitted with official certificates stating that they were for military or medical use and that all sanitary and medical precautions had been taken to prevent the spread of the disease, might be so carried,, Aircraft were inspected upon arrival and animals imported without an official certificate 14 Figure 5, and United States paratroopers with their Icelandic mascot en route to England in a C-47. August 1943. were confiscated. The nearest representative of the Ministry of Agriculture and Fisheries was notified and he collected the ani- mal and assumed responsibility for its proper disposition. Procedures for aircraft outbound to overseas airdromes included inspection of immunization registers of military person- nel, No person was allowed to proceed who had failed to comply with the immunization requirements in respect to yellow fever. All outbound passengers and crew members were briefed on the health hazards to be encountered enroute, and the most effective prevent- ive measures were outlined, (Figure 6) . *• Foreign aircraft arriving or departing from airports under the jurisdiction of the United States Army were required to conform with the regulations established for aircraft of the United States. A slight change in the procedures relating to disposition of animals illegally brought into the theater became necessary be- cause no law existed in England in respect to certain animals. Their disposition was left to the deseretion of British officials by a second revised directive. The several circulars issued by the War Department late in 1944, reference to which has already been made in connection with the discussion on seaports, introduced significant changes into the procedure for control of air traffic. The most important alteration was in respect to the time of inspection, which substi- tuted predeparture certification fof the classical method of in- spection on arrival. This procedure had been selected for its advantage in military traffic and theoretically it contributed to a more complete attainment of purpose. The United States Array Quarantine Liaison Officer suggested that appropriate changes be made in the regulations of the theater to bring them in accord with general practice of the United States Army throughout the world generally. Quarantine clearance on the basis of predeparture cer- tification was proposed to the British Ministry of Health with Particular reference to military aerial traffic, and as alterna- tive to the traditional processing upon arrival. Their approval and indorsement was obtained. The United States Public Health Service had furthermore agreed to suspend quarantine requirements in the case of personnel aboard military aircraft who departed the United Kingdom for the United States after at least two weeks resi- dence in the United Kingdom, in the absence of quarantinable dis- ease in significant degree, A substitute theater directive was therefore prepared, designed to bring about implementation of War Department and theater procedures. 15 The methods of dlsinsecting aircraft were altered to con- form to newly published procedures of the Army Air Force. It was likewise possible to increase the number of areas exempt from disin- section which previously had included the United States, Canada and the United Kingdom and certain areas on the European continent. New regulations exempted plains from spraying if traveling from Iceland, Newfoundland, Labrador, Bermuda, and the Bahamas. It has also become apparent that planes from the Azores Islands need not be treated because of the very limited presence there of potential disease bearing insects and the energetic mosquito control about air ports of departure. The most important change in regulations was that all crew members and passengers were determined to be free from communicable disease and vermin before departure from the theater and also on arrival from localities outside the theater, unless certified to have had such examination within 48 hours of arrival* In implementation of these newly defined regulations and to coordinate them with Army regulations and War Department circu- lars, a memorandum was prepared by the European Division of the Air Transport Command which set forth in detail the provisions required for the quarantine of aircraft and the management of sonnel. The substance of this memorandum is given below; Quarantine of Aircraft and Air-Borne Personnel.—A medical Clearance Room will be set up in or near passenger terminals of EURO ATC base units, where the appropriate medical procedures outlined will be accomplished. Definitions Quarantinable Diseases are those recognized as such by the International Sanitary Convention, i.e. typhus, yellow fever, small- pox, plague and cholera. Endemic areas of insect-borne diseases are those areas south of 54 degrees north latitude, and north of 45 degrees south latitude, except the United States, Alaska, Canada (and adjacent areas )., British Isles, Newfoundland, Mexico, Curacao, Aruba, Bahaaas, Bermuda, Azores, Galapogos Isles and that part of Continental Europe west of 13 degrees east longitude and north of 42 degrees north latitude, 16 Figure 6 Soldiers of the 1st and 9th Infantry Divisions homeward bound by Air Transport Command, Orly Held, Paris, June 1945, Communicable Diseases: Cerebrospinal Fever (meningoccic) Common Respiratory diseases Diphtheria Influenza Measles Measles, German Mumps Typhoid Fever Paratyphoid Fevers Types A and B Dengue Malaria Plague, Bubonic Relapsing Fever Plague, pneumonic Pneumonia, primary Pneumonia, secondary Poliomyelitis, acute Scarlet Fever Tuberculosis, all forms Typhus Fever Yellow Fever Chancroid Gonorrhea Syphillis Lymphogranuloma Inguinale Granuloma Inguinal Chickenpox Scabies Smallpox Fever, still undiagnosed Tetanus Pneumonia, pri- mary atypical Hepatitis, epi- demic Vincent angina Whooping Cough Cholera, asiatic Common Diarrheas Dysentery, baciL lary Dysentery, Proto zoal Dysentery, un- classified Responsibility Commanding officers of all AAF Base Units are responsible, with the technical advice of the Post Surgeon and within the juris- diction of the Army, for the enforcement of regulations and direct- ives pertaining to quarantine. A specific responsibility of the commanding officer is the designation of personnel for inspection of all aircraft, with the exception of aircraft excepted below, to determine whether animals, plants, or the products thereof are be- ing imported without an official permit. 1, Operations Section is responsible for disinsectiza- tion of aircraft and maintenance of appropriate records thereof. 2. Priorities and Traffic Section is responsible for: Inspection of all incoming EURD ATC scheduled transport aircraft to determine whether animals, plants, or the products thereof are being import- ed without an official permit. Certification on passenger manifest of outgoing aircraft that all persons aboard meet quarantine requirements. Review of all passenger manifests on incoming aircraft and notification to the Post Surgeon of any exceptions to quarantine requirements. 17 3. The Medical Department is responsible for: Technical supervision of quarantine functions, in- cluding inspections, recommendations, and consul- tation* Certification at airports of departure that indiv- iduals meet quarantine requirements. Accromplishment of appropriate measures at airports of arrival in regard to all quarantine risks. Submission of reports on quarantine. Maximum use should be made of personnel other than that the Medical Department in the execution of the foreign quarantine program since the bulk vof the procedures are routine and clerical and can be carried out by personnel otherwise concerned with pro- cessing of conveyances and traveling personnel. Procedures for Aircraft to Overseas Airdromes Medical Briefing: Commanding Officers of Aerial Ports of Embarkation and of all stations along foreign routes will be re- sponsible for medical briefing of all personnel. [uarantine of Personnel: Travel in aircraft under the jurisdiction of EURD ATC will be contingent on the satisfaction of immuniza- tion requirements of the War or Navy Department, and on freedom from vermin or quarantinable diseases. Prior to departure from one theater of operations to another on EtJRD ATC aircraft, all personnel will have in their possession a certificate, EURD Form 536 (MD) (Inclosure 3) signed by a Medical Officer within the pr&vllous 4-8 hours, certifying that the individual ’ satisfies these requirements. Duplicate copies of this form will be accomplished, the second copy of which will be turned in to Priorities and Traffic by the individual at the time the ticket for air travel is issued. The pilot of the aircraft will be notified in writing that all persons aboard, unless otherwise indicated on EURD Form 537 (MD) (Inclosure U) have met these requirements. This certificate will be in addition 18 to the individual certificate referred to above. If there are no exceptions to the quarantine requirements, EURD Form $37 (MD) (Inclosure 4-) need not be accom- plished and this certificate may be fulfilled by enter- ing the following statement on the manifest: "All personnel listed on this manifest are free from quarantinable diseases and vermin. Current immunization requirements of the War Department have been met or are in the process of being met,” This certificate will be signed nFor the Commanding Officer" by a responsible officer. Military and civilian personnel of foreign countries traveling on U.3.military aircraft will not be re- quired to comply with existing U.S. military regula- tions on immunization with the exception of smallpox (in all those cases not covered below) and yellow fever when required by regulations of countries to and through which travel will occur. Such individ- uals should be advised of the value of immunization and may be immunized upon their request. For immuni- zation requirements of all other personnel see Immu- nization Chart attached as Inclosure 1. aircraft and passedeparting from an area in which typhus is prevalent, and on which passengers or crew members show evidence of louse infestation or give history of exposure to typhus, will be dis- infested prior to departure. No person will be transported by air who is ill with pneumonic plague or whose last possible contact with pneumonic plague has been within seven (7) days. Waivers of any of the above requirements will be made and embarkation permitted only under circumstances of great urgency and when recommended by the Medi- cal Corps Officer conducting physical inspection and immunization and approved by the Commanding Officer of the port of aerial embarkation. Yellow fever im- munization will not be waived unless requirements for it have also been waived officially by countries to and through which travel will occur. 19 Disinsectization of Aircraft: In view of the danger of introduction of insects which are economic hazards or vectors of disease, aircraft under Army jurisdiction departing any station in areas of endemic insect-borne disease (see above) regardless of destination will be disinsectized as follows: Disinsectization will be carried out immediately prior to departure of the aircraft concerned, using aerosol insecti- cide or a substitute therefor as described in Inclosure 2, attached. Disinsectization will be accomplished: By the pilot of the aircraft or, under his direction, by personnel of the flight crew; After full loading of fuel, baggage, cargo, passen- gers and crew, and during or prior to the warm up of the engines; With all doors, windows, hatches and other openings closed during spraying, and until take-off, which shall not be sooner than two (2) minutes after spraying with hand sprayer; In all cabin, cockpit and baggage compartments and other places deemed necessary; if any are inaccessible from within the airplane, they will be sprayed when loading is completed; and Will be certified in the clearance (AAF Form No,23 or the equivalent)of the aircraft, as well as signalled to the control tower. Aircraft will not sbfe for take-off until completion of disin- sectization has been indicated to the control tow- er. Operations officers will maintain appropriate records by flyingLAAF Form 23, with notation there- on of action taken at both ports of departure and port of entry. Quarantine of Plants. Animals, and their Products; In order to avoid the transmission of animal or plant diseases and pests, and in order to observe strictly all pertinent civil and military regula-' tions, no animal or plant product likely to convey disease or subject to quarantine or other restrict- ive regulations, and no living plant or animal (mammal, reptile, bird, fish, etc.) will be’carried across national boundaries by airplane under the 20 jurisdiction of the Army except upon specific permit. This permit will be secured in advance from the proper civil authority of the country into which importation is intended with the ap- proval for the appropriate Theater Commander. Pertinent regulations of the United States, its territories and possessions are noted in Ap- pendix II of AAF Regulation 61-3, dated 9 August 19Uo Such permits will be requested only for plants, animals and plant or animal products intended for scientific, educational or military pur- poses, Requests will show the species and num- bers, type of container, source, destination, purpose for which intended, and the nature of any pathologic state. It will be the responsibility of the shipper prop- erly to pack, crate, tie, administer sedative drugs to when necessary, and arrange for care of, all animals during flight. Written instructions for care, including feeding, watering, exercise, etc,, will be attached. Conspicuous labels, containing instructions for full protection of handlers, will be attached to all cages containing animals infect- ed with pathogenic organisms, or the animals will be accompanied by a person responsible for their care; proper disposition will be specified for bedding, dejecta, and other material liable to be contaminated. Even though otherwise authorized, no animal will be transported by aircraft unless certified by a qualified veterinarian to be free from disease, ex- cept as provided above. Pathogenic cultures or tissues, or animals infected with pathogenic organisms, may be carried by aircraft only under the provisions above. Pathogenic cultures or tissues intended for shipment' by mail will be packed in accordance with postal reg- ulations, (U,S. Code, Title A, Section $&9, Postal Laws and Regulations. See also AR 4,0-310, Collection and Shipment of Specimens to Laboratories), 21 Raw meat and dressed poultry, or kitchen waste con- taining scraps thereof, will not be landed by air- craft except in accordance with pertinent military and civil regulations, Particular attention is di- rected to restrictions pertaining to the use or sale of such material for animal feeding. "rocedure for the Reception of Incoming Aircraft. Upon arrival, all aircraft will be inspected to determine whether any animals or plants or the products thereof are being imported without an official certificate. If such is the case, animals imported without an official certificate will be confiscat- ed or destroyed, except that in the United Kingdom the nearest representative of the Ministry of Agriculture ana aisheries will be notified, who will collect the animal and assume responsibility for its proper disposition. For aircraft arriving from airports within the same Theater of Operations and not from endemic areas of insect-borne disease, no quarantine procedures are necessary. On aircraft arriving from another Theater of Operations and not from endemic areas of insect-borne disease, the following will be accomplished. The pilot of incoming aircraft will furnish the ap- propriate officer at the port of arrival with the statement which is written on the passenger manifest certifying that all persons aboard the aircraft are free of vermin and quarantinable disease and that they satisfy current WD Immunization requirements. If there are any exceptions to this statement, they will be listed on EURD Form 537 (MD) (Inclosure 4) in the space provided and this form will be furnish- ed the appropriate officer in lieu of the statement on the passenger manifest. These certificates will be filed with the manifests for a period of six months at the airport of arrival. If there are no exceptions to WD immunization and quarantine requirements as shown by the certifying statement on the manifest, no quarantine procedures will be necessary at airport of arrival. 22 If there are exceptions to WD immunization and quarantine requirements for air travel as shown on EURD Form 537 (MD) (Inclosure U), or if there is no certification of quarantine requirements, such individuals will proceed to the Medical Clearance room where the surgeon or his represents tive will accomplish the followings Incomplete immunizations will be completed as far as possible in accordance with Immuniza- tion Chart (Inclosure 1) and passengers will be examined for quarantinable disease and ver- min. If quarantinable disease or vermin is found among U.S. military or U.S. Civilian personnel, movement of such cases will be restricted and disposition of persons concern- ed will be made by the post surgeon. If quar- antinable disease or vermin is found in foreign military or civilian personnel, movement of such cases will be restricted and the appropriate military or civilian quarantine authority will be informed. Disposition of personnel concern- ed will be as requested by the appropriate quarantine authority. If an aircraft arrives from areas where a quar- antinable disease is known or suspected to exist, or an aircraft arrives carrying an individual who is suspected of having a quarantinable or communicable disease, all passengers and crew members will be given a card, EURD Form 538 (MD) (Inclosure 5). In the event of the arrival of personnel having cerebrospinal fever, diphtheria, acute poliomy- elitis, scarlet fever, measles, mumps, typhoid fever, or hepatitis, the patient will be hos- pitalized in the most convenient U.S. Military Hospital and the surgeon of the airdrome will, by the most expeditious method available, notify the Chief Surgeon of the Theater concerned, the Surgeon of the EURD aTC, and commanding officers of all commands to which the military personnel aboard are assigned0 23 On aircraft arriving from endemic areas of insect-borne disease, the following will be accomplished: Before any of the crew or passengers are permitted to disembark, the pilot will furnish the operations officer or his representative with the certificate of disinsectization of aircraft, showing compliance with the provisions of AAF Regulation 61-3 dated• 9 August 19AA* This statement may be certified on the Clearance (AAF Form No. 23, or its equivalent). Each passenger and crew member arriving in the European Theater of Operations from areas of en- demic insect-borne disease will be given a card, EURD Form 538 (MD) (Inclosure 5). Scope The provisions of this Memorandum will apply to all air- craft, including foreign aircraft, arriving or departing bases com- pletely controlled by EURD ATC. At bases where EURD ATC shares joint occupancy and control with other units of the U.S. Army, or with foreign governments, the provision of this Memorandum will apply only to aircraft under EURD ATC jurisdiction. Re ports In compliance with par 3 a (6), AR U0-225, dated 21 Novem- ber 1944, reports of foreign quarantine activities performed by personnel of the Army will be included in the monthly sanitary re- port under paragraph "Subjects not covered by other headings." Patients Patients being evacuated by aircraft are exempt from the provisions of this Memorandum- 24 AREA EUROPEAN MEDITERRANEAN THEATER ASIA (RUSSIA) CENTRAL AFRICA PACIFIC OCEAN THEATER • AFRICA, EUROPE (other MIDDLE EAST CENTRAL & SOUTH AREA WEST OF than ETO) , MOUNTAINOUS PERSIAN GULF AMERICA (2) HAWAII CENTRAL & SO, AMERICA, BAST INDIES • MEXICO & ALASKA Original Stim Original Stim Original Stim Original Stim Original Stim All U.S. Military Smallpox 3 yr Smallpox 1 yr Smallpox 1 yr Smalloox 1 yr Smallpox 1 yr Personnel & ILS0 Typhoid i yr Typhoid 1 yr Typhoid 1 yr Typhoid 1 yr Typhoid 1 yr Civilians on Fld0 Tetanus 1st yr Tetanus 1st yr Tetanus 1st yr Tetanus 1st yr Tetanus 1st yr Duty Status Typhus 1 yr Typhus 6 mo Typhus 6 mo Typhus 6 mo Typhus 6 mo Cholera 6 mo Yellow F k yr Cholera 6 mo Plague 6 mo Smallpox 3 yr Smallpox 1 yr Smallpox 1 yr Smallpox 1 yr Smallpox l yr All AAF Personnel Typhoid 1 yr Typhoid 1 yr Typhoid 1 yr Typhoid 1 yr Typhoid l yr other than ATC Tetanus 1st yr Tetanus 1st yr Tetanus 1st yr Tetanus 1st yr Tetanus 1st yr Air Crew Typhus 6 mo Typhus 6 mo Typhus 6 mo Typhus 6 mo Typhus 6 mo Cholera — Cholera — Cholera 6 mo Cholera — —- Cholera 6 mo Yellow F — — Yellow F — Yellow F Yellow F k yr Plague 6 mo Yellow F — — Smallpox 1 yr Smallpox . 1 yr Smallpox 1 yr Smallpox 1 ■yr Smallpox 1 yr Typhoid l yr Typhoid 1 yr Typho id 1 yr Typhoid 1 yr Typhoid 1 yr All AAF ATC Air Tetanus 1st yr Tetanus 1st yr Tetanus 1st yr Tetanus 1st yr Tetanus 1st yr Crew Personnel Typhus 6 mo Typhus 6 mo Typhus 6 mo Typhus 6 mo Typhus 6 mo Cholera 6 mo Cholera 6 mo Cholera 6 mo Cholera 6 mo Cholera 6 mo > Yellow F U yr Yellow F k yr Yellow F k yr Yellow F h yr Plague 6 mo Yellow F k yr Smallpox 3 yr Smallpox 1 yr Smallpox 1 yr Smallpox l yr Smallpox 1 yr POW & US Civilians Typhoid 1 yr Typhoid 1 yr Typhoid 1 yr Typhoid 1 yr Typhoid l yr not on Fid. Duty Typhus: l yr Typhus 6 mo Typhus 6 mo Typhus 6 mo Typhus 6 mo Status ■* Cholera 6 mo Yellow F k yr Cholera 6 mo Plague 6 mo All Other Including * V Smallpox 1 yr Smallpox l yr Foreign Military & Smallpox 3 yr Smallpox 1 yr Smallpox 1 yr Yell6w F U yr Civilian Personnel IMMUNIZATION REQUIREMENTS - EUROPEAN DIVISION ATC For Travel to or Through or Stationed in the Following Areas (l) (1) Prior to departure of individuals from overseas commands immunization requirements of the Command concerned and of any land areas to be traversed while enroute to the U.S, will be complied with. (2) YELLOW FEVER. All personnel traveling to or through (or stationed'in) endemic yellow fever areas by Army transport or airplane, will be immunized against yellow fever within four years and not less than 10 days prior to entry into an endemic yellow fever area. This policy applies to all persons ten years of age and older. In order to meet the requirements of certain foreign governments, children under ten years of age who travel by Army tranport or airplane must have been immunized within two years. For the purpose of meeting quarantine requirements of all foreign countries, the endemic yellow fever area is defined as followsj (1) In the Eastern Hemisphere, that portion of Africa lying between latitude 18° South and the Northern borders of French West Africa, French Equatorial Africa, and the Anglo-Egyptian Sudan, including the islands immediately adjacent thereto. (2) In the Western Hemisphere, the mainland of South America lying between latitudes 13° North and 30° South, including the islands immediately adjacent, and Panama, including the Canal Zone, However, .. transit through the Panama Canal with brief sojourns within the Canal Zone will not be considered as travel through an endemic area. A. Use of Aerosol Insecticide (QM Issue, Stock No, 51-1-159): 1, Follow instructions on container, or furnished with item. 2, Spray all compartments and spaces, dividing pro- portionately the overall time indicated in the table below. B. Alternate Insecticide: In lieu of Aerosol Insecticide, disinsectization may be accomplished by fine vaporization from a hand or other spray of a 1 to $ dilution in kerosene, etc., of standardized pyrethrum ex- tract (marketed as pyrethrum concentrate, 20 to 1 strength; 26 pyrethrum extract standardized; pyrethrum extract No. 20; pyrethrum concentrate No. 20; or No, 20 extract standardized). Approved in- secticide and hand spray may be obtained from Quartermaster, and should be used in accordance with the table below. TYPE OF AIRCRAFT AEROSOL (hold 2 min) HANDSPRAY (hold 5 min) Single-seat Planes 3 s,€fc* ‘ 3 ccc B-17, B-25, B-26, C-47, etc. 15 sec 10 cc B-2A, C-87, etc. 25 sec 15 cc B-29, C-5A, etc. 40 sec 25 cc A watch with second hand will be used by all sprayers. 27 PRE-EMMRKATI ON HEALTH CERTIFICATE Name Hank Serial Np. For the information of quarantine officers and for transmittal to the responsible commanders enroute and at destination, the following state- ments are herewith certified; 1. Those infectious and parasitic diseases to which the personnel concerned have been exposed, or which are known to be present among them, are as follows; The exposure to or incidence of vermin among the personnel (or the incidence of vermin infestation in the areas from which the personnel are drawn) is a follows; Disinfestation (was)(was not) performed date 3. This (officer) (enlisted man) was inspected at (date) (hour) and was found free of actite communicable disease including venereal disease, with the following exceptions; U0 He is not suffering from a quarantinable disease (cholera, leprosy, smallpox, plague, epidemic typhus or yellow fever) with the following ex- ceptions: 5. He satisfies immunization requirements of AH U0-210 and other War Department and pertinent theater directives concerning special immuni- zations. Special cognizance is taken in this regard of the requirements of land areas to and through which he will be transported. The follow- ing exceptions are made; For the reason of 6. This individual will be required to take prophylactic atabrine until .(date) Name of examiner) Grade) This certificate expires hours after the date shown in paragraph 3 if plane is not boarded. SURD Form (MD) STATEMENT OF COMPLIANCE WITH WAR DEPARTMENT REQUIREMENTS FOR AIR TRAVEL All persons aboard aircraft are certified to be free of vermin and quarahtinable disease*, and to Satisfy immunization requirements of the War or Navy Departments for duty abroad, except as noted below; (Number, flight, etc.) No. exception ( EVIDENCE OF NECESSARY AND WAIVER REQUIREMENTS NAME CHARACTER OF EXCEPTION REASONS THEREFORE Date Place For the Commanding Officer; Name of Officer Rank Position •Cholera , leprosy, plague, smallpox, louse-borne typhus, yellow fever SUED Form 538 (MD) Important Notice to all persons Arriving by Air from Other Countries While abroad, you may have been in contact, without knowing it, with some dangerous epidemic disease prevalent in other countries., Therefore, if you fall ill during the next 21 days, consult your medical officer or doctor immediately and give him this card so that he may see the notice on the reverse side. Notice to Medical Officer or Physician The bearer arrived in this country by air at on in aircraft No, It is consequently possible that the holder of this card may be suffer- ing from some form of infectious or tropical disease acquired elsewhere, and has arrived before the end of the period of incubation. If you find or suspect such a condition, notify the Chief Surgeon, European Theater of Operations U.S, Army, APO 88?» U.S, Army, at once. FIGURES 1, The dock area of the Port of Marseilles, France. Ships in the outer harbor await clearance, October 1944. 2. The first soldiers to be discharged under the point system and liberated prisoners of war mount the gang plank of a ship back to the United States, May 1945. 3. A plane of the 1st Infantry Division lands on a newly acquired sector of the Autobahn superhighway in Germany, March 1945. 4. A Flying Fortress arrives from the Zone of the Interior at an American airdrome in England. 5. British and United States paratroopers with their Icelandic mascot enroute to England in a C~47, August 1943. 6. Soldiers of the 1st and 9th Infantry Divisions homeward bound by Air Transport Command, Orly Field, Paris, June 1945. A HISTORY OF PREVENTIVE MEDICINE IN THE EUROPEAN THEATER OF OPERATIONS UNITED STATES ARMY 1941 - 1945 Part IV - Nutrition by Colonel Wendell Ho Griffith* SNCo Chief of Nutrition Branch* Division of Preventive Medicine Office of the Chief Surgeon* ETO TABLE OF CONTENTS Part IV - Nutrition Page Relationship to the Quartermaster ........ 1 Summary of Activities. . 2 Scope of Responsibilities of the Nutrition Branch. Aim of Program. 3 Program. •. 3 Special Policies..... 4 Personnel 4 Medical Department Dietitians ............ 6 The Nutrition of the United States Army in ETO;. Troop Rations in the United Kingdom; British and British- American Rations , 7 Early Development of the American Ration... 8 Investigations by Nutrition Branch. 9 Waste of Food in 1942. 10 Revision of Ration Scale.... 11 Menus. 11 Average Type A Menu in the United Kingdom. 11 Hospital (Patients1) Ration.•.«.••...••• 12 Planning for Rations in Combat.............................. 13 Combat Rations. 14 Type B Ration.«............«...««........•••••........«».... 15 Rations for Patients. «««.<> o.««.• 17 TABLE OF CONTENTS (cont’d) Page Rati OriS on the 0 Ont inGn*t 9 oooooooooeo«*o«o«co*«ooooocao»oooo © 18 HOSpXtal Ra tX ons oooocoeooocoooooooooooooooo»ooooo»oocoooeooo 20 Augmentation and Reduction of Rationso © o © o ©©©©o o© © © ©©o ©©© © <> © 21 Section on Food and Nutrition in Monthly Sanitary Reports,, oo 27 7xtamxn Suppiementatxon © © © © © © © © © © © © © © © © © © © © © © © © © © © ©«© © © © © © © © 27 Malnutrition in Recovered Allied Military Personnel0©•»©©©o© 28 Malnutrition « Types Treatment© 0 c©*©© ©o© «•©©©©© ©«,©.© c© © 31 Sxmp1e MainutrX t ion oooooooooooooaoooooooooooeoooooooaooooeoo 31 EmacxafcXon Syndrome©©©©©©©©©©©©©c©©©©©©©©©©©©©©©©©©©©©©©©©©© 31 ACUte S barvatX on ooooooocooooeooooooooooooooooaooocooooooooao 35 Other Ration Problems; Milk and Ice Creai0oo..o.oc.,o.o.,o,o 35 Deity drated IOOdSo©e©©©o©©©o©ooo©©o©©ooooe©oo©oo©ooo©ooooo©o© 3b Local Procurement of Foodstuffs„*©©©o©©©©©©©©o©©o©©o©©©©o»o© 37 Ratxons xn Stagxng Areas©©©©©©©©a©©©©©©©©©©©©©©©©©©©©©©©©©©© 38 I*eedxng of Troops on 39 feeding on nospxta1 i-rains©©©©©©©©©©©©©©©©©©©©©©©©©©©©©©©©©© 40 The Nutrition of Prisoners of War, Allied Nationals, and Others; Rations for Prisoners of War*© ©©©©•© ©©«© © ©©© ©©»« 41 Feeding of Prisoner of War Patients© ©©<> 0© ©©o© ©©©©© ©©©o© ©o©. © 42 Rations for Allied Nationals and Others©©©© ©©„©©©©«©©©©©©©©© 43 Enemy Civilians 0000000090000000000000000000»00$000000000000» 43 List of Tables List of Figures 0 0 0 9 0 • O • O 000*000000 0 9 0 *00000 Part IV - Nutrition A Nutrition Branch was established in the Division of Preventive Medicine of the Office of the Chief Surgeon, ETOUSA, following the arrival late in August 1942 of the Nutrition Of- ficer who was to serve as Chief of the Branch for the ensuing three years* At this time, two additional nutrition officers, assigned to the Eighth Air Force, reported for duly in the theater. Although the first large convoy of troops had disembarked in North Ireland in the latter part of January 1942, the total American force in the British Isles amounted to only 156,000 men by the first of September, nearly one-half of these having arrived during the month of August. The Nutrition Branch began its activi- ties therefore, early in the history of the theater and at a period when the ration scale for troops in ETOUSA was still a sub- ject of discussion. From that time it set the dietary standards for rations provided by the Quartermaster and it determined the nutritional needs of the Army. The Nutrition Branch grew with the theater, as did also the magnitude of its responsibility for the nutritional health of troops and of hospital patients and the variety of its interests in all phases of array messing. By D-day, 6 June 1944, the number of nutrition officers had increased to 23 and that of troops to 1,549,000. Another one and one-half millions were added to the troop strength by May 1945. The enlargement of fixed T/o bed capacity and the increase in the number of hospital patients was even more spectacular. The total number of hospital admissions during 1942 was less than that during a 2-week period in the winter of 1944-1945. For the 4-week period ending 29 Janu- ary, bed capacity, total admissions and patients remaining at the end of the period increased from 5727, 3789 and 3162 respectively, in 1943, to 203,670, 124,248 and 183,965 respectively in 1945. This extension of hospitalization in the theater as troop strength grew and as more and more units engaged in combat was of particular importance to the Nutrition Branch because the character and adequacy of the patient’s ration were two of its primary concerns. Relationship to the Quartermaster.—It was recognized that the functions of nutrition officers were investigative and advisory and that the accomplishment of the mission of the Nutrition Branch depended upon complete coordination with commanding officers, responsible for mess operation, and with officers of the Quarter- master Corps, responsible for the procurement and issue of rations and for the training of mess personnel* The Chief Quartermaster welcomed the authority and relied upon the cooperation of the Medical Department with respect to the nutritional and sanitary aspects of messing* The joint interests and duties of the Nutrition Branch, Office of the Chief Surgeon and of the Subsistence Division, 1 Office of the Chief Quartermaster were notably strengthened by the teamwork and spirit of friendly helpfulness which characterized the officers of the two Servicese This teamwork was so effective that it was possible for nutrition officers to serve as nutrition consultants to Quartermaster officers without prejudicing their function as representatives of the Medical Department, responsible for investigations and recommendations concerning the adequacy of the soldier’s food0 Summary of Activities.—The sections follow describe the planned program and accomplishments of the Nutrition Brancho Mary and varied were these activities, including some which were wholly unexpected and for which no prior plans had been made® They centered on the preventive aspects of sound nutrition but included the nutritional rehabilitation of malnourished recovered American prisoners liberated from German’ stalags, a problem which turned out to be one of the most important purely medical problems confronted by the Chief Surgeon’s Office® Field tests of the suitability of standard operational rations for combat troops in Europe were planned and directed, an activity of especial importance in the case of the new "lO-in-l** ration which had not previously been subjected to trial under field conditions® As a result of these trials and of other accumulated experience pertinent recommendations were made concerning the composition of "C", MKn and "lO-in-l" rations and particularly concerning desirable changes in the Overseas Expeditionary Force type "B” ration® The unofficial move to supply a so-called Americanized version of the British Army ration to American Forces in the United Kingdom was opposed and new ration scales for troops and hospital patients were pioneered® A troop ration was described in terms of groups of foodstuffs, in accordance with their nutritive significance, for the first time in a theater of operations of the U® S® Army; and, for the first time, hospitals were issued a type "A” patients’ ration which did not require an added monetary allowance® The nutritional welfare of troops in combat was constantly emphasized in theater directives and by personal contact with officers of combat units® This was doubly necessary because of the tendency ,to exaggerate the value of convenience of transport and issue of operational rations with resulting potential damage to the nutritional fitness of soldiers® This program, which was actively supported by the Chief Quartermaster, was so successful that the great majority of combat units received the modified type "A” ration rather than "C" or rtK” rations, even when in contact with the enemy (Figure 1)® Nutrition officers were particularly prominent in the supervision of special procedures which wore designed to maintain mess operation on a high level in the marshalling areas from which troops embarked for the liberation of France® Participation in programs to prevent waste of food and to develop a sense of individual responsibility for proper eating was encouraged® 2 Figure 1 Tankmen of the 94-th Infantry Division eat hot food, brought by truck, while awaiting assignment to battle near Nennig, Germany, January 1945. The manner in which nutrition officers met the challenge of these and other problems constitute irrefutable proof of the importance to the Army of competent representation of the Nutrition Branch in the organization of the Medical Department,, This was not the case in the peace-time Army so that nutrition officers in ETO were often handicapped by lack of support from other officers, in- cluding medical officers, who neither understood the function nor realized the benefits of the nutrition program,, The tendency has been widespread to view the mess as an activity of the Army which automatically looked after itself or which required only periodic inspection to ensure the periodic polishing of pots and pans® This attitude was strenuously opposed by nutrition officers to whom the proper procurement, issue, preparation and service of foodstuffs were indispensable factors for health - factors which merited the attention of a specialized, interested officer group® Scope of Responsibilities of the Nutrition Branch® Aim of Program®—The aim of the Nutrition Branch was the maintenance of the health and effectiveness of all U® S® Army military personnel in the theater insofar as health and effective- ness are influenced by the adequacy of the dietary and by the general acceptability of the ration, particularly by the manner in which the specific components are selected, combined, issued, cooked, served, and eaten® The Branch was aware of the beneficial effect of palatable, nutritious food on the fitness of troops and on the "esprit de corps" of units and fixed as a goal the attain- ment of superior messing in U® S® Army messes in the theater® Superior messing was defined as the service of tasty, clean, nutritionally-adequate food to men informed about food values, conscious of the necessity of conservation of food and possessed of a personal interest in nutritional health® Procurement and storage of suitable ration items, efficient distribution, and proper preparation were obviously additional prerequisites for the desired standard of messing® In supervising the adequacy of the soldier’s dietary the activities of the Nutrition Branch were closely integrated with the general program of the Division of Preventive Medicine and were directed towards the preventive aspects of nutrition rather than towards the control of nutritional diseases« Program0—-The effects of light, moderate or heavy labor, of training, of combat, of hospitalization, and of convalescence in rest camps on food requirements were determined and the Quartermaster was advised concerning the adequacy of menus for men in these categories. Investigations were made of the quantity and quality of food issued to and served in messes, particularly with respect 3 to changes in dietary value and accoptabilily resulting from sub- stitutions in the prescribed ration by issuing depots, from refusal of ration items by mess officers, and from improper issue, storage, preparation, and service of foodo The Nutrition Branch participated actively in measures designed to increase the consumption of food- stuffs of special nutritional importance and to prevent waste of food and of the nutrients in foods* These measures included in- struction in authorized training schools, drafting of directives, preparation of posters, and informal conferences with unit officers and mess personnel* Investigations and recommendations were made regarding the nutritional status and the food requirements of working and non-working prisoners of war and of other whose sub- sistence was the responsibility of the Army* Liaison was maintained with nutrition officers in allied military headquarters and with allied civilian nutrition agencies, and recommendations were made with respect to ration problems reported in Monthly Sanitary Reports. In general, the nutrition officer served as the representative and adviser of the Surgeon in matters pertaining to the medical aspects of rations and of mess operation and coordinated these concerns of the Medical Department with the related interests of other Services, particularly with those of the Quartermaster Corps* Special Policies*—In addition to the general policies governing the activities of all Branches of the Division of Preventive Medicine, the Nutrition Branch adopted the following policies with respect to dietary standards and the character of rations in the theater: a* The minimum standard for U* S* Army rations will be the daily allowances of vitamins, minerals, and other essential nutrients recommended by the National Research Council (Table 6). b. Vitamin concentrates or tablets will not be author- ized as supplements to the "type A field ration if suitable foods are available to satisfy the vitamin requirements. c* The desirability of fresh, natural foodstuffs will be stressed and rations consisting solely of processed components will not be approved except for limited periods of time* Personnel*—A total of 30 Sanitary Corps nutrion officers, exclusive of those assigned to the Public Health Section, G-5, SHAEF, or to the European Civil Affairs Division, was sent to the theater during the 3 years subsequent to August 1942 (Table 1). Twenty of the 30 arrived before 6 June 1944, and participated in the pre-invasion planning and training in the United Kingdom* Most of 4 the officers were transferred to the continent during the summer and fall of 1944 (Table 1). The nutrition officers on duty in the thea- ter were exceptionally competent and highly qualified by previous training and experience for the work of the Nutrition Branch. All had either completed or were engaged in post-graduate studies in Biochemistry, Physiology, Animal Husbandry or' Food Technology prior to military service and were well versed in nutritional science. Furthermore, they had acquired indispensable practical knowledge of the duties of Army officers and of the problems of Army sanitation and messing through attendance at the School for Nutrition Officers at the Array Medical Center and through an average of 18 months service in camps in the United States. Medical officers were assigned to the Nutrition Branch, Office of The Chief Surgeon, Hq. ETOUSA, for varying periods during 1945 and rendered valuable assistance as members of teams which investigated the nutritional status of recovered allied military personnel, prisoners of war and German civilians. The proper location of the personnel of the Nutrition Branch was a vexing problem, particularly on the continent, because of the lack of provision for such officers in established Tables of 0rganizationo As a result, it was frequently necessary to make as- signments on the basis of greatest need. The distribution listed in Table 2 does not include many organizations in which opportunities for real service existedo For instance, only 2 of the 5 Armies in the theater, the Third and the Ninth Armies, made arrangement for the assignment of a nutrition officer on the staff of the Army Surgeon, and this was not done in the Third Array until late in 1944. Two of- ficers were assigned to the Ground Force Reinforcement Command but were compelled to confine their activities to the depots to which they belonged even though their abilities would have been of in- estimable service to other depots in the Reinforcement Command. Officers were on duty in 7 of 9 Base Sections established during the 12 months following the Normandy invasion but only 4 of the 7 oc- cupied a position on the staff of the Section Surgeon. The fact that many officers were carried on an uncertain, attached basis rather than on permanent assignment was not only a handicap to the operation of a consistent long range theater program but was also unfair to the officers because deserved promotions wore often delayed and, in some instances, impossible. In spite of this handi- cap the success of the nutrition officers was outstanding and the group received 12 awards. The ratio of nutrition officers to troops in the theater during the first half of 1945 was 1:125,000. It would have been advantageous if officers had been available on not less than a 5 1:75,000 basis and if their distribution had been according to either of the following alternatives: a® T/0 assignment of one or more officers to each major headquarters, including Hq® ETOUSA, First, Third, Seventh, Ninth and Fifteenth Armies, Eight and Ninth Air Forces, Assembly Area and Ground Force Reinforcement Commands, and Base Sections® bo Temporary duty assignments throughout the theater from an authorized theater pool, supervised by the Theater Surgeon and having an established T/0 with suitable grades. The second alternative has the merit of flexibility and would have permitted the temporary assignment of officers to armies and other commands according to troop strength and according to the occurrence of special problems related to the varying phases of activity of staging and of rest areas, of centers of hospitalization, of schools, and of prisoner of war enclosures® Medical Department Dietitians .—One or more Medical Depart- ment Dietitians were assigned to each hospital in the theater, ex- cept field and 400-bed evacuation hospitals. The Nutrition Branch was not responsible for these officers, from an administrative stand- point but aided them in every possible way to carry out their functions more successfully. In some hospitals, dietitians were considered no more than assistants to mess officers and were handi- capped in the performance of their duty of rendering professional assistance in the feeding of patients. The Nutrition Branch sup- ported the professional standing of the dietitian and encouraged their participation in programs designed to improve the nutrition of hospital patients. Frequent conferences of dietitians for discus- sion of pertinent problems were arranged by nutrition officers at headquarters of base sections and hospital centers. A dietitian was assigned to the Chief Surgeon’s Office in May 1945, following a visit to the theater by the Chief Medical Department Dietitian, Office of The Surgeon General. There was real need of the services of this officer at headquarters and her assignment was a boon to the dietitians in the theater who previously had no representative in the Chief Surgeon’s Office. The new Chief Dietitian was attached to the office of the Nutrition Branch, an arrangement which was mutually helpful. 6 THE NUTRITION OF THE UNITED STATES ARMY IN ETO Troop Rations in the United Kingdom. British and British-American Rations#—The first American units which arrived in Northern Irelandon 26 January 1942 were is- sued British rations and were loaned British Army cooks who fa- miliarized American cooks with the ration components and with the stoves and other kitchen equipment. The same procedure was used as additional forces reached Ireland and England. The British Home Service ration (Column 1, Table 3), included a cash element of 2-l/2d (pence) per day which was used by British messes in the pur- chase of condiments and other items supplied by NAAFI. This die- tary was soon found unsuitable for the American Array and the amounts of meat, grain products, sugar, evaporated milk and dried fruit were increased (Column 2, Table 3). Troops engaged in hard labor were authorized a increase in this Augmented British or so- called British-Amorican ration. Table 4 shows the nutritive value of the British and British-American rations on an "as issued” and an "as consumed" basis. The latter values were obtained by making the following deductions from the "as issued" values: a. The over-all average loss of foodstuffs during the issue, storage, preparation and service of the ration components is estimated as 5%. This is a minimum figure which is greatly exceeded in inefficient messes. b. The quantity of uneaten meat fat and cooking fat is estimated as 25%. Co Losses of thermolabile vitamins in cooking are estimated according to the National Research Council tentative recommendations listed in Table 5. These are minimum losses which are greatly exceeded in Array messes if food is overcooked or al- lowed to stand in warming ovens or on steam tables for long periods. According to American standards and tastes, the British ration was unsatisfactory because of its low caloric value and low content of milk, egg, beef, pork, tomato products, canned fruits and fruit juices, and coffee. On the basis of consumption, it failed to provide the levels of calcium, riboflavin and as- corbic acid recommended by the National Research Council (Table 6). 7 The inadequacy of the Home Service ration for British troops was recog nized by the British War Office and improvements were made in 1943 (See footnote 3, Table 4)e The British-American ration was more than adequate in calories but was deficient in tomato products, fruits, and fruit juiceso Its nutrient supply was greater than that of the British Home Service ration but, on a consumption basis, it failed to supply the recommended levels of calcium, riboflavin, and niacin« Early Development of the American Ration..—American rations were authorized on paper in February 1942 but no menu was published and troops continued to receive either the British ration or the British-American ration.. The components of the authorized type "A" field ration were the same as those of the garrison ration except that 4 ozo of wheat flour and 8 oz. of bread replaced 12 oz. of wheat flour (Column 3, Table 3)o The listing of the garrison ration as the basic field ration in an overseas theater is inexplicable in view of the fact that the garrison ration was designed for the cal- culation of the monetary value and not for the issue of a ration., There was concern over the authorization of this ration because of its weight (4.55 lbs.) and caloric value (5127 Cal.), and in May a revised ration was published in which beef was decreased from 7.43 to 5.20 oz., potatoes from 10 to 8 oz., sugar from 5 to 4 oz., bread from 8 to 7 oz., and flour from 4 to 3 oz. These changes lowered the caloric value from 5127 to 4562 but still left the ration far in excess of the British Army ration so that pressure was continued to decrease the difference between the rations of the 2 armies. Undue attention was paid at this time to the weight of the authorized ration and to the shipping which would be required to transport it across the Atlantic. No consideration was given the fact that the list of components did not constitute an acceptable ration nor the fact that the weights were not significant because boneless meat would be shipped rather than carcass meat, dehydrated potatoes rather than fresh potatoes, evaporated and dried milk rather than fresh milk, etc. On 28 July 1942 the first menu was published by the Office of the Chief Quartermaster and this served as the tentative basis of issue to units adjacent to the relatively few depots which were in operation at that time0 The ration prescribed by this menu was patterned after the Expeditionary Force Menu No. 1 with adjust- ments made to bring it into line with the authorized ration scale. The activation of Quartermaster depots proceeded rapidly during the early fall and units were transferred from the British-American ration to the American ration accordingly. This change-over was nearly complete by the end of October except for those units of the Air Force which shared stations with the R.A.F. At these stations either British or American rations were issued depending upon which force was numerically greater. It is interesting that neither group was satisfied with the ration to which it was unaccustomed. 8 American Air Force enlisted personnel at stations issued the British ration (not the British-American ration) were particularly unhappy and requests for supplementation of the ration with canned fruits and fruit juices were not infrequent. Supplementation in these in- stances was impracticable and was not approved,, Fortunately this situation did not continue long because incoming Air Force personnel made possible the general issue of American rations„ Investigations by Nutrition Branch,—Early in the summer of 1942 the Chief Quartermaster realized the need of expert advice with respect to the ration, particularly if further decreases were in prospect, and requested the Chief Surgeon to designate an officer who could collaborate with the Subsistence Division on this matter. This was done immediately as a temporary measure and The Surgeon General was requested to provide a qualified Food and Nutrition of- ficer o This officer arrived on 30 August 1942 and on 4 September 1942 was assigned to the Division of Professional Services as Senior Consultant in Nutrition,, On the following day this activity was transferred to the Division of Preventive Medicine and the Nutrition Branch was established in that division,, The first menu for the type "A” field ration (Column 3, Table 4), which was published on 28 July 1942 as a tentative basis of issue, was authorized by the Theater Commander on 6 September 1942. The letter of authorization frcxn Hq. ETOUSA directed that the services of the newly assigned nutrition officer would be utilized to make the best possible use of subsistence and that the contents of the proposed menu should be modified when justified by further study. It became the first duty, therefore, of the Nutrition Branch to determine the adequacy of the ration prescribed by menus prepared by the Subsistence Division and to recommend im- provements, if necessary. The reports of the resulting studies of the first menu authorized on 6 September 1942 and of the second menu (Column 4, Table 4) authorized on 12 October 1942 paved the way for the subsequent complete revision of the ration scale upon which these menus were based* The reports, which were forwarded to the Chief Quartermaster and which served as a basis for the first of many regularly-occurring conferences at which theater rations were dis- cussed and evaluated during the tmsuing 3-year period, emphasized the following points: (l) The caloric levels of the first and second menus were approximately 4800 and 4500 respectively, both of which were in ex- cess of the actual energy requirement of troops. Adjustment of this level should not be accomplished at the expense of the nutrients of the ration. 9 (2) Forty per cent of the calories were from fat, a large part of which would not be eaten# Special measures to salvage un- used fat were therefore necessary. (3) The substitutive table which was patterned after the one described for the garrison ration listed vegetables, in general, as substitutes for plant sources of vitamin ”AW. In order to safe- guard the adequacy of the ration it was essential that substitutes for leafy, green and yellow vegetables should be limited to vege- tables in that category. Similarly, substitutes for tomatoes should be limited to tomato or citrus fruit products. (4) Increased issues of fresh cabbage and potatoes, milk and tomato products were necessary in order to provide an acceptable ration. (5) Menus should be used as an instructional medium for mess personnel and should include data on methods of conserving nutrients during the preparation of food, on the necessity of complete utilization of the nutritionally-important foodstuffs and on other pertinent phases of mess operation. Waste of Food in 1942#—During Novanber 1942 an extensive survey of American "units in the United Kingdom was made by repre- sentatives of the Nutrition Branch, of the Subsistence Division, and of the British Army Catering Corps# This investigation demonstrated that the issue of excess food was resulting in widespread wastage because of failure to use the ration economically and to return unused items to depots# This was distressing, not only because it represented financial loss and the futile transportation of supplies across the Atlantic but also because of the unfortunate effect it had on the British who were campaigning for the maximum prevention of waste. The report of the Nutrition Branch discussed the fundamental problems as summarized below and recommended that necessary measures be taken as follows: (l) To emphasize the responsibility of unit commanders for mess supervision and mess operation. (2) To increase the waste-consciousness of the American forces. (3) To increase the sense of individual responsibility for nutritional health. (4) To strengthen and extend the facilities for the training of mess officers, mess sergeants and cooks. 10 Revision of Ration Scale.—On 12 December 1942 the Chief of the Nutrition Branch was specifically ordered to recommend what- ever changes in the current directives on rations were deemed ap- propriate as a result of his investigations in the theater. As a matter of fact, the third menu, published 22 December 1942, was satisfactory in most respects because most of the earlier recom- mendations of the Nutrition Branch had been approved by the Sub*- sistence Division, OCQM, and incorporated in the menu. The caloric level had been decreased temporarily to 3800 as a means of emphasiz- ing the necessity of complete utilization of the ration* None of these changes were in accordance with the theater ration directive so that there was need of a restatement of the basic components and allowable substitutive items of the ration. Advantage was taken, therefore, of this golden opportunity to describe the field ration in tenns of food classes composed of nutritionally similar food- stuffs (Column 5, Table 3). Substitutive items were rigidly restricted to those of nutritional equivalence and both basic com- ponents and substitutes were limited to those known to be available. The proposed new directive on rations was forwarded to the Theater Commander on 14 January 1943 and was published on 11 February 1943. Only minor changes in the troop ration scale were necessary in sub- sequent revisions of this circular. Menus.—Separate menus were prepared by the Subsistence Division, Office of the Chief Quartermaster, for the type "A” field ration used in the United Kingdom through January 1945, at which time practically identical menus were authorized for the troops in the United Kingdom and on the continent. During the 25-month period frcm 1 January 1943 to 1 February 1945, 15 menus were published in the United Kingdom, These varied according to the seasonal supply of locaily-available fresh foodstuffs and according to the levels of depot stocks. Substitutions for gas-forming foods were authorized for Air Force personnel. Subsequent to January 1944 each menu included a table showing the nutritional analysis of the prescribed menu, data on the more important nutrients, and a state- ment that the menu had been analysed by the Office of the Chief Surgeon and approved ”as being adequate for the nutrition of troops if the food is prepared properly and eaten.” Average Type A Menu in the United Kingdom.—The composition of the average type A field ration issued in the United Kingdom between 1 January 1943 and 1 February 1945 is described in Column 1, Table 7, and its nutritive value in Column 5, Table 4 (Figure 2). Comparison of the ”as consumed” value of this ration with the recom- mendations of the National Research Council (Column 4, Table 6) 11 shows that the ration was adequate in all nutrients except riboflavin which was 10% less than the recommended allowance* This was not believed significant and there was no evidence of ariboflavinosis in the troops* It is highly probable that 2*0 mg* of riboflavin daily are more than sufficient* From a practical standpoint it is vdry difficult to provide this level even in a varied diet contain- ing meat, milk, and eggs without occasional servings of liver and without riboflavin-enriched flour and bread* Worthy of emphasis is the fact that U* S* Array rations in the United Kingdom contained neither white flour (70% extraction) nor white bread* British flour (85% extraction) and British bread were used and the consumption by the troops was very satisfactory (0*424 lb* daily)* The average intakes of evaporated milk and of dried egg were the equivalent of one pint of whole milk and of one egg daily* Servings of cabbage and of brussels sprouts were in excess of American food habits. The average daily issue of all fresh vegetables, other than tomatoes and potatoes, amounted to 0*375 lb*, 28% of which consisted of cabbage and sprouts (Figure 3). Hospital (Patients*) Ration The first theater directive on hospital rations in February- 1942 authorized one field ration plus a monetary allowance of one shil- ling (approx* 20 cdnts) for the feeding of patientso Quartermasters were directed to procure the extra foodstuffs, requisitiohed by hos- pital commanders, from "any available source*" Later, hospitals were allowed to purchase food supplies for patients from local civilian sources as well as from the Quartermaster* The monetary allowance was unsatisfactory in the United Kingdom because of the very limited number of foodstuffs which could be procured by local purchase* Fur- thermore, requisitions from Quartermaster stocks did not guarantee a nutritious patients’ ration except in those instances in which die- titians were delegated the responsibility for the expenditure of the cash allowance* For these reasons, the theater abolished the mone- tary supplement in February 1943 and adopted a special patients’ ration at the same time that the revised troop ration was authorized (Column 1, Table 8)* The first patients’ menu, effective 1 March 1943, was pre- pared by the Nutrition Branch* Subsequent menus were prepared by the Subsistence Division with the collaboration of the Nutrition Branch. In November 1943, the availability of supplies permitted revision of the hospital ration scale and small increases were authorized in meats, milk products, fruit juices and potatoes* These additions were offset by decreases in legumes and grain and the energy content remained ap- proximately 4000 calories* Up to this time the majority of patients consisted of sick individuals without particularly hearty appetites (Figure 4)* As more and more wounded Air Force personnel arrived in 12 Figure 2 The new field ration "An of the European Theater of Operations, England, February, 194-3. Figure 3 An enlisted men’s mess of an Ordnance Company, England, January 194-3. Figure 4 The kitchen of the 29&th General Hospital, Bristol, England, January 1944-. the hospitals, the ration which heretofore had been adequate re- quired supplementation. Provision was therefore made for signi- ficant augmentation whenever necessary. Prior to D-day increases (Table 8) were authorized in the hospital ration in anticipation of the expected change in the type of hospital patient. The greater appetite and food consumption of average battle casual- ties compared with average patients is noteworthy (Columns 1 and 2, Table 10). Between 1 Mar. 1943 and 31 Jan. 1945, 8 hospital menus were published* The menu, effective 1 Feb. 1945, was used with- out change through Oct* 1945* By this date practically all battle casualties had been evacuated to the United States* The hospital ration in the United Kingdom was never the same as that issued on the continent because of the greater supply of fresh meat and vegetables in England. Menus described the regular patients' diet only and the responsibility for special diets were required for 10 to 20$ of the patients* Provision was made for modifi- cation of the ration issue whenever the need of special diets in- creased above 20$* This was the case if certain hospitals special- ized in specific types of patients, such as those with hepatitis, with jaw injuries, etc* Provision was also made for the feeding of soup, sandwiches, egg nog, fruit juices and coffee at air strips receiving casualties by plane from the continent* Similar arrange- ments were made at so-called "transit hospitals" receiving casualties transported by water* The special hospital ration used in the United Kingdom was composed of the items appearing in the troop ration (foot- notes, Table 7) plus skimmed milk powder (for fat-free diets), malted milk powder, egg noodles, brown sugar, canned soups, purees, etc. It supplied 100$ more chicken and fruit Juices, 65$ more milk, 20$ more egg and 40$ more fruit than the troop ration. The composition and nutritive values are shown in Columns 1 and 2, Tables 9 and 10, respectively. Planning for Rations in Combat. The continuation on the continent of the excellent ration supplied in the United Kingdom was impossible for many months after the establishment of a beach heado The enormity of the problem of transport across the channel and from beach depots to rapidly moving armies demanded the temporary use of nonperishable, conveniently packed, and easily prepared rationsa Operational rations, such as C, D and K, and the nonperishable type B ration were already stocked in depots in the United Kingdoaio Because the latter ration consisted of more than 100 different foodstuffs in as 13 many different containers, the Chief Quartermaster proposed the pre- paration of a so-called 12-in-l ration which would supply in a single box an assortment of type B components sufficient for one day’s sup- ply of food for 12 menB The Uo S0 Army had used a 5-in-l ration and the British a 14 man composite pack in North Africa0 These had greatly simplified the subsistence of the two armies in the periods in which supply was difficult« Before more than a few units of the 12-in-l had been assembled the theater was informed of the availa- bility of the new 10-in-l ration in the United Stateso The 10-in-l appeared to fill the need for a ration intermediate between C and K and the type B ration and plans for the 12-in-l were therefore droppedo Combat Rationso--In order to familiarize the theater with the advantages or possible disadvantages of operational rations, a Ration Board headed by the Chief of the Nutrition Branch was ap- pointed in 1943 and directed to conduct comprehensive field tests on rations which would be used later in combato In the first of these field tests it was noted that troops remained in reasonably good physical condition during a 10-day period on C, K, and 5-in-l rations but that the rations were deficient in calories, especially for large men (Figure 5)0 The report listed the following recommen- dations; the use of the D ration as a supplement only; the restric- tion of the use of C and K rations to 5-day periods unless supplemen- ted; the replacement of the wholly unsatisfactory dextrose and malted milk tablets of the K ration with a desirable confection; the replace- ment of the fruit powder component of C and K rations with a source of ascorbic acid which would guarantee the utilization of this nutrient; and, the addition of cigarettes, gum, matches and toilet tissue to the rations which lacked these articleso The report of the second trial noted the acceptable quality of the majority of the components of the recently developed 10-in-l ration and the excellence of its packaging but emphasized its marked inadequacy in calories (3300-3400) for troops during 15-day maneuvers in moderately cool weather (35 -55°F), The following recommendations were made: an increase in caloric value to 3900 calories; a limita- tion of 30 days in its issue and of a total of 40 days in the issue of 10-in-l and unsupplemented B rations; the replacement of the dehydrated baked beans, the fortified fruit powders, the K-l biscuits and the dextrose and malted milk tablets; and, the addition of cocoa beverage powder, pea or bean soup powder, extra cereal mixture with increased sugar in the mixture, components for hot drinks twice daily, heating units, and extra paper towel So The conception of the 10-in-l ration was basically sound but it was obvious that it was developed for use in warmer areas than 14 Figure 5 A Ranger Battalion cook ”5 in 1" rations during a field ration trial in Southern England, July 1943. western Europe* Because of the demonstration of the marked caloric deficiency of this ration the theater decided to use it on an 8-man basis or to supplement it with additional food if it was issued on a 10-man basis0 Type B Rationo—The conviction that the physical fitness of troops would be impaired in the event future tactical situations required subsistence on unsuppleraented operational rations for long periods also applied to the use of the type B ration,, Early in 1944 the Chief of the Nutrition Branch spent 5 weeks observing the preparation* service and acceptability of this ration as issued to combat and service troops and hospital patients in North Africa and Italy© The adverse effect of the monotonous character of the unsupplemented ration was most impressive even though strenuous attempts had been made to improve its palatability following a survey by the Chief of the Nutrition Branch* Office of The Surgeon General* in November 1943© The unacceptability of the type B ration for continued use was primarily due to the unfortunate choice of its meat components© The least desirable of these* meat and vegetable hash* meat and vegetable stew, Vienna sausage* and chili were served a total of 8 time in each 10-day period© The hash and stew aggravated monotony because they were also components which appeared daily in the C ration© The distinctive appearance and taste of the Vienna sausage and chili made it exceedingly dif- ficult for cooks to change the method of preparation© Luncheon meat, pork sausage* corned beef, corned beef hash, and salmon* which were served a total of 12 times in each 10-day period* were more satisfactory because it was possible for interested cooks to introduce variations in the product served© In view of the fact that there was no certain way of fore casting the time which might elapse between the planned invasion of the continent and the opportunity of transporting fresh foodstuffs to the invasion troops* it was believed hazardous to disregard the experience of the North African Theater., Consequently* strong representations were made to the Chief Quartermaster to withhold approval of the type B ration and also of the 10-in-1 ration until it was demonstrated that the acceptability of the former and the caloric adequacy of the latter had been improved.. Specific recom- mendations with respect to feeding troops on the continent included the following: shipment of bakery units and of fresh meat to the continent at the earliest possible moment after D-day so that the maximum period for subsistence of troops on wholly processed rations (D* C, K, 10-in-l* and B) would not exceed 40 days; sub- stitution of canned roast beef or canned meats for less desirable components of the B ration; replacement of the butter substitute* 15 Carter's Spread* modification of the 10-in-1 ration as previously recommended* supplementation of C and K rations with miscellaneous nonperishable foodstuffs (sardines, peanuts, jam? etc0) as a means of avoiding monotony* supplementation of C and K rations with mul- tivitamins after 16 days in the event these were the only rations available* and provision of individual heating units, preferably tablets of the "hexamine" type0 These efforts to improve the quality of processed oper- ational rations were supported by the Chief Quartermaster and were successful insofar as the 10-in-l ration was concernedo The theater was informed in April 1944 that the caloric value of the 10-in-l had been increased from 3400 to 3700 and that in future procurement in the United States the ration would provide 3900 calorieso These improved types were received before the termination of hostilities on the continent but improved C and K rations were not available until the later spring of 1945o Additional type B meat components, such as canned beef and gravy, pork and gravy, sardines, etcQ, were received but not until after the type B ration had been replaced by the A ration with its fresh foodstuffso Individual heating units of the wax candle type were received but were little used because of their unsatisfactory character0 Although the highly successful course of the war following the invasion had removed the necessity of reliance upon operational rations for extensive periods, the efforts to bring about fundamental changes in these rations were continued0 In July 1944, at the re- quest of the Chief Quartermaster, the problem was discussed in detail with a representative of The Quartermaster General, to whom specific and general recommendations were madeo The recommendations, which dealt with the basic considerations involved in the development and use of operational rations, emphasized the following points: impairment of nutritional status as a result of failure to eat rations which become unacceptable because of their monotomy* the beneficial effect of variety and of the absence of highly seasoned foodstuffs on the avoidance of monotony* necessity of emphasis on optimum rather than minimum intakes of indispensable nutrients* assessment of the adequacy of an individual type of operational ration on the basis of the total period a soldier is expected to subsist on it and all other nonperishable rations* enrichment of operational rations, if necessary, so that it is a complete source of known nutrients* and, incorporation of nutrients in major ration components, if enrichment is necessaryo The indoctrination of medical officers, line officers and troops with respect to rations was aided by the publication of directives prepared by the Nutrition Brancho The first of these 16 described operational rations for the information of medical of- ficers and emphasized the inadequacy of operational rations for continued use0 The second was a theater directive to all officers to supervise the utilization of rations by troops so that the maximum consumption of critically-important foodstuffs would be achieved,, The third was prepared for the briefing of invasion troops and consisted of material to be presented by company of- ficers. The latter was subsequently the basis of an article in Tftarweek, a supplement to the Stars and Stripes devoted to preparations for the invasion of the continent. Rations for Patients*—A supplementary ration for the nourishment of casualties in beach heads was essential because C or K rations were wholly unsatisfactory for this purpose* The procurement of such "patient1s operational ration" was one of the first activities of the Nutrition Branch* The Quartermaster agreed to prepare cases, each containing fruit juice, milk, sugar and coffee for 20 men, if an equivalent ration could not be procured from the United States* Subsequently, the 25-in-1 hos- pital supplement was developed in the United States and was used with great benefit in Italy and in France* Procurement of this supplement became impossible in the spring of 1945 so that an ad- ditional quantity was assembled in the United Kingdom for use by the armies in Europe* In addition to the 25-in-1, a second supplement, the B-C pack, was requested by the theater and supplied from the United States* This unit contained bouillon cubes and cigarettes and was designed for issue to aid stations* These components were selected following a survey of battalion medical officers in experienced divisions which had arrived in England from the North African theater* The value of this supplement was questionable, mainly because of the successful provision of other nourishment to front line units* The final plan for the feeding of patients on the continent included the issue of rations as follows* Battalion and Regimental Aid Stations and Collecting Companies - Troop Ration (C, K or 10-in-l) plus B-C unitso Clearing Companies and similar units - Troop Ration (C, K or 10-in-l) plus the 25-in-1 hospital supplement. 17 Field and Evacuation Hospitals - 10-in-1 or type B ration plus the 25-in-1 supplement. Station and General Hospitals - Type B or type A ration plus hospital supplements<> Rations on the Continent0 Type C and K rations, supplemented with the D chocolate bar, were used on the continent until D/5, at which time 10-in-1 rations were available for issue to troops in rear areas0 The latter ration was widely used until D/33 when type B components were dis- tributedo By D/40 fresh bread and meat were issued in limited quanta tieso The supply of bread increased rapidly as new bakery companies arrived and went into production, The early establishment of bakeries on the continent and the movement of these with the Armies contributed immeasureably to the maintenance of the nutritional health of the troops (Figure 6)<> Operational rations were supplemented with captured enemy foodstuffs and with fresh vegetables and eggs which were surplus in many districts of Normandy and Brittany, Shipments of potatoes and carrots were received from the United Kingdom after D/90 and, at the same time, arrangements were made with French authorities to obtain tomatoes, onions, celery and cabbage whenever these were in surplus of civilian requirements0 The listing of fresh meat and vegetables in monthly menus of the modified Type A ration was pos- sible starting with the September menu,. It is estimated that about one-half of the meat and vegetable issue during the fall and winter consisted of fresh itemso Combat troops and hospital patients were given first priority on fresh meats (Figure 7), The meat issue in the Amies was augmented by the capture of large cold storage plants well-stocked with carcass beefo Vigorous efforts were made by the Nutrition Branch and by many Quartermaster officers to minimize the use of operational rations, except as emergency rations for front line troops, Supply officers were inclined to over-emphasize the convenience of transport and issue of the C, K, and 10-in-l rations at times when convenience was not a tactical necessity, The justification for the use of the modified A ration with its hot, varied meals did not depend on a theoretical effect upon physical fitness and moral So These positive effects were real and were recognized by the personnel of experienced divisions (Figure 8), The contrast between old and new combat divisions in this respect was most enlighteningo Table 11 shows the proportional use of operational rations on the continent The extent of issue of nonoperational rations to combat, as well as 18 Figure 6 A field bakery in Belgium, 3026th Quartermaster Bakery Company, November 194-4-. Figure 7 Loading refrigerator trucks with frozen meat for distribution to combat troops, Advance Section, Communications Zone, Homecourt, France, November 194-4. Figure 8 An abandoned German stable serves as a kitchen for members of the 36th Infantry Division in Alsace Lorraine, December 194.5. 9 service troops, was most gratifying® It is significant that the "Battle of the Bulge," which occurred in an area easily supplied with A rations, did not increase the issue of operational rations (Dec® 1944 and Jan® 1945, Table 11)® This is in contrast to the re- quirement of these rations in the period of rapid movement away from supply depots during the over-running of Germany (April - May, 1945)® The nutritive value of the operational rations (as issued) is shown in Table 12® In general, the data do not reflect the in- take of nutrients because of the common failure to eat all of the ration® Troops were on a diet practically devoid of ascorbic acid whenever they subsisted on un-supplemented, C, K, or 10-in-1 rations in the cold weather which was general in Europe® This re- sulted from the refusal to prepare and drink the lemonade which may be made from the fortified lemon or other fruit powders® Table 12 describes the nutritive value of the improved 10-in-l but not the improved C and K rations® Revised forms of the latter were on hand late in the war but the bulk used between D-day and April 1945 consisted of unimproved -types® These were unpopular and were poorly utilized® Limited experience with the newest C ration indicated that troops preferred it to the K ration® The K ration appeared more desirable than the unimproved C ration except in units which made provision for heating the C ration (Figure 9)® These units set up field ranges as close to the front as was feasible, heated the meat components of the C ration in boiling water, repacked the hot cans in cases and sent them forward for distribution® The taste of the C ration meat component is greatly improved if warmed® The composition of the type A and B rations used on the continent is shown in Columns 2-5, Table 7® Infrequent but highly appreciated shipments of oranges and shell eggs are not included in the data in Table 7® The effect of these rare items on morale was tremendous and wholly justified the extra transport required for their procurement and distribution® Considerable difficulty was experienced by the Quarter- master and by G-4 in maintaining complete stocks of type B components in depots and at railheads® Ships carrying "balanced" stocks of rations were sometimes moved, when partially unloaded, to make way for higher priority cargo on other ships® Railroad trains carrying balanced rations frequently lost one or more cars due to mishaps with the result that unbalanced or incomplete stocks arrived at railheads® Shortages of miscellaneous items, especially of salt and baking powder, were common during the first month of use of the B ration® 19 The nutritive value of these rations, as issued and as con sumed, is described in Table 13o The deficiency in thiamine and the questionable deficiency in riboflavin in the type B ration (July, Column 1, Table 13) was corrected as quickly as fresh items became available„ The ration was adequate by October 1944 and by February 1945 was superior in its content of nutrients to that supplied in the United Kingdom before D-day (Comparison of Column 4, Table 13 with Column 5, Table 4)0 The difference is primarily due to en- riched flour, that used on the continent having a higher content of thiamine and riboflavin than the British National flouro The data in Tables 7 and 13 do not include extra ration allowances authorized combat units occupying positions in contact with the enemyo These augmentations included a 10% overall in- crease for units receiving the A or B ration and additional meat, jam, bread and coffee ingredients for troops receiving operational rationso Full advantage was taken of these authorizations and the service of sandwiches and coffee to front line troops as supplements to C and K rations was a common occurrenceo In June 1945, rations for most inactive personnel, except patients*, was automatically decreased 10%o Fortunately the ration was rich enough in nutrients so that minimum allowances were still suppliedo Overall deductions are hazardous because of the failure to distinguish between foods of high and low nutrient contento The decrease in June was necessitated by the theater shortage in rationso It should be noted in this connection that the average ration was insufficient for units performing very heavy labor and required augmentation (See Page 22 )o Hospital Rations,,—The feeding of battle casualties was quite satisfactory,, The rapid evacuation to the hospitals in the United Kingdom, both by air and by water materially eased the load on the medical units which preceded general hospitals to the continent,. The result was that operational hospital rations were only required in the early stages of the invasion (Figure 10)„ Most of the casualties arrived very quickly in areas where type B or A components were available„ The composition and nutritive value of the hospital rations on the continent is shown in Columns 3-6, Tables 9 and 10 respectively*, The hospital ration on the continent differed from that in the United Kingdom in that the continental ration consisted of the troop ration plus a supple- mentary list of foodstuffs whereas patients in the United Kingdom were supplied a separate special ration,, The continental issues were generally excessive unless hospital mess officers refused components of the troop ration which were not needed,. The nas 20 Figure 9 A wireman of the 57th Signal Battalion heats !lCn rations for his crew, Hochfelden area, France, January 194-5. Figure 10 iA7+>.ArkitChnnoUnd?r camras feedE 1200 Patients of the 167th General Hospital, Tourlaville, France, January 1945. consumed" data in Columns 3-6, Table 10.do not include the sig- nificant quantities of unused hospital rations and are therefore larger than the actual consumption.) Column 2, Table 10, gives a more accurate picture of the food consumed by patients® This was a particularly successful ration which supplied the needs of the sick and of casualties with the minimum of waste.. The authorization for the use of the special hospital ration on the continent was refused by headquarters for the reason that depots would find it too difficult to provide two rations rather than one ration plus a supplement., As a matter of fact, the Nutrition Branch found it necessary to investigate constantly the issue of the supplement in order to be sure that it was received by the hospitalso The objections to the.meat components of the type dis- cussed on page 15 applied with even greater force to the feeding of casualtieso The additional variety provided by meats in the hospital supplement was far from that which is desirable in patients’ diets® In this respect the hospital ration of the Expeditionary Force Menu was most unsatisfactory® Augmentation and Reduction of Rations. In August 1942 authority was granted the Commanding General, SOS, ETOUSA, to increase the "Augmented British Ration” (British-American Ration) 15% if not less than 75% of an organization was engaged in hard physical labor for 10 or more hours daily, 6 days per week® This augmentation ceased as troops received the American ration in September and October of 1942« Early in 1943, upon the request of the Air Force Surgeon, members of Air Force combat crews on operational status were authorized 3 fresh eggs and 3 oranges per man weekly and 0o0625 lb® of powdered whole milk daily® Later, Air Force combat and repair crews on operational status were allowed the following augmentation Item Lbso per 1000 rations Meat, canned 6808 Fruit Juice, canned 108 o2 Fruit, canned 6107 Coffee (R and G) 6o 9 Milk, evaporated 9ol Bread 28o6 Butter 6o9 Sugar 9o2 21 The request for shell eggs and oranges was approved by the Office of The Chief Surgeon as a morale measure and not because of nutritional necessity,. The request for components for a fourth meal was granted by the Theater Commander without the reference of the matter to the Chief Surgeon for investigation and recommendation,, In view of the increasing number of requests for augmenta- tion of rations, mainly from port and engineer battalions, an extra allowance for units performing arduous tasks was written into the theater directive on rationso Nutrition officers had been assigned to the staffs of Base Section Surgeons by this time so that it was possible to make the augmentation contingent upon an investigation by the Base Section Surgeon which "shows that the authorized ration issue is properly prepared, served and eaten and that a need for additional food still exists„n The augmentation, which supplied approximately 400 calories, was purposely limited to bread or flour, potatoes and lard, although most units which requested extra food desired more meato The basic ration was adequate in nutrients and generous in its meat components and it was believed to be sound policy, therefore, to confine supplements to reasonably available foodstuffs which provided the necessary calories0 Units which were not interested in eating more bread and potatoes were not con- sidered to be suffering from a shortage of foodo As a matter of fact, few of the requests for augmentation were found to be justi- fiedo These investigations by nutrition officers did prove to be excellent opportunities for instruction of untrained or careless mess personnelo The above procedure which provided for a thorough survey of the physical well being of troops as well as a determination of the adequacy of the quantity of the ration issue was a most satis- factory method of controlling the vexing problem of ensuring that soldiers were well-fed without incurring the risk of waste of food because of over-supply,, Unfortunately, it became necessary in July 1944 to replace this system with one which liberalized the issue of augmented rations and recognized the fact that it was easier to supply extra food to a unit than it was to insist upon ef- ficient mess operation,, Prior to the invasion of France requests for augmentation of the ration increased enormously due to the number of depot and port units which ran day and night shifts„ Some units attempted to feed sandwich meals at night rather than hot meals pre- pared by a night shift in the mess„ The ration was not adapted for sandwich meals at night rather than hot meals prepared by a night shift in the mess. The ration was not adapted for sandwich mealso Night feeding was poor therefore, and vegetables, canned fruits, etc„ accumulated in storerooms0 In other units, which served regular hot meals at midnight, men on the night shift were permitted to get 22 up and eat the midday meal with the day shift., The total daily food intake of these men was no greater but this practice did deprive the day shift of its normal share of the more desirable components of the ration, especially of its share of the meat issue. Artificial shortages of certain ration items developed from these failures of mess officers to insist upon mess discipline and proper mess operation. During this period the Commanding General of the Theater Services of Supply believed it necessary to authorize many augmentations without the usual preliminary survey. All investi- gations were therefore discontinued and augmentation requests were approved as they were received. As soon as the emergency created by the main invasion operations had passed, the augmentation procedure was brought under control again by a new directive which rescinded all previous written and verbal authorizations for extra rations and which described the specific types of augmen- tation which might be requested. The ration increases for the Air Force, referred to above, were reaffirmed. An automatic increase of 10 percent was allowed messes serving less than 50 men in order to provide adequately for the many isolated anti-aircraft and similar groups consisting of 5 to 20 men. The Chief Quartermaster was authorized to grant extra food to troops engaged in hard labor to noncombat sectors, to troops returned to rest camps after combat and to troops operating under exceptional circumstances provided the Chief Surgeon recommended the augmentations as es- sential for the maintenance of physical fitness. These types of augmentation were listed: a. 10$ increase in all ration components. b. Daily sandwich meal consisting of the following: Item Lbso per 1000 rations Meat, canned 180 or Cheese 90 Bread 180 Sugar 30 Coffee (R and G) 40 o. Daily fourth meal consisting of the following: Beef, boneless (B and S) 300 or Beef, boneless (G) 300 or Beef, corned, canned 240 or 23 Eggs, dehydrated 50 or Pork, boneless 270 Potatoes 300 Bread 120 Coffee (R and G) 40 Sugar 30 Jam 60 or Mamalade 60 (Issues of meat and egg components were rotated.) In addition, division or similar commanders were authorized to grant the following increases to troops actually occupying positions in contact with the enemyo a, For troops subsisting on the type ”A" or WB" ration: the 10% overall increase, the sandwich meal or the fourth meal described aboveo bo For troops subsisting on type "C", "K" or w10-in-l" rations, the following daily augmentation: Meat, canned 180 or Cheese . 90 Jam 60 or Marmalade 60 Soup, dehydrated 40 Coffee (R and G) 40 Milk, evaporated 45 Bread 180 Further provision, as follows, was made in October 1944 for an adequate daily supply of coffee for field and air force units engaged in operations on the continents Coffee (R and G) 40 or Coffee, soluble 16o8 Milk, evaporated 45 Sugar 30 This augmentation was continued through the winter months. 24 The listing of specific augmentations which included meat naturally resulted in a flood of requests* most of which were sent to headquarters with no justification other than that mess officers thought they should obtain "all that the law allowed0" The directives admirably ensured satisfactory rations for small units which needed the 10% increase and for combat troops which needed supplements to operational rations0 However* the responsibility of the Nutrition Branch of the Chief Surgeon8s Office for recommendations regarding augmentation requests from units not in contact with the enemy placed a heavy burden on that office because many areas on the continent were not covered by section nutrition officers., It was necessary to approve many requests without investigation of their justification and then to survey the units as time permitted,, In this respect, the 30-day limitation on each approved request proved particularly valuable., In June 1945 the theater ration and augmentation directives were drastically revisedo The new directive, which took into con- sideration the cessation of hostilities and the critical shortage of rations within the theater, included the following provisions: a© All augmentations were discontinued except the 10% increase for small messes (under 50) and increases for crews of small water craft0 The way was left open for augmentations which were ap- proved by the Chief Surgeon but it was emphasized that nutritional necessity, and not convenience in mess operation, would be the sole factor governing the approval of an augmentation requesto bo Decreases in normal ration issues were authorized for the first time in the theater: (1) Rations for all military personnel engaged in sedentary duties were automatically reduced by 10%o (2) Base Section and other Commanders were directed to review constantly troop lists in their respective commands and to apply reductions up to 10% for all troops engaged in light or moderately active duties.. (3) A percentage reduction, as follows, was directed for all messes not affected by the provisions of par® a and b, above: 25 Strength of Mess Percentage Reduction Over 1000 7 30 - 1000 5 Under 300 0 None of the above reductions applied to ration items, such as shell eggs or fruit, issued on the basis of one per man0 Further- more, personnel in the following categories were exempted from all re- ductions: Hospital patients; troops undergoing vigorous training or engaged in hard labor; troops on leave or in officially designated rest areas; messes serving less than 50 men; and, recovered allied prisoners of war (RAMP8s)0 Certain readjustments were recommended by nutrition officers from time to time as units were found to which ration reductions had been applied even though the units required full ration issues0 This difficulty arose from the tendency of Section Commanders to follow the convenient administrative procedure of ordering 10% deductions for all units instead of directing nutrition officers to investigate and to recommend proper action,, The adjustment of the ration according to the needs of troops who are engaged in work, training or combat with extreme gradations of physical activity and who are exposed to varying living and climatic conditions is a complicated problem which was not solved by any of the methods used in the theater® The established Army procedure of providing a single ration with percentage increases or decreases has the merit of convenience and, certainly, there are periods of emergency when the convenience of the transport and issue of a single ration becomes a most important factor® Nevertheless, there is little justification for the issue of the same quantity of food to one who spends his day at a desk under reasonably comfortable conditions and to another who may be working or marching in the rain or snow® If the ration satisfies the needs of the latter, surplus rations are issued to the former® Surplus rations always favor wastage and permit unwise selection of individual ration items both in the preparation and in the service of meals® Food would be saved and troops would be better nourished if ration issues were based on nutritive requirements rather than on convenience of issue® This is especially true if the term "convenient” is used loosely to refer to a procedure to which one happens to have become accustomed® The problem could be simplified by recognition of the fact that the main variable in the feeding of adult men is the caloric requirement® The fundamental error in overall deductions lies in the fact that all foodstuffs, regardless of their content of nutrients and of calories, are decreased to the same extent in 26 order to decrease the energy value* The intake of some nutrients, notably thiamine, should vary according to the caloric metabolism but this would never be a problem if bread prepared from vitamin- enriched or from high extraction flour were used as the principal source of energy in supplements to a basic ration which furnished the vitamins, minerals, protein and calories required by the group of troops engaged in sedentary duties* Section on Food and Nutrition in Monthly Sanitary Reports* Monthly Sanitary Reports which contained pertinent com- ments on rations, messing or nutritional status of military person- nel were routinely referred to the Nutrition Branch for information and action* Relatively few problems were brought to light in these documents because of the activity of theater nutrition officers in recognizing and solving difficulties before it became necessary for medical inspectors to include them in their reports* Those problems that did appear in Sanitary Reports usually dealt with the possible need of ration augmentation* The original theater directive on Sanitary Reports required comments "on the extent to which food is properly prepared and served and on the adequacy of the food consumed by the soldier*" This was subsequently expanded to include data on the following points: type, quantity and quality of the ration issue; adequacy of storage facilities; competence of mess personnel; the conservation of nutrients by proper cooking procedures; conservation of foodstuffs; and, the nutritional adequacy of the ration* Later, additional comments were called for concerning the necessity of vitamin supplementation and the need of nutritional rehabilitation in the case of troops required to subsist on emergency rations for prolonged periods* The insistence upon remarks covering a reasonably extensive list of nutritional topics had unquestionable merit in view of the unfortunate tendency of many medical inspectors to take messing for granted* In this respect, the procedure outlined above became a valuable instructional device insofar as new and inexperienced inspectors were concerned* Vitamin Supplementation*—The supplementation of rations with multivitamins was a relatively unimportant feature of ration- ing in ETO except in the case of hospital patients and Air Force personnel* The former required extra vitamins if the food intake was insufficient to provide the necessary levels of these nutrients* Combat crews were supplied multivitamins at the request of the Air Force Surgeon* This may have been justified as a preventive measure related to a possible greater need of certain nutrients by aviators* The basis of such a need was never demonstrated* 27 In Feb© 1944 a survey of the dietary histories of the person nel of small detachments (1-15 men) of the Corps of Military Police, Finance Department, and Transportation Corps, located in cities, towns and villages throughout the United Kingdom, showed that the intake of vitamins was well below the minimum standards© These men were isolated from U© S© Army messes and received a monetary allowance in lieu of rations© Obviously no control of their purchase of food was possible except that of the British rationing regulations© Ar- rangements were made to supply multivitamins to these detachments although no evidence of nutrient deficiency was uncovered© Provision was made for distribution of vitamins to combat troops in the event subsistence on unsupplemented rations continued for periods in excess of 15 days© Fortunately, few units were ever in this category© Conferences with division surgeons disclosed that few believed that vitamin supplementation was necessary,, These conferences always served the purpose of re-emphasizing the desir- ability of extending even more the common practice of augmenting operational rations with sandwiches and other items© The use of multivitamins in the nutritional rehabilitation of recovered prisoners of war is discussed on Page 32® Malnutrition in Recovered Allied Military Personnel Prior to the crossing of the Rhine by allied forces, the location of the German prison camps for allied military prisoners was fairly well-known® Forecasts were available of the expected population of these camps but there was little information concern- ing the conditions in the camps® The reports from the International Red Cross were meager and sketchy and, as later investigations were shown, were inaccurate in their descriptions® The immediate problems in the overrun camps were those of rectifying the prolonged and previous negligence of the German government and primarily involved sanitation, delousing, adequate living quarters, and nursing care with adequate medical supplies® Nutritive rehabilitation was almost universally required by all prisoners, ambulatory and hospitalized® One would usually find the prison hospitals loaded to capacity with from 50-400 patients and many hundreds more who should have been hospitalized but for whom facilities were not available, although it should be said that hospitalization in many of the prison camps was merely a word and not actual medical care as practiced in the American army® The insatiable desire for food on the part of these RAMP’s had to be 28 Figure 11 American prisoners of war liberated by the Third Army in Fuchsrauehl, Germany, after a thirty-five mile forced march from Bad Orb, labor in a salt mine and a starvation diet, April 194-5. Figure 12 Americans in their prisoner of war quarters after liberation by the Third .Army, Germany, May 1945, satisfied* The generosity of the overrun units at times in distri- buting the food was really detrimental to these prisoners* The ingestion of operational rations such as C, K and 10-in-1, almost universally precipitated acute gastro-intestinal upsets with disastrous results* This resulted in an increased load of patients on the foreward hospitals and evacuation systems* The field and evacuation hospitals performed their unexpected tasks in a superior manner* The evacuation of the sick and wounded was prompt and ef- ficient, usually by air to communication zone general hospitals* Those who were evacuated by the British in the northern German sector were flown back to the United Kingdom directly by the RAF* The first evacuation of non-hospitalized RAMP's from liberated camps in the American sector was by air to Camp Lucky Strike (near Le Havre), which had been designated as RAMP Camp $1* From the point of view of the medical department it was these RAMP’s, evacuated through command channels, who presented the greatest problems* The coordination finally achieved by the Provost Marshall Office and the Office of the Chief Surgeon made acceptable supervision of this group possible* This first group presented a difficult therapeutic problem because they were the sick prisoners who were incapable of making forced marches required by German evacuation of the camps* The farther inland the advancing allied armies went, the farther back the Germans marched the bulk of the prisoners with the rapid weeding out of the sickest who were the& recovered by the Allied armies* About the 25th of April 1945, word was received that the Ober Koramandantur of the Wehrmarcht had agreed to stop the mass evacuation of the military prisoners from threatened prison camps* This agreement alleviated a good deal of the suffering which the prisoners were being subjected to by the forced marches away from the liberating armies* Consequently, the bulk of the allied military prisoners were recovered shortly there- after* The total number of American RAMP’s was over 83,000* The initial survey of German stalags at Limburg, Zigenheim and Heppenheim by the Nutrition Branch revealed the magnitude of the RAMP problem and furnished the background for the measures adopted to ensure nutritional rehabilitation of the men (20% of total) who required immediate hospitalization or who were hospitalized during or after evacuation to the camps in the rear areas and of the men (80% of total) who, although suffering from malnutrition, were not hospitalized and remained under the control of the Theater Provost Marshal0 A directive was im- mediately distributed to hospitals outlining therapeutic dietary procedures for the various categories of malnourished patientso The nutritional care of non-hospitalized was effected by 29 the authorization of a special bland, high protein, high calorie ration for use in RAMP camps. Conferences were held with Base Section Surgeons and with medical officers in these camps in order to guarantee the pro- per use of the bland dieto This dietary regime was necessary because of the extreme gastro-intestinal sensitivity which characterized RAMP’s. Diarrhea was almost universal before corrective measures were instituted. This is illustrated by the following data on the first RAMP’s who were flown to the Lucky Strike RAMP camp after the screening out of all who required immediate hospitalization in the foreward area. Out of 4800 men, 260 required hospitalization upon arrival at the air strip near the camp and 564 were hospitalized upon arrival at the camp. The morning sick call rate prior to the introduction of the bland diet represented nearly 20% of the population of the camp. Of all of these hospital- izations, Q0% were due to gastro-intestinal distress. After the insti- tution of the bland ration, the morning sick call rate dropped to 4$. The beneficial effect of the planned dietary regime is evident from the fact that on 14 April 1944, before ration control was effective, 749 out of the camp population of 2850 were hospitalized, whereas on 18 May 1945 only 1500 out of 48,334 required hospitalization. The irritating effect of unrestricted rations in RAMP’s is also illus- trated by an incident in one of the temporary RAMP camps in which 150 men out of 1000 required hospitalization following the ingestion of one meal of the 10-in-l ration. It was necessary to prohibit the distribution to RAMP’s of peanuts, candy bars, doughnuts, etc., by the Army Exchange Service and by the Red Cross because it was evident that these well-intended measures were in reality harmful. Studies of nutritional rehabilitation in the RAMP camps were not undertaken because it was the original policy of the theater to evacuate these troops to the United States immediately. Provision was made for the continuance of the bland ration on the ships carrying them home. The RAMP policy in the United Kingdom differed from that on the continent in that all who arrived (by air) were placed in hospitals for quarantine and screening purposes. Otherwise, the medical problems encountered were quite similar. The 15th Hospital Center reported 999 admissions with malnutrition listed as the primary diagnosis in 412 and as the secondary diagnosis in the remainder. The diagnosis was based upon weight loss, edema, gastro- intestinal disturbances of a non-infectious origin, scarlet tongue, calf tenderness, and paresthesia of the hands and thighs. The 83rd General Hospital admitted 250, one of whom reported a weight loss of 101 lbs. Dependent edema in the absence of cardiac failure or of renal disease, glossitis, cheilosis, parethesia, and scars of healed skin ulcers were observed. Edema, which disappeared later occurred during therapy. Laboratory findings showed low serum proteins, low red cell counts, and negative stool cultures. At the 97th General Hospital the syndrome of fever with negative chest X-ray and absolute leukopenia was observed. This hospital admitted 15 RAMP’s with a diagnosis of hepatitis and malnutrition. In this hospital also, the temporary appearance of edema during therapy was noted. The 91st General Hospital reported a 20% incidence of atypical pneumonia. 30 Malnutrition - Types and Treatment Malnutrition in RAMP1s was classified as simple malnu- trition, emaciation due to prolonged starvation, and acute star- vation*, Available records list not more than 6 fatalities occur- ring in Uo So Army hospitals as a result of malnutrition in these formso Whether permanent impairment occurred in any of the vast majority who,apparently recovered satisfactorily is, of course, not known*, Simple Malnutrition®—The largest group suffered from mild or moderate malnutrition and were not hospitalized unless gastro-intestinal distress was severe0 This group did not show clinical signs of malnutrition other than loss of weight and gastro-intestinal sensitivity*, That the diarrhea which was so common was generally not of infectious origin was demonstrated by the failure to find positive stool cultures in the majority of stool examinationso The character of the abnormality of the alimentary tract is illustrated by the report of the 217th General Hospital on a group of 25 RAMP’s selected for X-ray exami- nation*, This showed puddling, segmentation, gas, and loss of normal markings in the small bowel® Delayed emptying time was universale It is pertinent that nausea and vomiting were uncommon*, One post-mortem examination showed general atrophy of the mucous membrane and atony of the musculature of the small' intestine which was smooth and erythematous® Ulcerations were present in the large intestine® Emaciation Syndrome*, — In the malnutrition which leads to the emaciation syndrome, the intake of fluid and of calories are sufficient to ensure prolonged survival but insufficient to main- tain a normal metabolic level® The outstanding deficiencies in calories and in protein account for disappearance of body fat and for the extreme wasting of the muscles® The patient as seen in the late stages presents a characteristic picture® One observes a completely apathetic very thin individual, usually lying immobile® The legs are flexed on the abdomen and the arms folded across the abdomen or chest® This position of the arms and legs is maintained even if the patient is rolled on his side® There is no true ankylosis of the joints as the patient can with much effort and persuasion extend his lower extremities to their full length® This is apparently a very painful process and is not done willingly® The skin is dry, coarse and cold to the touch® The extensive atrophy of all the muscles is one of the most strikihg signs® The legs and arms are apparently merely the bony contours of the long bones covered by skin® The buttocks are concave and follow the 31 contours of the ilium and ischiumo In fact the bony prominences of all bones including the skull stand out so that the term "§kin and bones" becomes a true description rather than a metaphor© Closer examination reveals evidence that this atrophy is universal© The face shows very sparse hair growth© The voice may be quivering and high pitched© These secondary sex character changes are very common in the late stage of the emaciation syndrome and undoubtedly reflect the universal physiologic atrophy of the endocrine system© The pulse rate is slow and respirations are shallow and slow while the patient is resting© The slightest excitement or activity precipitates a dyspnoea and tachycardia, indicating an extremely limited cardiac reserve© The eyeballs are soft and the conjunctivas wrinkled© There is a marked enopthalmus and dry eye© One frequently sees a malar flush, cyanotic in hue© The lips will vary in color depending upon the relative amount of anemia© While there is an absolute depression in the amount of hemoglobin, the heom-concentration may give an ap- parently normal hemoglobin© The tongue is usually smooth and beefy red© The size will vary© There may be many fissures© The gums as a rule present a fairly normal appearance except for color change© Deep tendon reflexes will vary from marked hyperactivity to complete absence and, because of the painful joints, it is difficult to evaluate them properly© Blood pressure is usually very low© Anal incontinence is very common and is manifested by the fecal incrust- ations in the gluteal folds (Figure 13)© These people represent physiologically, a hibernating stage of protoplasmic mass® They weigh from fifty to seventy-five pounds® The greater part of this weight is represented by meta- bolically inactive skeletal structure® The daily caloric require- ments are apparently in the range of from four hundred to seven hundred® This explains the absence of florid clinical mani- festations of nutrient deficiencies® Those who manage to accom- modate to the reduced nutrient intake by a compensatory decreased metabolic level survive for surprisingly long periods® The adjustment of the circulatory system and other physio- logical processes is a very narrow one and the integrity of life is dependent upon not upsetting this balance too abruptly© It must be recognized that these people continue to live only because they have developed minimal metabolic processes© Enthusiastic therapy* abruptly started in an attempt to restore these patients too rapidly to their previous state of normal, may result in a breakdown of these compensatory mechanisms® Therapy must be started very cautiously, and with the recognition of all of the factors involved® Certain of the vitamins function 32 Figure 13 American soldiers captured during the "Battle of the Bulge" receive medical care following liberation from the prison hospital, Fuchsrauehl, Germany, April 1945. as essential components of enzyme systems in carbohydrate and protein metabolism. With metabolic levels at a minimum, the demand for these vitamins is also very low. When, however, one burdens the body with a sudden plethora of foodstuffs, the vitamin requirements immediately increase proportionately, and unless this new require- ment is fulfilled, acute deficiency results0 In addition as has been pointed out the cardiac reserve is limited, A sudden change in the circulating blood volume throws a burden on the atrophic flaccid degenerated cardiac musculature with which it cannot cope. Therapy then is directed towards first supplying the vitamins of the B complex, then protein, and eventually complete caloric and nutrient definitive therapy. Experience has shown that oral administration, when tolerated, is the route of choice. Intravenous therapy is advisable only in the presence of nausea, vomiting or intractable diarrhea. Milk and egg mixtures, either fresh or powdered, are well tolerated by the majority. No attempt should be made for the first twenty-four to forty-eight hours to do more than re-educate the gastro-intestinal tract to the acceptance of these foods. No more than 1500 cc, of fluid mixture should be given by mouth in each of the first two twenty-four hour periods of treat- ment, If nausea or vomiting is precipitated by the oral adminis- tration then intravenous therapy should be instituted. Here, more than ever, extreme caution must be used. No more than 500 cc, of normal human plasma or blood should be given in the first twenty- four hours, and at a rate no faster than two cc, per minute, preferably slower. These patients are extremely sensitive to the intravenous administration of fluids and a very high percentage of reactions will be seen. Thiamine and niacin should be given regularly in the dose of 30 mg, of the former and 500 mg, of the latter in each twenty-four hour period. Oral therapy should be carried out as soon as is feasible. Such foods as cooked cereals, custards, white bread and dairy butter, mashed potatoes and thin soups are added slowly according to tolerance. In other words all foods must be low residue, mechanically non-irritating, and bland, for several weeks in order to avoid precipitating acute gastro- enteritis, Autopsy material lends credence to these clinical observations. At postmorten one sees an atrophic mucous membrane of the whole gastro-intestinal tract. There is loss of the normal folds and the surface is smooth, hyperemic and not infrequently ulcerated. Ulcerations are most commonly found in the large bowel from the iliocecal value down to the anus. Once recupera- tion has started and the patient has demonstrated his ability to tolerate therapy, then more active treatment can be instituted. Plasma, twice concentrated, can be given intravenously to the extent of 500 to 750 cc, daily. Whole blood in the presence of severe anemia will speed the convalescence. Iron therapy is of 33 no value until a positive nitrogen balance has been well established. In addition, iron salts by mouth are notorious for the gastro- intestinal upsets they produce. Vitamin therapy is only supple- mentary to the high protein, high caloric intake, but it is a neces- sary adjuvant. The first oral feeding will frequently determine the speed of convalescence. Should the food produce an enteritis or gastro-enteritis, convalescence will be greatly prolonged and therapy made more difficult. The emphasis cannot be placed too strongly on the clinical evaluation of the gastro-intestinal and circulatory aspects of these patients with total emaciation. It may be redundant to say again that many of these patients are in a precarious state of balance. The circulatory collapse secondary to violent retching and vomiting may precipitate death, just as readily as the injudicious use of intravenous fluids. The nasal or stomach tube, while theoretically of great aid in these patients, may lose its importance in actual practice. The struggle which some patients manifest against the introduction of this device may overtax their strength and precipi- tate a collapse. Edema is not an infrequent finding during the intermediary stages leading up to emaciation syndrome. This edema varies from dependent lower extremity swelling to an anasarca. The edema is usually due to low serum proteins, values as low as 1.8 having been observed. If the gastro-intestinal tract can tolerate the bland diet regime, it is simple to get the patient to ingest a hundred and sixty grams of protein daily in the form of milk and egg drinks. Mild cases of edema will disappear in a few days with this high protein intake. Severe anasarca will take a somewhat longer time but diuresis will be manifest by the second day. Intravenous therapy is generalized anasarca is again a matter of clinical judgment. If nausea and vomiting preclude the oral intake of food, then the parenteral route must be utilized. A preliminary injection of 250 cc. of normal strength plasma may be given very slowly, to determine the patient*s tolerance. If tolerated very well then double strength plasma should be started very slowly. It will usually be found that the patient will tolerate no more than 1000 to 1500 cc. a day. The use of more fluid intravenously before diuresis sets in will only result in an exaggeration of the edema. One must be constantly guided by the pulse rate, respiration, precordial distress, nausea and urine volume output as clinical indices to the intravenous therapy. Very emaciated patients may have surprisingly low plasma proteins without edema0 If rehydration occurs at a faster rate than restoration of plasma proteins, temporary edema occurse The lack of 34 correlation between plasma protein and edema in severe emaciation is probably related to a state of dehydration in which new equilibria control the distribution of water and electrolytes between blood and tissueso Acute Starvationo-~In contrast to the picture of chronic emaciation is the clinical syndrome of acute starvation By this is meant that condition in which the individual has been completely deprived of food and of fluid for several days0 In this acute condition ketosis* acidosis* and marked dehydration occur0 These patients require intensive therapy as quickly as it can be toleratedo Intravenous fluids with emphasis on the glucose-saline mixtures is indicatedo No special dietetic therapy is necessary except that which secondary conditions require0 Recovery is usually prompt and complete0 Other Ration Problems Milk and Ice Cream—°Milk issues consisted almost exclu- sively of evaporated and dried whole milk0 Small amounts of skimmed milk powder were included in the hospital ration for use in low-fat diets0 One shipment of 3200 quarts of frozen whole milk was received in good condition in the United Kingdom in March, 1945, and was distributed to hospital So Beverage milk and eggnog were prepared and served in hospitals but no serious attempt was made to popularize the use of beverage milk in troop messes although suitable instructions for its preparation .were published in mess bulletinso The dried whole milk was very acceptable, however, and yielded a reasonably good fluid milk if care was used in its rehydration and particularly if the product was flavored with chocolate or vanilla0 In view of the lack of apparatus for the large scale reconstitution of fluid milk from milk powder, emphasis was placed on the utilization of dried and evaporated milk in cooking, in cocoa, on cereal and in similar ways0 Consumption of the milk component of the ration was satisfactory0 This would not have been the case in the absence of an intensive educational programo Early ration directives authorized the daily issue of the equivalent of 5 ounces of evaporated milk per man0 This was not considered sufficient and the Nutrition Branch was instru- mental in having the allowance increased to 7 and 10 ounces* and later to 8 and 12 ounces*, for troops and hospital patients respectivelyc Thus* troops received the equivalent of one pint of whole milk daily o The additional milk added greatly to the acceptability of the ration and assisted materially in assuring satisfactory intake of calcium and riboflavin0 35 The use of fresh milk from local sources in the United Kingdom and on the continent was restricted and later prohibited be- cause of the medical hazard involved and because of the scarcity of the supply for civilian usec The original directive in January 1942 stated that "fresh milk will not be used except when boiled in cook- ing* unless it is definitely established that it has been pasteurized, stored and delivered in sanitary containersow In September* 1942* the use of fresh milk was practically prohibited by an order which re- quired that milk could be procured only if herds and processing plants conformed to Uo So Army standards © In November, 1943, the directive on milk was included in a more general order which prohibited the purchase of poultry, meat* meat food* marine and dairy products from commercial sources in the United Kingdom and on the continent0 Subsequent ration directives did not change this policy insofar as Uo So military were concernedo The manufacture of ice cream by British concerns was prohibited by governmental order as a means of conserving materials and of insuring a uniform distribution of available milko The American Army supported this policy and ice cream was not supplied except as it was prepared by hand freezing in small quantities in a few messes0 The British restriction was removed after the liberation of France and Belgium and in January* 1945* the use of ice cream by Uo So Array units in England and in the continent was authorized and encouragedo It was specified* however* that ice cream would be prepared from ration components exclusively and that civilian manufacturing agencies must maintain Uo So Army standards of sanitation In August* 1945* ice cream mix became a normal component of the ration issueo Dehydrated Foodso—The issue of dehydrated foods was not a serious problem in the European Theater because these items never predominated in the rationD Dried milk was acceptablso Dried egg was not received enthusiastically but it was a useful item if used as an ingrediento The wastage was excessive whenever it was served as an omelet or as scrambled egg because of the inability or refusal of cooks to prepare it properlyo Onion was very satisfactory if used with ground beefo It was unsatisfactory if used as a vegetable0 Potato was acceptable if reconstituted properly0 Sweet potato was a good product but the amount in the B ration was excessive for the average soldiero Carrots and beets were reasonably satisfactory0 Obviously* none of these dried foodstuffs was a good substitute for the canned producto The problem of dehydrated foods was worsened by the fact that relatively few cooks had received sufficient train- ing on the handling of this type of foodstuffo 36 Local Procurement of Foodstuffs0—The general policies governing the procurement of foodstuffs from sources within the theater were designed to save transoceanic shipping by the maxi- mum use of local surpluses and, at the same time, to protect the food rationing programs of the British and other allied govern- ments by restrictions on miscellaneous purchases by individuals and units of the American forceso In the case of certain food- stuffs, particularly milk, the factor of medical hazard was also involved., The British Ministries of Food and of Agriculture made available large quantities of such foodstuffs as flour, bread, prepared cereals, rolled oats, tea, marmalade, syrup, condiments, potatoes and vegetableso Procurement through authorized Quarter- master Purchasing Officers was also authorized on the continent but this was limited largely to fresh vegetables and the supply permitted only occasional issue.. The supply of potatoes, cabbage, carrots, beets, rutabagas and Brussels sprouts was practically unlimited in England although the quality of stored items became very inferior by springe Tomatoes and lettuce were only abundant during short seasons so that the dietary was generally lacking in fresh salad componentse (Figure 14)0 Fresh fruits were notably lacking in the American ration0 Seasonal apples and pears were unrationed in England and the same was true of apricots and grapes in France but the former were of inferior quality and the latter were readily available only in southern France., Shipments of oranges which were received occasionally in 1944 and 1945 were therefore especially appreciated by the troopso The purchase of meals in public restaurants was pro- hibited on the continento No such restriction prevailed in the United Kingdom although the demand for meals sometimes exceeded the supply. The American Red Cross provided snack bars which were well patronizedo These were limited to British sources of supply and to British rationing in the United Kingdom but were allowed to purchase Quartermaster subsistence supplies on the continent. The sale of Quartermaster ration components to individuals, except general officers, was never authorizedo Direct purchase of subsistence from British sources by organizations of the first units arriving in the British Isles was prohibited. In November 1943, type "B” officers* messes were permitted to purchase locally available unrationed food- stuffs but this authorization was soon withdrawn. Type f,B" mes- ses continued to operate in the United Kingdom and on the continent, except in the communications zone, and purchased food- stuffs from the Quartermaster exclusively. In June 1945, all messes in the theater became type "A" messes except those 37 specifically exempted by the Theater Commander0 In common with British practice* American forces cultivated gardens in order to provide an additional supply of fresh vegetables0 An agricultural officer was designated in each post* camp and station to supervise the gardening program with the assistance of a British agricultural officer0 It was specified that troops would not be used for this project if it interfered with trainingo Actually* most of the work was performed by British labor and* later* by prisoners of warQ Considerable quantities of potatoes, peas* green beans* let- tuce* greens* cucumbers* onions and radishes were grown in large and small plots of ground in and adjacent to campso Many static units continued this program on the continent in the spring of 1945* especially after prisoners of war labor became plentiful„ Rations in Staging Areaso--The most important problem in connection with staging areas was that faced in the Marshalling area” which extended along the southern English coast and from which troops embarked for the invasion of France0 Elaborate plans were made for the rapid movement of troops from the camps to the nearby embarkation docks and beaches but less imposing precautions were taken to ensure adequate nutrition in the invasion troops and satisfactory sanitation in the campso The Chiefs of the Nutrition Branch and of the Subsistence Division were directed to inspect personally messing procedures and to institute corrective measures* if necessary* throughout the areaG The majority on the staff of the Division of Preventive Medicine, Office of the Chief Surgeon* as well as nutrition officers* sanitary engineers* and medical of- ficers assigned to Southern Base Section* worked in these camps for weeks before and after D-dayo A special ration provided a particularly choice menu for the invasion troops0 The use of leftover foods was rigidly restricted and hashes and milk and bread puddings were omitted from the menus to minimize the possibility of outbreaks of food poisoning0 Additional instruction was given mess personnel in all phases of mess The "housekeeping” detachments in the camps had been drawn from many miscellaneous units throughout the United Kingdom and the majority of the mess personnel had been given preliminary but inadequate training in messes of static service units0 The maintenance of superior standards was also handicapped by the fact that medical inspectors for the camps were drawn from personnel of general hos- pitals which had recently arrived in theater and which had the mini- mum of field expertence0 38 Figure 14 A special shipment of tomatoes from the Canary Islands for issue to troops, May 1945. The original plan for embarkation of troops was based upon the uninterrupted loading of ships with no provision for hot meals at loading points® Stormy weather interfered with the loading schedule after the movement of troops from marshalling area camps to loading points was underway so that troops were held at loading points 1 to 6 dayso The Nutrition Branch successfully opposed the feeding of operational rations during this period and arrangements were immediately completed for the feeding of hot mealso At the Southhampton docks a large central kitchen distributed cooked food to various feeding points® At Weymouth, and elsewhere, cooked food was supplied by messes in nearby marshalling area camps® The two systems worked unusually well particularly that at Weymouth® There, the long lines of vehicles on the beach, laden with troops and with equipment and halted long enough for the service of a hot meal before moving on into the LST?s, proved an unforgettable sight® Much that was accomplished in the marshalling areas and all that was done at the loading points was omitted from the original planning® The unfortunate tendency of staff officers to take messing for granted in the planning of staging camps seriously needs correction® Although this phase of planning had been given some consideration in the marshalling area operation the actual provision of kitchen equipment and the prior training of housekeeping personnel were far from satisfactory® The situation on the continent, particularly in the staging area near Le Havre was immeasurably worse® Here, practically no attention had been given to messing until after troops arrived in the area® The Nutrition Branch was never informed of the setting up of this staging area until complaints were received because of the non- existence of messing facilities® The vigorous, combined efforts of the section nutrition officer and of messing teams of the Quartermaster Corps corrected this otherwise impossible situation® Feeding of Troops on Trains®—’The same problem of faulty planning, which interfered with the satisfactory nutrition of troops in staging areas, was found in the original operation of troop trains on the continent® In this case, no provision, other than the issue of C or K rations, was made for the subsistence of troops who would travel on unheated trains for 24 to 48 hours® These plans were made without the information or recommendation of either the Nutrition Branch or the Subsistence Division® Repeated conferences of these two interested groups with representatives of Transportation Corps and of the Ground Force Reinforcement Command were necessary before kitchen cars were added as components of the trains® This was accomplished and a special train ration was issued so that the service of hot meals became possible® 39 A similar problem was encountered in connection with the feeding of truck drivers on the famous Red Ball Express and on other regular convoy routes,. In this case, messes were installed along the highways for the feeding of hot meals, a procedure incomparably superior to the more convenient but less effective reliance upon C or K rationso Feeding on Hospital Trains®—In contrast to the failure of planning for the feeding of troops in staging areas and on troop trains, adequate provision was made for the nourishment of patients on hospital trains (Figure 15)® These trains were used on a small scale in the United Kingdom before D-day® Nearly 50 were in operation on the continent early in 1945® Nutrition officers traveled on the trains at frequent intervals and aided materially in the development of ”hot meal” service® In the original plan in the United Kingdom, meals consisted of sandwiches, hot drinks and fruit juices although the Nutrition Branch had urged the service of hot meals® Hot meals were found practicable as the personnel on the trains gained experience and at least one hot meal daily became the rule (Figure 16)® A special ration was issued hospital trains and ingredients for between-meal supplements of soup, eggnog and fruit juices were included® 40 Figure 15 The kitchen car of a hospital train. Figure 16 The serving of food to litter patients on a hospital train. THE NUTRITION OF PRISONERS OF WAR, ALLIED NATIONALS, AND OTHERS Rations for Prisoners of War. A small number of German and Italian prisoners of war (POW) were brought to the United Kingdom from North Africa in 1943o Prisoners captured in Normandy in 1944 increased the number but the total in the United Kingdom under the control of the Uo So Army was never large,, These POW were issued a ration which did not differ greatly from that supplied American troops (Column 1, Table 14)» No distinction was made in the rations for working and nonworking prisoners.. POW on the continent were issued a similar ration until 7 December 1944, except that nonworkers received 20% less than workers (Columns 2 and 3, Table 14)o At this time the worker’s ration was reduced from 3860 to 3258 calories; nonworkers received 10%, less (Columns 4 and 5, Table 14)0 Another reduction was made in April 1945 (Columns 6 and 7, Table 14)<> For the first time separate rations were authorized nonworkers because it was not feasible to make an overall percentage deduction in the worker's ration to bring the caloric level down to the 2000 calorie level ordered by the Theater Commander for nonworkers0 These ration decreases were the result of the disparity between tremendous numbers of captured prisoners and the relatively small stocks of available foodstuffs (Figure 17)* Furthermore, the 2000 calorie ration was authorized as the theater ration for displaced persons and others whose subsistence was the responsibility of G-5. The earlier rations supplied nonworkers were in accordance with the Geneva Convention and were in excess of the actual requirements of the prisoners« This original policy was bitterly criticized by allied civilians because nonworking prisoners had more to eat than allied workerSo Following the German surrender in May 1945, practically all the prisoners held by the Armies inside of Germany were classified as "disarmed forces" and their subsistence became the responsibility of the civilian food administration. POW in the Communications Zone remained on the POW ration (Figure 18). The components of POW rations were mostly Quartermaster supplies originally intended for use in the troop ration. The quality, therefore, was good. The method of preparation preferred by the Germans was the concoction of a stew containing nearly all of the ration components. This was fortunate because it was pos- sible to issue dehydrated potatoes and vegetables, which served the purpose admirably and which were less acceptable in the troop ration,, Captured enemy flour was used as long as it lasted. 41 In February and March 1945 the Nutrition Branch was directed to investigate the nutritional status of POW in American custody® The survey team* consisting of 2 medical and 2 nutrition officers examined 800 prisoners in representative work camps and enclosures® The results showed that the nutrition of prisoners who had been in American hands for 50 days or more was satisfactory and considerably superior to that of newly captured Germans® This indicated that the POW ration in use during the early part of 1945 was superior to the ration of the German Army® In August 1945 the Nutrition Branch was directed to make a second theater survey of the adequacy of the feeding of POW and of German disarmed forceso The 2000 calorie ration was found to be insufficient for German prisoners under 21 years of age and for others who were classed as nonworkers but whose caloric needs were significantly increased by fatigue duties, calisthenics or marching* The 2000 calorie ration was adequate for individuals who were inactive in facto The German civilian ration issued to disarmed forces varied from 1200 to 1500 calories at that time and was inadequate* This was especially true because there was no opportunity for the men in the enclosures to supplement their rations as German civilians were able to do from gardens, household supplies, etc* Feeding of Prisoner of War Patients® — German prisoner of war patients were fed the same ration as American patients until July 1945® They were given medical care in U® S® Army hospitals and in hospitals operated by captured German medical officers and enlisted personnel® The question of supplying the hospital ration to the German-staffed hospitals was thoroughly discussed before it was accepted as a sound policy® Later, it was realized that this method of nourishing German prisoner patients could not be controlled insofar as military hospitals within Germany were concerned® The distribution of the regular hospital ration to these units was abused and there was no way to prevent the dissipation of desirable components of the ration throughout the civilian population® This was true because of the lack of sufficient American personnel to supervise closely the many German units involved® As a result, the policy with respect to the feeding of prisoner patients was changed and a special POW hospital supplement was issued to these hospitals in place of the regular troop ration and supplement® Prisoner patients in American hospitals, however, continued to receive the American hospital ration® The POW supplement was composed of meat, egg, milk, sugar, etc®, and was a thoroughly desirable and useful addition to the POW ration® Prisoner patients were better nourished than civilian patients or "displaced person” patients® 42 Figure 17 8000 Nazi prisoners captured by the 8th Infantry Division in the Ruhr pocket near Renscheid, Germany, receive ,IK" rations, April 194-5. Figure 18 German Prisoners of War in a mess line at Central Enclosure No. 404, Delta Base Section, May 1945. It should be realized that conditions made it impossible to adhere to the usual interpretation of the Geneva Convention as it is applied to the subsistence of prisoners of war„ The Office of the Chief Surgeon based its action on the policy that all prisoners must be fed sufficient food to permit preservation or attainment of good healtho In accordance with this policy, a maintenance ration was supplied nonworkers0 Workers were allowed additional food in proportion to the energy demand of the work performed,. Patients were given a supplement which permitted sound nutritional therapy,, The feeding system was investigated repeatedly in order to be certain that prisoners were treated humanely and decently,, Rations for Allied Nationals and Otherso--The Nutrition Branch was not directly concerned with civilian feeding in Europe inasmuch as this problem was assigned to the Public Health Branch of SHAEFo Prior to the organization of that Branch, the Nutrition Branch had participated in early plans for this phase of the Army’s general task on the continent„ It continued to cooperate with the Public Health officers and assisted the latter in preliminary surveys in Germanyo Nutrition officers were transferred to these survey teams, which were later directed by the Public Health Branch, G-5, as rapidly as the needs of the Army permitted., Contrary to earlier expectations, the nutritional status of the civilian populations of France, Belgium and Luxemburg at the time of the invasion was surprisingly goodo Scarcity of food existed in the large cities but not in rural areaso The situation in the cities was far from extreme and there was no interference with the tactical operations of the Army on this account., The Army used civilian labor wherever possible.. Rations were supplied to this group in order to make certain of their nutritional fitness„ They were supplied 1 to 3 meals daily depend- ing upon whether they worked in areas adjacent to their homes or elsewhere., In addition to this Continental Civilian Employee's Ration, the Quartermaster was authorized to issue rations to the following groups: Italian service units; Russian nationals; liberated manpower units; and, certain units attached to the French Army., These rations were regularly reviewed by the Nutrition Brancho They were patterned after the American Army ration, except that account was taken of racial food habits, and they supplied 3000 to 3200 calorieso Enemy Civilians„-°Investigations of the nutritional status of German civilians were made as quickly as possible after occupation by American forces in order to ascertain whether lack of food was a public health problem which might immediately affect the welfare of the Armyo These surveys which included examinations of displaced 43 persons and recovered prisoners of war as well as of German civilians, demonstrated the urgency of the RAMP problem and the advisability of using German civilian food stocks in the feeding of displaced persons# Generally, enemy civilians were well supplied with food, especially in smaller communities and rural areas# Certainly there was no justification for the wholly inadequate rationing of allied prisoners held in the German stalags# Even in the industrial Ruhr there was no noticeable impairment of civilian nutrition# Here, however, it was evident that food stocks were low and that a future shortage was likely, particularly if it was expected that the area would resume some phases of its former industrial activity# The complete picture of German civilian nutrition will be found in the records of the Nutrition Branch of G-5# 44 Table 1 NUTRITION OFFICERS IN ETOUSA Name and Rank ✓ i ■ ■ mmrnmmX Serial Number Date of Arrival Principal Assignments ♦Barrick, Elliot R0 Majo (then Capt), Sn o C o 0-438413 27 May 1943 Hq0 ET0USA Advance Section Bell, Thomas Ao 1st Lto, SnoC« 0-374116 12 Febo 1944 Southern Base Section 15th Hospital Center 1 J Black, Alex Captog SlloC o 1 i 0-488968 12 Febo 1944 1 Southern Base Section United Kingdom Base, Hqe TSFET Bratton, Robert W® Capto (then 1st Lt® * Sri © C o 0-493225 20 Octo 1943 ; * i Eighth Air Force 12th Hospital Center Channel Base Section Braun, Winfred Capto, Sn0C. 0-473079 23 July 1944 Oise Intermediate Secti on Butts, Joseph So Major, Sn0Co 0-228840 1 Septo 1942 Eighth Air Force Carroll, William Ro Capto, Sn0Co 0-479107 20 June 1944 Ninth Army ♦♦Chambers, William Ho '0-442246 18 Jan» Hqc ET0USA Lto Colo (thenMajo) Sn © C o 1943 • United Kingdom Base 12th Army Group ♦Combs, Gerald Fc Majo (then Capto) Snc C o 0-408734 27 May 1943 Hq» ET0USA Southern Base Section Crookshank, Herman Fo 0-475952 ( 20 Oct, North Ireland Base Capto, SnoCo 1943 e * Section, Normandy Base Section, 807th Hospital Center Table 1 (cont!d) Name and Rank Serial Number Date of Arrival Principal Assignments Davis* Horace Jo Majo (then Capto), | SnoCo j 0-492381 14 Deco 1943 Southern Base Section G-5 (SHAEF) Gardner* Karl Eo Capto (then 1st Lt») Sn0Co i 0-517410 11 Febo 1944 Western Base Section Channel Base Section Third Army ♦ ♦♦Griffith* Wendell Ho] Colo (then LtoCol.)i Sn0Co 0=v426073 31 Augo 1942 Chief* Nutrition Branch, ET0USA i Menderson, LaVell Mo* SnoCo - ... ... i 0-376471 26 May 1943 Medical Field Service School . Johnson* Clyde Sc Capto * Sn0Co 0-448377 2 May 1945 Oise Intermediate Section ♦Jones* Joseph Lo C ap to* Sn o C o 0-474315 23 July 1944 Hq0 Command* Com Z Normandy Base Section Lambooy* John Po Capto * Sn © C o 0-474692 20 Mare 1944 Ninth Air Force Light* Amos Eo Capto(then 1st Lto), SnoCo 0-503733 14 Deco 1943 Western Base Section 802nd Hospital Center McVicar* Robert WQ Capto (then 1st Lto) Sn0Co 0-385331 26 May 1943 Eastern Base Section Brittany Base Section Assembly Area Command ♦Nasset* Edmond So LtoColo(then Majo) Sno C o 0-427889 1 June 1943 Ninth Air Force Rouse* Warren Wo 1st Lto* Sn0C0 0-516386 8 May 1945 Seine Section ♦Schaefer* Arnold Eo Majo(then 1st Lto) Sn o C o 0-375737 27 May 1943 Western Base Section Channel Base Section 2 Table 1 (cont’d) Name and Rank Serial Number Date of Arrival Principal Assignments Stock, Carl G. Capt,(then 1st Lt.) Sn.C. 0-517478 2 July 1944 Western Base Section 803rd Hospital Center Sullivan, Royal A. Capt.(then 1st Lt.) Sn.C. 0-518547 23 July 1944 3rd Reinf. Depot Supplee, William C. Maj,(then Capt.)Sn.C. 0-467137 2 July 1944 Western Base Section 805th Hospital Center ♦Tuckey, Stewart L. Maj,(then Capt.), Sn.C. 0-496837 14 Dec, 1943 Central Base Section Seine Base Section 814th Hospital Center ♦Weswig, Paul H, Maj,(then 1st Lt,) Sn.C. 0-447368 5 Sept. 1942 Eighth Air Force USSTAF ♦White, Julius Maj.(then Capt.) Sn.C. 0-506727 12 Dec. 1943 16th Reinf. Depot Wilcke, Harold L, Maj,(then Capt.) Sn. C. 0-244972 23 July 1944 Seine Section ♦ Awarded Bronze Star. ♦♦ Awarded Bronze Star with Oak Leaf Cluster. ♦♦♦ Awarded Legion of Merit and Bronze Star, Officers assigned initially to G-5, SHAEF, or to the European Civil Affairs Division are not included. The following officers were assigned to the Nutrition Branch for short periods in connection with nutritional surveys: Major Capt. Capt, Capt, Howard J. Agaston, M.Co Raphael Greenstein, M.C. Leonard Horn, M.C. Herman C. Weinberg, M.C. 3 In addition, Dean So Fleming, then 1st Lt0, MoC0, supervised nutrition activities in the Office of the Chief Surgeon from 4 to 31 Augo 1942; and, Herbert Pollack, then Lto Col., MoCo, Chief of Medical Service, 15th General Hospital, was assigned to the Nutrition Branch on continued temporary duty starting 1 Jan0 19450 Officers were on duty in the medical sections of the headquarters of •commands listed in table0 Actual assignments were in most cases in units under the control of the respective headquarterso 4 Table 2 DISTRIBUTION OF NUTRITION OFFICERS IN ETOUSA a . . . b 1 Jan* Assignment ✓ 1943 1 July 1943 1 Jan. 1944 1 July 1944 L Jan. 1945 1 July 1945 1 Jan, 1946 ETOUSA, UoKo and Con. 1 3 3 2 2 Z 1 Eighth Air Force, U.K. Eighth AoF0 Composite 1 1 1 1 — - - Command, UoK0 Eighth AoFo Fighter 1 1 — p • • • — Command, UoKo Ninth Air Force, U.K. • 1 1 1 —' and Corio Ninth AoFo Bomber Command, - — 1 1 1 - — U„Ko and Con0 - - - - 1 1 1 - U.SoStrategic Air Force, Con. - - - - 1 1 - Third Army, U.K. and Con, - - - - - 1 1 Ninth Army, UoK. and Con. - - - 1 1 1 - Assembly Area Command, Con. - - - - - 1 - 3rd Reinfo Depot, GFRC, Con. 16th Reinfo Depot, GFRC, — — • 1 1 1 UoK. and Conc Medical Field Service School, — 1 1 1 1 UoK. and Con. - 1 1 1 1 1 - Central Base Section, U.K. - - 1 1 1 - - Eastern Base Section, U.K. North Ireland Base Section, 1 1 1 — •• U.K. - - 1 1 - - - Southern Base Section, U.Ko - 1 2 4 - - - Western Base Section, U.K. - 1 2 5 - - - United Kingdom Base, UoK0 - - - - 1 1 - Advance Section, Con. - - - 1 1 1 - Brittany Base Section, Con. - - - 1 1 - - Channel Base Section, Con. - - - - 2 2 - Normandy Base Section, Con. - - - 1 - 1 - Oise Intermediate Section,Con • ** - - - 1 2 1 Seine Section, Con. - - - - 2 1 - 12th Hospital Center, U.K* - - - - 1 - - 15th Hospital Center, U.K. - - - - 1 1 - 802nd Hospital Center, U.K. - - - - - 1 - 803rd Hospital Center, U.K. - - - - 1 - - 805th Hospital Center, U.K. - - - - 1 - - 807th Hospital Center, Con. •• *• • •• 1 — 1 Table 2 (cont’d) Assignment 1 Janc 1 July 1 Jan0 1 July 1 Jan0 1 July 1 Jan» 1943 1943 1944 1944 1945 1945 1946 812th Hospital Center* Con0 - - - = 1 - - 814th Hospital Center* ConQ - - - - 1 1 - Total in United Kingdom 3 9 15 21 7 3 0 Total in Continent 0 0 0 2 . 18 19 4 Total in Theater 3 9 ° 15 -L 23 d 25 6 22 f 4 a Officers assigned to G^-5* SHAEF* or to EGAD are not 1 ncludedo b Officers were on duty in the medical sections of the headquarters listed in the table although actual assignments were* in many instances, in units under the control of the respective headquarters0 0 One officer subsequently reassigned in the United Stateso d One officer subsequently transferred to European Civil Affairs Division e Four officers subsequently transferred to European Civil Affairs Division and one to UoSo Group Control Councilo f Four officers subsequently transferred to European Civil Affairs Division* 13 reassigned or discharged in the United States and one deceasedo 2 Table 3 TROOP RATION SCALES IN ETOUSA (Ounces per man per day) ✓ COMPONENT 1 British Home Service Ration 1942 2 British American Ration 1942 3 Cir0 #8 Hq.USAFBI 16 February 1942 4 Cir. #13 Hq. ETOUSA 11 February 1943 Beef, as boneless 3o21 5.31 7 o43 4.90 Pork and Ham, as boneless 0o64 1.06 2.97 2.25 Chicken, fresh, undo - - 2.00 - Lamb, car0 0o92 1.51 - 0.70 Fish, cdo 0o43 0.43 - 0.35 Bacon 1,43 3.00 2.00 1.00 "Other Meat" Group 1 o71 1 o 71 - 2.95 Eggs, as dehydo - 0.07 0.50 0.60 Cheese 0,57 Oo 57 0.25 Oo 50 Milk, as evapo 3o75 4.00 5.00 7o00 Butter or Margarine 1 o 50 2.00 2.00 1.50 "Other Fat" Group - 0 o 28 1.28 0o85 Sugar, grano 2o00 3.00 5.00 4.00 Fruit Spreads loOO 1.00 0.50 Oo 50 "Other Sugar" Group - 0.64 0.50 0.80 Bread 10o00 10.00 8o00 6.00 Flour 2,00 2.50 4.00 3.00 "Other Grain" Group 1086 2043 2.35 2.00 Dried Legumes Oo 57 0.57 0.50 1.25 Peanut Butter - - - 0o25 Potatoes 13o00 10.00 10.00 10.00 Vegetables, LG and Y, fres h 3o00 8.00 - - Vegetables, cdo - - 5.00 6.50 Tomato Group, fresh loOO loOO - - Tomato Group, cdo - - 2.00 3.00 Citrus Fruits, cdo - - - 2.42 Lemon Crystals - - - 0.08 Vegetables, Other, fresh 1 ©71 5o00 2.00 - Vegetables, Other, cdo - - 2.00 4o00 Fruits, Other, od. - - 3.90 5.00 Fruits, Other, dried 0.86 2.00 0.30 Oo 70 Cocoa 0.19 0ol9 0.30 0.30 Coffee 1 o 75 2.00 1.10 1 Table 3 (cont’d) COMPONENT I British Home Service Rati on 1942 2 British American Ration 1942 3 Cir» #8 Hq.USAFBI 16 February 1942 4 Giro #13 Hq® ETOUSA 11 February 1943 Tea 0o29 0ol4 0o05 OolO Baking Powder and Soda - 0o08 0o09 0,20 Bouillon Cubes - - - 0«04 Flavoring Extracts, fluid - 0o02 0o02 0o03 Pickles, asstdo - 0ol4 0ol6 0 o 50 Salt 0o38 0o50 Oo 50 Oo 50 Sauces - 0ol8 - 0o06 Other Condiments - 0ol5 0c05 0o07 Vinegar - Ooll 0„16 0*40 Yeast - 0o02 - - Cash Allowance 2-l/2d - - - Total Weight in Ibso So 20 4o35 4o 55 4o71 lo Carcass beef and pork are expressed as boneless meat according to the ratio l:0o743o 2o Margarine (lo5 ounces) was a component of the British Home Service and British-American rations only0 3C The cash allowance of 2-1/2 pence, approximately 4 cents (US), is used for the purchase of miscellaneous foodstuffs and is estimated by the British War Office to supply 214 additional calories« 2 Table 4 NUTRITIVE VALUE OF TROOP RATIONS IN THE UNITED KINGDOM, WITH AND WITHOUT CORRECTION FOR MINIMUM LOSSES DURING ISSUE, STORAGE, PREPARATION, AND SERVICE OF FOOD Nutrients 1 British Home Service Ration 1942 2 British American Ration 1942 3 U.S.Ration Aug.-Oct* 1942 4 U.S.Ration Nov.-Dec. 1942 5 U.S.Ration Jan,1943 Jan.1945 Energy Cal * 3060 4182 4766 4465 4049 (2776) (3704) (4170) (3940) (3624) Protein Gnu 96 124 149 136 130 (91) (118) (142) (129) (125) Fat Gnu 117 197 215 205 165 (97) (156) (164) (161) (132) Carbohydrate Gnu 406 478 557 519 536 (385) (457) (532) (494) (486) Calcium Gnu 0*63 0*77 0*88 0,87 0*96 (0*60) (0*73) (0*84) (0*82) (0*91) Iron Mg. 19 25 29 28 27 (18) (24) (28) (27) (25) Vitamin A I.U* 3050 1233 1503 2474 2448 (animal) (2890) (1170) (1428) (2350) (2330) Carotene IoU. 4647 ' 9695 9638 9842 11482 (plant) (4415) (9200) (9156) (9350) (10910) Thiamine Mg* 1.98 2*69 3.01 3*05 2.61 (1.50) (1*99) (2*18) (2.13) (1*88) Riboflavin Mg* 1.83 1*97 2.43 2.42 2.40 (1.58) (1*71) (2.11) (2.08) (2.07) Niacin Mg. 20 24 32 28 27 (16) (19) (26) (22) (21) 1 Table 4 (contfd) 1 2 3 4 5 British British UoS.Ration TJoS.Ration UoS*Ration Home American Augo-Octo NoVo-Deco Jan.1943 Nutrients Service Ration 1942 1942 Jan.1945 Ration 1942 1942 Ascorbic Acid Mgo 100 147 134 164 167 (45) (69) (104) (97) (96) Uncorrected and corrected values represent "as issued" and "as consumed" values respectivelyo Corrected, or "as consumed" values, are estimated by making the following deductions from "as issued" values: a0 Deduction of to cover wastage loss during issue, storage, preparation, and service of ration components. bo Deduction of 25% of meat and cooking fat which is assumed to be uneaten. Co Deduction of nutrient losses listed in Table 5, The corrected value in the table is the value in parenthesis. The composition of this ration is shown in Column 1, Table 7, Analysis is based on Tables of 1'ood Composition, UoS,D0Ao Miscellaneous Bulletin, No, 572, (1945), This value was calculated according to the procedure used in estimating caloric values of U,S0 Army rations. The British War Office estimates the average value of the monetary allowance as 214 calories, thus increasing the total ration value to 3274, The energy content of the ration was increased 284 calories in May 1943 and an additional allowance of 200 calories was authorized troops undergoing hard training. 2 Table 5 LOSS OF NUTRIENTS OF FOODSTUFFS DURING COOKING Food Group Loss in percent Thiamin Riboflavin Niacin Ascorbic Acid Meat 35 20 25 0 Eggs 25 10 0 0 Cereals 10 0 10 0 Legumes 20 0 0 0 Vegetables, L.G.Y. 40 25 25 60 Tomatoes 5 5 5 15 Vegetables, Other 25 15 25 60 Potatoes 40 25 25 60 Recommendations of the National Research Council, 7 June 1945, Table 6 ALLOWANCES OF NUTRIENTS (AS CONSUMED) RECOMMENDED BY NATIONAL RESEARCH COUNCIL Nutrients Prior to 19 April 1945 After 19 April 1945 1 2 3 4 Energy Cal < 3000 3750 3000 3750 Protein Gnu 70 70 70 70 Fat Gnu - - - - Carbohydrate Gnu - - - - Calcium Gnu 0o80 0o80 0«80 0,80 Iron Mgo 12 12 12 12 Vitamin *IAW I.U, 2000 2000 2000 2000 Carotene I„U< 3000 3000 3000 3000 Thiamin Mgo 1 o80 2c05 1 o 50 1,73 Riboflavin Mgo 2,70 3o00 2,00 2.30 Niacin Mgo 18 21 15 17 Ascorbic Acid Mgo 75 75 75 75 The National Research Council recommended level of 5000 I.U. of total vitamin A is listed in the table as 2000 I,U, of vitamin A (animal sources) and 3000 I.U. of carotene (plant sources). Table 7 COMPOSITION OF RATIONS PRESCRIBED BY AUTHORIZED TROOP MENUS IN ETOUSA (Pounds per 100 men for 10 days) 1 2 5 5 5 UK,1 Jan. Con.July Con.l Aug. Con.l Oct. Theater, 1 Component 1943 to 31 1944 to 30 Sept.1944 to 31 Feb.1945 to Jan. 1945 1944 Jan.1945 31 Oct.1945 Bacon 61 95 85 75 52 Beef, boneless 264 - 93 157 246 Pork, boneless, and Ham 162 - 64 105 109 Fowl, undrawn 64 - - 74 92 Lamb, carcass 13 - - - 17 Fish, canned 28 48 36 34 21 Meat-Vegetable Group 46 265 165 107 26 Other Meat Group 148 412 343 256 207 Eggs, as dehyd. 36 37 39 40 40 Cheese 29 34 34 33 32 Milk, as evap0 438 347 347 393 475 Butter, fresh 80 - 20 34 50 Butter, canned - 46 35 34 19 Other Fat Group 45 32 32 36 44 Sugar, granc 248 259 259 279 257 Fruit Spreads 69 136 136 56 80 Other Sugar Group 41 35 35 58 18 Bread 424 198 300 450 465 Biscuits 17 170 110 10 - FI our 149 130 130 152 137 Other Grain Group 94 111 111 108 118 Dried Legumes 41 72 72 48 56 Peanut Butter 17 20 20 23 25 Potatoes, fresh 711 - 180 353 313 dehydo - 47 47 48 49 LG and & Vegetables, fresh 279 - - • 88 105 canned 195 238 238 185 210 dehyd• 8 15 15 6 3 Tomato Group, fresh 29 - - 9 3 canned 189 235 235 171 217 Citrus Fruits, canned 119 133 133 146 164 Lemon Crystals 4 9 9 4 4 1 Table 7 (cont’d) 1 2 3 4 5 UK,Uan0 ConoJuly Con0l Aug0 Con0l Octo Theater, 1 1943 to 31 1944 to 30 Sept0 1944 to 31 Feb<>1945 to JaHol945 1944 JanQ 1945 31 0cto1945 Component Other Vegetables# fresh 134 111 82 canned 109 125 125 115 119 dehydo 3 5 5 2 2 Other Fruits# fresh 41 . 33 canned 284 358 358 255 300 dehyd0 4 5 5 3 4 dried 48 43 43 39 29 Cocoa 14 9 9 10 12 Coffee 72 80 80 79 88 Tea 5 1 1 7 5 Baking powder and soda 7 9 9 14 9 Bouillon cubes Oo 9 204 2o4 108 loO Flavoring extract# fluid c o 00 Oo 5 0o3 Tablets - 0o2 Oo 2 Ool Ool Pickles# assorted 31 16 16 15 26 Salt 27 20 20 41 36 Sauces 2o0 0o3 0o3 Oo 3 lo6 Other Condiments 2o70 3o 25 3o25 5o71 2o70 Vinegar 11 6 6 14 9 Yeast# dry loO *• Go 3 loO Canned corned beef hash, meat and vegetable hash, and meat and vegetable stew. Frankfurters, cold cuts and canned sausage, chili, luncheon meat, chicken, turkey, corned beef, roast beef, beef and gravy, pork and gravy, and ham. Lard substitute and salad oil. Apple butter, marmalade, assorted jams and jellieso Dessert powders, syrup and candy„ UK-prepared from British 85% extraction flour0 Continent-prepared from U0S0 enriched white flour0 2 Table 7 (cont’d) Breakfast cereals, cornmeal, cornstarch, hominy grits, macaroni, spaghetti and riceo Beans, white or kidney, lima beans, baked beans (calculated as dry bean), and dehydrated bean and pea soup. String beans, broccoli, cabbage, carrots, greens, lettuce, peas and brussels sproutso Green asparagus, string beans, carrots, peas, pumpkin, sweet potatoes, and spinacho Cabbage, carrots and sweet potatoes. Tomatoes, tomato juice, catsup and puree. Grapefruit, grapefruit juice, orange juice and blends. Fortified with ascorbic acid, 3980 mg« per lb„ Beets, cauliflower, celery, corn, cucumbers, leeks, marrow, green onions, dry onions, parsnips, radishes, rutabagas and turnips. Green lima beans, beets, corn and sauerkraut. Beets and onions. Apples, apricots, pears and grapes. Apples, applesauce, apricots, berries, cherries, figs, fruit cocktail, grape juice, peaches, pears, pineapple and pineapple juice. Apple and cranberry. Apple, apricot, peaches, prunes and raisins. Lemon and vanilla. Lemon, vanilla and maple. Celery salt, cinnamon, cloves, ginger, dry mustard, nutmeg, pepper and poultry seasoning. 3 Table 8 HOSPITAL (PATIENTS’) RATION SCALES IN ETOUSA (ounces per patient per daily) Component 1 Circ #13 HqoETOUSA 11 February 1943 2 Adnu Cir0 #85 S0S,ET0USA 21 November 1943 3 Giro #63 ETOUSA 5 June 1944 4 Cir0 #81 ETOUSA 15 June 1945 as boneless 4o 20 5o00 5o00 5o90 Pork and Ham* as boneless lo50 2o00 2o00 2e00 Chicken* fresh* undo 1 o 50 2075 2o75 3o85 Lamb* car0 0o70 - - - Fish* cdo 0o70 0o70 0o70 Oo 35 Bacon loOO loOO loOO loOO "Other Meat" Group lolO 0o70 0o70 0o70 Eggs* as dehydo 0c70 0o75 0o75 0o75 Cheese Oo 30 0o40 0o40 0o40 Milk* as evapQ 10o00 12o00 12o00 12o00 Milk* malted, pwdo 0o02 OolO OolO OolO Butter 1 o 50 1 o 50 1 o 50 1 o 50 "Other Fat" Group 0o75 0o65 0o65 0o75 Sugar* granc 4o00 4o00 4o00 40 50 Fruit Spreads loOO loOO loOO loOO "Other Sugar" Group lo30 0o80 0o80 0o80 Bread 4o00 40 50 70 50 7o00 FI our 2 oOO 1 o50 1 o 50 2o00 "Other Grain" Group 2o00 1 o 50 1 o 50 1 o 50 Dried Legumes Oo 50 0o30 Oo 30 0 o 50 Peanut Butter Oo 25 0o20 0o20 0o30 Potatoes 4o00 6 oOO 9o00 9o00 Vegetables* LG and Y* cdo 6o00 6o00 6 oOO 6o00 Tomatoes* cdo 4o00 4o00 4o 50 4o44 Citrus Fruits* cdo 2044 3ol2 3ol2 4o00 Orange Crystals Oo22 Oo 22 0 022 - Lemon Crystals 0o04 0o06 0o06 0o06 Onions* dry loOO loOO loOO loOO Vegetables* Other* cd« 3o00 3o00 3o00 2o50 1 Table 8 (cont’d) : J Giro #13 Hq. ETOUSA Component , u j.-.ebruary 1943 “TT Adm, Cir0 #85 SOS,ETOUSA 21 November 1943 3 Cir0 #63 ETOUSA 5 June 1944 3 Cir. #81 ETOUSA 15 June 1945 Fruits* Other, ccU 7 oOO 7 o 00 7 ©OO 7.00 Fruits, Other, dried 0o60 0o60 0o60 0,60 Cocoa 0,30 0.30 Oo 30 0.30 Coffee, R and G lolO 1 o28 1 o28 1.44 Tea OolO OolO OolO 0.08 Baking Powder and Soda 0o20 Oo 20 0.20 Oo 25 Bouillon Cubes 0o04 0o04 0o04 0.04 Flavoring Extracts 0o03 0o03 0c03 0.03 Pickles, asstdo 0 o 50 Oo 50 Oo 50 0.50 Salt Oo 50 Oo 50 0.50 0.50 Sauces 0o06 0o06 0.06 0.06 Soups, cdo 1 ©60 1 o60 1.60 1.60 Other Condiments 0o07 0o07 0.07 0.05 Vinegar 0o40 0o40 0.40 0.40 2 Table 9 COMPOSITION OF RATIONS PRESCRIBED BY AUTHORIZED HOSPITAL (PATIENTS’) MENUS IN ETOUSA (Pounds per 100 Patients for 10 Days) Uo Component tc Aug 1 Ko 1 01943 31 01944 2 UoKo 1 Septol944 to 31 Oct.1945 3 Con0 July 1944 4 Con0 1 0ctol944 to 30 Septol944 5 Con0 1 Oct.1944 to 28 Feb,1945 6 Con„ 1 March 1945 to 31 Oct. 1945 Bacon 65 53 . 95 85 71 49 Beef, boneless 305 310 - 93 188 256 Pork* boneless and Ham 150 218 64 130 108 Fowl, undo 84 197 - - 102 96 Lamb, car 0 - - - - - 18 Fish, cdo 40 39 67 55 51 41 Meat-Yegetable Group OJB OB 265 207 86 21 Other Meat Group 95 100 557 488 342 294 Eggs, as dehydo 43 46 45 47 41 50 Cheese 26 8 34 34 34 33 Milk, as evap0 663 686 674 674 713 748 Milk, skim, pwd» 5 7 . - - » 9 Milk Products,pwdo 13 5 1 1 2 7 Butter, fresh 92 90 ~ 20 45 52 Butter, cdo - - 96 85 68 38 Other Fat Group 40 45 41 41 46 48 Sugar, gran0 246 254 259 259 275 268 Fruit Spreads 99 84 143 143 69 116 Other Sugar Group 58 63 53 53 71 67 Bread 286 482 198 300 460 518 Biscuits 7 - 170 110 8 - Flour 106 151 130 130 155 137 Other Grain Group 109 94 138 138 129 144 Dried Legumes 31 32 141 141 100 56 Peanut Butter 11 21 26 26 28 26 Potatoes, fresh 386 700 - 180 427 304 Potatoes, dehydo « - 77 77 62 39 Vegetables,LG & Y, fresh 175 137 101 102 cdo 242 259 290 290 257 293 dehydo 5 - 29 29 16 3 1 Table 9 (cont’d) 1 UoKo 1 ✓ Maro1943 to 31 Aug o1944 2 QoKo 1 Septol944 to 31 0ctol945 3 Con0 July 1944 4 Con0 1 Oct.1944 to 30 Septd944 5 Con. 1 0ctd944 to 28 Feb.I945 6 Cono 1 March 1945 to 31 0ctol945 Tomato Group* fresh 21 - - - 7 4 cdo 199 246 304 304 243 276 dehydo 2 - - - - 2 Citrus Fruits* cdo 244 300 186 186 301 267 Lemon Crystals 4o9 3o 5 9o4 9.4 2.4 4ol Other Vegetables* fresh 131 138 - - 109 77 cdo 129 150 128 128 126 153 dehydo 3 2 5 5 2 2 Other Fruits* fresh 38 - - - 26 - cdo 433 457 365 365 308 457 dehydo 9 4 5 5 3 4 dried 34 36 57 57 50 30 Cocoa 13 18 19 19 20 16 Coffee* H and G 71 83 95 95 92 89 Soluble 2 2 - - 1 2 Tea 5 4 2 2 7 4 Baking Powder and Soda 4o5 7o0 9o0 9.0 12.7 8.9 Bouillon Cubes 2d Flavoring Extracts* 2.1 2 04 2o4 1.8 lol fluid 1 o07 0ol9 - - 0.40 0o33 Tablets - 0o09 0o20 0o 20 OdO 0<>42 Pickles* asstdo 35 15 16 16 15 24 Salt 29 21 20 20 37 37 Sauces 2o4 0,7 0o 3 0.3 0.4 1.8 Other Condiments 3o60 1 o 36 2o03 2 o 25 4.B2 3.03 Vinegar 13 2 6 6 13 10 Yeast* dry Oo 7 Oo 2 - - 0o4 1,0 Multivitamin Capsules 0ol7 Oo 26 0o27 Oo 27 c- C\2 0 o 0,38 Soup* asstdo*cdo 49 67 i 21 21 31 69 2 Table 9 (cant’d) footnotes Individual components include those listed in footnote. Table 7, and the following special hospital supplements: tuna, cd0; ovaltine, cocoraalt, and malted milk powder; brown and confectioner’s sugar, gelatin dessert powder, and glucose syrup; egg noodles; purees of string beans, beets, carrot, peas, and spinach; assorted soups, cd0; and, multivitamin tablets. 3 Table 10 NUTRITIVE VALUE OF HOSPITAL (PATIENTS’) RATIONS (TYPES A AND B) IN ETOUSA, WITH AND WITHOUT CORRECTION FOR MINIMUM LOSSES DURING ISSUE, STORAGE, PREPARATION, AND SERVICE OF FOOD. Nutrients 1 Type A UK March 1943 to Aug o1944 2 Type A UK Septo1944 to Octo 1945 3 Type B Con0 July 1944 4 Modified Type A ConoAugc- Septd944 5 Modified Type A ConoOcto 1944 to Jan„1945 6 Type A Con,Feb, Oct.1945 Energy Cal < 4063 4615 4795 4854 5007 4813 (3647) (4139) (4317) (4369) (4511) (4337) Protein Giiio 130 152 168 170 178 168 (123) (144) (159) (161) (169) (169) Fat urn o 176 191 191 197 207 189 (143) (154) (156) (160) (170) (153) Carbohydrates Gfflo 490 572 599 600 608 608 (467) (544) (569) (571) (576) (582) Calcium , 0mo 1 o28 1 o 24 lo75 1 o 50 1 o 54 1,46 (1.22) (1.18) (lo 66) (1.42) (1,46) ;i.39) Iron Mg o 23 28 35 34 34 33 (22) (26) (35) (33) (32) (30) Vitamin A IcUo 3285 3113 2619 3365 3635 3713 (animal) (3121) (3007) (2488) (3157) (3454) 3526) Carotene IcUo 10108 10728 11769 10973 11785 9890 (plant) (9603) (10192) (11181) (10425) (11196) 9395) Thiamine Mg o 2o37 3o02 20 23 2,58 3,13 3,00 (1o 75) (2o22) (1.75) (2,00) (2,41) 2,34) Riboflavin Mgo 2 c 84 3cl3 3o 36 3o45 3,77 3,78 (2»52) (2o 76) (2o 99) (3,07) (3,36) 3,35) 1 Table 10 (cont’d) 1 2 3 4 5 6 Type A UK Type A UK Type B Modified Modified Type A March Septo1944 Con Type A Type A ConeFebo 1943 to to Octo July Con0Aug0- ConoOcto 0ctol945 Augo1944 1945 1944 Septol944 1944 to Jan<>1945 Niacin Mg. 28 35 31 33 38 37 (22) (28) (26) (26) (30) (29) Ascorbic Acid Mga 162 179 138 135 146 159 (US) (120) (105) (105) (96) (116) Uncorrected and corrected values represent "as issued” and ”as consumed' values respectivelyo Corrected, or ”as consumed" values, are estimated by making the following deductions from "as issued" values: a. Deduction of 5% to cover wastage loss during issue, storage, preparation, and service of ration componentso b0 Deduction of 25% of meat and cooking fat which is assumed , to be uneaten* Co Deduction of nutrient losses listed in Table 5* The corrected value in the table is the value in parenthesis* Composition of rations in Columns 1-6 above, is shown in Columns 1-6, Table 9o Analysis of rations is based on Tables of Food Composition, Miscellaneous Bulletin, No0 572 (1945)o The multivitamin tablets in the hospital ration are not included in the analyses0 2 Table 11 ISSUE OF OPERATIONAL RATIONS (Per cent of rations issued) Period A or B Rations C Operational Rations K 10-in-1 Total 1944 June 0 14 15 71 100 July 57 6 9 28 43 August 52 14 14 20 48 September 58 18 10 14 42 October 79 7 5 9 21 November 88 3 5 4 12 December 87 3 5 5 13 1945 January 91 2 3 4 9 February 91 2 4 3 9 March 88 4 5 3 12 April 74 8 7 11 26 May 87 2 4 7 13 June 94 1 3 2 6 July 96 1 2 . 1 4 Data supplied by Office of the Chief Quartermaster, Hq» ETOUSAo Table 12 NUTRITIVE VALUE OF OPERATIONAL RATIONS SUPPLIED ON THE CONTINENT IN 1944 (as issued) 1 "D" 2 "C" 3 "K" 4 ”10-in-1" 5 "B" Energy Calo 1770 2775 2786 3927 3915 Protein Gbio 32 121 89 124 * 122 Fat (ho 95 78 129 171 141 Carbohydrate Giiio 200 379 317 473 532 Calcium Gbi. 0o70 0.82 1 o 28 1 o 31 lo00 Iron Mgo 11 33 14 22 27 Vitamin A I0U0 0 18370 4674 5220 9430 Thiamine Mgo 1 o 50 lo00 2ol0 2 c 30 1 „98 Riboflavin Mgo 0o50 o CD O 2o40 2.70 2<>42 Niacin Mgo 1 28 15 24 27 Ascorbic acid Mgo 0 87 65 80 103 Data from TB Medo 141s WoDop Febo 1945o Approximately 60 mg0 in the form of fortified "lemon crystals"0 Approximately 37 mg0 in the form of fortified "lemon crystals"<, Table 13 NUTRITIVE VALUE OF TROOP RATIONS (TYPES A AND B) ON THE CONTINENT, WITH AND WITHOUT CORRECTION FOR MINIMUM LOSSES DURING ISSUE, STORAGE, PREPARATION, AND SERVICE OF FOODo Nutrients 1 Type B July 1944 2 Modified Type A Augo- Septo 1944 3 Modified Type A Octo1944- JanQ 1945 4 Type Ao Febo-Octo 1945 Energy Cal o 3893 3952 4105 3979 (3493) (3545) (3687) (3571) Protein Gnu 127 129 137 136 (120) (122) (130) (129) Fat Gilo 147 152 162 156 (117) . (121) (131) (125) Carbohydrate Gnu 516 517 525 506 (490) (492) (497) (483) Calcium Gmo 1 o24 0o99 1.03 loOl (1ol8) (0o94) (0o98) (0o96) Iron Mg© 28 28 28 28 (27) (27) (26) (26) Vitamin A I0U0 1292 2038 2308 2805 (animal) (1227) (1936) (2193) (2664) Carotene I0U0 9221 8425 9237 8276 (plant) (8760) (8004) (8775) (7862) Thiamine Mgo 1 o78 2ol3 2o68 2o63 (1 o 41) (1»66) (2o07) (2o03) Riboflavin Mgo 2o41 2o 50 2o82 2o89 (2ol5) (2o2l) ( 2 o 50 ) (2.65) 1 Table 13 (cont’d) Nutrients 1 Type B July 1944 ~T~ Modified Type A Aug o - Sept. 1944 3 Modified Type A 0ctd944- Jan«1945 4 Type Ao Febo-Octo 1945 Niacin Mgo 25 26 31 32 (20) (21) (25) (25) Ascorbic acid Mgc 112 110 121 121 (87) (87) (78) (82) Uncorrected and corrected values represent "as issued" and "as consumed" values respectivelyo Corrected* or "as consumed" values* are estimated by making the following deductions from "as issued" values; a0 Deduction of 5% to cover wastage loss during issue, storage, preparation, and service of ration components» to Deduction of 25% of meat and cooking fat which is assumed to be uneateno Co Deduction of nutrient losses listed in Table 5* The corrected value in the table is the value in parenthesise Composition of rations in Columns 1-4 is shown in Columns 2-5, Table 7C Analysis is based on Tables of Food Composition* UoS0D0Ao Miscellaneous Bulletin* No0 575 (1945)0 2 Table 14 NUTRITIVE VALUE OF PRISONER OF WAR RATIONS (as issued) Nutrients 1 UK until 7 Dec0 1944 Workers and Non- Workers 2 3 Continent Until 7 Deco 1944 Non- Workers Workers 4 5 Theater 7 Dec0 1944 to 16 Apr0 1945 Non- Workers workers 6 7 Theater 16 Apro 1945 to 31 Goto 1945 Non- Workers workers Energy Cal o 3612 3860 3089 3258 2632 2955 2038 Protein Gmo 119 120 96 108 97 106 80 Fat Gnu 126 141 113 75 67 45 26 Carbo- hydrate Gmo 500 528 422 538 410 532 371 Calcium Gmo 0o 81 0o 90 0o72 0o63 0o 57 0o 72 0o 59 Iron Mgo 27 30 24 25 23 28 20 Vitamin A (animal) loUo 1481 1208 966 376 338 543 318 Carotene (plant) LUo 7975 14190 11784 7843 7057 7950 7359 Thiamine Mgo 2ol3 lo79 1 o43 1066 1 o49 2o 31 1066 Riboflavin Mgo lo97 2o00 lo60 1 o 55 1 o40 lo95 1 o 50 Niacin Mgo 23 22 18 23 20 20 15 Ascorbic acid Mgo 132 99 79 162 145 82 73 FIGURES 1. Tankmen of the 94th Infantry Division eat hot food, brought by truck, while awaiting assignment to battle near Nennig, Germany, January 1945o 2» The new field ration "A" of the European Theater of Operations, England, February 1943o 3o An enlisted men’s mess of an Ordnance Company, England, January 1943» 4o The kitchen of the 298th General Hospital, Bristol, England, January 19440 5o A Ranger Battalion cook "5 in 1" ration during a field ration trial in Southern England, July 1943o 60 A field bakery in Belgium, 3026th Quartermaster Bakery Company, November 1944„ 7„ Loading refrigerator trucks with frozen meat for distribution to combat troops. Advance Section, Communications Zone, Homecourt, France, November 1944» 8o An abandoned German stable serves as a kitchen for members of the 36th Infantry Division in Alsace Lorraine, December 1945o 9o A wireman of the 57th Signal Battalion heats "C" rations for his crew, Hochfelden area, France, January 1945* lOo A kitchen under canvas feeds 1200 patients of the 167th General Hospital, Tourlaville, France, January 1945« 11o American prisoners of war liberated by the Third Array in Fuchsmuehl, Germany, after a thirty-five mile forced march from Bad Orb, labor in a salt mine and a starvation diet, April 19450 12« Americans in their prisoner of war quarters after liberation by the Third Army, Germany, May 1945<> 13o American soldiers captured during the "Battle of the Bulge" receive medical care following liberation from the prison hospital, Fuchsmuehl, Germany, April 1945o FIGURES (cont’d) 14, A special shipment of tomatoes from the Canary Islands for issue to troops. May 1945, 15o The kitchen car of a hospital train. 16« The serving of food to litter patients on a hospital train. 17o 8000 Nazi prisoners captured by the 8th Infantry Division in the Ruhr pocket near Renscheid, Germany, receive "K” rations, April 1945, 18o German Prisoners of War in a mess line at Central Enclosure No® 404, Delta Base Section, May 1945, TABLES lo Nutrition officers in ETOUSAo 2o Distribution of nutrition officers in ETOUSAo 3o Troop ration scales in ETOUSAo 4o Nutritive value of troop rations in the United Kingdom, with and without correction for minimum losses during issue, storage, preparation and service of food*, 5o Loss of nutrients of foodstuffs during cookingo 60 Allowances of nutrients (as consumed), recommended by National Research Councilo 7o Composition of rations prescribed by authorized troop menus in ETOUSAo 80 Hospital (patients’) ration scales in ETOUSAo 9» Composition of rations prescribed by authorized hospital (patients’) menus in ETOUSAo 10» Nutritive value of hospital (patients1) rations (types A and B) in ETOUSA, with and without correction for minimum losses during issue, storage, preparation and service of food*, 11o Issue of operational rationso 12o Nutritive value of operational rations supplied on the Continent in 1944o 15o Nutritive value of troop rations (type A and B) on the Continent, with and without correction for minimum losses during issue, storage, preparation and service of food„ 14» Nutritive value of prisoner of war rationso A HISTORY OF PREVENTIVE MEDICINE IN THE EUROPEAN THEATER OF OPERATIONS UNITED STATES ARMY 19a - 1945 PART V - Veneral Disease Control by Colonel John E. Gordon* M.C* Chief of the Division of Preventive Medicine Office of the Chief Surgeon, ETO TABLE OF CONTENTS PART V Venereal Disease Control Page The Early Problems in the United Kingdom . . 3 Provision of Proper Prophylactic Facilities. .... 4 Epidemiologic Studies. . 5 The Initiation and Maintenance of Cooperative Relationships with other Agencies. 6 Consultation with Command 7 Consultations on Methods of Diagnosis and Treatment 8 The Later Situation in the United Kingdom. .......... 8 The Development of Coordination of Educational Programs. ... 8 Provisions of Prophylactic Facilities and Materials 9 Epidemiologic Studies 10 Cooperation with other Military and Civilian Agencies .... 11 Consultrtion with Command 14- Consul tsti on on Methods of Diagnosis and Treatment. . • • . • 15 The Phase of Planning and Mounting the Continental Invasion 15 Provision of Prophylactic Facilities 15 Epidemiologic Studies. ..... ......... 15 Cooperation with other Agencies. .... .16 Consultation with Command. ...... .... 16 Page Consultation on Methods of Diagnosis and Treatment ... 17 The Continental Phase from the Beachheads to Paris ... 17 Prophylaxis . . . . o . . . . . 20 Epidemiologic Studies . . . . 20 Cooperation with other Agencies .20 Consultation with Command . . 21 The Continental Phase from Paris to the Rhine ...... 21 Education ......... . .22 Prophylaxis ........ 22 Epidemiologic Studies and Cooperation with other Agencies. 22 The Continental Phase After the Investiture of Germany .... 26 Prevalence and Incidence of The Venereal Diseases .... 28 Venereal Disease in the Major Forces .....30 The Services of Supply and the Communications Zone. ... 30 Venereal Diseases in the Air Forces 31 Venereal Diseases in the Field Armies 31 Venereal Disease in the United Kingdom and on the Continent During Active Operations . . 31 Racial Differences in Rates for Venereal Disease 32 The Kinds of Venereal Disease. 32 Page Comparison with other Theaters of Operation 32 Personnel in Venereal Disease Control at Theater Headouarters . . 33 ✓ List of Figures List of Tables PART V Venereal Disease Control A Branch for Venereal Disease Control was created in the Division of Preventive Medicine of the Office of the Chief Surgeon of the European Theater of Operations on 25 September 1942„ Prior to that time, general over-all supervision of the venereal disease program, including both treatment and preventive activities, had been under the direction of the Division of Professional Services of the same office,. Beginning 25 September 1942, supervision of preventive and control activities passed to the newly created Venereal Disease Control Branch of the Division of Preventive Medicine, while supervision of treatment was retained by the Pro- fessional Services Division throughout the life of the Theater* The present discussion is limited to aspects of prevention and control of the venereal diseases* At the time the Branch for Venereal Disease Control was formed, a full time venereal disease control officer was attached to the Office of the Surgeon of the Western Base Section which then contained the majority of the service troops„ Among the Ground Forces Units which were then present, the 1st Infantry Division, the 34th Infantry Division, the 1st Armored Division, and the Headquarters, II Corps, had full or part time venereal disease control officers who functioned for their organizations, and to some extent in liaison with civilian communities„ The Eighth Air Force Composite Command had a full' time venereal disease control officer who was energetically pursuing a well-rounded program including efforts to develop cooperation with the civilian authorities in Northern Ireland., None of these officers were in a position, however, to develop a comprehensive program embracing all of the necessary control activities„ At the outset of the operation of the Branch for venereal disease control, a protocol was drawn up to reduce to a working classification the responsibilities of the Branch, and the activities t© which it should devote major attention,, These activities were classified into the following categoriess 10 The development and coordination of educational programs for men, officers, and medical officers,, 2o Plans for and the supervision of provision of proper prophylactic facilities and materials, both mechanical and chemical„ 3» Epidemiologic studies to determine the extent and location of venereal disease problems, with particular reference to causes of high venereal disease rates and the remediable factors® 4® Initiation and maintenance of cooperative re- lationships with other military and civilian agencies seeking the same objectiveso 5® Consultation with command regarding policies and administrative procedures relating to venereal disease control® 6® Consultation on methods of diagnosis and treat- ment for those who become infected,, In the period of the existence of the Branch as such, from the time of its original formation until the dissolution of ETCXJSA, it was never found necessary materially to alter the original pro- tocol for content® As situations developed and circumstances changed, marked alterations in the distribution of emphasis were found to be necessary, and these perhaps constitute the most significant experi- ences to be related® These changing circumstances were of infinite variety and constant occurrence, but for the purpose of this narrative may be divided into six phasess 1® The early problems in the United Kingdom, when the military situation was that of creating a base of operations® 2o The later situation in the United Kingdom when, with the establishment of bases well along, major problems were crested by the tremendous concentration of United States troops in the already overcrowded British Isleso 3® The phase of planning for and mounting the in- vasion of the continent® 4® The continental phase from the beachheads to Paris® 5® The continental phase from Paris to the Rhine® 6® The continental phase after the investiture of Germany 2 The narrative will be construeted, therefore, on the plan of discussing, in so far as it is applicable, each of the items of the original operating protocol as it was developed in the successive phases<. The Early Problems in the United Kingdom®—From the very beginning there was a serious need for educational materials which was finally resolved only long after this phase of the operation was over® An adequate number of copies of the Training Film 8-134$ "Sex Hygiene" was made available in the autumn of 1942* but the majority of the men had seen this film so many times during their training period that it had lost much of its effective ness® On 13 May 1943$ a request was transmitted for duplicate negatives of the films being displayed in the United States by the American Social Hygiene Association® Copies were made and widely displayed, and since the films were fresh material they were well received in spite of the fact that their appeal was directed much more towards the civilian than a military population® Lacking supplies from the United States* posters and other types of visual aids were developed locally® This resulted in material which was sometimes excessively crude* was usually badly reproduced since almost all of it was done on the standard mimeograph* and rarely contained a new appeal® These disadvantages were offset to some extent by the development of poster contests with prizes* usually in the form of special privileges® Where this idea was enthusiastically carried out, the publicity attendant upon the contest was frequently of more value than the resulting posters® Both because of the circumstances and because it was the considered opinion of those responsible that it constituted the most fruitful method* the educational program depended to a large extent upon word of mouth in informal discussions0 In promoting this idea* the full time venereal disease control officers devoted their attention to discussions with medical officers and with commanding officers of the higher echelons0 Figo lo In the discussion with the medical officer, however, it was emphasized that a large part of his responsibility was to see to the proper education of the junior officers of the command to which he was attached* who in turn would be charged with the edu~ cation of their noncommissioned officers and men® Early in 1943$ the suggestion was being made that the education of the rank and file of soldiers be made the responsibility primarily of the noncommissioned officers® 3 Courses of instruction in venereal disease control for officers were included in the officer's instruction courseso Provision of proper prophylactic facilities©--'Up until the end of 1942, all of the condoms available, save those which forehanded commanders had brought with their unit supply, were being procured from British sources of manufactureo These articles were totally unsatisfactory for two important reasons© In the first place, they were too small, and secondly, they were made with a deep constriction about three centimeters back from the closed end, and the effect being to give them a freely hanging tip to which our soldiers objected strenuouslyo They were, how- ever, of good quality latex and withstood inflation tests without difficultyo By the end of 1942, condoms of American manufacture meeting standard specifications were available for purchase in the post exchanges, but free issue was not to come until later© Up to the end of 1942, there were no supplies of the pocket chemical prophylactic kit available but early in 1943 a small supply of V-Packettes was receivedo In order to utilize these to the greatest advantage, they were earmarked for issue solely to organizations of the VIII Air Force© Almost immediately there began to appear isolated reports to the effect that the silver picrate jelly in the V-Packette was painful to the urethral mucosa and therefore the men were tempted to avoid its use© Alternatively there were reports that the jelly was so irritating as to produce a nonspecific urethritiso These reports, however, were isolated and in general the kit was well received and used as extensively as available supplies would allow© During this phase of the operations there was very little use made of station prophylaxis© This was in sharp contrast, both to what had been seen in the training camps in the United States and what was later observed on the Continent of Europe© There were a number of reasons for this which probably must be taken in summation in order to afford an adequate explanation for the observed phenomenon© There was, of course, a prophylactic station as an integral part of every regular medical department installation© It is a matter of common experience that these prophylactic facilities are not as extensively patronized as ad hoe prophylactic stations set up in convenient locations outside of military installations© In the United Kingdom the small use of the prophylactic facilities in medical department installations continued, but there was a general and equally small use made of the ad hoc installations as well© A number of reasons for this was readily apparent© 4 Figure 1 Physicians consider the problem of venereal disease control, Medical Field Service School, England, 1943. In the first place, it was difficult, sometimes to the point of impossibility, to secure from the British adeouate quarters in which to house a. prophylactic station,, There was a critical shortage of housing; all requisitions for space had to be approved by the British Ministry of Works; and in the face of the enormous demands which were being placed upon them by the influx of American troops, they were unwilling to release for use as a prophylactic station quarters which were suitable for any other purposeo In the second place, where stations were established, it was impossible to mark them in a manner to make them easy to findo British sensibilities forbade the display of prominent signs and the rigid requirements of the total blackout forbade the use of the conventional green light„ Perhaps the most important reason for the small use of station prophylaxis, arose from the fact that the vast majority of the sexual exposures were wholly uncommercial and on a friendly basiso Surveys among soldiers revealed that under these circumstances they were much less impressed with the desirability or necessity of prophylaxis after exposure„ Epidemiologic studies„ —The original epidemiologic studies were conducted on two lines„ The first related to investigation of the circumstances prevailing within organizations reporting exceptional venereal disease rates,, In these surveys, units with rates conspicu- ously lower than the average for comparable organizations were studied, as well as those whose rates were higher,, From the former group many valuable ideas were gained which were passed along for utilization where applicable„ The latter were studied with particular reference to the educational status of the troops, the facilities for pro- phylaxis, the existence of recreational facilities, and the type of control exercised by command over the environment„ The second type of epidemiologic work was based on the use of ETOUSA MD Form 302 „ This was developed prior to WD MD Form 140 and was so applicable to the particular problems encountered that it was continued in use throughout the life of the theater,, Long before it was possible to make use of the contact information contained on these forms they were subjected to periodic analysis by the Medical Records Division to determine the distribution of places of exposure„ With this information, studies were made of the conditions obtaining in the civilian communities which were reported as sources of venereal infection out of proportion to their population or the number of troops stationed in the vicinity,, Where possible, factual information of this type was used for discussion with local civilian authorities,, 5 The initiation and maintenance of cooperative relationships with other agencies0—During this first phase, excellent cooperative relationships were established with the appropriate officers of the British Army, the Canadian Army, the Royal Air Force, the American Navy and the British Ministry of Health,, The closest contact and most cordial relationships were maintained with all of these agencies throughout, but save for the Ministry of Health, more than an exchange of amenities was seldom required,, Respects were also paid to the appropriate medical officers of the Royal Navy0 The excellent cooperative relationships which were enjoyed with the Ministry of Health began under exceedingly happy auspices„ The Chief of the Division of Preventive Medicine had since 1940 been in intimate association with the British Ministry of Health, first as a civilian expert on loan from Harvard University and later as the head of the American Red Cross-Havard University Field Hospital Unito Ihrough him introductions to all of the proper people were readily arranged and the Chief Medical Officer of the Ministry of Health, Sir Wilson Jameson, proved from the outset to be interested in the venereal disease problems and was most helpfulo His blessing assured easy access to local medical officers of health, who, each in his own area, was virtually autonomous0 The cordial relationships established with those local medical officers of health during this first phase were of incalculable value in facilitating the develop- ment of the scheme of contact investigation which came a little latero It was readily obvious that not only would it be fruitless to attempt to establish working arrangements with the civilian police authorities but mere importantly that such efforts might be misunder- stood by the British as reflecting desire on our part to meddle in affairs which they considered strictly their own* and so might occasion resentment<> The fruitlessness of such an attempt arose out of the fact that the British consider sex behavior as entirely a personal matter not subject to legislation or regulation0 Fig 2„ Public opinion frowns upon brothels and so very few were known to exist, and outside of London itself, there was relatively little commercialized prostitution,. Whether professional or amateur, how- ever, so long as the woman ostensibly was acting as a free agent, and so long as a procurer or facilitator was not readily apparent, there were no laws in the British Isles to govern her behavior providing she conducted herself in such a manner as to avoid other breach of the peace, except for one London Statute of 1828, which forbids obstruction of free passage in a public way0 This is interpreted by the Metropolitan police as involving the laying on 6 Figure 2 c. London means Picadilly* h of hands, so that if a professional prostitute on the streets of London actually attempts to manhandle her prospective customer, she may be had up in Bow Street and fined forty shillings© Only two other civilian agencies need be mentioned at this time; the British Social Hygiene Council and the Central Committee for Health Education© The former was essentially the analog of the American Social Hygiene Association while the latter was made up of chosen members of the former with the direct although somewhat behind- the-scene sponsorship of the Ministry of Health© It acted as a medium for the dissemination of health information with (although not so stated) especial emphasis on the venereal diseases© Cordial and cooperative relationships with both of these agencies were established from the outset and the Chief of the Branch for Venereal Disease Control sat from time to time on committees of these organizations© Since their objectives were largely the development of a long range program for the British population, little if any of their activities had immediate bearing on the problems of the United States Army© Consultation with commando—From the outset it was determined as a matter of policy that the Branch for Venereal Disease Control of the Division of Preventive Medicine of the Office of the Chief Surgeon would insofar as practicable limit its consultations with command to the performance of staff function; courtesy calls on commanding officers when visiting posts; and consultation on specific questions when requested© It was thought much more desirable to deal in general with the senior medical officer in an organization or a camp, post, or station; make to him both general and specific recommendations relating not only to his activities but also concerning recommendations which he might make to command and then to leave to him the responsibility for developing local plans in keeping with general policy but with a view to local problems© It was the consensus of all concerned that this latter made for better relationships between the surgeon and his commanding officer; had the advantage of avoiding the natural resistance which sometimes develops toward gratuitous suggestions from outside; and facilitated the development of more workable venereal disease control programs© In the performance of the staff function, an unvarying policy was adopted to keep command directives concerning venereal disease control at the absolute minimum© It was felt best to rely on a few simple directives containing clear statement of basic principles and then to allow each organization to work out the details in the man~ ner most suitable for its problems and personnel, assisting them from the central office when specific problems arose© 7 Consultations on methods of diagnosis and treatmento-“The closest and most cordial relationship existed between the Branch for Venereal Disease Control of the Division of Preventive Medicine and the Branches of the Professional Service Division which were charged with treatmento There was constant informal interchange of information and suggestions and no important steps were taken by either without consultation with the other0 The Chief of the Branch for Venereal Disease Control, however, had no formal association with the care of patientso The Later Situation in the United Kingdom,, —Wlth the develop- ments which followed as a natural consequence of the increasing troop strength, a number of important changes were made in the organization and administration of the venereal disease control program0 In the earlier phase the entire program was administered directly from the Office of the Chief Surgeon0 During the second phase which roughly began in the Spring of 1943 with the creation within the various echelons of Surgeon5s offices of competent staffs in Preventive Medicine, the administration of the routine activities in venereal disease control was transferred largely to the responsibility of the respective base sections for the Communications Zone troopsj to the Surgeon of the Eighth Air Force (later to become USIAFF Surgeon when portions of the Ninth Air Force began to arrive for the Air Force) and to the Headquarters of Corps and Aimes as they arrivedo The Branch for Venereal Disease Control thus became in large measure an agency for collecting and disseminating information, for coordination of the activities of the various echelons which were actually operating the venereal disease control program, and the medium through which suggestions on general policy and procedure could be channelled to commando In one important particular, however, which will be brought out below in the discussion of contact investigation, the Branch retained active operational direction of what at this time was a pioneer project in the British Isles0 The Development of Coordination of Educational Programso Early in 1943, a study was made of the educational status of troops arriving in the European Theater of Operations from the continental United Stateso Information was sought of the adequacjr of the infor- mation of the soldier concerning the general nature of venereal diseases, the method of their transmission, and the available methods for their prevention0 The result of this survey indicated the necessity for intensification of the educational program in the European Theater, and afforded the suggestion which was transmitted informally that there 8 be intensification of the educational program for the troops during their training period in the United Stateso Through an informal arrangement with the Surgeon of the Central Base Section the venereal disease control officer for that base section was placed in over-all charge of the educational program., He procured the services of a professional artist* who upon designs and suggestions which had been previously approved by a board appointed for the purpose, created a series of educational posters which compared favorably with those acquired two years latter from the United States® At the same time the Central Base Section was made the testing ground for various types of educational approach and so far as the European Theater of Operation is concerned it was here first demonstrated that the venereal disease noncommissioned officer trained to lead informal small discussion groups was a powerful factor in venereal disease education® During this period all of the base section venereal disease control officers carried on extensive educational programs working largely through the medium of the unit medical officer, and were made personally responsible for wide display of the available films which included the then shopworn TF 8-154 and the American Social Hygiene Association films "In Defense of the Nation," "With These Weapons," "Health is a Victory," and "Plain Facts®" Fig® 3® The Branch in the office of the Chief Surgeon prepared and sponsored for publication in the theater newspaper, the Stars and Stripes, a series of educational and informational articles on the venereal diseases and members of the staff of the Branch lectured periodically to medical officers at the Medical Field Service School® Provisions of prophylactic facilities and materials®—The relatively small use of station prophylaxis continued during this period but even with only a small percentage of the troops who were being exposed seeking it, the troop strength was increasing so rapidly and there were so many venereal exposures that the available ad hoc stations came in for enough patronage to justify their existence® Relentless pressure from our side had by this time served somewhat to wear down the British objection to giving us space so that In the larger population centers it was possible to provide decent premises of reasonably convenient location® Also local arrangements in many instances had gained the approval of the blackout warden for the use of a shaded and much subdued but at the same time visible green light as a marker at night® The most important advance in this direction was made through an agreement with the American Red Cross whereby the Army was given space for the operation of prophylactic stations on 9 the premises of Red Cross Clubs© This arrangement was ideal since men on pass or furlough were virtually required to stay in Red Cross hostels because of the shortage of housing facilities among the civilian population, and so found a prophylactic station right in their path when they returned to quarters after a sexual exposure© Another important advance was made in the facilitation of widespread use of prophylactic materials by the War Department authori- zation for free issue of condoms and chemical prophylactic kits© In developing the mechanism of this free issue it was found impracticable to have the actual distribution done by the Medical Department© This was because of the fact that in both of the larger groups of troops* the Service Forces and Air Forces, it was not uncommon for men to be quartered at considerable distances from the Medical Department installa tions from which they received medical care© Under these circumstances the soldier would seldom be near the dispensary unless reporting for sick call and the medical department had no personnel to devote to the task of supervising a general distribution of prophylactic materials in barracks and day-rooms© Accordingly, the Medical Department con- tinued procurement of prophylactic materials, but by arrangement, the Quartermaster accepted responsibility for storage and issue© Up until the continental invasion, storage and issue was with Class I supplies; on the continent it was found more practicable to store and issue with Class II and IV supplies© This arrangement was subject to a certain amount of criticism from outside the theater but for those who saw it function it seemed a simple and practicable solution to a minor supply problem© In May 1943* there was instituted a trial of sulfathiazole by mouth for the prophylaxis of gonorrhea and chancroid© The results of the first three months trial in three organizations with appropriate controls were so encouraging that recommendations were made for use of the method according to the principles laid down in Circular Letter No© 146* Office of The Surgeon General* 12 August 1943<> Epidemiologic studies ©—Both routine and special epidemiologic studies were carried out in much the same manner as originally planned* with particular effort to focus attention and direct effort toward organizations with unusually high venereal disease rates and communities which were reported as providing more than their proportionate share of venereal infections© A special type of epidemiologic study is described in the following section under the heading ”Contact Investigation©” Pig© 4© 10 Figure 3 The British public house, colloquially "pub’1, was the soldier* s club as well as that of the common man of Britain, Figure 4 The GrI finds Britain to his liking. Cooperation with other military and civilian agencies0-4ln April 1943> under the auspices of the British Home Office the££**ras held a meeting which was attended by a large number of the higher dignitaries of the British Government and by representatives of the American and Canadian Armieso After an extensive discussion of the problems caused by the venereal diseases, both to the services and to the British civilian population, it was agreed to form a committee to be known as the Joint Committee on the Venereal Diseases, which by its articles of reference was charged with making recommendations both to the services and to the British Government with regard to future policies and procedures in venereal disease controlo Nothing happened until under continuing pressure from the American side the committee finally had a first meeting in June 1943« The Chairman was Sir Weldon Dalrymple-Champneys, Barto, of the Ministry of Health, and the members were as follows; Brigadier T. Ee Osmond, RAMC War Office Air Commodore To McGlurkin, RAF Air Ministry Lto Colonel M0 Ho Brown, RCAMC Canadian Army Colonel John Eo Gordon, MC United States Army Mr0 To Lindsay Ministry of Health Mr0 To Mathew Home Office Chief Constable E*. A0 Cole Metropolitan Police Dr® Mo Mo Goodman Department of Health for Scotland Mr» Eo Ao Hogan Department of Health for Scotland Mr® Jo So Munro Scottish Home Department Surgeon Commander Do Duncan, RN Admiralty (later nominated) Mr» Ho Ro Hartwell, Secretary Ministry of Health 11 Eight meetings of this committee were held from 25 June until 24 September 1943* and at the last meeting there was brought in a series of sixteen recommendationso The first eight of these dealt with specific recommendations for the development and extension of an educational program; nine through fourteen* inclusive* recom- mended in detail a program for contact tracing; and the last two concerned the desirability and feasibility of routine serologic testing of certain classes of patients* especially pregnant women0 Up until that time the committee had given considerable promise of accomplishment but at the last meeting it bogged down on a dis- cussion of prostitution and was never revived0 The cooperative relationships with the other military and civilian agencies previously named were continuedo During July and August 1943* Dr0 Joseph Earle Moore* re- presenting the Sub-committee on Venereal Diseases of the National Research Council* of which he was Chairman* and upon invitation from the British Ministry of Health and the Theater Surgeon made an ex- tensive tour of the British Isles with particular reference to the interrelationships between the military and civilian venereal disease problemso This visit was the subject of two reports; one was con- fidential to the Theater Surgeon with copies to the Secretary of War and The Surgeon General; the other which was more widely circulated was to the National Research Council« At the time of arrival of the first United States soldiers in the British Isles* the only venereal disease control measure practiced among the civilian population was the attempt to provide conveniently located free treatment facilities<> Discrete little advertisements announcing the location of these treatment facilities were posted in public latrinesp but there was no other educational programo There was no reporting of the venereal diseases either by clinics or private physicians and at that time under the provisions of the 1916 Venereal Disease Act* the privacy and secrecy guaranteed the patient were such that it constituted libel even to imply that an individual might have a venereal diseaseo This* of course* rendered any type of epidemiologic work and contact tracing im- possible because no infected person could afford to risk an action for libel by giving the name of one with whom he had sexual contact and who therefore might have a venereal diseaseo In the autumn of 1942* however* under pressure from the Ministry of Health for an amplification of the existing methods of venereal disease control* the Privy Council drew up and eventually approved a regulation under the Defense of the Realm Act* known as Defense Regulation 33B* which became operative in December 1942o 12 Under the provisions of this regulation, a patient with a venereal disease was given an opportunity to name if he chose, after having been warned that there were severe penalties for false infor- mation, the individual he would identify as "the source of infection0" This information was transmitted by the physician receiving it to the local medical officer of health of the place of residence of the named individualo The medical officer of health, if he were satisfied that the information was valid and given in good faith, held it for file, and if he received a second notification on the same individual, was empowered by the provisions of the regulation to serve upon this "source of infection" certain legal documents requiring the individual to submit to examination and treatment if necessary® Numerous other legal documents were involved in making final disposition of the case, but from our standpoint the important things was that here for the first time was a mechanism whereby an individual with a venereal disease could legally give the name of sexual contacts, even though legally he did have to contend that one particular indivi- dual was the "source of infection®" A review of the records showed that insofar as information given by United States soldiers was concerned there would be very few actions taken under the strict provisions of Regulation 33B, because it was relatively unusual for one woman to be named twice with suf- ficient identifying particulars to make operative the legal provisions of the regulationo As has been frequently experienced elsewhere, many promiscuous women were named by more than one soldier, but more commonly than not, only by partial name or partial address, whereas under the letter of the regulation complete names and address were required before action could be taken® It was therefore apparent that we could expect little from the operation of the letter of the regulation by the British authorities® This being the case* authority was gained from the Chief Surgeon to utilize a staff of Army nurses as "contact investigators" and with the concurrence of Sir Wilson Jameson, Chief Medical Officer of the Ministry of Health, the medical officers of health of six counties in East Anglia were approached to gain their concurrence in the operation of the schemeo Briefly* the scheme was that the nurse would interview the soldier with a venereal disease* gain from him as much information as could be done by skillful and tactful questioning regarding the identity of his venereal contacts and then attempt to identify these womeno If identification could be accomplished* the women were tactfully approached with the suggestion that the medical findings on a friend who was an American soldier* suggested that the woman herself might be in need of medical examination which could be ob- tained from a private physician or at a designated clinico 13 In the beginning, there were many who were dubious that the scheme could be made to work, primarily because of fear that the women would take offense at being approached at all on so delicate a matter and particularly at being approached by an American Army nurse, who for reasons of Theater policy was required to remain in uniform0 Only one of the original group of medical officers of health approached, however, refused to give support to the proposal and this individual capitulated soon after the scheme began successful operation in neighboring countiese Fortunately the fears were entirely unfounded0 Of the first group of nearly five hundred women approached* only one took offense and there seemed reasonably good evidence to indicate that she was a professional prostituteo A few of the others (4 percent of the total) took.no offense* but nevertheless did not accept the suggestion to submit to examination* More than 76 percent of those identified reported to a clinic or private physician as suggestedo The efficiency which the previously existing system had exhibited in controlling the venereal diseases was brought out by the fact that of the entire group only 15 percent had applied for medical care prior to the visit from the United States Army nurse* The remaining 5 percent were found in jails or other institutions0 Tiie success which attended the operation of this scheme made a great impression on the British and as a matter of fact, induced them in many areas to attempt something of the sort on their own initiativeo The happy effect which this had on Anglo- American relationships was more than offset during this same period by recurring reports which reached the British concerning the number of soldiers with venereal disease who were disembarking in their ports to mix with and infect their peopleo This had been duly reported but it continued to such an extent that it finally became a diplomatic issue and occasioned on the 24th of February 1944, a letter from Mr0 Winant to General Marshall0 Consultation with commando—Efforts to have published a 1943 version of General Pershing8s famous General Order No0 77, which clearly defines the responsibility of the unitpcommander in venereal disease control, resulted in the publication on 31 December 1943, of a letter addressed to each unit commander from General Jacob Lo Devera then commanding0 This contained the following passages:000 "Contraction of venereal disease is considered evidence of improper indoctrination of the individual which is an indication of poor leadership on the part of the unit commanderc00The responsibility for proper schooling in preventive measures lies with the unit commander| it is inalienable from commando It is essential that 14 commanding officers devote their personal attention to the control of venereal diseaseo„oThe percentage of physically fit soldiers in a command is strong evidence of the efficiency of the commanding officer0” Consultation on methods of diagnosis and treatment® — The close cooperation originally established between the Professional Service Division and Section of Venereal Disease Control in matters which related to the professional care of patients with venereal disease was maintained,. The Phase of Planning and Mounting the Continental Invasion0— During the phase of planning and mounting the invasion cf the Continent* the activities concerning the venereal disease control program within the United Kingdom were largely turned over to the Base Sections for operational management* most of the ground work having been accomplished by this time® With the great increase in the troop strength, and the crowding which it inevitably produced* the problems of liaison with the British civilian authorities became increasingly important and were accordingly given a large portion of the effort of the Branch for Venereal Disease Control® The development and coordination of educational programs for men» officers» and medical officersThe Branch continued routinely to contribute material for stories in the Stars and Stripes and its weekly feature magazine* War Week» On 27 April 1944 there was published material designed for the basis of an informal talk between company grade officers and their men in the marshalling areas just prior to in- vasion and this was later made the basis of stories in the Stars and Stripes* War Week* and Army Talks® Otherwise, aside from continuing to participate in the teaching activities of the Medical Field Service School* virtually all of the remainder of the educational activities were operated by the Base Sections* Armies and Air Force® Provision of prophylactic facilitiesQ—By the Spring of 1944, there was an adeauate distribution of prophylactic stations all over the British Isles, the majority of the extra-cantonment installations being in the Red Cross Hostelso These were never widely patronized but they were used enough to justify their existenceo By this time, also, the supply of condoms had been stabilized to the point of allowing an issue at the rate of six per man per month and provide also for sale in the Post Exchanges for those who cared to purchaseo The rate of sale tended to fluctuate slightly but commonly averaged about 1®7 per man per montho The supply of chemical prophy- lactic kits was still irregular and since these items were shipped with a low priority the supply position remained totally unpredictable® Late in 1943, the VIII Air Force had conducted some clinical trials of a one tube prophylactic kit which had been prepared for them in England according to a formula of sulfathiazole, 15 percent, calomel, 33 percent, and lanette wax base to make 10 grams® The clinical trials conducted with the small numbers of this item available occasioned request to The Surgeon General8s Office for a supply of a similar item in a more suit- able base which at the time was under clinical trial in the United 15 Stateso This request was granted and the item was placed on procurement but unfortunately it was given the same number as the old tube item so that it is impossible to determine when it first reached the Theatero Epidemiologic studieso —The general epidemiologic studies con- tinued and it was found that certain of these, particularly the consoli- dated analysis of ’’place of exposure,” could be more easily done in the central office and handled as a unit rather than be handled by the individual Base Sections, so this was one activity which was not delegatedo For the same reasons the central branch continued to do special epidemiologic studies where these were indicated,, Cooperation with other agencieso--During this period the number of troops in the United Kingdom was so great that it was deemed necessary and desirable to extend the scope of the contact investigation program until finally eight nurses were engaged in this activity0 They worked* however* under the direction of Base Sections* although main- taining the closest liaison with the central officeo During this same period* at the suggestion of the Ministry of Health* numerous local medical officers of health* influenced to some extent* no doubt* by the fact that the skies had not fallen when we started contact investi- gation* had organized teams of their own* working on an informal basis and without waiting for a second notification as required by the letter of the Regulation 33Bo These activities were of great assistance to our nurses in facilitating their work and the success of the entire scheme is reflected in the low venereal disease rate which was attained in the Theater over this periodo The other cooperative activities were continued without • significant changeo Consultation with commando—As a part of the routine job of mounting the Continental operation, the directives regarding the pre- vention and control of the venereal diseases were gathered together and clarified for the benefit of the Forward Echelon and the Advance Section of the Communications Zoneo While this was being done, it became apparent that it would be desirable to gather material covered in several directives into one compact directive, and also to reinforce certain points of existing regulations« Accordingly, there was published on 2 May 1944., Circular Letter No<> 49Headquarters, ETOUSA, which covered all of the command aspects of the prevention and control of the venereal diseases0 It is to be noted that in the fifteen months of the existence of the Theater after the publication of this directive it was not found necessary to amend or alter it0 In anticipation of problems which would be encountered on the Continent, this directive contained the following paragraph? ’’The practice of prostitution is contrary to the best principles of public health and harmful to the health, morale, and efficiency of troopso No member of this command will, directly or indirectly. 16 condone prostitution, aid in or condone the establishment or main- tenance of ]?rothels, bordellos, or similar establishments, or in any way supervise prostitutea in the practice of their profession or examine them for the purposes of licensure or certification0 Every member of this command will use all available measures to repress prostitution in areas in which troops of the command are quartered or through which they may pass0 A broader and more general order was published by Supreme Headquarters, Allied Expeditionary Force on 24 May 1944o Consultation on methods of diagnosis and treatmento—Dis- turbed by the-increasing frequency of the diagnosis of nonspecific urethritis and fearing that this was being used as a subterfuge to evade making a diagnosis of gonorrhea, on 10 March 1944* there was published a. directive on the diagnosis and reporting of the venereal diseases which set down criteria permitting a clinical diagnosis of gonorrhea and purposely made any other diagnosis in the case of acute urethritis so difficult as to discourage evasive diagnoses unless there was good clinical or epidemiologic evidence upon which to base doubt of a diagnosis of gonorrhea0 It was recognized that this would lead to an occasional erroneous dia- gnosis of gonorrhea but with the removal of penalties for the venereal diseases, it was felt that the injustice occasioned by this error would be more than offset by the better management of the patiento The Continental Phase from the Beacheads to Paris With the invasion of the continent the complexity of the venereal disease control problem was greatly increased,, For many months after D-Day the operation of bases, the provision of facilities for hospitalization, the staging of troops and the operations of the "Till Air Force called for such a troop concentration in the United Kingdom that the extent of the venereal disease problems there remained essentially unchanged,. Shortly after the transfer of the Headquarters of the European Theater of Operations to the continent and with the formation of the United Kingdom Base the Branch for Venereal Disease Control of the Division of Preventive Medicine of the Office of the Chief Surgeon transferred the responsibility for the program in the United Kingdom to the Branch for Venereal Disease Control of the Division of Preventive Medicine of the Office of the Surgeon, United Kingdom Base, which continued the operations with few modifications of the original protocol„ 17 The main activities in venereal disease control from this time on lay in the development of a program which was suitable to the differing conditions which were encountered on the continento As was noted above* it was not found necessary at this time to make major alterations in the protocol under which venereal disease control was set up and operated in the United Kingdom* but the marked differ- ences in the problems encountered necessitated a revision of the distribution of emphasise In the United Kingdom conditions were such that the major emphasis of the extra-cantonment venereal disease control program was properly and most fruitfully directed toward contact investi- gation and to closely allied epidemiologic methods® There* also* with the virtual absence of openly organized prostitution* and with British law and custom respecting with such diligence the rights and privileges of the individual* no attack on the venereal diseases through repression of prostitution was possibleo On the continent quite a different situation prevailed® Fig® Prostitution was recognized and accepted as a part of the social structures in contrast* epidemiologic studies were not so fruitful as previously® It was obvious* therefore* that a determined program for the, repression of prostitution was the method best calcu- lated to minimize the incidence of venereal infection® Where this was done* as it was done consistently in areas under the control of the Advance Section of the Communication Zone* the troops enjoyed a low venereal disease rate® Where it was not done* the venereal disease rates were a direct measure of the degree to which prosti- tution was tolerated* condoned or encouraged® Obviously it was impracticable for the headquarters group to initiate and carry out the development of a long range program during the first month after D-Day 0 The education of troops and the provision of prophylactic materials had been taken care of dur- ing the period of training and of mounting the operation, and at this point "on-the-spot” activities had to be left to those who were there0 On 6 July however, the Chief of the Division of Pre- ventive Medicine paid a visit to France» "There he found inyCherbourg houses of being run for, and indirectly by, American troops, with the' familiar pattern of the designation of one brothel for Negro troops and the others for white, with Military Police stationed at the doors to keep order in the queues which formedo This is exactly what had been anticipated and was the specific 18 Figure 5 France welcomes America, reason for the incorporation in Circular 49 of the paragraph quoted previously,, In consultation with the Surgeon of Advance Section of the Conumnication Zone*, the undesirability of this procedure was made readily apparent and proper con~ sultation with Command succeeded in having these brothels effectively placed off limitso” During the remainder of the summer of 1944, almost the only control methods applicable were the provision of prophylactic facilities and the utilization of the off limits authority,, During the first months of the continental operations all towns were placed off limits as a matter of general policy, with the principle of the prevention of the venereal diseases only of secondary consideration„ Pigo 6* As the supply lines lengthened; as Cherbourg became more and more important as a port and as larger cities, such as LeMans and Rennes were captured and developed into supply centers with complements of static troops, a more selective use of the off limits authority was developed,, There was no unanimity of opinion, however, as to how it should be used, or for that matter as to the attitude which should be adopted with regard to prostitution„ "oooThe history of venereal disease control problems in France has been largely one of differences of opinion, between those who favored segregation and licensure of pros= titution and those who opposed it0 Unfortunately, the subject being what it is, it has never been possible to gain a free and open discussion; it is generally accounted that since the War Department policy is clearly stated and specifically directs repression of prostitution, it is necessary to give apparent support to such a policy, even while doing the contrary., wThe contrary has been done in many instances in spite of the clear directive contained in Circular 49°oo” *It is to be noted that Cherbourg was not under the command of the Advance Section at the time these brothels were being operated in this fashiono The area passed to the Command of Advance Section the day after this recorded conversation and placing the brothels off limits was one of the first command functions exercisedo 19 Prophylaxiso —During this period the most reliable estimates indicated that there was on the average much less venereal exposure than had been taking place among the same group of troops in the United Kingdom<> There were at least three readily discernible reasons for this0 Early in the campaign large numbers of civilians, especially those of the camp follower type, had either fled before or had been carried with the retreating German Armieso The circumstances of active military operations reduced both the opportunity and inclination for sexual exposureo Finally, the language difficulty interposed a very real barrier during this phaseo In spite of these factors making for a reduction in the amount of venereal exposure and the observations that this was the case, the use of station prophylaxis increased tremendously among troops in France as contrasted to the experience of the same troops in the United Kingdom0 It was relatively easy to provide the facilities for this by virtue of the fact that the enemy in garrisoning the towns which we were taking had without exception built and equipped an adequate number of well located prophylactic stations0 These were ©quipped according to standards identical with our own, and aside from the occasional difficulty of providing running water because the local water supply had been disrupted, they were usually ready for immediate use0 Epidemiologic studieso—At this time epidemiologic studies were continued but on quite an elementary basis, since the military situation precluded the gathering of much accurate infoimatdono As static troops were moved in for the operation of the supply line, the same type of routine epidemiologic studies which were done in the United Kingdom were organ!zed0 Plgo 7o Cooperation with other agencies o—In the process of cooperation with other agencies a new element which had not been previously encountered was introduced - the G~5, or Civil Affairs Branch of the Arayo This agency sometimes created extraordinary complications* sine© apparently there was no overall policy or procedure concerning venereal disease control in the organization* and there were virtually as many different policies as there were Civil Affairs Detachments in operation Just as was true in Command, these ranged all the way from an enlightened attitude toward the role of prostitution in the spread of the venereal diseases to a firm conviction that the operation of brothels was a duty which the Amy owed to the individual soldier., 20 Figure 6 Towns were placed "off limits” as soon as occupied, St. Michel, France, 1944. Figure 7 Ihe small town cafes welcome American soldiers, Littry, France, July 1944. Where civilian governments continued to exist they were at this time exceedingly willing to be cooperative but in general unable to do anything for us or their own population that we could not do ourselves« With regard to the repression of prostitution, many of the Trench thought we were mildly mad, but their temper at that time was to assist us to do anything that we wishedo Consultation with commando—During this period was limited almost entirely to a discussion of the desirability or undesirability of operating GI brothels <, In some instances the effort was made to educate officers who believed that the Army should operate brothels for the benefit of the soldiers, but it was soon learned that such educational efforts were largely futileo Apparently a belief in the desirability of licensed prostitution is not subject to logical analysis or discussion but instead is based on the sort of faith that leads a small boy to believe that if he places a horsehair in a bottle of water it will turn to a snakeo The Continental Phase from Paris to the Rhineo—In the liberation of Paris in the last days of August 1944* the general picture again changedo For obvious reasons Paris quickly became the center of operations for our activities on the continent) the number of troops stationed there rapidly increased; the city became the natural objective of every soldier on pass or furlough; and countless numbers of soldiers in groups all the way from one or two to entire convoys "got lost" on their way from hither to yon and wound up in Paris for a bit of sight-seeing® The German occupation had done nothing to improve the morals and behavior of the Parisian women of the byothels and boulevards and the lack of later of fuel* gave the American soldier with a K-ration an unbeatable bargaining position® Pig® 8® The immediate result was the venereal disease rate began to rise rapidly; an increase which did not level off until the rate had approximately doubledo Here again the previously employed methods of control were placed into operation, but again it was necessary to rearrange the emphasiso In the first place, it was necessary to go all over again with the Command of the Paris area the problem of pro- stitutions "On 2 September 1944 the Provost Marshal of the newly formed Seine section (Paris and vicinity) stating that he was acting at the direction of the Commanding General* made a tour of Paris brothels accompanied by a representative of the Brigade Mondaine for the express purpose of selecting certain 21 houses of prostitution to be set aside for officers, others for white enlisted men, and still others for colored enlisted meno This policy was somewhat interfered with by protest from the Chief Surgeon<>ooH Educationo —During this period the educational program again had to be largely developed locally because of the difficulty of getting the necessary transportation priority to bringing in supplieso Helpful and newsworthy stories were published by Stars and Stripes and as base sections developed on the continent and venereal disease control officers were assigned the program of word-of-mouth education was continuedo Figo 9o Prophylaxis *>—With the liberation of Paris the demand for prophylactic facilities in that city became enormous and was well supplied under the auspices of the Venereal Disease Control Officer of the Seine Sectiono Elsewhere in the larger cities as they were occupied, the policy was continued of attempting to acquire space for prophylactic stations in the American Red Cross Hostels9 This was not quite so successfully accomplished as was the case in the United Kingdom, but a number of such installations were made and successfully operated*, During this period adequate supplies of individual prophylactic materials, both chemical and mechanical, were availableo Epidemiologic studies and cooperation with other agencies*,— Even before the liberation of Paris it had been possible to get routine epidemiologic studies under way in the areas in which the troops were statico Shortly after the United States Amy reached Paris, through the cooperation of the Ministry of Health of the DeQaulle Government, it was possible greatly to extend these studies and they soon approxi- mated in scope and detail the well organized scheme which had been conducted in the British Isles0 Not the least important of these was a weekly analysis of the place of exposure which during the latter part of 1944s consistently showed Paris to supply a large fraction, sometimes as much as two-thirds, of all the venereal infections acquired in Franceo Contact investigation was already under way in Cherbourg at the time Headquarters were established in Paris and was soon extended to include all of the areas in which large numbers of static troops were located*, It did not operate as successfully in France as had been the experience in England, primarily because the language diffi- culty made it less frequent for the soldier to be able to give 22 Figure 8 Ihe Paris boulevards were the center of all GI ambitions for leave* Figure 9 Athletic contests were fostered as a form of substitutive activity, 10th Armored Division, Garmisch— Partenkuchen, Germany, June 1945, accurate identifying information concerning this venereal contacto With the extensive cooperation of the French Health Author!ties* and through them -with the French Police, an exceedingly worthwhile contribution was made toward the reduction of the venereal disease problem,. In this regard there is one point which is worthy of emphasis» It was standard policy and procedure to regard the activities of the Medical Department in venereal disease control as strictly related to medical and public health activities, reserving the policing aspects of venereal disease control to the military police on the one hand and their cooperative relationships with civilian police on the other* Certain individuals from time to time departed from this, but the policy itself was unvarying and was generally accepted and applied,, This had two important effects, both of which may seem at this range to involve legal hairsplitting, but both of which were at the times and places in which they were applied, of crucial importance in avoiding the creation of unpleasant incidents between the American Army and the civilian population* The first one was that epidemiologic information concerning a civilian venereal contact was invariably transmitted by us to the appropriate health agency* We knew, of course, that local custom in most instances resulted in that information being handed forthwith to the police without intermediate action on the part of the health officials, but nevertheless our dealings were entirely with the health agency* The second point was that where* as they did in many in- stances* our military police accompanied the civilian police in raids or on other occasions in which they might be apprehending civilian women* they went along for the real purpose of protecting the civilian police from American soldiers in case there happened to be any about who resented the apprehension of the civilian women» Since we were alone in our particular sphere of influence at this point there was very little opportunity for cooperation vd-th other military agencies* Such as there was, however, continued the close and cordial relationships which had been experienced in the United Kingdom and formal exchange of courtesies with the appropriate officers of the French Army was done in every instance in an at- mosphere positively reeking with goodwill* The details of cooperation with the French civilian health authorities have been previously described; 23 "Not the least helpful of the present activities is the cooperation which has been gained from the French Ministry of Health,," Monsieur Cavaillon, who is the Chief Medical Officer of the Ministry* has long been interested in the venereal diseases and was not only willing* but positively eager* to offer us any cooperation which was possible in venereal disease control,, He realizes the crucial importance of the venereal diseases to French public health and also is keenly aware of the undesirability of legalized prostitution„ There have been many meetings with Monsieur Cavaillon* the first on 31 August,, The most im- portant meeting* however* was on 8 September* when he was presented with a letter from the Chief Surgeon for trans- mittal to the Acting Minister of Health* requesting cooperation of the French in excluding our troops from brothelso This eventuated on 15 September in a letter from the Minister of the Interior to all Prefects of Police in France* informing brothel keepers that they must exclude American military personnel from their premises on penalty of having the brothel closed for violation,, The French have made a serious effort to implement this regulation, but un- fortunately in many areas* the local American commander has been unable* or unwilling* to assist in the policing problem involved,, The fVench quite understandably refuse to attempt the policing of United States soldiers without help from our military police* so the brothels flourish,. "The lack of consistency reflected here has led the French health authorities to believe that we are mildly con- fused in reconciling the established policy with actual procedureo The Chief Medical Officer of the Ministry of Health was quite uncomplimentary in the comments that he made concerning a report to him from the medical officer of the Department of the Meuse concerning the operation of brothels in Gommercy and elsewhere by the United States Army0 ’’On the strictly medical level* however* there has been worked out a cooperative scheme between ourselves* the Ministry of Health and local health authorities, from which is being built an effective control system, based primarily on contact tracingo At the present time this is being some™ what impeded on the one hand by the difficulty of getting reliable identifying information from American soldiers regarding their French contacts, and on the other by the lack of personnel on the part of both ourselves and the 24 French civilian authorities to do the field epidemiologic worko Increasing familiarity with language and place names is serving to ameliorate the former difficulty and as the years ends there is some hope that a temporary loan of nurses from UNRRA may relieve the problem of personnel®" With the liberation of Belgium, in general the same policies and procedures were practiced as had been developed for France® The Belgians proved themselves to be most cooperative and in Liege, which was the only one of the large cities in our zone of influence, and which late in 1944 and early in 1945 became the hub of the supply system for the front, the cooperative relationship between ourselves and civilians was excellent® Fig® 10® "On 28 March 1945* there began at the Hospital Recollets in Liege, the final step in a complete venereal disease program for that community and our troops stationed thereo Since November there has been a well organized and efficiently functioning venereal disease program, including a contact tracing scheme which has worked out in cooperation between ourselves and the civilian authorities® It has been handicapped, however, by the lack of adequate treatment for the women found to be infected® Because of the unique situation in Liege and particularly the high degree of cooperation which has been given by the civilian authorities, authority has been granted to utilize 400 ampules of peni- cillin a month in the treatment of selected civilian women® The protocol of the procedure is attached as inclosure 9<> This protocol and the circulars to which if refers, have been translated into French and flemish for the benefit of the various staffs of hospitals and the first patients have been treated®" The directive referred to provided that penicillin would be used for no other purpose than for the treatment of women known or reasonably suspected of being sex contacts of United States soldiers with a venereal disease, excepting when they were found to have late syphilis® The treatment was directly under the supervision of an officer and nurse of the Medical Department of the United States Army and carefully drawn criteria for diagnosis and determination of cure were supplied® 25 During this period the consultations with Command were limited almost entirely to efforts to break up the still existing habits of many commanding officers of punishing noncommissioned officers for acquiring a venereal disease by reducing them to rankso This is exemplified by the publication by the Commanding General of the Headquarters Command of ETOUSA of a directive creating an efficiency board to review the case of any non- commissioned officer who acquired a venereal disease with accompanying memorandum to the members of the Board making it clear that the Commanding General expected every noncommissioned officer brought before this board for having had a venereal disease to be reduced to ranks for inefficiency,, The Continental Phase After the Investiture of Germanyo — After the invasion of Germany, two new problems of crucial importance were encountered., Both of these had been anticipated, but for neither had there been made satisfactory planso The first of these was the problem created by displaced persons« These had been encountered before the actual invasion of Germany had taken place but were found in increasing numbers as the Armies pushed deeper into Germany and released the camps of slave labor.. The social and economic problems which these people presented were terrific© The circumstances under which they had been living were such as to leave them with virtually no sense of moral respon- sibility © Promiscuity was the rule rather than the exception and the incidence of the venereal diseases among them must have been high, although there was no reliable information on this subject© The second of the problems was that caused by the non-frater< nization policy? ijiwii "In anticipation of the special problems which would arise with the cessation of hostilities, the effort was made to obtain clarification of policy with regard to the venereal diseases acquired in enemy countries„ As early as November 1944# a decision was requested regarding the advisability of application for prophylaxis or for treatment for venereal disease being considered as prima facie evidence of frater- nization with the enemyo No clear statement of policy was obtained, so that with the occupation of Germany, especially after the cessation of hostilities, there was lack of uniform policy© Some commanders attempted to establish a program, but others went so far as to refuse to establish prophylactic stations on the assumption that to do so would be encouraging 26 Figure 10 A house of prostitution in Liege, Belgium, is placed "off limits" to U. S. troops, October 1944. fraternization,, In some organizations, men were tried before a summary court-martial, and fined the usual $65, simply for reporting with a venereal disease„ An Adjutant General letter order of 4 June 1945 clarified the situation: ”2® The contraction of venereal disease or the facts con- cerning prophylactic treatment will not be used, directly or indirectly, as evidence of fraternization or as evidence of violation by the individual of the policy on non-frater- nization with the inhabitants of Germany,,11 With the slowing down of the Annies and the final cessation of hostilities, the supply problem became very much better, and at long last, in the late spring of 1945> a series of shipments of venereal disease posters totaling 70,000 was received from the United Stateso This represented the first poster material received for distribution in the European Theater of Operations proper, although sometime prior to the date of the receipt of this material on the continent, similar supplies had been received in the United Kingdom Base« Copies of the educational films ”Pick-*ip" and MFor Your Information” also were made available during this period,. The cessation of hostilities was followed immediately by a sharp upward trend in the incidence of the venereal diseaseso Un- fortunately, this skyrocketing venereal disease rate was accompanied by such a kaleidoscopic shifting in the make-up of the commands in the theater and the complete redistribution of responsibility, that during this period very little which was effective in organized venereal disease control could be accomplished*, Tig., 12 0 Another minor misfortune occurred at this time in the with- drawal from issue of the V-Packette and the substitution therefor of the one-tube prophylactic kit of which adequate supplies were not available® This created a critical supply problem for what was already a critical period in the venereal disease experience of the theater and there was much speculation as to whether or not this limitation of prophylactic supplies materially contributed to the increasing venereal disease rate® Prior to this period the issue of condoms had been cut from six per man per month for issue and an average of lo7 per man per month for sale through the post exchanges, to a total supply of four per man per month for both issue and sales purposes® This otherwise undesirable move had been necessitated by directions from The Surgeon General’s Office based on the supply problem® 27 Efforts were made to continue epidemiologic studies but with the cessation of hostilities and the tremendous amount of troop movement which developed immediately thereafter* these proved to be of less value than at any time during the life of the theater0 Cooperative relationships with other agencies which had been developed were maintained and during this period a beginning was made toward the development of a venereal disease control program* applicable to the people of Germany for the protection of the Army of Occupation,, Prevalence and Incidence of The Venereal Disease^—It remains to assess the conditions that existed and the methods that—The Eighth Air Force remained continuously in Great Britain and the rates for the venereal diseases quoted for Air Forces in Great Britain are essentially those of the Eighth Air Force„ The Ninth Air Force operated on the con- tinent, and continental Air Force troops were principally of that commando Venereal diseases among men of the Ninth Air Force were more frequent than for those of the Eighth Air Force; but the differences were not great, and the spread was by no means comparable to that for Communications Zone troops under the two conditions, (Table 4* Figure 16) o Venereal Diseases in The Field Armieso—Until completion of active operations in May 1945 the venereal disease rates for field armies were consistently the best of all troops of the theater, so much so that there was scant comparison® Differences between the five armies constituting the Ground Forces are difficult to demonstrate, (Table 5* Figure 17)„ Sometimes one army would have the better record for a month or so, sometimes another® The behavior of all was characterized by a sharp rise as the war ended, with no question remaining of where the explanation lay for the greatly increased rates of the theater as a whole, which characterized the final weeks® Venereal Disease in the United Kingdom and on the Continent During Active Operationso—Venereal Diseases were very definitely more frequent among troops serving on the continent than among those in the United Kingdom Base® The commonly expressed belief that the 31 greater rates for the theater during the time of active operations was completely an expression of the forces serving on the continent ;vas not wholly true* for the venereal diseases were more common in both localitieso The rates in the United Kingdom were 4-7 per thousand per year compared math 35 for the year 1944* and the frequency of these conditions among troops on the continent was no more than 59° The general increase was a function of both commands0 (Table 6)0 Racial Differences in Rates for Venereal Diseases0 —The usually observed differential between venereal diseases among white and colored populations was consistently observed among troops of the United States Army serving in Europee The rates for both groups were higher on the continent than in the United Kingdom# but the relative difference remained almost identical# about 4o5 to lo (Table 7# Figure 1B)0 The Kinds of Venereal Disease<>—-The distribution of the venereal diseases according to clinical form# grouped as syphilis# gonorrhea and others# is presented in Table B# for the four different years of the European Theatero Gonorrhea constituted the great bulk of the rates for syphilis remained fairly similar throughout the years except for a rather well-marked increase in 1943s> when the proportion of syphilis to other forms of venereal disease was increasedo The rise in rates for the group classed as other venereal diseases and noted in 1945 was distinctly related to the troops arriving in the European Theater from Italy# where the incidence of chancroid was measurably greato The monthly reports of syphilis show a uniform distribution throughout each year0 The high incidence in 1943 is shown to be particularly a function of the latter part of that periodo (Table 9)o Similar data are presented for gonorrhea in Table 10o Comparison with Other Theaters of Operation0 —~Comparison of the rates for the venereal diseases among troops of the European Theater with those of American troops serving at home shows the experience of the theater to be commendableo The rates were greater* but rates are always greater among troops serving in a foreign country0 Compared with the experience of the British Army serving at home* the rates for American troops in Great Britain were measurably highero (Figure 19)o Among American troops of the various theaters of operation* the European theater fared much better in compaiisorio The highest average rate attained in any theater was that in the Mediterranean* 32 Figure 15, Venereal diseases, all forms, European Theater of Operations, U. S. Army, base sections of the Communications Zone in Continental Europe, rates per 1000 strength per annum by weeks, 1 September 1944 to 9 June 1945, inclusive* Figure 16 Venereal diseases, all forms, European Theater of Operations, Air Force in United Kingdom and on the Continent, rates per 1000 strength per annum by weeks, 1 September 1944 to 29 June 1945. rH d •P s a •H ■s o o a •rl B © •H E «< • to s -< co 3 •-S P o> CM w o g 45 C 2 © & 6 o I 0 © 43 u a. • © 43 to t rH fi - a a A4 © © © « 8- * 1 Z . 8 S § 1 - 41 fe rH p, rH © X • W) a C © « a u. © 43 © (0 m •H O •O Q rH rH 2 »• u © © p. c © a t> « 43 • © 2 *• • « as fa (§ Figure 18 Venereal diseases, all forms, European Theater of Operations, U. S* Amy, colored and white, cases and rates per 1000 strength per annum by montho* February 1944 to June 1945, inclusive* Figure 19 Venereal diseases among British and American troops. United Kingdom, January 1942 to March 1944. with an overall rate of 90„5<> The African and Middle East theater was next with a rate of 67, and Latin American was close up with 54 per thousand per yeara The overall rate of the European Theater of 47 rates fifth place among the nine theaters of operations of the United States Army0 (Table 11)o Personnel in Venereal Disease Control at Theater Headquarterso— The Venereal Disease Control Branch was continuously under the direction of Major (later Lt<> Colonel) Paul Padget, MCo He took over responsibility on 26 September 1942.and remained until activities ceased 30 June 194$o Captain (later Major) Raymond Heitz became his principal assistant on 18 January 1943 and served continously throughout the operationso Captain (later Major) Charles P<. Anderson, joined the division the same day and remained for more than a year, until he took up duties as venereal disease control officer in Eastern Base Section and later in Seine Section, Paris0 A number of nurses served with the branch in connection with case finding activities,, They included 2nd Lts0 Marie Co Goik and Margaret Fo Malley, who were assigned to duty 6 September 1943<> Among others subsequently engaged in this feature of venereal disease control were 2nd Lts0 Eleanor C„ Mikkelsen, Marjorey Bo Storey, Ethel Hammond, Rosalie Co Giaceme, Marjorie Eo Davies, Catherine Lo Whyts, Harriette Mo Malone and a number of others0 33 Table 1 Venereal Diseases, All Forms European Theater of Operations, U0 So Army by Major Commands, in Great Britain 1 January 194-3 to 30 June 1944> and on the Continent 1 September 1944 to 29 June 1945» Rates per 1000 strength per annum, by weeks Week Ending UNITED KING DOM Ground Forces Air Forces Services of Supply 1943 Jan 1 47 75 71 8 47 63 6$ 15 46 42 68 22 37 45 46 29 17 59 88 Feb 5 34 49 52 12 « *- # 19 83 76 62 26 53 64 58 Mar 5 ■* # 12 60 58 50 19 42 50 57 26 44 70 39 Apr 2 22 57 50 9 37 72 49 16 51 53 59 23 42 60 50 30 30 58 40 May 7 32 35 35 14 48 57 40 21 36 47 63 28 31 34 44 June 4 35 34 37 11 20 43 42 18 27 31 33 25 50 33 30 July 2 * * * 9 24 36 36 16 27 44 33 23 43 39 29 30 35 39 38 Aug 6 21 29 29 13 20 40 35 20 21 36 37 27 10 43 41 Table 1 (contfd) Week Ending UNITED KINGDOM Ground Forces Air Forces Services of Supply Sept 3 21 33 33 10 10 37 45 17 26 33 40 24 27 32 43 Oct 1 22 35 40 8 26 * 15 23 34 31 22 18 37 32 29 8 35 34 Nov 5 9 35 23 12 16 29 30 19 11 28 35 26 17 28 30 Dec 3 18 23 28 10 13 29 31 17 22 30 27 24 • 13 26 23 31 20 22 26 1944 Jan 7 14 23 20 14 16 33 19 21 15 31 30 28 16 29 31 Feb 4 15 23 24 11 16 26 21 18 16 28 24 25 15 27 23 Mar 3 17 21 20 10 13 23 15 17 16 27 21 24 15 23 28 31 17 28 24 Apr 7 18 29 20 14 16 33 23 21 14 31 23 • 28 13 28 18 May 5 11 28 14 12 14 30 19 19 14 33 15 26 17 29 23 June 2 13 33 18 9 19 32 20 16 22 31 20 23 19 31 17 30 12 38 19 Table 1 (cont’d) Week Ending CONTINENTAL EUROPE Ground Forces Air Forces ComZ GRFC 1944 Sept 1 4 15 8 10 15 15 17 27 22 27 102 45 29 28 120 76 Oct 6 24 95 78 13 26 103 88 73 20 26 111 93 98 •' 27 27 101 90 80 Nov 3 21 77 96 46 10 23 89 86 42 17 22 87 78 48 24 23 75 85 66 Dec 1 20 81 83 67 8 24 82 91 93 15 27 99 88 90 22 24 78 89 74 29 21 70 74 68 1943 Jan 5 19 58 76 61 12 20 69 92 50 19 20 68 93 56 26 17 73 92 67 Feb 2 16 69 81 72 9 19 68 79 95 16 22 76 81 75 23 21 61 73 88 Mar 2 18 60 66 75 9 18 66 67 82 16 22 72 79 67 23 22 74 80 74 30 22 65 80 90 Apr 6 18 62 62 68 13 19 70 71 76 20 18 64 80 72 27 29 68 72 99 May 4 31 56 69 76 11 42 69 70 76 18 53 89 91 79 2$ 68 74 92 75 Table 1 (cont'd) CONTINENTAL EUROPE Week Ending Ground Forces Air Forces ComZ GRFC June 1 70 75 82 104 8 86 94 96 128 15 91 100 94 143 22 93 107 117 155 29 140 120 107 153 No data available© Source: Division of Medical Records* Office of the Chief Surgeon* European Theater of Operations* Uo So Army Table 2 Venereal Diseases, All Forms European Theater of Operations, Uo So Army- Base Sections of the Services of Supply in United Kingdom Rate per 1000 strength per annum, by weeks, 1 January 1943 to 30 June 1944, Inclusive Week Ending BASE SEC HONS Central Eastern Southern Western North Ireland 19-43 Jan 1 68 50 107 8 45 71 97 15 73 68 88 22 36 53 67 29 60 125 110 Feb , $ 71 33 57 12 * * 19 75 71 54 26 79 21 102 Mar 5 * * # 12 51 19 92 19 52 58 85 26 43 21 69 Apr 2 39 53 73 9 54 50 49 16 40 44 118 23 53 38 67 30 58 36 33 May 7 15 21 30 79 14 0 34 49 58 21 15 66 73 62 28 29 52 48 33 June 4 56 40 32 42 11 41 54 29 45 18 66 39 34 21 25 22 21 33 57 July 2 a- ■M- * ■M- 9 20 42 37 34 16 9 44 20 52 . 23 18 19 31 46 30 53 58 16 36 Aug 6 32 41 26 19 13 23 42 26 43 20 22 34 45 47 27 0 29 46 78 Table 2 (cont'd) BASE SECTIONS vV66K ending Central Eastern Southern Western North Ireland Sept 3 0 30 29 63 10 34 37 36 67 17 7 48 . 14 79 24 20 36 41 69 Oct 1 6 47 27 63 8 * K *- 15 0 27 23 61 22 6 46 22 43 15 29 15 32 29 52 28 Nov 5 20 27 12 36 33 12 10 31 15 55 7 19 32 55 16 50 11 26 4 31 26 78 17 Dec 3 9 28 16 42 89 10 18 36 14 55 24 17 4 24 19 50 21 24 15 37 17 24 29 31 10 24 19 48 11 1944 Jan 7 13 27 16 30 0 14 20 14 9 34 23 21 6 27 29 44 15 28 9 46 17 41 61 Feb 4 18 26 21 31 24 11 11 31 15 32 11 18 26 30 19 32 4 25 14 23 17 39 10 Mar 3 6 30 17 19 33 \ ; 10 5 21 10 20 I 21 17 8 31 15 27 21 24 13 35 29 28 33 31 17 47 22 20 19 Apr 7 ■ 41 27 18 18 13 14 5 31 29 19 17 21 13 17 21 29 27 28 25 41 15 16 6 May 5 5 7 14 14 24 12 10 16 27 13 19 $ 10 23 13 26 13 35 17 22 June 2 13 15 24 32 9 12 27 15 10 16 18 14 29 23 21 14 23 30 _ 7 15 30 . * No data ava: liableo Source : Division of Medical Records* Office of the Chief Surgeon European Theater of Operations j U. So Amy0 Week Ending Advance Section Continental Advance Section Brittany Base Section Channel Base Section Delta Base Section Normandy Base Section Loire Section Oise Section Seine Section 1944 Sept 1 12 10 16 * * 8 11 22 14 28 11 15 26 22 * 27 36 83 22 67 36 21 51 98 29 110 28 63 46 72 128 Oct 6 96 96 119 40 10 264 94 13 125 82 117 28 222 82 164 20 122 129 155 35 50 96 186 27 98 76 124 52 135 252 134 N ov 3 98 86 144 49 98 250 151 10 80 91 136 42 120 153 153 17 67 101 88 48 63 176 115 24 86 125 89 ** 40 100 148 121 Deo 1 66 88 111 47 *** 131 146 8 99 105 87 59 140 136 15 79 63 118 8? 178 54 93 128 22 79 73 114 80 165 50 100 136 29 55 29 100 66 139 62 93 98 Venereal Diseases*, All Forms European Theater of Operations s Uo So Army- Base Sections of the Communications Zone in Continental Europe Rates per 1000 strength per annums by weeks 1 September 1944 to 29 June 1946g Inclusive Table 5 Week Ending 1 Advance Section 1 Continental Advance Section Brittany Base Section Channel Ease Section Delta Base Section Normandy Base Section Loire Section Oise Section Seine Section 1945 Jan 5 58 16 81 91 179 46 82 88 12 72 33 128 87 179 47 106 133 19 91 62 127. 80 169 54 92 115 26 66 50 146 92 167 61 105 115 Feb 2 52 66 96 77 180 56 72 128 9 45 56 98 86 133 76 93 122 16 48 66 88 153 79 81 101 23 45 57 87 137 65 83 S3 Mar 2 37 49 83 100 60 99 78 9 36 42 82 110 70 70 106 16 43 33 118 155 80 80 92 23 50 69 94 159 74 81 95 30 45 74 111 143 85 69 66 Apr 6 39 46 83 96 63 52 89 13 38 42 66 101 83 65 94 20 , 46 65 77 96 96 76 111 27 50 60 75 105 76 66 99 May 4 47 39 66 125 72 69 90 11 48 31 87 102 75 65 93 18 50 30 120 128 101 87 145 25 49 81 96 121 93 104 109 June 1 46 50 63 105 99 63 118 8 65 72 109 130 104 94 81 15 57 79 94 140 68 82 109 22 63 69 96 167 103 112 119 29 80 67 101 137 102 119 105 Sources Division of Medical Records* Office of the Chief Surgeon* European Theater of Operations* U„ S» Army Table 3 (cont3d) * Activated ** Assigned Coirmnmications Zone* ETO *** Inactivated Table 4 Venereal Diseases, All Forms European Theater of Operations Air Forces in United States and on the Continent Rate per 1000 strength per annum, by weeks 1 September 1944 to 29 June 1945 Week Ending Continental Europe United Kingdom 1944 Sept 1' 52 8 ' ■ 51 15 55 22 102 57 29 120 54 Oct 6 95 62 13 103 71 20 111 78 27 101 61 Nov 3 77 56 10 89 83 17 87 59 24 75 62 Dec 1 81 46 8 82 48 15 99 54 22 78 56 29 70 59 1945 Jan $ 58 44 12 69 54 19 68 55 26 73 54 Feb 2 69 34 9 68 38 16 76 45 23 61 47 Mar 2 60 35 9 66 42 16 72 55 23 74 58 30 65 61 Apr 6 62 50 13 70 29 20 64 55 27 68 58 Table 4 (confd) Week Ending Continental Europe United Kingdom May 4 56 62 11 69 57 18 89 72 25 74 64 June 1 75 47 8 94 49 15 100 60 22 107 63 29 120 58 Source: Division of Medical Records, Office of The Chief Surgeon, European Theater of Operations, Uo So Army0 Table Venereal Diseases, All Forms European Theater of Operations, Uo So Army- Armies in Continental Europe Rates per 1000 strength per annum, by weeks 1 September 1944 to 29 June 1945 Week Ending First S~1 Third Seventh Ninth Fifteenth 1944 Sept 1 1 7 8 12 9 7* 15 28 14 4 22 35 21 11 29 30 33 4 Oct 6 23 33 11 13 27 34 ■! i 9 20 30 30 1 10 27 27 32 14 Nov 3 26 25 13 10 26 30 15 17 24 23 17 24 26 20 23* 18 Dec 1 20 16 20 23 8 26 18 20 22 15 22 20 20 29 22 26 21 14 24 29 18 14 23 21 1945 Jan 5 20 16 15 14 12 29 15 13 15 19 28 17 15 16 26 26 14 10 17 Feb 2 20 12 12 17 9 29 14 16 17 16 30 15 16 26 23 27 17 16 25 Mar 2 20 18 16 18 4* 9 23 16 16 18 7 16 26 15 18 23 26 23 30 13 19 22 20 30 21 16 18 29 17 Apr 6 19 10 18 18 26 13 18 10 20 23 26 20 17 11 13 24 26 27 35 15 33 34 31 Table 5 (cont1*! Week Ending First Third Seventh Ninth Fifteenth May 4 37 17 24 34 42 11 50 24 39 46 55 IB 35 44 60 74 25 40 70 77 93 June 1 48 64 78 101 8 56 89 110 94 15 84 102 92 75 22 84 101 *-* 96 29 126 162 113 * First Report received« Redeployedo Source; Division of Medical Reports , Office of the Chief Surgeon, European Theater of Operations, UoSo Army0 MONTH Total United Kingdom Continent Cases Rate Cases Rate Cases Rate 1944 September 5695 35 2673 40 3022 31 October 7876 57 2203 53 5673 59 November 7311 48 1935 48 5376 48 December 11223 50 2379 40 8844 53 1945 January 9472 48 1968 39 7504 52 February 9284 45 1797 38 7487 47 March 12747 48 2454 > 48 10293 48 April 9985 , 46 1780 46 8205 46 May 13705 62 1856 62 11849 62 June 27705 105 3048* 66 24657* 113 Total 115003 56 22093 47 92910 59 * Estimated Sources Medical Statistics Division® Office of The Surgeon Generals War Departments Washington® DeCa Venereal Diseases* All Forms European Theater of Operations* U© S© Army United Kingdom and Continent Cases and Rates per 1000 strength per annum* by months September 1944 to June 1945* Inclusive Table 6 Total White Colored Cases Rates Cases Rates Cases Rates 1944 February 2115 30*1 1426 22,0 689 127.3 March 2590 25.1 1775 18*6 815 106*4 April 2451 26o4 1707 19*9 744 102*9 May 2291 22*8 1632 17o6 659 82*5 June 2993 23o5 2137 18*1 856 83*3 July 2371 21*8 1753 17*3 618 83*1' August 2594 20.4 1906 16*3 688 59*0 September 5695 34*8 4282 28*3 1413 113*5 October 7876 56 o 6 5469 42*8 2407 212*1- November 7311 48.0 5027 35*9 2284 182*4 December 11223 49o5 7764 37*2 3459 190*8 1945 January 9472 48,3 6179 34*5 3293 196*2 February 9284 45ol 6290 33*3 2994 173*3 March 12747 48o 2 ■3842 36*4 3905 179*3 April 9985 45*6 7221 35*9 2764 154*6 May 13705 61c8 10432 51*9 3273 177*6 June 27705 105.2 20463 84*9 7242 324*4 Total 132408 47*6 94305 36.9 38103 169*4 Source; Medical Statistics Division* Office of The Surgeon General War Department* Washington* Do C« Venereal Diseases*, All Forms European Theater of Operations*, U© S© Army Colored and White Cases and Rates per 1000 strength per annuma by months February 1944 to June 1945*, Inclusive Table 7 DISEASE Total 194 t2 1943 1944 1945 Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Syphilis 21929 6o9 420 5,8 2798 10,6 8269 5.6 10442 7o6 Gonorrhea 119780 37,7 2196 30,2 7945 30© 1 41824 28,4 67815 49,5 Other 6886 202 119 1.7 601 2,3 1525 1,0 4641 3,4 TOTAL 148595 46,7 2735 37,7 11344 43,0 51618 35,0 82898 60,5 Source: Medical Statistics Division, Washington, D, C, Office of The Surgeon General, War Department, Venereal Diseases European Theater of Operations» U» So Army Cases and rates per 1000 strength per annum by Clinical Forms by Years February 1942 to June 1945* inclusive Table 8 MONTH TOTAL 1942 1943 1944 1945 Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate January ' 206? 7*7 112 10*2 567 9*2 1388 7*1 February 2096 7*4 1 3*2 50 5*9 606 8*6 1439 7*0 March 2714 7*2 3 3*8 32 3*9 738 7*1 1941 7*3 April 2230 6*9 2 2*3 105 9*9 637 7*4 1436 6*6 May 2390 7*2 9 4*2 ’ 104 11*0 613 6*1 1664 7*5 June 3308 8*1 8 2*3 86 7*1 640 5*0 2574 9*8 July 706 5*3 28 4*4 220 11*5 458 4*2 August 796 5*1 59 6*7 295 15*2 442 3*5 September 1034 5*2 47 3*7 337 14*4 650 4*0 October 1245 6*5 107 6*4 401 10*9 737 5*3 November 1317 6*4 96 8*6 395 9*6 826 5*4 December 2026 6*7 60 6*4 661 10*2 1305 5*8 TOTAL 21929 6*9 420 5*8 2798 10*6 8269 5*6 10442 7*6 Source? Medical Statistics Division, Office of The Surgeon General, War Department, Washington, D« c* Syphilis European Theater of Operations9 Uo S» Army Cases and Rates per 1000 strength jper annum/,, by months February 1942 to June 1945® Inclusive Table 9 MONTH Total 1942 1943 1944 1945 Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate January 9396 35o0 512 46.3 1451 23.6 7433 37.9 February 9067 31.8 2 6.5 410 48.5 1428 20.3 7227 35.1 March 12103 32.1 11 13.9 378 45.6 1749 16.9 9965 37.7 April 10260 31.7 11 12.5 460 43.5 1646 17.7 8143 37.2 May 13464 40.4 29 13.6 322 34.1 1601 15.9 11512 52.0 June 26195 64.5 24 6.8 335 27.6 2301 18.1 23535 89.3 July 2594 19.3 103 16.1 627 32.8 1864 17.1 August 2926 18.9 155 17.7 654 33.8 2117 16.7 September 6128 30.7 450 35. d 730 31.3 4948 30.2 October 8598 44.7 538 32.2 1043 28.5 7017 50.4 November 7820 38.2 416 37.3 1051 25.7 6353 41.7 December 11229 37.3 457 49.0 1423 21.9 9349 41.3 TOTAL 119780 37.7 2196 30.2 7945 30.1 41824 28.4 67815 49.5 Source 2 Medical Statistics Division, Office of The Surgeon General, War Washington, D.C® Gonnorrhea European Theater of Operations, U« So Army Cases and Rates per 1000 strength per annum, by months February 1942 to June 1945, Inclusive Table 10 THEATER Total January 1942 to June 1945 inclusive All Venereal Diseases Gonorrhea j Syphilis Other 1942 1943 1944 1945 Total Array 37 27o6 5o5 309 38 28 37 52 Continental U, So 33 26o0 4,8 1,9 39 26 33 44 Total Overseas 44 30o4 6,6 7,2 33 34 41 57 Mediterranean 91 54o9 12,4 23o2 35 56 111 102 Africa Middle East 67 29©0 13,6 24o 7 86 69 60 75 Latin America 54 31oT 10ol 12,1 74 58 36 27 China~Burma° India 50 22o7 11,5 15,8 64 53 51 47 European 47 37©7 6,9 2,2 38 43 35 61 South West Pacific 26 17o0 3©1 5o4 33 15 7 57 North America 12 10o0 lo5 ,4 10 10 14 18 Alaska 5 3*8 ,8 ,1 7 3 5 9 Pacific Ocean Area 6 ' 4o3 1,2 ,3 11 5 5 3 Sources Medical Statistics Division, Office of The Washington, Do C, Surgeon General, War Department, Venereal Diseases, All Forms By Theaters of Operations, Bo So Army Rates per 1000 strength per annum by years January 1942 to June 1945, inclusive Table 11 FIGURES I# Physicians consider the problem of venereal disease control. Medical Field Service School, England; 1943* 2# London means Picadilly# 3# The British public house, colloquially "pub? was the soldier’s club as well as that of the common man of Bid.tain# 4® The GI finds Britain to his liking# 5# France welcomes America# 6# Towns were placed "off limits" as soon as occupied, St. Michel, France, 1944® 7# The small town cafes welcome American soldiers, Littry, France, July 1944® 8# The Paris boulevards were the center of all GI ambitions for leave # 9# Athletic contests were fostered as a form of substitutive activity, 10th Armored Division, Ger*- many, June 1945® 10# A house of prostitution in Liege, Belgium, is placed "off limits” to IIo S® troops, October 1944* 11# Fraternisation "verboten" for 101st Airborne Division soldiers, Kbnigsee, Germany, June 1945® 12# A soldier of the 42nd Infantry Division and his girl stroll through Vienna woods, June 1945* 13# Venereal diseases, all forms, European Theater of Operations, U# S# Army, by Major Commands in Great Britain, 1 January 1943 to 30 June 1944 and on the Continent, September 1944 to 29 June 1945, rates per 1000 strength per annum, by weeks# 14# Venereal diseases, all forms, European Theater of Operations, U<» S# Army, base sections of the Services of Supply in United Kingdom, rate per 1000 strength per annum, by weeks, 1 January 1943 to 30 June 1944, inclusive# 15o Venereal diseases, all forms, European Theater of Operations, Uo So Army, base sections of- the Communications Zone in Con- tinental Europe, rates per 1000 strength per annum by weeks, 1 September 1944 to 9 June 1945, inclusive0 16« Venereal diseases, all forms, European Theater of Operations, Air Force in United Kingdom and on the Continent, rates per 1000 strength per annum by weeks, 1 September 1944 to 29 June 1945 o 17* Venereal diseases, all forms, European Theater of Operations, Uo So Army, Armies in Continental Europe, rates per 1000 strength per annum by weeks, 1 September 1944 to 29 June 1945o 18o Venereal diseases, all forms, European Theater of Operations, U« So Army, colored and white, cases and rates per 1000 strength per annum by months, February 1944 to June 1945, inclusive o 19« Venereal diseases among- British and American troops, United Kingdom, January 1942 to March 1944# TABLES lo Venereal diseases, all forms, European Theater of Operations, UoSo Army, by Major Commands in Great Bid tain, 1 January 1943 to 30 June 1944 and on the Continent, 1 September 1944 to 29 June 1945* J?ates per 1000 strength per annum, by weekso 2o Venereal diseases, all forms, European Theater of Operations, U0S0 Amy, Base Sections of the Services of Supply in United Kingdom, rate per I'OOO strength per annum, by weeks, 1 Janu- ary 1943 to 30 June 1944, inclusiveo 3« Venereal diseases, all forms, European Theater of Operations U0S0 Army, Base Sections of the Communications Zone in Con- tinental Europe, rates per 1000 strength per annum, by weeks, 1 September 1944 to 29 June 1945* inclusiveo 4o Venereal diseases, all forms, European Theater of Operations, Air Forces in United Kingdom and on the Continent, rates per 1000 strength per annum, by weeks, 1 September 1944 to 29 June 1945, inclusiveo 5o Venereal diseases, all forms,. European Theater of Operations, U0S0 Army, Armies in Continental Europe, rates per 1000 strength per annum, by weeks, 1 September 1944 to 29-June 1945* inclusiveo 60 Venereal diseases, all forms, European Theater of Operations, Uo So Army, United Kingdom and Continent, cases and rates per 1000 strength per annum by months, September 1944 to June 1945, inclusiveo 7o Venereal diseases, all forms, European Theater of Operations, Uo So Amy, colored and white, cases and rates per 1000 strength per annum, by months, February 1944 to June 1945, inclusiveo 80 Venereal diseases, European Theater or Operations, Uo So Army, cases and rates per 1000 strength per annum, by clinical forms and years, February 1942 to June 1945* inclusive0 9o Syphilis, European Theater of Operations, Uo So Amy, cases and rates per 1000 strength per annum, by months, February 1942 to June 1945* inclusiveo 10o Gonorrhea, European Theater of Operations, U» So Army, cases and rates per 1000 strength per annum, by months, February 1942 to June 1945* inclusive Q 11o Venereal diseases, all forms, by theaters of operations, Uo So Amy, rates per 1000 strength per annum, by years, January 19-42 to June 1945> inclusive o A HISTORY OF PREVENTIVE MSDIGINS IN THE EUROPEAN THEATER OF OPERATIONS UNITED STATES ARMY 191+1 - 191+5 Part VI - Medical Intelligence by Colonel John S« Gordon, M*C» Chief of the Division of Preventive Medicine Office of the Chief Surgeon, BTO TABLE OF CONTENTS PART VI Medical Intelligence Page Functions and Policies 0 . . e 6 . 0 . e „ . c # , 0 „ 1 Source of Materials 2 Activities , . , 0 3 Transfer to Operations Division 0 » A Personnel . 0 . „ . A List of figures Parts YI i Medical Intelligence Actual work in this particular field of preventive medicine was limited to the staff of the central division at theater head- quarters* However, the material that was collected had wide circu- lation and use in the various branches of the Division of Preventive Medicine, in the several divisions of the Office of the Chief Surgeon, and in numerous instances by surgeons of other echelons* The primary objective was to secure data and make available current information on the movement and behavior of the communicable diseases* In ad- dition, information was gathered on various other features of pre- ventive medicinej on nutrition, veneral disease, and environmental sanitation* Types of organization and the quality of medical care furnished military and civilian populations of enemy countries were subsidiary interests. These ends were sought through contact with representative British research institutions, through attendance on scientific meetings and committee conferences, and through continuing familiarity with current medical literatureo Contributions to med- ical research and especially the development of improved methods in preventive medicine were investigated and evaluated* Functions and Policies-While medical intelligence* strictly speaking* relates only to medical material bearing on enemy or enemy occupied territories* the work of the branch included sim- ilar interests in Great Britain* as a medium for improved practice in the work of the division both in its epidemiological activities and in military planningo The functions and policies to govern work in medical intelligence were defined as followsa lo To acquire information and specific data on com- municable diseases in countries or areas where the United States Amy lias* or anticipates having* close contact or relationships and to make such information available to responsible officers of United States and allied forces0 20 To assemble th© fullest possible information on methods* studios and projected developments in bi olo gic wa rfare • 3o To collect information, study and analyze the provisions for medical care and the sanitary conditions, procedures and needs of American and allied troops and of civilian populations in countries to which American military operations are likely to extend. U<> To effect liaison with military and civ- ilian organizations or persons of countries in which our troops may be located, in respect to suggestions bearing directly upon health and sanitary conditions. of Materials.—Information on communicable diseases was obtained primarily from the "Weekly Return of Infectious Diseases published by the British Ministry of Healths from the weekly Record of Infectious Diseases of ports and other Localities at Home or Abroad, Ministry of Healths from the weekly bulletin of infectious diseases of the North Midland region, the weekly returns of cases of infectious disease notified in Scotland, and the weekly return of cases of infectious disease notified in North Ireland. Much worthwhile information came from the monthly bulletin of the Emergency Public Health Laboratory Service and from the monthly summary of Information on Typhus and other Important Epidemic diseases in Europe, both issued by the Ministry of Eealtho Other more general informa- tion came from the registrar general's Weekly and Quarterly Reports of Births and Deaths in Great Britain. Perhaps as valuable infor- mation as any arose from personal contacts and through various com- mittees of the Medical Research Council and other British medical and scientific societies. The meetings of advisory councils and special committees of the three British military services were particularly informative0 No small amount of information came from interviews with allied military personnel returned from their native countries o Specific information on how a currently existing disease was affecting enemy troops often proved of value in directing our own attack on the problemo To that end, frequent use was made of the help to be derived from the intelligence officers of Field Amies in the course of the interview and examination of recently captured prisoners of war, Examples of such interest were the frequency in the German a my of trench fever, louse infestation, trench foot, and typhus fever, and the methods used for their pra- vention and controlo (Figo 1) At least three other American agencies in the theater were engaged in the collection of medical information as it re- lated to our allies and to the enemy. All three had a represent- ative detailed for this particular purpose* and assistant medical military attache at the American Embassy* the permanent represent- ative of'the Office of Scientific Research and Development* and an officer of the United States Navy. Like good newspaper men— for work in medical intelligence resembles the practice of that 2 Figure 1. Soldiers of the VIII Corps, U. S. Army, interrogate German prisoners of war in the Neuchateau-Bastogne sector, January 1945. Information was obtained on the prevalence of influenza, trench fever and trench foot. profess ion--the various workers in the field held frequent meet ings and conferences on matters of common interest,, There was free exchange of information,, Activitieso--Two continuing reports were prepared by the Medical Intelligence Branch® The first was a general weekly sum- mary of information on infectious diseases, exclusive of experience in the European Theater of Operations, prepared from all available sources and submitted to the Chief Surgeon® The second was a weekly summary of the trend of the communicable diseases in the European Theater of Operations, with attack rates for the more im- portant conditions and including illustrations, graphs, and charts representative of both civilian and military experience® So much of the work that enters into medical intelligence has to do with the collection and analysis of statistical informa- tion—’the records of what others are doing and have done—that it is not a particularly stimulating activity, nor does it give op- portunity for much creative effort* It does demand continued and sustained interest* There is no question of its being essential to logical planning of future military operations in countries not too well known* The reasonableness of an attack on an epidem- iologic problem often depends in considerable degree on how soundly the proposed measures are based on the particular conditions to be met and the past history of similar events* The outstanding interest is in the interpretation of the information that is collects do What is the bit of critical in- formation within the mass of irrelevant? What is the reliability of the sourest What is the relative authority of the several statements on a single subject? Medical Intelligence also had its lighter side, and some of the problems presented served to bring out all the elements of the best detective thriller* Reports intercepted in 19U3 showed that two and a half train loads of live tortoises had recently been shipped from Bulgaria into Germany* With the limited rolling stock available to the Nazis and the pressure on transport which was as great with them as it was with us, why did the Germans have this urgent need for a quarter of a million live tortoises? If intended for food, why were they shipped alive, for there is certainly much wastage of shipping space in transport of a live tortoise* If intended for biologic experiment, why the huge number? If for manufacture of some biologic preparation, or testing of some chemical product, what could it be? The affair of the tortoises remained one of the unsolved mysteries of the war* 3 Transfer to Operations Division0--The Chief Surgeon initiated plans in I9I4.3 for broadening the program in medical intelligence be- yond the limits which had been defined and to an extent measurably beyond the interests of preventive medicine0 These plans included consideration of conditions in enemy countries related to medical edu- cation, to research in a number of subjects allied to medicine, to medical supply and equipment, to the organization of medical and health facilities in enemy armed forces, and to the manufacture of drugs and biologicalso Because of this enlarged scope of activities, the Chief Surgeon transferred formal work in medical intelligence to the Operations Division of the Office of the Chief Surgeon on 6 No- vember 19U3 o Those features of medical intelligence which related pri- marily to epidemic diseases* and to preventive medicine problems in the areas occupied by American forces were continued as an obliga- tion of the Division of Preventive Medicine* through delegation or that interest to the Epidemiology Branch of the office0 Throughout the subsequent existence of the Military Intel ligence Branch under the Operations Division, there was continued and close cooperation by Preventive Medicine, particularly on the exchange of information on the communicable diseases* The Medical Intelligence Branch devoted much effort to assembling information on biologic warfare* This material was of great aid to the Chief of Preventive Medicine in the discharge of his duties as represent- ative of the Chief Surgeon in that fields As military operations extended intp Germany, a number of mutual interests led to col- laboration in field studies Those of more strictly professional interest included the preparation of typhus vaccine by German lab- oratories, epidemic hepatitis and the control of German biological laboratories* Others involved the evaluation of medical and scientific institutions, and of German medical education* Personne1o--The Medical Intelligence Branch was under the direction of Captain Joseph T„ Marshall, M0C0, assisted by 2nd Lieutenant (later Captain) Edna M« Cree, AoNoCo 4 FIGURE lo Soldiers of the VIII Corps, U® S. Amy, interrogate German prisoners of war in the Neuchateau-Bastogne sector, January 1914.5* Information was obtained on the prevalence of influenza, trench fever and trench foot. A HISTORY OF PREVENTIVE MEDICINE IN THE EUROPEAN THEATER OF OPERATIONS UNITED STATES ARMY 191+1 - 19U5 Part VII - Laboratory Service % by Colonel John B* Gordon, M*C* Chief of the Division of Preventive Medicine Office of the Chief Surgeon, BTO TABLE OF CONTENTS PART VII Laboratory Service Page Laboratory Service 0 0 0 0 0 0 . 0 . a . 1 Policies and Functions c . „ 0 . 0 . . . . 2 Organization of the Service ,0,000,##0, 2 Laboratory Facilities in the United Kingdom c « . . . o <, . 3 Central Laboratory Service „ 0 , 0 , . , „ . , „ . . . . . 4 Regional Laboratory Service 0 „ 0 • • c . . <, • • , , , • e 6 Unit Laboratories . 0 , 0 0 . , « « . o • , . . « « , . . » 6 Laboratory Service in Continental Operations 0 0 » <, « . . • 7 Central Laboratory Service 0 . 0 <, <> <. » • » 0 . 0 . « • • . 8 Regional Laboratory Service „ , 0 0 0 . « 0 . • . . , « . . 9 Unit Laboratory Service 0 0 0 „ „ 0 c 0 „ s . • • . , „ , . 10 Other Laboratory Service 0 0 „ 0 , „ « 0 <> • . . . * . . » „ 11 Supervision of the Laboratory Services 0 0 • « , 0 . . • . 0 11 Professional Personnel of Laboratories 0 0 » • • a . . . „ , 13 Special Topics „ 0 0 0 „ 0 c 0 0 c . . . , . . . . . . . . . 13 Food Laboratory 0 0 . . • . „ » c . . . . . . c « . , . . « 14 Laboratory Supplies and Reagents 0 , 0 0 c . 0 14 Stock Bacteriologic Cultures „ „ „ , , 0 . . „ . , . 0 . „ 0 14 License for Animal Experimentation , 0 0 0 0 , . . . , 0 . , 15 TABLE OF CONTENTS (Continued) PART VII Laboratory Service Page Messenger Service ... 15 Technical Services of the Central Laboratory, ......... 16 Pathology Service 16 Serologic Tests for Syphilis, . • 17 Epidemiologic Service . . 17 Research and Laboratory Investigation • IB Personnel . 18 Summary ......... ....... 19 List of Tables Part VII Laboratory Service A comprehensive laboratory service designed to meet the needs of the Medical Department in a theater of operations has three principal obligations0 The first is to provide a good service in clinical pathology, in order that hospitals of the theater may be assured the diagnostic aids so essential to good medical practice0 laboratory facilities are necessary in support of the program in preventive medicine0 In addition to the ordinary public health laboratory methods -which enter into every day conduct of work in sanitation—the examination of water, food, and dairy products—provision must exist for the more highly specialized examinations -which complete a well-rounded epidemiologic study0 The third essential is a strong central control laboratory with superior staff and equipmentQ Aside from a primary obligation to guide the choice of technical procedures by unit laboratories and to evaluate their performance, the duties of a central laboratory include responsibility for the many intricate examinations beyond the capacity of hospital or other diagnostic laboratoriesD Research, study and investigation of medical problems closely concerned with military operations constitute an additional function0 Finally,, certain laboratory services are best accomplished on a theater basis, either because of the special training required in their performance, or because they are particularly susceptible to examination in mass numbers9 or because of the need for complicated apparatus0 In addition to what may be termed the professional re- quirements of a good laboratory service, certain administrative con- siderations have an important influence on its ultimate usefulness0 The quality of the services provided—of methods, procedures, and performance, both diagnostic and public health-must be assured through periodic consultation with staffs and supervision of the activities of unit laboratories0 Laboratories must furthermore be so spaced geographic- ally that ordinary diagnostic and public health laboratory service is readily available to most military units 0 Courier or other messenger service is needed to assure prompt service to all parts of the theater; in the dispatch of specimens and the return of reports between subsidiary laboratories and the central laboratory, and between units in the field and the local or central laboratory0 policies and Functions0—-While the general supervision of laboratory services of the theater was a responsibility delegated to the Division of Preventive Medicine in the Office of the Chief Surgeon, in actual practice it was a highly cooperative activity with the central control laboratory® The general policies which involved broad application of the laboratory services to medical practice were formulated at theater headquarters® The criticism and advice on administrative and professional requirements contributed by the various divisions of the Office of The Chief Surgeon made for their practicability and usefulnesso Regularly practiced review by the staff of the First Medical General Laboratory assured technical soundness® Actual supervision of laboratory practice in the field was more than a joint activity? it was largely contributed by the staff of the Med- ical General Laboratory0 The Laboratory Branch of the Division of Preventive Med- icine, Office of the Chief Surgeon*, operated according to the fol- lowing scheduled functions* (1) The development and supervision of a comprehensive laboratory service for the theater® (2) Provision of consultation and aid to hospital and other laboratories of the theater in methods and policies® (5) Evaluation of the qualifica- tions of laboratory personnel, with recommendations for their assignment, (1+) Provision of assistance in epidemiologic investi- gations, through the Epidemiology Branch, to all units of commando (5) Cooperation with the Chemical Warfare Service in the control of industrial health hazards incident to that service® Organization of the Serviceo —Three broad divisions of responsibility and of influence form the framework of a system meet- ing the requirements of a theater laboratory service as brought out in the foregoing discussion® The first is that of the central control laboratory0 The facilities of a central laboratory should be such as to provide the theater generally with the type of laboratory ser- vice which originates from the Amy Medical School for the army as a whol»0 Certain supply functions fall within its obligations*, particularly in rerpect to diagnostic reagents« It provides oppor- tunities for the training and instruction of laboratory officers and technicianso Throughout its existence, the European Theater of Opera- tions had a functioning central laboratory that met these require- ments® Its base of operations was in southern England, at Salis- bury, Wilts® Because of the barriers of time and distance intro- duced by the extension of operations to the continent, a sub-central 2 laboratory was later established in Paris* France® It functioned more or loss independently in providing central laboratory service to military units of that area* with the main laboratory in the United Kingdom Base continuing to provide consultation service and the more highly technical examinations® As troop strength and theater medical activities on the continent became progressively greater* these two laboratories exchanged places® The second echelon of the theater laboratory service functioned on a regional basis® The laboratories providing the service were units of Medical Laboratory T/O 8-610 (Amy or CoZo)® They were designed t® meet the needs of large bodies of troops relatively far removed from central laboratory service® In actual practice* their location was determined as much on an organiza- tional as a regional basis* since five of the seven in the European Theater were assigned to armiesj and yet the arrangement was re- gional in that their obligations extended to all units within a given army area® One unit was in the Delta Base Section* and an- other acted as the sub-central laboratory in Paris* later in Great Britain® The medical laboratories gave a service somewhat lass pretentious than that of the medical general laboratory although including most of the essentials* especially those of consultation and the investigation of epidemics® The laboratories of hospitals constituted the third echelon of laboratory serviceo Both public health and diagnostic laboratory service was ordinarily extended to units in their vicinity* although such laboratories were designed primarily to serve the needs #f the particular hospital of which they formed a parts Collectively they performed the great proportion ©f lab- oratory examinations for the theater* making most of the diagnostic examinations and a considerable part of those relating t® public health and sanitary procedureso Laboratory Facilities in the United Kingdom®--From the earliest days of its~existence, the United States forces in the European area had adequate and satisfactory laboratory service® This came about through the circumstance that at the time war broke out in December 19Uls an American laboratory with American equipment and personnel was working in Great Britain under the Ministry of Health® The American Red Cross--Harvard Field Hos- pital Unit had been established in 19i+0, for the purpose of con- tributing laboratory and epidemiologic service to British civilian and military installations® By good fortune, it was located al- most in the center of that part of England which was to see the greatest concentration of American troops® The sponsors of the unit* with agreement by the Ministry of Health* offered the fac- ilities of the unit to th© United States Army0 It provided theater laboratory service and epidemiologic aid for the first eight months of military activities at a time when army facilities were decidedly limited® • Most of the laboratory and field work incident to an extensive outbreak of homologous serum jaundice in the spring of 191+2 was done by this organization® Central Laboratory .ServiceV-In accordance with an agree- ment made some months previously between the sponsors of the Amer- ican Bed Cross Harvard Unit* the Ministry of Health and the United States Army* this laboratory was activated as an integral part of the Medical Department in mid-summer* 16 July 191+2* The staff was composed entirely of members of the original unit who volunteered for military service* and the entire plant and equipment at Salisbury was turned over to the army with the understanding that at the end of hostilities* it should revert to the Ministry of Healtho As Medical General Laboratory A it operated as the central laboratory of the theater* performing the usual functions of a med- ical general laboratory® It was in full operation the day it was activated® Its first field epidemiological study for the army was undertaken within a week® Fortunately, the demands for actual laboratory service at this time were not great because of the relatively small troop strength® This gave opportunity for planning and initiating the necessary changes to develop the facilities of the installation to the extent required for a theater of the size envisioned for BTC® On 23 July 19<-i2, the Chief Surgeon directed that the plant be brought to a sis© sufficient to house a general medical laboratory® The first draft of building plans was completed on 3 August 19i42 and by the middle of August specifications had been prepared for laboratory furniture and for necessary equipment and supplies® These plans provided added facilities for pathology* for water, milk and other sanitary examinations? for dental and veterinary sections, and a special section for virus and rickettsial studies® Facilities for preparation of media and cleaning of glassware were measureably increased® The need was met for greater housing accommodations, for more office space and for a teaching laboratory® Major Halph S® Muckenfusa took command of General Medical Laboratory A on 9 November 19li2® Under his direction building opera- tions gained new impetus, and eventually by the spring of alter- ation of existing buildings had been completed, newr buildings were finished and furniture and equipment had been installed for their operation® With certain additions to its staff to meet the increas- ing needs of the developing theater. Medical General Laboratory A j+ continued to provide central laboratory service until the arrival of the First Medical General Laboratory on 7 June at which tine that unit occupied the Salisbury laboratories, and supplanted Medical General Laboratory Ao The latter was disbanded 25 June 1914.3• A number of its personnel were added to the complement of the First Medical General Laboratory, while others ware directed to new assignments® The First Medical General Laboratory was ordered into active military service at Camp Rucker, Alabama, on 15 June 19142 and arrived in Great Britain on 3 June 19^3» Four days later it assumed its new duties as the central laboratory for the European theater, and continued in that capacity until 7 June 19145° (Figo 1) The general policies under which it functioned weres (1) All specimens from autopsies both gross and in fixatives to be sent to the central laboratory, with autopsy reports and summary of clinical record® Th® laboratory will complete the necessary examinetions and forward all material to the curator of the army medical museum® (2) Specimens are accepted from laboratories when confirmation, identification or special examinations beyond the resources of the local laboratories are required® (5) Specimens of medico-legal importance, to include all instances of suicide or homicide, are to be sent to the general laboratory® (U) Assist- ance will be provided local laboratories when demands of a tem- porary nature exceed their facilities® (5) Assistance will be given in epidemiologic investigations on request of the Division of Preventive Medicine, Office of The Chief Surgeon, and through that office to all units of th© command® '(6) Assistance is to be given in unusual problems requiring the resources of a general medical laboratory® (7) The general laboratory will act as the central food control laboratory of th© theater, in cooperation with the Quartermaster Corps® (8) Laboratory aid will be fur- nished th© Chemical Warfare Service in the control of industrial health hazards incident to activities of that service® (9) Re- search will be undertaken on medical and sanitary problems in- timately associated with the work of the theater® (10) Instruc- tion and training is offered to laboratory and sanitary personnel® During its long tour of duty in Great Britain, the First Medical General Laboratory provided a superior quality of labor- atory service, contributed materially to the work of the various units of the Medical Department, and was the center of research and investigation® (Figo 2) Eventually th© changing character of the theater and the overwhelming preponderance of troops on the continent mad© advisable its transfer to a location where it could enter more intimately into the medical work of the theater® Accordingly it moved 29 March 19U5 from its familiar location in 5 Salisbury„ Great Britain, to new quarters in Paris*, The same situation which made necessary a central type of laboratory service both in the United Kingdom and on the continent still held good when the First General Medical Laboratory moved to Pariso To meet this requirements the st Medical Composite De- tachment (Laboratory) which had been furnishing similar services on the continent exchanged places with the First Medical General Lab- oratory, and commenced operations at Salisbury 12 April 1945° Rera organized as the 3&lst Medical Laboratory, it continued there until 31 July I9U5® at which time central laboratory service in the United Kingdom cease do Regional Laboratory .Service 0—A number of Medical Labor- atories*, army type* were stationed temporarily in Great Britain in the course of preparations for invasion of the continent by the armies to which they were assigned*. Their activities were limited to planning and training* and throughout operations in the United Kingdom there was no regional laboratory service** The First Med** ical General Laboratory provided the consulation and special ser- vices ordinarily demanded from both first and second echelons* an arrangement mad© possible by the relatively limited territory within which troops were stationed*. Unit Laboratorieso—The first hospital, laboratory to take up duties in the European'"tHeat©r was that of the 10th Station Hos- pital at Londonderry, North Ireland, 2h January 19i|-2o It was joined that spring by the laboratory of the General Hospital, which located at Belfast*, In the next several months new hospitals with their laboratories continued to arrive in the British Isles, so that at the end of 19J+2 there was a total of 10, five of which were general hospital labo,ratorieeQ (Fig*. 3) At tii© end of 19U3 the number of American hospital lab- oratories was 50® of which 15 were general hospital laboratorieso The number in 1914+ was 102, with 72 at general hospitals} and when activities ceased in June 19U5* the total number of hospital lab- oratories operating in Great Britain was 39* of which $0 were in general hospitals*, The numbers cited apply only to hospitals and their laboratories which were actively in operation*, Units that were staging are not included*, Almost without exception the lab- oratories were connected with either general or station hospitals*, The few evacuation hospitals in Great Britain functioned irregularly and usually were only staging for future continental operations® The geographical location of hospitals was so arranged as to pro- vide adequate medical car© for all troops within the theater area*, 6 Figure 1. First Medical General Laboratory, Salisbury, England Figure 2 . Bacteriological Laboratory at First Medical General Laboratory. Figure 3. Laboratory of the 2nd General Hospital, Oxford, England. Consequently, no field unit within the United Kingdom was far removed from a source of satisfactory local laboratory service. (Fig- U) As hospital centers came into being in Great Britain in late and 19l+5» an arrangement developed that corresponded in a way to second echelon laboratory service such as that pro- vided by Medical Laboratories0 Hospital centers were formed from varying numbers of General Hospitalso These wore ordinarily of a superior type, with well equipped and well staffed laboratories,. The laboratory work of a center was under the direction of a laboratory co-ordinator* and it was common practice for one hospital laboratory to take responsibility for a particular feature of the work* such as path- ology, another for serology* and a third for chemistry 0 As a result* a superior type of service was developed and became avail- able to units of the surrounding area0 While the United States Army had a comprehensive and competent laboratory service in the British Isles, it was not all inclusiveo On many occasions and particularly in the earlier days of the theater* the United States forces were indebted to various British laboratories of universities and scientific in- stitutes for material aid in special situations, and for certain types of examinations beyond the capacity of even the best field laboratories o When American hospital laboratories were limited in number in 19U2 and I9k3s the Emergency Public Health Laborato2”y Service of Great Britain placed the full facilities of its central and constituent laboratories at the service of the United States Army0 These laboratories were widely distributed through- out England*, were freely used and were of decided help in the formative days of the theatero Laboratory Service in Continental Operationso--In con- junction with the iiospitalization ©1 vision of the Office of The Chief Surgeon, plans were initiated in July 191+5 for labor- atories of hospitals intended to serve with the Communications Zone in Franc@o These were general and station hospitals,, Speci- fications were provided for space, lighting, electrical outlets, and other technical features suitable to both tented and hutted accommodationso Decision was also taken to provide a separate central laboratory for the continent,. The initial requirements were to be met by a small separate detachment of the First. Medical 7 General Laboratory® Central Laboratory Service®—A detachment of six officers and twelve enlisted men from the First Medical General Laboratory arrived in LeMans, France, on 19 August 19hh° Laboratory space, rations, and quarters ware provided by the 19th General Hospital® The first laboratory specimen was examined 21 August I9I4U0 The laboratory service in common with the theater generally, encountered many difficulties at this time because of the rapidly changing military situation, the lack of communications and uncertain- ties in supply® Order started to come out of the wild rush across France when the headquarters of the Communications Zone were estab- lished in Paris in early September® Early consideration was given to an improved laboratory service® Paris was unquestionably the best place for a central laboratory® The communication system of France centers about that city, and better service could be anticipated in the receipt of specimens and the transmission of reports® There was the further desirable feature of having the laboratory near head- quarters® By arrangement with the commanding officer of the 108th General Hospital, Paris, commodious quarters were furnished the laboratory detachment in the former Beanjon Hospital, one of the modern medical institutions of Paris® within weeks the detachment was providing a very satisfactory service® The volume of work in- creased as the location of the laboratory became known, and as com- munications improved® By October, most of the special services ordinarily provided by the parent laboratory were being accomplished by this small hard-working detachment® Improved cross-channel com- munications furthered the transfer of special materials between the detachment and the central laboratory in Salisbury® Eventually, the demands for laboratory service exceeded both the facilities at Beaujcn and the capacities of the modest de- tachments, The Madical composite Detachment (Laboratory)* a unit comparable in size and equipment to an Amy Medical Laboratory, was therefor assigned to this duty0 The detachment of the First Medical General Laboratory continued to work with th®m* however* until 50 October 19UU0 laboratory itself was transferred on 16 December 1914* from the 108feh General Hospital to the Institut Pasteur* where it occupied the third floor of the main building* with parts of the first floor* and additional storage space0 By the end of I9I4I4 it became apparent that the First Med- ical General Laboratory could not continue indefinitely to give adequate service to the theater from its location in England® The 8 medical laboratory GENERAL HOSPITAL LABORATORY STATION HOSPITAL LABORATORY Figure 4. Distribution of "capital Laboratories in the United Kingdom, 31 December 1944. English Channel constituted an obstacle to communications and to the rapid transmission of specimens and reports to an extent seriously impairing the usefulness of laboratory examinetions0 Furthermore, personal consultation on laboratory problems was al- most impossible# Plans wore therefor made to move to the con- tinent# The quarters at the Pasteur Institute were too small to accommodate a medical general laboratoryo As a result of search for other facilities in Paris, arrangements were eventually made for the laboratory to take over unfinished quarters at the Faculte de Pharmacie, University of Paris® The French contractors who had started construction of these new laboratories Just before the war* agreed to complete the building operations0 The work suffered the usual wartime delays© consequently, when the First Medical dene re 1 Laboratory arrived in Paris on 2? March 19U3 to relieve the 3&lst Medical Composite Detachment (Laboratory) it was compelled to take over the quarters in the Pasteur Institute then occupied by that organization Not until the latter part of May did the first sections of the laboratory move into their new quarters at the School of Pharmacie, and the transfer was not completed until 1 June 19i±5o By that time the First Medical General Laboratory had received orders for redeployment to the Pacific Theater® After a tenure of six days they turned over responsibility to the Fourth Medical laboratory© This unit continued the services of the central theater laboratory until the activities of STO ceased on June 50, 19l+5o Regional Laboratory Service #—Each a my of the Ground Forces had its own Medical Laboratory (Army or Communications Zone type), a standard unit of the United States Amy which included eleven officers and forty-seven enlisted men# These laboratories served the combat troops, and the hospitals attached to armies# (Fig# 1+) They supported the preventive medicine services of armies through an active epidemiologic service# Army laboratories had the same privileges in respect to the facilities of the central laboratory as did all other organiza- tions of the for special examinations beyond the capacity of their equipment or staff, for consultation on technical problems, and for checking of results0 Epidemiological consultation and field aid were likewise furnished to all of the army laboratories by members of the staff of preventive medicine at theater head- quarters* and by the medical general laboratoryo The first laboratory to take part in continental opera- tions was the Tenth Medical Laboratory# It served with the First 9 United States Amy, landing on Omaha Beach, Normandy, on D plus 11, 17 June Organizational equipment -ms found in the various supply dumps on the beach, and on 29 June 19144-5 laboratory work be» gan0 (Figo 5) Thereafter the laboratory moved over prance with the First Army, into Supen in Belgium, for a time in Luxembourg, and eventually into Germany0 As the other armies of the ground forces came into action, their laboratories also became operational® (Table 1) The history of all was of th© same active service, and the same frequent shifts in base of operations0 Their work was done in tents, in abandoned buildings, in schools, and sometimes but not often, in first class existing laboratories0 (Pigo 6) The First, Third, and Seventh Armies had laboratories almost from the time they took the field, but service for the Ninth and th© Fifteenth was delayed somewhat because of lack of available units0 The Fourth laboratory was the only one of this type that served a Communications Zone unit*, Delta Base .Section® Regional laboratory service was necessary in this instance because of the geographic isolation of Delta Base Section*, and because of the many special problems of the region requiring laboratory aid. The 5&lst Composite Medical Detachment (Laboratory) served for a time as the central laboratory on the continent*, and later as the base labora- tory in the United Kingdom® Unit Laboratory Serviceo“-Laboratory service at its basic level continued to be furnished to the Medical department on the continent by the laboratories of hospitals, again primarily concerned with diagnostic work for th® units of which they were a part, but nevertheless giving a considerable amount of aid in public health laboratory methods to other military installations contiguous to them® In the United Kingdom, only general and station hospitals par- ticipated in this service® They continued on the continent to pro- vide the bulk of unit laboratory service% but there was additional help from the laboratories of evacuation hospitals, located almost exclusively in army areas and with armies, and to a certain extent from th© laboratories of field hospitals® (Figo 7) The latter had no laboratory officer but did have provision for the simpler lab- oratory examinations® They were commonly located well forward where they were particularly useful, because regular service was far removed® Unit laboratory service on the continent was liberally provided and almost invariably available within a reasonable distance® (Fig® 8) At the end of 1914-4-* 99 hospital laboratories were in opera- tion, of which I4.3 were in general hospitals, 1I4. in station hospitals, and 142 at evacuation hospitals® when operations ceased on 30 June 19l45s the number of unit laboratories functioning on the continent 10 Figure 5. 10th Army Medical Laboratory, Normandy, France Figure 6. Laboratory of clinical pathology under field conditions. 10th Medical Laboratory, France. Figure 7. Laboratory of the 48th Field Hospital, Germany 3 MEDICAL LABORATORY BENERAL HOSPITAL laboratory STATION HOSPITAL LABORATORY EVACUATION HOSP. LABORATORY „FRONT LINE Figure 8. TUstribution of Hospital Laboratories in Continental Europe, 31 December 1944. was 112, with a distribution of 56 general, IB station, and 48 evacuation hospital laboratoriese Evacuation hospitals made frequent moves0 The numbers listed show those operational on the dates given although a few were in all probability in course of transferring locations and not actually receiving patients or providing laboratory servicec In addition to hospital laboratories, general dispensaries and the convalescent hospitals of armies pro- vided a certain additional amount of laboratory service0 pther laboratory Service0°-French and Belgian civilian laboratories were not used by the American forces to the extent that had held for the United Kingdom, primarily because installa“ tions in the areas of greatest troop concentration had suffered greatly from the war and lacked their usual facilities; and also because there was less need0 The Army in France was liberally supplied with laboratories0 Special mention, however, is de- servedly made of the Institut Pasteur of Paris, which not only housed the United States Central Laboratory for many months, but throughout the course of operations made available the special technical facilities of that famous institution, and gave liberal aid in consultation0 Supervision of the Laboratory Services0—Experience during the early months of the theater served to bring out the considerable variety of training and experience among the various directors and staffs of hospital laboratories0 Decision was therefor taken in late 194-2 to institute a general inspection of all labora- tories of the theater, with the purpose of determining their ability to take a proper place in provisions for the care of patients0 This objective could presumably have been accomplished by various members of the preventive medicine staff at headquarters in the course of their general supervisory duties throughout the Services of Supply; or it could be made a special activity of some one or more individuals particularly skilled in laboratory work and actually engaged in laboratory practice» The latter arrangement promised greater usefulness and exactness0 The commanding officer of the First Medical General Laboratory agreed to accept the re- sponsibility0 The general scope of what was wanted, of methods of handling reports, and for action on recommendations were de~ finedo The first inspections were made during the early months of 194-3, in the course of which all laboratories of the theater were visitedo A variety of factual information was acquiredo The value of such study and the recommendations for improvements in staff, equipment and service were such that the 11 the project was made a continuing activity,, Major W0 SQ Spring of the laboratory staff was assigned to the work0 A goodly proportion of his time was spent in actual field inspections0 His headquarters were at the First Medical Cxeneral Laboratory where he participated in courses of instruction for officers and technicians9 bringing to this work the practical knowledge of common deficiences and needs which came from actual contact with problems in the fieldc From time to time he was on temporary duty with the Division of Preventive Medicine at theater head- quarters facilitating action on various recommendations concerning supplies, equipment and personnel which arose from his observations0 Other special inspections by members of the laboratory staff or of the Division of Preventive Medicine were made on occasion, such as the sur- vey of laboratory service during the early days of continental opera- tions but in the main this activity was conducted in the manner indi- cated o It is to be recommended„ A trained specialist directly engaged in active laboratory work has an advantage in approach that comes from familiarity and sympathy with problems,, He is likely to find more ready acceptance of the purposes of his visit than an administrative officer who too often has the inspector point of viewD Admirable opportunity was like- wise presented for effecting close liaison between unit laboratories and the central laboratory in respect to services which the latter was able to provide0 This project continued an active interest throughout the life of the theater0 Detailed reports on each laboratory were made at the time of the original survey in 19439 and for all new units as they arrived in the theater0 Particular effort was made to visit these newly arrived units as promptly as possible, in order to acquaint them with theater directives and the policies of the general laboratory program0 There- after 5 at subsequent visits, note was made of the extent to which de- ficiencies in equipment or methods had been remedied, on changes in staff, and of special interest or problems of the laboratory or of the region in which it worked0 A file was kept for each unit0 Reports of in- spections were submitted to the Division of Preventive Medicine for action through the appropriate division of the Office of the Chief SurgeonQ The subjects considered in the course of these inspections included problems of equipment, and of the training and experience of the staffs of laboratories, both officer and enlistedQ Technical and administrative procedures were reviewed to the end of effecting improvements In the service provided0 Information was obtained on the amount and character of public health laboratory work performed for units of the surrounding areac Finally common interests of unit and central laboratories were reviewed in respect to 12 consultation service, diagnostic reagents and other relationships, in an attempt to eliminate difficulties and inadequacies0 Professional Personnel of Laboratories0--Personnel mat- ters affecting officers and men of laboratories received important attention in the course of laboratory inspectionse In the United Kingdom the problems were those of an occasional change in assign- ment to remedy specific deficiencies of a laboratory„ Most hospital laboratories arrived with well qualified and trained staffSo Later in the war, less time had been given to training and organization and fewer laboratory specialists were available„ Adjustments were more frequently necessary0 Particular consideration was given to the needs of in- dividuals for further training, or their desire for experience in special fields0 The Medical General Laboratory organized compre- hensive courses for both officers and men at the central labora- tory0 Opportunity for attendance came in large part from the recommendations of the laboratory inspector0 In addition to formal courses, opportunity was given to laboratory workers with a special interest in some field or in some specific technic, to spend a week or two in the appropriate division of the general laboratory0 The great number of new hospitals requisitioned for the theater in 1944 and 1945 lad to a situation where many arrived with staffs lacking chiefs of major services, of the laboratory rather frequently0 These deficiencies were met by promoting those junior members of the staffs of existing laboratories who had demonstrated special aptitude and skill in the professional and administrative features of laboratory practice0 As a part of a general theater activity, the laboratory service made a study of the professional training and qualifica- tions of officers in laboratories, not only of the medical corps but of all branches of the medical department,. The analysis and subsequent classification were of profit in reassaying the per- formance of officers of the theater, and in bringing about indi- cated changes in assignment Special Topics0 — Mo attempt will be made to set down the nature or the scope of those many details which enter into the conduct of a laboratory service at theater level? the requisition of some special piece of apparatus, shortages in authorized tables of equipment, personnel problems, or the administrative action required of unusual or particularly significant laboratory re- sults o Certain problems attained importance because of difficult- ies presented in their solution, or because they led to establish- 13 ment of significant theater policy, From others came the develop- ment of special services, subsequently characterizing the work of the theater. Some were almost wholly administrative, others were of professional nature0 They are presented in that order0 Food Laborstoryo-»■■■ A food control laboratory had been included in the original plans of the Quartermaster Corps0 The First Medical General Laboratory of the Medical Department had like- wise included staff, equipment, and facilities for the sanitary examination of food and dairy products0 Concentration of the work in one organization had apparent advantages0 By mutual agreement of the two services, the medical department accepted responsibility for all laboratory examinations in this field, and for the necessary consultation service to the Quartermaster Corps„ Laboratory Supplies and Reagents,—The laboratories of the London County Council had developed over a number of years a system of supplying baoteriologic culture media and reagents peculiarly adapted to the use of small laboratories and especially to military installations under field conditions. The materials are supplied ready-prepared in special type tubes. The needs of the British Army and Navy had been met from this source throughout the war. Arrangements were made for a similar service to the United States Army, with requisitions through ordinary supply channels of the U, S, Army Medical Department, but with shipment direct from the manufacturers. The service was prompt and the materials first- class, A similar system is recommended for the peace-time labora- tories of the army and for future operations. The products are particularly adapted to laboratory chests of mobile laboratories. Diagnostic reagents for bacteriologic examinations, such as agglutinating serums and antigens, are prepared by the Army Medical School0 Their peculiar characteristics make distribution through regular medical channels unsatisfactory,, The first Medical General laboratory was designated the source of central supply for this class of materials, through direct requisition by unit labors- torieso Stock Bacterio logic Cultures,—Because of danger in working with certain cultures of bacteria, so great that they should not be handled at all unless justified by definite emergency, a policy was adopted that cultures of bacteria would not be fur- nished unit laboratories except to meet specific needs. Strains of brucella abortus, vibrio comma, and bacillus anthracis would not be furnished under any conditions, and would not be maintained by the central Medical laboratory unless required by the most unusual circumstances. u License for Animal The United Kingdom had stringent regulations that govern the um of experimental animals in laboratories„ A specific license was required, ap- plicable to specified laboratory premises which were subject to inspection, and an individual license must be held by each individu al operator concerned with animal experimentation0 In the early days of the theater, permits were obtained in the prescribed manner from the British Home Office for staff members of the central laboratory, and for the few other labora- tories where animal tests were essentlal0 The changing character of operations and the greatly increased numbers of medical units, made an altered procedure necessary0 Laboratories frequently moved from place to place and licenses were given for a fixed locationo Changes of personnel were frequent under military con- ditions, and licenses were issued to particular individuals0 Furthermore, it was believed sound principle that the United States Array should control its own operations0 There would seem to be no more reason for a United States laboratory to be subject to in- spection by a civilian authority, then for an army mess to be under control of the local health officer0 A number of conferences with officials of the British Home Office led to agreement that His Brittanic Majesty9s Government would waive the requirement for license and regulation for United States military forces, and that the United States Army would introduce a system of licensure in- corporating the essential provisions of the British Cruelty to Animals Act of l8?6o Thereafter, permits v;ere Issued to labora- tory units and to individuals over the signature of the Chief Surgeon and the Chief of the Division of Preventive Medicine„ Messenger Service0—Because of the delays involved, the Army postal system proved wholly unsatisfactory for the transport of pathologic material and the return of reports0 The GHQ Mes- senger Service was substituted through agreement with the Signal Corpso At least six different courier routes were operated0 Transfer of material destined for the central laboratory from one route to another continued to give rise to delay, and the loss of materials was altogether too frequent0 The courier service ap- preciated the problem; it entered equally into their other general activitieso A series of conferences served to bring about an im- proved systemo Special instructions were issued by the Medical Department to govern transport of medical materials0 As exper- ience increased and as the need for care in packing became apprec- iated, a fairly satisfactory courier service became available0 The same general courier system was used in operations on the continento The history of the United Kingdom was repeated 15 In the beginning the courier system was none too satisfactory, because of the common disorganization and difficulties in trans- ports tionQ Gradually the service was bro\ight into order, and in 1945 conditions could be said to be again good0 This matter of rapid transport of materials and reports is one of the greatest difficulties to be surmounted in providing a usable laboratory ser- vice o The problem was never wholly solved in the European Theater0 It remains a feature to be given needed attention in future plans for a theater of operations„ Technical Services of the Central Laboratory-A cir- cular letter of the Office of The Chief Surgeon, 10 October 1942, described the services in medical consultation available to the theatero It stated that the central laboratory was prepared to furnish aid and consultation to chiefs of laboratory service of general and station hospitals, and to surgeons of ground force and air force units on request© The laboratory was not designed to do routine examinations but would undertake the more special features of laboratory work beyond the facilities of smaller laboratories0 The fields in which consultation was available were bacteriology, virus infections, clinical chemistry of blood and urine, and problems related to entomology and insect infestation0 Subse- quently, a number of command circulars and circular letters from the Chief Surgeon gave direction on specific features of laboratory practiceo These were eventually brought together in November 1943, and the directive then issued continued to be the guide to the laboratory facilities and procedures available at the central laboratory,, Pathology Service 0 — A central service for pathology was one of the early developments0 An order of 31 October 1942 directed that autopsy protocols and clinical records of all deaths of United States Army personnel were to be forwarded to the First Medical General laboratory,, It was desirable to include specimens of tissue for microscopical and gross examinations An acceptable form of autopsy protocol was outlined0 Subsequently, the Medical Gen- eral Laboratory was established as the histopathologic center for the theatero All tissues for examination originating from station hospitals were required to be sent to the central laboratory, while general hospitals retained the option of making their own examina- tions, or sending the material to the central laboratory 0 The pur- poses of establishing the histopathologic center were to eliminate the difficulties encountered in obtaining apparatus and to elevate professional standards0 A service for examination of surgical and biopsy tissues came into being somewhat later„ Special directions were given for the conservation and examination of ophthalmologic tissueso 16 The Army Medical school was in need of pathologic material of certain specified kinds0 To facilitate its collection, and to more adequately care for the large amount of material that was accumulating in the course of the greatly increased medical activities of the theater, it was directed that all autopsy protocols and autopsy tissues for transmission to the Army Med- ical Museum should be forwarded through the First Medical General Laboratory,, / Serologic Tests for SyphilisV-To meet observed de- v flciencies in the performance of serologic tests for syphilis, arising from performance of these examinations by smaller lab- oratories that lacked trained staff and equipment, it was directed in February of 194-3 that all such examinations on blood serum should be performed in laboratories of general hospitals or of the central laboratory,. All specimens of cerebrospinal fluid were to be examined by complement fixation and only at the central laboratory0 On the recommendation of laboratory inspectors as to qualifications of staff and adequacy of equipment, the Chief Surgeon might designate other laboratories to perform these tests0 Further provision was made for periodic inter-laboratory checks between the various laboratories of general hospitals and the Medical General Laboratory,, Subsequently, information was cir- culated on the false positive serologic reactions observed in the course of non»syphilitic diseases, the conditions under which they occurred, the interpretation to be given, and the course to be followed in the management of patients„ A further directive under date of 2 October 194-3, incorporated the general features of previous orders and added a number of technical details„ These included directions for uniform recording of results, and pro- vision that all positive results obtained by the qualitative Kahn test on serums taken routinely or incident to a physical examina- tion, should be checked by complement fixatlon0 Epidemiologic Service0—Almost no epidemiologic in- vestigation is complete if it lacks the information furnished by laboratory examination of materials arising from the field of study0 Field studies were ordinarily initiated by preventive medicine officers, or by unit surgeons0 All laboratories of the theater have had a part in a number of such studies0 Aside from purely laboratory contributions relatively few laboratories have failed to participate in some one or many actual field investiga- tions, the Medical Laboratories attached to armies to a greater extent than others„ The laboratory of the Fifth General Hospital made extensive investigations of homologous serum jaundice and of tuberculosiso 17 Epidemiologic consultation was a continuing function of the First Medical General Laboratory® In purely laboratory aspects this was almost a daily activity® Field studies were undertaken in problems of any intricacy or magnitude® A small station hospital operated in conjunction with the central laboratory provided hospital accommodation for the study of patients with communicable disease of unusual or indefinite nature, as encountered in the course of field studies or of other origin® Research and Laboratory Investigation® — That special laboratory studies anS research should be limited to problems of direct bearing on operational needs was early established as a general theater policy® Particularly complicated studies and those which promised to be of long duration, were to be referred to research institutions of the Zone of the Interior® This in no way inhibited the Medical General Laboratory in developing many research interests, in which most of the divisions of that organization participated® The sections devoted to the study of virus and rickettsial diseases, and to pathology were especially productive® Many of the results are incorporated in published papers® The specific record of accomplish- ment is to be found in the reports of th© First Medical General Laboratory® The commanding officer of the First Medical General Laboratory was appointed Director of Research for the theater and as such functioned as a member of the group of consultants in the Div- ision of Professional Services of the Office of The Chief Surgeon® This served to facilitate the reference of problems which arose in the course of professional activities® The variety was greats they came sometimes from th© air force, sometimes from the services of supply and sometimes from the ground forces® They were treated in a variety ©f ways® In many instances members of the central lab- oratory staff were assigned to further exploration of problems re- ferred from field or clinic® In other instances, medical officers were detailed for temporary duty at the central laboratory, that they might investigate their own problems, with the facilities and equip- ment of that organization at their disposal® Personnelo-°.The officers responsible for administration and supervision of the theater laboratory service came from two groups, those at theater headquarters in the Division of Preventive Medicine, and those associated with the staff of the First Medical General Laboratory, At theater headquarters no ©ne officer ever devoted full time to this interest until the latter days of the theater, when 18 Major Wo S® Spring was transferred from the central laboratory to the Division of Preventive Medioineo General direction of activities was under the chief of the division, with principal assistance by a number of officers, ordinarily those associated with the Epidemiology Branch, including Captain Joseph To Marshall, Lieutenant Lawrence Kilham and Lieutenant Colonel Richard Mason0 Supervision and inspection of unit laboratories of hos- pitals was accomplished almost entirely by the staff of the First Medical General Laboratory0 The commanding officer. Colonel R0 $0 Muckenfuss took personal direction of this part of the work and made many of the inspections himself. Major W® S® Spring had this duty as his principal obligation® Some special problems had the attention of Lieutenant Colonel Murray Angevine and Lieutenant Colonel Joseph Smadelo Summary®--So much depends on the human factor in laboratory work, that quality of service bears a direct relation to the train- ing and aptitude of the men who provide it® The facilities they had to work with were in most instances adequate® It was surprising in the course of active field operations—-and this relates particularly to the laboratories of Annies--how much good work came out of laboratories working in tents under most difficult conditions® Tech- nical equipment was in general sufficient! indeed, it was decidedly good® The single outstanding suggestion for improvement of a theater laboratory service which comes from this experience, is of adminis- trative rather than professional nature® It would appear that if a central laboratory is to function to the fullest extent in the capacity for which it is designed, that the great bulk of routine work which fell to the First Medical General Laboratory in the European theater, should be eliminated® The major effort of a general laboratory should be devoted to specialized types of laboratory examinations! to consultation, and to field and laboratory research® It is believed that a central laboratory of such circumscribed responsibilities could meet its obligations with a staff whose numbers were essentially those of the present Medical or Army type Laboratory® Their training and experience should be that which generally characterize staffs of medical general lab- oratories® There can be disadvantage in too large an organization too permanently established® It should be able to move with less difficulty than the present general laboratory® Equipment and sup- plies should be commensurate with the mission--and therefor superior to those of the primarily diagnostic laboratory® The mobile sections of the Army Medical Laboratory, so well adapted to epidemiologic studies, should be a feature® 19 It is believed that all routine tests and most of the semi-specialized examinations could be handled to better advantage by an appropriate number of Medical Laboratories (Army or CoZo) assigned on a regional basis to be determined by troop concen- tration and geographic area involved,, In the ETO as it existed, two or at most three additional regional laboratories would have met all requirements„ Under such an arrangement the average distance from unit installation or hospital laboratory to a lab- oratory of superior facilities would be materially less0 It should make for more prompt service; the limitations imposed by transportation and courier services have already been statedo Regional laboratories would have a similar advantage in acting as sources of supply for laboratory reagents and in providing in- spection and supervision of unit laboratories,, The central lab- oratory, freed of these responsibilities, would be permitted full employment of its resources in the more highly technical services for which it was designed, and in a wider participation in field studies for the control of epidemics„ This is recommendation of a more decentralized lab- oratory service, to provide the Communications Zone and the Air Forces with the advantages which the Ground Forces alone had under the existing scheme„ 20 Name of Unit Assignment Date Becoming Operational Date relieved 1st Medical Laboratory Seventh Army 6 October 1944 On duty ETO 30 June 45 4th Medical Laboratory Delta Base Section Central Lab* 9 September 1945 On duty ETO 30 June 45 7th Medical Laboratory Third Army 1 August 1944 On duty ETO 30 June 45 10th Medical Laboratory First Array 29 June 1944 10 June 1944 28th Medical Laboratory Fifteenth Army 1 April 1946 3 June 1945 361st Medical Laboratory Sub-central Theater Laboratory 2 October 1944 29 March 1945 362nd Medical Laboratory Ninth Army 24 December 1945 30 May 1945 ARMY MEDICAL LABORATORIES SERVING ON THE EUROPEAN CONTINENT 1944—1945 TABLE I FIGURES 1. First Medical General Laboratory, Salisbury. 2. Bacteriological Laboratory at First Medical General Laboratory. 3. Laboratory at the End General Hospital, Oxford, England. 4. Distribution of Hospital Laboratories in the United Kingdom, 31 December, 1944. 5. 10th Army Medical Laboratory, Normandy, France. 6. Laboratory of clinical pathology under field conditions, 10th Medical Laboratory, France. 7. Laboratory of the 48th Field Hospital, Germany. 8. Distribution of Hospital Laboratories in Continental Europe, 31 December, 1944. TABLES Table 1. Medical Laboratories, T/0 and E 8-610, Serving in Continental Europe„ A HISTORY OF PREVENTIVE MEDICINE IN THE EUROPEAN THEATER OF OPERATIONS UNITED STATES ARMY 1941 - 1945 Part VIII - Gas Casualties By Colonel John E* Gordon, M. C« Chief of The Division of Preventive Medicine Office of the Chief, Surgeon, ETO TABLE OF CONTENTS PART VIII Gas Casualties Page Gas Casualties 1 Gas Casualty Branch, Division of Preventive Medicine 0 o * 2 Policies • ••••»•••••. • ••«•*•••••»« 2 Activities 3 Kit Water Testing Poisonous* . . 0 3 Reestablishment of the Gas Casualty Division „ 4 Personnel ....... 0 . 4 List of Figures PART VIII GAS CASUALTIEi Gras Casualties o—°No definite organization for attention to the medical aspects of chemical warfare existed in the European Theater prior to the autumn of 19420 Realizing the need for such organization* the Chief Surgeon of the theater requested that a medical officer specially trained to chemical warfare medicine be assigned to the theater0 For the immediate need* Lieutenant Colonel Perrin H„ Long* M <, C 0* was appointed acting senior consultant in chemical warfare medicine 17 November 1942* serving in this capacity in the Division of Professional Services for a period of one month* at the end of which time he left the theatero Colonel William D© Fleming* M© Co* former Chief of the Medical Department Research Laboratory* Edgewood Arsenal* arrived in the theater in February 1943 and was assigned as Medical Gas Defense Officer* 24 February 19430 A new division of the Office of the Chief Surgeon was shortly established and later given the title of The Gas Casualty Division© The division was divided into three branches* with interests centered in liaison* plans and training* and in ad- ministration and supplyo The liaison branch effected close and continuous contact with all phases of chemical warfare* British and American* and with both research and military aspects© Re- sults of investigations in chemical warfare medicine were circu- lated to the various installations of the Medical Department of the theater© The Plans and Training Branch worked to attain a satisfactory standard of proficiency for the Medical Department in training and medical aspects of chemical warfare and to adjust the Medical Department to the rapid changes in tactics and techniques of chemical warfare medicine© The Administrative and Supply Branch* in addition to the routine office administration* cooperated with the Supply Division* Office of the Chief Surgeon* in procurement and issue of adequate supplies and proper materials for medical service of gas casualties © Several unavoidable circumstances definitely hampered many of the division activities o Obvious and outstanding among these was the non-existence of chemical warfare® Popular opinion existed among the American forces that Germany would not introduce chemical warfareo Under such prevailing ideas * it was difficult to maintain interest in the Medical Department concerning.chemical warfare © Adequate requirements for the theater were not at first realized in personnel trained in chemical wafrare medicine# Personal contact and repeated inspections were required to adjust the medical service to this subject# The problem of gas casualty supplies also hampered some of the aspects of the work# For example*, adequate supplies for testing of water contaminated with chemical agents were much delayed and a method for detection of nitrogen mustard in water had to be developed# Under the direction of Colonel Fleming*, a strong program ill training methods in chemical warfare medicine was developed# A comprehensive plan was developed for activities in this branch of medicine during the invasion# The results of medical research were circulated to the Medical Department© Members of the staff worked inconjunction with the British and a representative of the United States Navy in treating many industrial accident and other eye casualties resulting from chemical warfare agents $ and a great deal of research work was done on the effect of chemical warfare agents on the eyes © With the departure of Colonel Fleming for duty in the Pacific Theater* the Gas Casualty Division in the course of an office reorganization became The Gas Casualty. Branch of the Divi- sion of Preventive Medicine* 13 January 1945© It continued to function as such until 11 June 1945© Gas Casualty Branchy Division of Preventive Medicine0»» The policies and functions under which the Gas Casualty Division had operated remained unchanged when the work was incorporated into the Division of Preventive Medicine # They were founded on the many advances in medical knowledge of chemical warfare made in recent years# Outstanding among them were the rapid first aid measures*, marked by the trend to self°aid as much as possible® Definitive treatment was determined by developments in research and the study of actual cases 0 Maximum utilization of Gas Casualty supplies was stressed*, with location of the materials at points where gas casu- alties were expected or were to be received* (Figure 2) Special attention was directed to training and instruction of units most likely to be concerned in the medical service of gas casualties# Policies ®—First aid against gas was based on the principle that each soldier must be trained to carry out personal decontamination 2 Figure 1 Problems encountered in a gas barrage are simulated for U. S. Array nurses by the Chemical Warfare Service at the American School Center, Shrivenham, England, September 1944. Figure 2 Two soldiers at the gas school in Northern Ireland wearing impregnated clothing, January 1944. on tho spot as his own responsibility and become familiar with the means available to him in the field to render this first aid© It followed that he was not to give up ground in the face of chemical attack* but to utilize these aids and his gas mask in continuing tho fight0 (Figure 3) Policies were reflected in three theater directives initiated by the original Gas Casualty Division in 19i4i+o Methods previously designed for reception and handling of gas casualties had largely been based on employment of elab- orate decontaminating chambers with facilities for bathing0 This obviously entailed lines of contaminated individuals awaiting their turns for shower baths© In line with established policies on first aid and to eliminate lines of contaminated individuals* a scheme was developed in which the decontamination chamber was largely eliminated, enabling a maximum number of cases to bo handled in a short time© The disposition of gas masks of personnel having communi- cable diseases, was left to the discretion of the responsible medical officer© If he considered the mask a possible source for the spread of communicable disease* disposition of the same was described© In addition to the measures mentioned in training for first aid, steps were taken to assure adequate knowledge of chemical warfare medicine among Medical Department personnel© Special direc- tions and equipment for treatment of gas casualties were grouped and issued© Activities ©--Training in the medical aspects of chemical warfare required repetition at frequent intervals© In order to clarify the policies of the theater for medical units* personal visits were made to hospitals for conference with commanding officers and gas casualty officers of each installation© Indoctrination in the theater policies of chemical warfare medicine was accomplished* and return visits made several months later at which time inspections were made to determine the standards of proficiency attained by the personnel© Hospital centers were afforded the primary indoctrination and thereafter carried out their own inspections* using a standard inspection check list© Nine ports and sub-ports of the theater were visited for conference with port surgeons in regard to medical service of gas casualties resulting from air attack or accidents with chemical cargoes© Kit Water Testing first of the newly developed kits for testing water g&fvhe presence of poisons and 3 for quantitative determination of chemical agents in water was re- ceived in the theater during the last week in December I9I4I4.0 The supply of these kits was not sufficient to permit distribution, but the equipment was demonstrated to the gas casualty officers of the several Armies that they might be familiar with it and the auxiliary kits to accompany them© The regular item was ultimately made avail- able and the first of the auxiliary kits was received 3 January 19U5« This auxiliary kit supplied a means of determining the amount of fluorine in water© Reestablishment of the Gas Casualty Division--With the return of Colonel Fleming to the European Theater* on 11 June 19U5 the Gas Casualty Branch of the Division of Preventive Medicine was again constituted as an independent Division of the Office of the Chief Surgeon and so functioned until the cessation of theater operations 0 Personnel©--The direction of the Gas Casualty Branch of the Division of Preventive Medicine was the responsibility of Lieutenant General Albert M© Johnston, M©Co, assisted by Captain Francis D© Brown, M©Co The staff included two enlisted men trained in chemical warfare medicine© Fi gur e 3 Periodic inspection of gas masks in the 83rd Infantry Division at Courtil, Belgium, January 1945. FIGURES lo Problems encountered in a gas barrage are simulated for tJ, So Army nurses by the Chemical Warfare Service at the American School Center, Shrivenham, England, September I9I4I+0 2o Two soldiers at the gas school in Northern Ireland wearing im- pregnated clothing, January 19l+i*o 3» Periodic inspection of gas masks in the 83rd Infantry Division at Courtil, Belgium, January 19U5» A HISTORY OF PREVENTIVE MEDICINE IN THE UNITED STATES AMY 1941 - 1945 PART IX - Sanitation By Colonel John E, Gordon, M.C, Chief of the Division of Preventive Medicine Office of the Chief Surgeon, ETO TABLE OF CONTENTS PART IX Sanitation Page Poll els s and punctjLozis ooooooooooooo«oe«*e 1 Personnel of the Sanitation Branch at Theater Headquarters* » 3 Water Supply 0000000000000000000000*0 il Water Supply in the British Isles ooooooooooo 5 Purification oooooooooooooooooooooo 5 StOTag6 000000000000000000000090 7 Bacteriological Control ooooooooooooooo© 8 Ha r cine s s of Wa ts r oooooosoooooooooooo 8 Sterilization of Ylater Mains ooooo«o.oooo.o 9 Water Supply in Continental Operations 0 o o o 0 o o « o 9 Purification oooooooeoooooooooooooo 10 Water Supply in Redeployment Staging Areas ooooooo 11 Wa ter Oi s c i p11ns oooooooooooooooo«ooo 11 Water Supply in Occupied Germany oooo.oeo.ooo 11 Water Supply in Prisoner of War Enclosures ooooooo 11 Difficulties in Winter Operation of Field Purification Units 0 0 0. 0 0 0 0,0 0 00 0 0 0 0 0 0 0 0 0 0 oooo 12 Bacteriological Control ooooooooooooe.oo 12 and Unit Purification of Water ooooooo 12 Municipal Supplies oooooooooooooooeooo 13 Page Beer and Other Beverages llj. Disposal of Wastes 16 Garbage •••••••« 16 Human Wastes «••••••••••••••••••••• 16 Pit Latrines (■••o*.********** • 18 Incineration of Feces ••••••••••••••••• 18 Bath, Ablution and Kitchen Wastes ••••••••••• 16 Sewage Disposal Plants ««••••••••••••••• 19 Sewage Disposal on the Continent 20 The Vidangeur 21 Field Methods of Disposal ••••• ••••• 21 Mess Sanitation «•••••••*•• 21 Mess Kit Laundries ••••••••••••••••••• 23 Chemical Treatment of Mess Gear •••••••••••• 2i4. Selection of Camp Sites and Camp Sanitation ••••••••• 2I4. Camp Sanitation in Staging Areas •••••••••••• 23 Camp Sanitation on the Continent •••••••••••• 23 Camp for Displaced Persons and Prisoners of War • • • • 26 Motor Convoys ••••••••••••••••••••• 26 Sanitary Surveys ••»«••«••••••••••••••• 26 The Monthly Sanitary Report •••••••••••••••*• 31 Rodent Control .oo0«««**»««««,««««*«##32 Pago InSCCt Control ooooooooooooooooooooooo 33 Insect Problems of the British Isles oooooooooo 3ii Insect Control on the Continent ooooooo.o.oo 3JL4. The Control of Insects ooooooo<.oooo»ooo* 35 Control of hums n Lice 00000000000000*00 35 Body Lice 000000000000090*00 00000 3^ Application by Individual 000000000000000 36 Mass Treatment of Individuals With Dusting Powder 0 o 0 36 Control by Use of Spray on Body and Fumigation of Garment Soooooooooooooooooooooooo 37 Delousing Garments 0000000000000000000 3® Head Lice 000000 00000000000000000 3® Crab LlCe OOOOOOOOOOOOOO OOOOOOOOO 39 Control of Adult Mosquitoes, House Flies, Bed Bugs, Fleas and Cockroaches 00000000000000000 39 Methods of Application 0000000000*00000* 39 Pests for Which .Residual Sprays are Suggested 00000 I4.O Be d Bugs 000000000000000000000000 i^l FleaS oooooooeooooooooooooooooo ij-l Cockroaches 0000000000000000000000 ill Aerosol Insecticide Dispensers 0000000000000 1+1 DDT Larvicides for Control of Anopheles and Other MOSqUitOeS ooooooooooooooooeoooooo ill Page Insect Control (Continued) Control of Anopheles Larvae 42 Application 42 Aqueous Emulsions , 43 Dust Form 43 Other Methods of Application ....... 43 Use of DDT Against Culicine Larvae. 44 Repellents for Mosquitoes, Biting Flies, Fleas, Mites and Ticks , . 44 Mosquitoes 44 Fleas, Mites and Ticks 4$ List of Figures PART IX Sanitation So many new fields in Preventive Medicine have been ex- plored and developed in recent years and so much of the emphasis in Preventive Medicine has turned from a consideration of things to one of people, that the true place of environmental sanitation in the maintenance of health tends to disappear from viewc Good sanitation has cane to be such a part of life, and particularly of American life, that it commonly is taken wholly for granted« The sharp jolt to complacency that can come from failure to observe the basic principles of environmental hygiene has been clearly dem- onstrated in those parts of this presentation concerned with typhoid fever and the diarrheas and dysenteries® Environmental hygiene still remains the basic discipline of Preventive Medicine, the foundation upon which programs and procedures are built® An improved level of accomplishment in environmental sanitation has cane from the increasingly evident extent to which trained sanitary engineers have taken over responsibility in this field* The modem engineer brings to these problems a kind of ex- perience and an attitude which few medical practitioners possess® The actual practice of sanitation in the European theater in unit areas was the responsibility of the unit commander0 He had the assistance of his unit surgeon® The policies of major commands came from Divisions of Preventive Medicine at Headquarters of those commands, and Surgeons at that level almost invariably had sanitary engineers on their staffs on whom they depended for the development of procedures and the supervision and direction of work*in sanitation® The guiding policy for the theater centered in the work of the Sani- tation Branch in the Office of the Chief Surgeon® The Branch was headed by a sanitary engineer, and his staff was made up of engineers and entomologists® The medical aspects of the work were effected through coordination with other branches of the Preventive Medicine service, particularly those of epidemiology and laboratories, and through the chief of the service® The Sanita- tion Branch was primarily an organization of engineers and medical technical experts® Policies and Functions®—The supervision and control of water supplies occupied first place among the fields of interest in sanitation0 The disposal of wastes was an important concern, primarily because of its relation to the potability of water, although of itself it contributed greatly to the decenqy and comfort of living and had a bearing on many phases of the main- tenance of health* The second general activity had to do with the cleanliness and orderliness of military installations, with attention devoted first to the sanitary facilities of camps, posts, and stations$ and secondly to the mechanism of mess operations* The third division of activity was related to the control of insects and of rodents* important as these considerations were in the general program for limitation of the communicable diseases, the pest element was of no minor concern and the economic aspects have long been adequately appreciated* The stated divisions of interest serve to give a broad conception of the work in Sanitation but fail to take into account the many diverse activities which enter into the conduct of a modern program of environmental hygiene* Perhaps more than any other part of the Preventive Medicine Service, the group in Sanitation found overlapping interests with the other branches of the organization, particularly with those of Epidemiology and Military Occupational fftrgiene* In the administration of professional medical affairs in the theater, it sometimes appeared that matters which failed to fit with any of the established divisions of the Office of the Chief Surgeon found their way to Preventive Medicine* Be that as it may, if they came to the Division of Preventive Medicine they were referred more commonly than not to the Sanitation Branch* A definition of policies to govern the work in sanitation was formulated in the early days of the theater and remained essentially unchanged throughout the course of operations* They were stated as follows: (1) To advise and make recommendations on all problems of water supply and water purification, sewerage and sewage disposal, waste disposal, rodent and insect control, housing and sanitation* (2) To investigate relevant sanitary situations in the field and to evaluate procedures followed and results obtained* (3) To make inspections of the sanitary facilities and sanitary conditions of proposed and existing camp sites, camps, billets, and stations* (A) To establish with the laboratory section a satisfactory organi- zation for the routine control of the potability of water supplied to existing camps and stations* (5) To provide consultation and technical aid in the emergency disinfestation of buildings, quarters, and other installations in respect to flies or other insect pests* 2 (6) To collaborate closely with the Quartermaster Corps and the Corps of Engineers in the provision of facilities for protection against lice, and for disinfestation of military personnel,, (7) To assist in investigations of communicable diseases which have a direct relation to environmental sanitation* (8) To assist in the establishment and enforcement of standards of sanitation* (9) To effect liaison with British and civilian and military personnel and organizations in allied fields* Personnel of the Sanitation Branch at Theater Head- quarters0 —Affairs of sanitation were a general function of the division until 24 July 1942 -when Major (later Colonel) Query C0 Cushing reported for duty as theater entomologist* In addition to the technical duties associated with his specialty, he carried general responsibility for work in sanitation until it was organized as a special branch of the Division of Preventive Medicine under an expert sanitary engineer, Lt0 Colonel Ralph C„ Sweeney, on 12 October 1942* The association of Colonel Sweeney with the Division and the theater was short lived, because of the need for assigning him to other duties in the Mediterranean area0 He was succeeded on 29 October 1942 by Major (later Lt0 Colonel) Ralph R0 Cleland, a sanitary engi- neer with much experience in Great Britain through his preceding connection with the Hospitalization Division of theater headquarters* Colonel Cleland directed the operations of the Sanitation Branch from late 1942 until 10 February 1945o His principal assist- ants were Captain (later Major) Edmund J* Marzec, who joined the staff 18 January 1943* and Captain (later Major) James K* Latham, whose service dated from 8 June 1943» Captain Robert M* Lingo and 1st Lieutenant, (later Captain) James T* Gibbs, served for short periods before taking up duties in base sections* Lt* Colonel Ralph C* Sweeney, returned to the theater from the Mediterranean area as a member of the forces of the Southern Line of Communications in the invasion of southern Prance* He succeeded Lt* Colonel Cleland as director of the Sanitation Branch on 7 March 1945 and remained in that position until the following June* The activities in entomology were continuously under the direction of Major (later Colonel) Query C* Cushing* He had as assistants Major Ralph W* Bunn, whose service dated from 25 June 1943* and C&ptain William L* Barrett who served on temporary duty from the First Medical General Laboratory for varying periods of time* 3 Water Supply Water Supply®--Like most features of Preventive Medicine, the problems of water supply in the European Theater were greatly- influenced by the nature of the operations in which troops were engaged at the moment, the conditions under which they were housed, and the country in which they were stationed® During the long stay in Great Britain conditions were not essentially different from those of camp life in the Zone of the Interior• Many troops were in fixed installations, oftentimes in camps previously occupied by British troops® Water was usually drawn frcm old established water supplies, in many instances from municipal sources that had existed for years and whose sanitary qualities were well known® The unusual demands of troops often overtaxes existing supplies and augmentation was frequently necessary® Many times emergency purification measures had to be installed® The result was that every water supply did not reach the standard to which soldiers had been accustomed in America and much education was necessary to change the too frequent attitude that any water drawn from a tap was safe® Field methods of purification were only employed to meet emergencies, and individual purification of water was almost unknown in Great Britain,, Not until troops moved into the marshalling areas in preparation for the invasion of Normandy did the Lyster bag make its appearance in any numbers and many troops were there introduced for the first time to the conditions of water supply which mark operations in the field,, Conditions on the continent were wholly another matter,, In the early days of the campaign the soldier came to depend in large measure on the individual methods of purification which he himself employedc The need for water discipline became a part of every day life<> When unit water supplies came into existence, they were field water supplies„ Safe water was supplied, but it was of limited quantity, not too easy to get, and it had to be chosen with care0 Service troops and others in fixed installations many times had the advantage of established and ordinary water supplies as conditions became stabilized, but the soldier of the field Army continued to depend in large measure upon the water the Corps of Engineers could get for him and the quantity that they could reason- ably supply,. Not until field operations ceased in May 1945 did American troops return to the conditions which had characterized camp life in the United Kingdom,, 4 Water Supply in the British Isles0—Water in the British Isles was never abundant0 The British public was not accustomed to the amount of water supplied to the average inhabitant of the United States, a country which is probably the most wasteful of water in the worldo The average consumption per capita by the American soldier in Great Britain was about one-half that to which he had been accus- tomed,, Much of this was a matter of necessity,, The size of the streams in the United Kingdom was much less and the density of population much greater,, A situation comparable to a third of the population of the United States concentrated in an area the size of South Carolina does not provide sufficient catchment area to be especially liberal with water,, A severe drought also prevailed in England from 194-2 to 1944 and brought about a situation sufficiently serious to require a rigid conservation of water to meet the needs of troops and of the country as a wholeo The scales for water to be supplied to troops came about through mutual agreement by the Medical Department, the Corps of Engineers, and the British War Office„ The amounts were based on imperial gallons per person per day, an imperial gallon being the equivalent of about lo20 United States gallons0 Where a water borne Sewerage system existed, 20 gallons per person per day was provided all establishments other than hospitals, where patients were allowed $0 gallons per dayc Where no water borne sewerage system existed, all established units other than hospital patients and men living in temporary tented camps were allowed 10 gallons per person per day* Hospital patients received 40 gallons, and men housed in temporary- tented camps had five gallons„ An allowance for vehicles of various types was also estab- lishedo Other than tanks* all vehicles had an allowance of 10 gallons per day and tanks irrespective of size received 40 gallons0 While the quantities provided were much less than those to which Americans had been accustomed, (200 gallons per day is not at all uncommon in American cities) on the whole the quantities allowed proved ample for most sanitary purposes when economy was practiced and an individual sense of responsibility developed,, Purification., ~~Re gar dless of the presumed or established quality of a water on the basis of previous experience* chlorination was required of all water supplied to United States troops0 This precaution was necessary by reason of the altered conditions associ~ ated with troop installations0 Water supplies were in many instances overtaxed* as were the facilities for purification,. The altered 5 conditions of a wartime existence tended to disrupt ordinary control of procedures for water treatment, and bombing incidents introduced emergency problems© The reliance on past history and performance of a supply was no longer justified© Most water supplied to American troops came from munici- pal water supplies, which were seldom chlorinated to an extent that met American Army standardse Sometimes chlorination had not been employed previously and it was necessary to introduce that process© To meet minimal militaiy standards auxiliary chlorinating systems were installed at the source or more commonly chlorinating apparatus was introduced into the course of the mains that delivered water to the camps© (Figure 1) Deep wells were a common source of supply where water was not taken from nearby municipal supplies0 Chlorination was ordinarily the only treatment required* Standard British practice in chlorination differed from that ordinarily employed in America in that the usual method was chlor- ammoniation© This arose from the strong objection on the part of the consumers to the taste of chlorine so regularly associated with simple chlorination*, Chlorammoniation requires a long period of contact for water purification, compared with ordinary chlorination, and sufficient storage facilities to provide at least four hours detention during periods of peak flow were commonly lackinge Consequently the British War Office agreed to the application of chlorine alone as the type of purification to be furnished United States camps© Newly installed plants were of this nature© Chlorination by hand treatment often had to be employed in the storage tanks of the many castles and manor houses used for quarter ing troopso These tanks were usually uncovered and often located in inaccessible attics0 In some instances they had to be rebuilt in order to insure a safe water* The shortage of chlorinators which existed in the early days of the theater was overcome by dividing the chlorammoniators provided by British manufacturers in such a way that the dual apparatus consist- ing of an ammoniator and a chlorinator were both used for simple chlor- ination© Whenever practicable, a residual chlorine content of 0©4 parts per million was maintained© The only exceptions permitted were instances where properly treated municipal supplies were furnished to distant stations© 6 Figure 1 Elevated water tank built by British contractors for U. S. Forces, England, January 1943. Water supplies from deep wells, after adequate treatment with chlorine, although hard were usually relatively pure as de- termined by bacteriological tests0 Surface supplies and others containing much suspended matter were sometimes subjected to coagulation, sedimentation, and filtration through steel pressure filters„ These more elaborate systems of water treatment were limited almost entirely to water supplies furnished to hospitals0 Adjustment of the alkalinity and hydrogen ion content of water was rarely necessary, but when corrosion of water lines occurred or the possibility of plumbo-solvency existed, lime, soda ash or sodium silicate was added0 Taste and odor problems were uiv- common, one of the outstanding experiences being a heavy infestation of a hospital water supply with Synura0 Super-chlorination was em- ployed to remove a fishy taste and odor from the filtered water <> Storageo—When water supplies were taken from a municipal water supply having reservoir capacity sufficient for two or more days total supply, storage facilities at military installations were limited to 25 percent of a normal day*s supply, except where a long or vulnerable main existed or where the distribution system was heavily overloaded, in which case a storage requirement sufficient for a full day was mandatorye Storage of water sufficient for one day was likewise required when water was obtained from supplies lo- cated within camps or other installations„ (Figure 2) Storage tanks were constructed of available materials such as timber, brick, steel or concrete0 Those used for domestic water supplies were covered in the most economical manner practicable, in order to reduce growth of algae by excluding sunlight, and to prevent pollution from accumulation of leaves, dust, and other extraneous matter* Cross connections between static storage tanks for fire protection and the sources of potable water existed many times* Through faulty construction, the inlet pipe was often submerged below the water surface0 Correction was accomplished by severing the inlet pipe above the surface of the water* Such uncovered static water tanks were a familiar part of the British war time scene* They were built at ground elevation and located in suffi- cient numbers throughout a given installation in order to store water for fire fighting* They were augmented with suction hose, pumps and discharge hose lines* British public health regulations required the installa- tion of storage tanks inside dwellings and other buildings in 7 order to break the connection between the water supply and the heat- ing system. In many of the manor houses and other buildings requisi- tioned for troops, the storage tanks were not covered and bacteriojLog- ically satisfactory water supplies could not be provided until the tanks had been cleaned, chlorinated, and covered* Bacteriological Control„—Bacteriological analysis of water supplies of all stations of the theater was required at monthly inter- vals, In the early days of the theater this was not possible and such water examinations as were made were through the assistance of British municipal and public health laboratories. By August 1942 the labora- tory facilities of the United States had reached sufficient develop- ment that monthly routine examinations were thereafter made mandatory. Many of the examinations were made at the First Medical General Laboratory, and the services of that organization were avail- able to all units of the theater* Probably the greatest proportion of such tests were performed at laboratories of station and General Hospitals, Instructions were issued on the proper technic for obtain- ing samples to be submitted to laboratories. Experience had demon<- strated that reports indicating an unsatisfactory water arose in a number of instances from lack of care in obtaining a sample of a water which otherwise met all prescribed requirements. Bottles for the col- lection of water samples contained sodium thiosulphate to neutralize the residual chlorine. Reports of water examinations were made to the unit Surgeon submitting samples and to the Surgeon of the Base Section, Air Force or Army to which the unit was assigned. The environmental examination of a water source has long been recognized as a consideration of equal importance with labora- tory examinations in determining the satisfactoriness of waters for human consumption. Upon reqeipt of laboratory reports of a non-potable water a field investigation was made by a representative of the Surgeon of the major command concerned, with the purpose of tracing the source of contamination. What had been considered a safe water supply could often not be so classed until chlorination was establi- shed or other means practiced for protecting the water system, such as covering elevated storage tanks, ferreting out cross connections or sterilizing mains. Hardness of Water,—With the exception of seme localities in Wales, northwest England and Scotland, the water encountered in the United Kingdom was regularly hard, especially that derived from 8 Figure 2 Field demonstrations of pump and filter units of a portable water purification apparatus, England, December 1942. deep wells® Water softening by the water authorities on the scale practiced in the United States was relatively uncommon in Britain0 Consideration was originally given to the intro- duction of water softening plants for treatment of general supplies but the lack of available equipment precluded that practice® As a substitute, zeolite softeners were commonly in- stalled on dish washing machines and for the water furnished hospitals for operating rooms, nose and throat departments and laboratories, where the hardness of the water exceeded 100 parts per million® Sterilization of Water Mains®~~The standard British practice in sterilizing newly constructed water mains was to fill the mains completely with a solution containing 10 parts per million of chlorine, which was allowed to remain in the main for four hours® This amount of chlorine was increased to 50 parts per million for a period of 24 hours, and even that was not always effective, as illustrated by the experience of one hospital where repeated treatments were necessary, although the water came from a satisfactory municipal supply® Water Supply in Continental Operations„-~The restrictions on the amount of water supplied to troops which is such an intimate part of operations in the field, first went into effect when the Ground Forces entered the marshalling areas in southern England in preparation for the invasion of the continent,, Conditions approxi- mated those of an active campaign,. Water was hauled to the camps in trucks and provision was made to supply quantities of three and < half gallons per man per day„ Troops were carefully instructed in water discipline, were warned that the quantity of water would soon be still more limited, and were further advised that the quality of the water in the country soon to be invaded was far from that to which they had been accustomed,, For the first two days cf the assault, the water allowance was two quarts per man per daye In plans for the construction of Communications Zone installations on the continent, the amount of water allocated was five United States gallons in instances where a waterborne sewerage system did not exist, and 15 United States gallons per man per day when such provision was present,. The amount of water supplied to combat forces in the course of operations varied a great deal and was largely governed by the particular circumstances under which they were operating,. No average figure can be given for the usual consumption of water by units in the line„ A common figure was about one gallon per man per day„ Naturally when troops entered rest areas or were in 9 reserve in semi-static installations, the amount of water provided was much greater. Purification,--Water for the forces in the field was secured primarily from water points operated ty the Corps of Engineers, who made use of any available supply irrespective of its quality, such as rivers, lakes, ponds, wells or whatever was at hand, (Figure 3) The water was filtered, using the United States Army portable water purifi- cation unit, model 194-0, with a rated capacity of 75 gallons per minute. Several deficiencies in the purification process were observed under actual field operations, which made it necessary to revise the procedures. In the first placd, the use of ammonia gave rise to chlora- mines ; and the high nitrogen content of many surface waters likewise contributed to the same effect. The rainfall in the autumn of 1944 commonly produced an excessive turbidity of surface waters. Filters were often operated at more than the rated capacity and the necessary pre-coagulation and sedimentation was not always practiced. To eliminate these operational faults and to assure the removal of entamebae, precise and altered directions were issued in respect to sedimentation and coagulation processes in the operation of the standard field water purification units, (Figure 4) The prescribed method of treatment provided a one hour period of coagulation, settling and prechlorination, followed by filtration at a reduced rate of ten gallons per minute for the portable unit instead of fifteen gallons per minute; and sixty gallons per minute instead of seventy-five for the mobile unit. When first introduced this procedure was required only in selected instances, A comprehensive survey by the Sanitary Engineer of the Third Army showed a far greater proportion of waters to be non- potable by bacteriologic standards than was desirable. Regulations were therefore amended to make pre-chlorination, coagulation and settling of waters Universally obligatory prior to filtration except in emergen- cies and on specific permission of Surgeons of major commands. General institution of this procedure not only improved the quality of the water bacteriologically, but clarity and taste were better. An increased output of the filters likewise resulted, in spite of the lower rate of filtration that was used, because filter runs were increased with a consequent saving in backwash water. The general improvement effected was shown by the experience of the Third United States Army for the autumn of 1944* Only 51 per cent of waters examined bacteriologically in August were potable. The proportion was increased to 72 percent in September, and in October the rate was 85 percent. Tests during November showed 89 percent of all waters examined to be potable and December 95 percent. 10 Figure 3 A portable purification unit and settling tank is operated by the 1142nd Engineer Group, Ninth Army, at Gulpen, Holland, March 1945* Figure 4 German Prisoners of War waiting to draw water, Germany, April, 1945. Water Supply in Redeployment Staging Areas®—-The construction after the war ended of tented camps in the Assembly Area Commands to house transient populations of over 750,000 men in connection with redeployment activities, placed an excessive demand on the available equipment for field water treatment„ Although standard scales provided five gallons of potable water per man per day, experience indicated that a minimum of ten gallons was desirable„ The available equipment was insufficient to treat the required quantity of water® Wells were drilled where satisfactory supplies of ground water could be obtained at a reasonable depth, and treatment plants for surface waters were installed where equipment was available® Coagulant was added to the water by means of a simple solution feeder prior to mixing and settling in tanks having a holding time of from one to two hours® The treated water was passed through pressure filters at a rate of three gallons per square foot per minute and chlorin- ation accomplished by pipe line chlorine feeders® Water Piscipline0--Water discipline in combat units im- proved as soldiers became accustomed to field conditions® Epidemics of common diarrhea due to water borne infection were always un- common and eventually became a rarity0 More untreated nonpotable water was ordinarily consumed by Ground Force troops in the rear areas than in the forward zone, primarily due to the natural laxity and letdown associated with rest areas and fixed installations, but also through leave in municipalities not having approved water supplies o As for troops of the Communications Zone, many units had • spent considerable periods in Great Britain or were newly arrived from the United States® The common attitude toward any water coming from a tap was that it was potable and that it was the responsibility of others to see that it was so® Such water supplies were frequently used when not authorized in spite of definitely posted instructions to the contrary® Water supply in occupied Germany®—As the troops of the Army of Occupation took up their duties effort was made to remedy sanitary defects in existing water supplies and to bring them to the level of United States Amy standards of potability® The general policy was to release troops from the obligation of using field methods of water purification! in a way a matter of necessity be- cause with the cessation of operations water discipline expectedly deteriorated® Water supply in prisoner of war enclosures0—-The large number of prisoners captured and held in Germany toward the end of 11 the war placed too great a demand upon the available water treatment equipment* (Figure 5) It was impossible to furnish a completely treated water and chlorinated river water was frequently piped into the enclosures* Difficulties in Winter Operation of Field Purification Units.—Operational difficulties were experienced during the winter due to freezing of water tanks, filters, barrels and hose lines during extremes of cold weather, (Figure 5) The difficulties were usually overcome by installing the filter and pumping equipment in a pyramidal tent heated with a tent stove or other heating unit; by draining the filter, hose lines and pumps when not actually in use; and through re- circulation of the water in the settling tanks, clearing them well when not in use, or installing an immersion type heating unit in the tank. The canvas storage tanks often froze to the ground, with ice sometimes reaching a thickness of more than six inches around the base. The tanks were moved with difficulty, and damage occurred with resultant leaks * Bacteriological Control*—During the early days of operations on the continent sufficient laboratory facilities were not available to accomplish the monthly examination of water supplies practiced in Great Britain, Furthermore, units changed location so frequently that bac- teriological examination of a particular water supply was rather useless. Water points shifted with equal frequency* Examinations for residual chlorine were consequently stressed as the most reliable index of a safe water. Bacteriological examination was required only of samples taken from water points operated by engineer units and not from the provisions of the individual water users* Waters originating from sources other than official water points, usually munic- ipal or other fixed supplies used by static units particularly of the Communications Zone, were examined* As the campaign progressed and condi- tions became more stabilized, laboratories came into operation and the routine examination of water supplies was resumed* The service was pro- vided by hospital laboratories, by the Medical Laboratories of Armies and by the central laboratory service in Paris, Individual and Unit Purification of Water,—Field methods for purifying water ih small quantities by the individual soldier consisted mainly of the newly developed Halazone tablets* Units employed lyster bags with hypochlorite* The prescribed two Halazone tablets per canteen were many times insufficient for proper purification because of the high chlorine demand of the water. Sane divisions introduced instructions re- quiring three tablets of 4 mgm„ each for clear water and four tablets for turbid waters. Eventually this became general practice in most field armies of the theater. 12 Figure 5 A water tower near the front line, Haguenan Area, France, in January 1945* The standard treatment of water in Lyster bags involved the addition of one ampule of calcium hypochlorite per Lyster bag of water<> This also frequently proved insufficient to produce a potable water, and additional ampules were added until orthotolldine residual tests for chlorine indicated an available chlorine content in excess of one part per million« Municipal Supplies*—Satisf actorv municipal supplies on the continent were the exception* In many instances battle or bomb damage had disrupted the municipal water purification plants* Where that had not occurred water purification practices commonly failed to meet United States Amy standards, in that rates of filtration were too high, insufficient sterilization was practiced, laboratory facilities were lacking or the avails able personnel for operation of water plants were improperly im- pressed with the necessary responsibility* The Paris water supply system was excellent* For the most part municipal supplies on the conti- nent were derived from shallow wells, surface streams, or from springs in the surrounding hills9 in which case water was secured by means of collecting galleries0 Filtration was ordinarily accomplished by the slow sand process9 European styleo The water was first run into roughing filters where the filter bed consisted of a layer of coarse sand to a depth of about 70 centimeters0 Following that5 the water passed through the final filters having approximately the same depth of sand but of a much finer size„ Rates of filtration varied from 15 to 30 cubic meters of water per -square meter of filtering surface per day for the roughing and from 4 to 8 cubic meters per day for the second stage of filtration,. Although the rates of flow were greater than those normally employed in the United States9 a fairly good water was usually obtained0 Purification by chemical means was accomplished by chlorine gas or Eau de Javelle (sodium hypochlorite solution)* Ozonation was used by some water authorities but chlorammoniation was not practiced as generally on the continent as in the United Kingdom* Whatever the method of treatment it was usually im- possible to detect residual chlorine in the water as it left the purification plant, for the reason that rates of application of chlorine varied from 0*02 to 0*20 parts per million| quantities which were more than consumed by the chlorine demand of the water* 13 Largely for this reason municipal supplies were rarely approved for use of United States troops unless the water was subsequently treated by Lyster bag or the Halazone method, Deep wells were not a common source of water supply as in the United Kingdom or in the United States, Gas fed chlorinators and hypochlorinators became more readily available in early 19and many units especially hospitals were provided a potable tap watero Chlorinators were most commonly installed on the mains leading from municipal supplies to the occupied buildings, although complete municipal supplies were sometimes chlo- rinatedo The existing javelle water feeder was placed in operation wfith the dosage sufficiently increased to assure a potable water* Beer and Other Beverages * Under conditions in the British Isles the problem of morals was not as significant as it was during continental oper- ations o The language was similar or at least understandable, and the soldier readily adapted himself to the life of the countryo The Special Services organization helped him in this, but one activity not sponsored by Special Services was the custom he developed of visiting the local British pub which ordinarily was within walking distance of any American installation* Here he had opportunity to talk with the average man of the country, for the British pub is the poor man’s club; and while so doing he had opportunity to drink his beero The opportunity to obtain such beverages on the continent was more difficult, especially in regions such as Holland, Belgium, and Luxembourg, The particular service that was needed was for com- bat troops. The greatly increased frequency of poisoning by methyl alcohol among troops of the line through drinking nondescript liquor was a principal reason for providing through army auspices a safe and relatively innocuous drink. Furthermore the troops came back to rest areas in bivouac or in quarters in towns where the existing facilities for relaxation wore over taxed and provision necessarily had to be made by the army. The morale of a soldier resting after combat was an important consid- eration© The brewing industry in the countries concerned had a repu- tation famous for centuries but many manufacturing plants had suffered deterioration or partial destruction as the result of the war, • It was essential that the beer provided come from a sanitary environment and be free from disease producing germsj and assurance was further- more necessary that the product had not been deliberately poisoned by the enemy® An inspection team to make special surveys of facilities for providing beer and soft drinks included a sanitary engineer, a toxicologist and a beverage expert from the Special Services Division at Headquarters, BTOUSAo The engineer checked on matters of sani- tation connected with the brewing industry such as water supplies, cleaning of vats, hose lines, bottles and tanks? sanitation of toilets and lunch rooms within the brewery, and the personnel hygiene of the employees., The toxicologist was concerned with the possibility of poisoning, either deliberately or by accident, and with toxic effects which might develop from the processes employed, such as the use of sodium fluoride in maintaining clean hose lines* The Special Services Officer was primarily concerned with procurement and distribution of the final producto The possibility was originally considered that the bacte- riological standards established for water might apply to beer, particularly the absence of coliform organisms., This was found later not to be true* Most specimens of beer contained lactose fermenting organisms not necessarily indicative of fecal contamin- ation® This was due to various factors® The fermentation tanks, in many instances holding thousands of gallons of beer, could not be adequately sterilized® Bacteria survived the fermentation process and subsequent storage for several months® Barrels and bottles likewise could not be sterilized® The normal peacetime practice was to coat the interior of barrels with pitch Just prior to each filling, but shortage of pitch and of fuel to heat it did not permit this practice® The water used in the production of beer often came from private sources, commonly owned by the brewery and located on the premises® Purification of the water was not attempted, because it interfered with the taste and production of beer® Principal stress in the measures introduced by United States authorities was to assure that the product was produced under satisfactory sanitary conditions, that employees had the necessary physical examinations, and that practices in personal hygiene were in compliance with the usual standards for food handlers® Sodium fluoride was eliminated as a measure for cleaning rubber hose lines and chlorine substituted as a sterilizing agent® 15 Most of the breweries were found acceptable when operated under conditions of American sanitary control* No instance ever came to the attention of army authorities of an outbreak of intestinal in- fection traced to beer. (Figure 6). Disposal of Wastes ' Garbage.—The nature of the food consumed by troops in the European Theater, consisting as it did so largely of dried eggs, boned meat, dehydrated vegetables, and the various types of field rations, materially lessened the quantity of garbage, and left little residual waste. The active campaign of food conservation contributed to the same end. The standard practice for disposal of garbage wastes required segregation of materials into four groups* The first was edible garbage suitable for feeding to animals* Non edible garbage was distinct from combustible trash such as paper and boxes not suitable for salvage, and from material such as ashes and bottles* In the United Kingdom edible garbage was universally sold to civilians for animal food* British law required that this be done for all wastes of civilian origin and the United states Army cooperated in respect to materials derived from American military installations* Garbage, less grease and bones which were required to be salvaged, was sold at a price of fifteen shillings ($3*00) p©r month per each 100 men assigned to a mess* The arrangements for sale were effected through the British Command and the British Catering Advisor of the district in which the camp or station was located* Grease and bones were col- lected in separate containers and given to the British through the same channels provided for the sale of garbage* In order to prevent foot and mouth disease, bones were required to be boiled before leaving the kitchen* Garbage and other waste materials presented few problems on the continent* Materials were usually given to civilians, buried or burned* The difficulties occurring in municipal areas were usually those which ajroae through disruption of collection facilities* Human Wastes.--The disposal of human wastes in the United Kingdom wa£ aggravated by the limited volume of the streams suitable for disposal by dilution*. A policy was therefore adopted that except where water supply, site conditions or accessibility to existing sewerage systems made provision of water borne sewerage more practical, that bucket or pit latrines would be used*. The bucket method was mdst 16 Figure 6 Testing beer before distribution to First Army troops in Belgium, November 1944. commonly employed with buckets provided on a scale of five per hundred ien<, Pit latrines were used only in occasional instances, although preferred to bucket latrines when in the opinion of the Senior Regional Medical Officer of the Ministry of Health their use did not endanger'water supplies or otherwise affect public health. The wastes from bucket latrines were disposed of by civilian contract wherever practicable0 when that could not be arranged, disposal was accomplished by troop labor, either by emptying the material in a nearby sewergge system, by burial in shallow trenches or pits in which case approval was necessary from a representative of the British Ministry of Health, or by incin- eration where frequent use was made of the Army School of Hygiene feces destructoro Pit latrines were more commonly used in the days immedi- ately preceding the invasion of Normandy, especially in the marshalling areas. Fortunately the area involved made this possible, for the supply of buckets approached exhaustion with the increased troop strength that had to be served and the difficulties in dis- posing of wastes which accumulated in such large amounts within limited areas. The bucket latrine method of feces disposal had many disadvantages,, It was a method of disposal foreign to the American soldier and he often ridiculed its useo A man will straddle a trench under field conditions but using a bucket for the same purpose in a fixed installation was not accepted with enthusiasm,, The disposal of the bucket contents and the maintenance of a satis- factory sanitary state of the latrines was often accomplished with difficulty because of the limited number of civilian contractors,, When disposal was of necessity done by military personnel it was an objectionable and disagreeable assignment0 Buckets contained two percent cresol solution to a depth of about one inch, for the purposes of controlling odors. The de- odorant was in critical supply and many times could not be obtained. Under agreements effected with civilian contractors the empty buckets were supposed to be washed, but the satisfactoriness of the result depended upon the individual operator. In some instances bucket washing equipment was installed. The disposal of bucket contents by contractor was again not always satisfactory from a hygienic standpoint, because of the common practice of composting the material with manure to make 17 fertilizer* Burial led to the same undesirable effect as came from the use of pit latrines. Dumping on the surface of the ground by irresponsible contractors led to pollution of streams. Pit Latrines.—It was unfortunate that pit latrines could not be used feasibly* In the first place the density of the population in many sections of the British Isles made it difficult to obtain land for this purpose, so located as not to contribute a health hazard through endangering water supplies* Much of the southern part of England also had a superficial underlay of chalk which because of its geologic nature and the readiness with which fissures formed, led to contamination of underground water supplies* The high water table in many sections, especially in the midlands and Bast Anglia, at times within a foot of the surface, precluded the use of pit latrines* Other considerations were decidedly advantageous to properly constructed installations. Flies were not present in the numbers found in the United States, and temperatures were not sufficiently high to cause nuisances from odors* Incineration of feceSc--Disposal of feces by burning was utilized only as a last resort and the practice was unsatisfactory at best* The British Army developed a flash burner utilizing crank case oil and water* Combustion of organic matter did not take place until the liquids had been evaporated and the cooking process was responsible for decidedly offensive odors in the absence of a strong breeze to windward* (Figure 7) Other difficulties arose from improper location of the apparatus* from the fact that gases could not be burned in the stack as the design contemplated and because the metal parts of the incin- erator burned out or buckled from the intense heat® It was difficult under any circumstances to charge the incinerator with fecal matter without spillage® It is apparent that the operation of the apparatus was not a task undertaken voluntarily by American soldiers* Prisoners of war were sometimes used for the work, but incineration never proved an acceptable method for the disposal of human wastes* Bath, Ablution and Kitchen Wastes.--Even for bath, ablution and kitchen wastes where preliminary grease trap treatment was prac- ticed, disposal by dilution was not satisfactory and in many cases caused water of streams to be unfit for cattle drinking aside from considerations of human health. Where complete sewerage systems wore not available to re- ceive liquid kitchen, bath and ablution wastes they wore disposed of 18 Figure 7 Feces incinerator, British design. by soakage pits or tile drainage fields where soil conditions and water tables permitted© Chemical treatment ins ullage tanks was otherwise employed© Disposal by the methods first mentioned was not often practicable and the design for tented and hutted camps and hospitals usually provided for sullage tanks© Sullage tanks were constructed of brick or concrete, varied in capacity from two to five thousand gallons, and had the necessary valve arrangement for decantation and sludge removal* Liquid wastes were received through sewers and the tanks operated on the fill and draw method* ferrous sulphate in solution was added at the rate of 3*5 pounds per 1000 gallons and the contents stirred for 20 minutes, following which a milk of lime solution was added at the rate of JLi.*8 pounds of the dry chemical per 1000 gallons* After additional stirring and settling the supernatant was run off into a stream or ditch or allowed to soak into the ground* The precipitated wastes were drawn on to sludge drying beds when appreciable quantities had accumulated* Sewage Disposal plants,,—■'The sewage disposal plants con- I f structed for United States installations in Great Britain followed \j standard British practice and were designed by civilian firms acting as consulting sanitary engineers to the British War Office* (Fig- ure 8). Sedimentation tanks provided for ten to fourteen hours detention of sewageo Trickling filters had a rated capacity of 'JO gallons of sewage per cubic yard of filter medium per day* Subse- quently the material was passed to humus tanks where it was held for four to six hourso The final part of the process made use of sludge drying beds so designed as to give 1*3 to 1*5 square feet of surface per capita* (Figure 9)- The British operating procedure had the disadvantage that during the treatment daily withdrawal of raw fecal matter was re- quired direct to the sludge beds© In cooperation with the Corps of Engineers a bulletin was prepared outlining methods of operation which assured that no nuisance was created© Under this procedure sludge was withdrawn at intervals of ten to fourteen days© During summer months the sludge was retained in the primary sedimentation tanks as long as the sludge capacity permitted or until septic action resulted in rising solids and lowering of efficiency of the trickling filter© A lime treatment process was introduced employing hydrated lime which was added to the raw sewage entering the primary tanks© 19 This acted as a precipitant and produced an innocuous sludge which drained more readily. Addition of lime was at an average rata of 50 pounds per thousand gallons of sewage. Standard British practice for smaller plants required that sludge drying beds be filled by successive drainings onto beds containing sludge which had been partially drained and dried. The process was changed so that the beds were completely filled at one time and dewatering was thereby enhanced. The chlorination of sewage effluents was not practiced. Ponding often occurred on trickling filters from ex- cessive loads and small size of filter medium, which in many instances varied from one-half inch to one inch. When ponding occurred the British practice was to remove the stone to a depth of six inches and replace it with new stone. It was determined by experiment that improved results followed when the surface of the filter was covered with high test hypochlorite for several successive days, the rate of application being one-fourth pound of the chemical per square yard of filter medium. In many instances it was necessary to replace an unsatisfactory filter medium with one of larger size. Coke was used in early operation of some of the trick- ling filters but was later discontinued because of the need for conservation of fuel. Vitrified clinker, slag, or hard stone was substituted. The effluent derived from sewage treatment plants at United States Army installations was generally unsatisfactory be- cause of the high biochemical oxygen demand* Treatment plants at hospitals gave the greatest difficulty* The design, construction and operation were often unsatisfactory and many times plants could not be operated efficiently at the rated capacity. Since the British War Office was responsible for the quality of the effluent, the responsibility of the United States Army was limited to testing the results of treatment and to offering recommendations. Chemical precipitation with lime proved satisfactory in plant tests but failed under actual operating conditions because of improper appli- cation of the coagulant. Sewage Disposal on the Continent.--Because of the unsatis- factory design and construction of sewageplants in Great Britain new standards were prepared f«r the continent wherein the sedimentation 20 Figure 8 Sewage Disposal Plant under construction by British contractor, England, January 19-43. Figure 9 Sewage Disposal Plant at Langford Lodge, North Ireland, January 194-3. tank was replaced either by a septic or an Imhoff tank. Little actual construction of permanent sewage treatnent plants was aver done because of the availability of permanent sewerage facilities where water flushed toilets were used. Other than units of the Services of Supply in permanent stations the movement of troops was so rapid from Normandy to Germany that little need existed nor was much thought given to the development of permanent sewage disposal facilities. The Vidangeur,—In the absence of sewerage systems the continental practice in collection of human excreta marde use of water-tight vaults or cess-pits, As the vaults filled, the contents ware pumped into tank trucks0 The vidangeur who accomplished this task was as important a member of the community as the baker, the butcher or other village tradesman, Because of the disrupted conditions in the wake of the war many of. the vehicles employed in the trade were out of commission through lack of parts, or had been destroyed. Consequently many U, S, Army vehicles were turned to this use when required by the needs of installations occupied by United States troops. This system of disposal was limited to towns and stations where troops were more or less permanently located. It was not selected by choice but was simply a question of making use of facilities that were available. New fcOnstruction was not under- taken except as no other alternative existed. The method was again decidedly unfamiliar to the American soldier but in general he ranked it ahead of the British bucket latrine from an esthetic standpoint. Field methods of disposalThree methods were used in the field for the disposal of human excreta, cat-holes, straddle trenches and pit latrines, Pit latrines could be used satisfactorily almost anywhere on the continent, in contrast to the conditions which existed in the United Kingdom, Before formally developed facilities became available to hospitals in course of construction, bucket latrines were commonly used for patients in wards and pit latrines for the hospital personnel. Convenience more or less determined excreta disposal or its lack under combat conditions, A man does not have much choice in the course of street fighting or whan he is pinned down in a foxhole• Mess Sanitation From a sanitary standpoint primary distinction is to b made between the messing facilities provided troops housed in permanent installations and those available to them under field 21 conditions. In Great Britain and on the continent the Ground Forces usually used field equipment for messing. Practice among the Air Forces was more diverse® The Eighth Air Force in the United Kingdom generally developed fixed installations for messing and field methods were uncommonly employed® On the con- tinent the situation was essentially reversed® The Ninth Air Force was a tactical unit working closely with troops and transfers of loca- tion were frequent® Consequently field conditions of messing were almost universally employed® Practice was more mixed for the Services of Supply and the Communications Zone® In the United Kingdom a large proportion of units lived under fixed conditions and had regularly established messes® A goodly number of organizations were under field conditions, especially engineer construction units and others® Hospital installations which entered so largely into the complement of Service Forces messed almost entirely under fixed conditions® On the continent the Communications Zone like the two other major components of the army operated primarily under field conditions and made use of field messes® Hospitals were the common exception, other than principal headquarters® The facilities provided organizations making use of permanently constructed kitchen and messing arrangements rarely compared with those of the Zone of the Interior. Those in the United Kingdom were provided largely by the British through lend-lease arrangements, and were less elaborate than those of the United States Army at home. This came about because of the policy initiated by European Theater headquarters early in 19U2 that time, materials and labor should not be devoted to elaborate construction with the exception of hospitals. The whole program was predicated on a brief stay in Great Britain which length- ened nevertheless to more than two years. Door and window screens were not often provided, and stoves and ovens were of a type not considered modern by American standards. Floor drains were often lacking and grease traps poorly designed. Storage facilities for perishable foods were not always adequate. Hospitals were usually provided with modern kitchen equipment such as dishwashing machines, sink and hot water facilities for pots and pans, well drained concrete floors and screening. The simplicity of field arrangements for messing made for a ready control of sanitary arrangements® Each soldier cared for his own messing utensils and community dish washing presented no problem. Rations were issued daily and perishable foods were so few that storage gave no difficulty® Garbage and other wastes were readily buried or incinerated, and conditions likewise acted to make the 22 amount of this material minimalo Left-over foods which so commonly caused trouble in messes of fixed installations, were usually discarded under field conditions rather than stored for future consumption. Under all conditions hospitals with well ordered permanent installations of kitchen equipment and messing facilities fared very well. So did the troops in the field because of the simplicity of their arrangements. The greatest difficulties in mass sanitation from a theater standpoint were associated with those units, principally of the Services of Supply, which had neither one nor the other. Living under temporary semi-pemanent conditions and consequently not using field methods of messing, they also lacked permanent equipment, and the makeshift arrangements under which they functioned were far from satisfactory, Many were housed in old manor houses, in hotels, barns and other buildings where the space allowed for kitchens and mess halls was too limited. The greatest difficulties, and the most frequent accidents in respect to outbreaks of diarrheal disease occurred in these situations. Mass Kit Laundrieso--The standard method for washing mess gear when troops were first stationed in Europe made use of three galvanized iron cans with a capacity of about 25 gallons. The first two cans contained hot soapy water and the third a boiling rinse water. The procedure was changed in 191+3 so that only the first can contained hot soapy water and the remaining two had boiling rinse waters. The change from a practice which had endured in the army for so many years required no little attention through education and demonstration, (Figure 10). Much British equipment was used by troops in Great Britain in mess kit washing*, Three 12 gallon soyer stoves were adapted to the American procedure., This varied so greatly from American standards which provided three 25 gallon galvanized iron containers for 250 men, that scales were changed to provide three such cans for each 125 men. Accumulated experience proved that three containers under either scale were insufficient for proper washing of mess gear and a modification was introduced whereby two additional containers were addedo The first can was placed at the head of the mess line and used for sterilization of mess gear immediately before its use, a process which came to be known as the “pre-dip*1*, The second was placed ahead of the soapy wash can in the washing lino, contained plain water was designed to remove coarse 23 food remnants, thus easing the load on the standard three cans. Excessive loss of heat made it difficult to secure and maintain boiling water. The immersion type water heater which is easily the most practical heating arrangement was available to only a few ground force units. Regulations were revised permitting the use of the burners of steel ranges for this purpose. Many units improvised burners that used gasoline as fuel, because of the shortage of British Soyer stoves and also of the United States field type rarge. (Figure 11). Most of the devices were of simple construction and easily dissembled for transportation, but had the disadvantage of danger from explosion when fired by personnel un- familiar with the device® The washing and disinfecting of dishes and mess kits was aggravated in many instances by the excess hardness of the water, inadequate facilities for heating water, and a shortage of cleaning supplies. Excessive hardness was mitigated through use of various water softening compounds, that known as "Gusto1* being most efficient. Gusto was a non-caustic alkaline detergent containing sodium carbon- ate and sodium metasilicate. The chemical was added to the hot soapy wash in proportions of three-fourth of an ounce, about a tablespoonful, per gallon of water and did much to eliminate the gummy deposits and greasy film that formed as a result of the reaction between soap and the calcium and magnesium salts present in the water. Chemical Treatment of Mess Gear.--Chemical treatment of rinse water was advocated and practiced when boiling water could not be obtained. Chlorine solution as prescribed in Field Manual 3-UO was first used, with one ounce of Grade A hypochlorite added to 25 gallons of water to give a concentration of at least 200 parts of chlorine per million. "Mikroklene** was subsequently recommended by the War Department. The package was of such size that when the contents were added to 25 gallons of water the resulting solution was deemed sufficient for disinfecting the utensils of 200 men for one meal. Chemical treatment was never considered a satisfactory substitute for boiling water. Selection of Camp Sites and Camp Sanitation The selection of camp sites on the continent was by ne- cessity limited to tactical rather than sanitary considerations. (Figure 12). Ip the United Kingdom considerable latitude was allowed sanitary officers in respect to proper location of camps to the extent that factor affected the health and morale of soldiers. 24 Figure 10 Water for mess kit laundry is heated by an immersion heater in the bivouac area of an armored division, Prance, September 19-44-. Figure 11 Improvised mess kit laundry unit at the Medical Field Service School, England 194-3. Figure 12 Artillery men pitch their tents beside their "self propelled 105" - 7th Armored Division, St. Vith, Belgium. January 194-5. Camp and hospital sites were selected in the United Kingdom by representatives of the Medical Department, the Corps of Engineers and of the British Ministries of Health, Food, and Agriculture.) Because Britain had to import the majority of her food supplies there was constant reluctance to devote land suitable for farming or grazing to military purposes© The general policy was to locate camps on land not suitable for other purposes© (Figure 13)» In the early days of I9h2 when air raids were common during day light hours, much emphasis in the selection of camp sites was placed on cover and concealment© Located in wooded areas or on poorly sloping ground, troops and their equipment found difficulty in keeping dry© Lack of sunshine not only affected health but decidedly influenced morale© In the course of time and as control of the air by allied forces was establi- shed this became a less pertinent consideration© Other considerations entering into the selection of camp sites pertained to drainage, water supply, prevalence of insects, rodents and proximity to civilian communities© Camp Sanitation in Staging Areas©°~The concentration of large numbers of troops in southern England just preceding the departure to Normandy brought special problems in camp sanitation© Never before and never thereafter were so many men crowded into such a small space© Each man was especially trained for a difficult assignment ahead and in the event he became a noneffective, replacement was not easy at that stage of military operations© Much stress was therefore placed on mess sanitation and personal hygiene© Commanding officers, cognizant of their responsibility, were held to strict account of violation of existing sanitary orders© Water supply and dewage disposal problems were more easily solved than those relating to mess sanitation, of which some of the difficulties have already been described© Camp Sanitation on the Continent©--Despite the more difficult "situation presented to troops by active operations, camp sanitation during the continental operation was consistently good© Repeated observations were made of the excellent condi- tion in which troops left camp sites after bivouac for a day or two in an open field© The general behavior in the maintenance of environmental sanitation was a credit to the American soldier© 25 Camps for Displaced Persons and Prisoners of War.—The subject can be epitomized by stating that almost without exception there were too many people for the facilities available# (Figure Uj.) Prisoner of war camps fared well enough during the orderly progress of operations in France and in the early days in Germany. The difficulty came with the end of the war, when the number of prisoners overwhelmed existing facilities. The sanitary situation which then existed so often has been brought out in the discussion of the out- breaks of dysentery and typhoid fever which were a direct result. The provisions that were made for displaced persons were always extemporized. In general, use was made of vacated German installations previously used for troops. Many were former casernes, far from modern and almost without exception tremendously overloaded. The problem was further complicated by the mixed population of men, women and children. Lack of sufficient military personnel to provide the necessary supervision served to aggravate the situation because most of the people living in the camps had been so unaccustomed to elaborateness in provisions that pride in environmental surroundings had largely disappeared. Motor Convoys0--Some of the poorest practices in camp sanitation arose in connection with motor convoys. The long supply lines across France made necessary overnight temporary staging by drivers in the long trips from ports to the front. Men in permanent installations developed a pride in their surroundings. The same was true to a considerable extent of organized units however housed. It did not hold for motor convoys, in a camp for a night and rarely ex- pecting to see that place again0 Disposal of excreta was not in con- formance with field methods and trash in the form of empty ration containers was indiscriminately discarded along the route. The Preventive Medicine Service was instrumental in initiating improved conditions in sanitary arrangements of convoys in road movements# Sanitary Surveys The Advance Section, Communications Zone, followed closely upon the Armies as they proceeded across the continent# As the first Communications Zone unit to enter liberated or occupied terri- tory, this organization had the obligation to stabilize and organize conditions for the permanent Base Sections that followed, for the Advance Section continued to move forward in support of the field Armies# The Advance Section performed these functions for the First, Third, Ninth, and Fifteenth Amies and the Continental Advance Section for the Seventh Army# 26 Figure 13 Lobscombe Corner Camp, Wiltshire, England, July 194-3. Figure 14. Prisoner of War Enclosure at Langenzenn, Germany, May 1943. A principal part of the duties of these two organizations was to perform sanitary surreys of the principal communities occupied., These cities and towns were the future centers of troop concentra- tions* The justification for the surrey was the need to know what health hazards existed and what health problems might be anticipated* A certain indefiniteness about health conditions always existed when any army arrived in a new locality* All possible in- formation had been collected by the Medical Intelligence Division of the Office of the Chief Surgeon during the long period of prepara- tion preceding D-Day, but only inspections on the spot gave a clear idea of conditions* Only actual survey determined the extent to which health hazards had been increased as a result of physical destruction and disruption of public services* Sanitary surveys were desirably made prior to the arrival of troops assigned to permanent occupation, in order that knowledge of necessary action might be promptly in their hands when they arrived* This was not always possible because troop locations sometimes had not been determined but many times it was possible to anticipate that certain cities would house appreciable concentrations of service troops* In the course of this work some forty surveys were performed in France and Belgium prior to 1 December I9I4J4.0 In the rapid developments that took place during the remainder of the war the number appreciably exceeded a hundred* The responsibility for preliminary sanitary surveys was assigned to the Preventive Medicine Division of the Office of the Surgeon of Advance Section* Ordinarily they were made by officer teams, consisting of an epidemiologist and a sanitary engineer* Information was collected on the general physical conditions of the area and on the particular parts which had been occupied by military forces* Special attention was given to water supplies, facilities for waste disposal, and to bath facilities* Data were collected on insect and rodent problems, on food and nutrition and on the pretence of communicable diseases* Information was obtained from a variety of sources, but civil affairs detachments and town majors were always visited on arrival in a new town* The Hotel de Ville was next visited in order to meet the civilian officials and gain detailed facts about the sanitary facilities of the community* Depending upon the size of the town, calls were made on the major, the chief of public works, director of water service and the director of public health* These officials proved to be uniformly cordial, cooperative and helpful 27 and either accompanied the officers or arranged for them to be guided on a tour of inspection* Each city presented a different situation and often special information was required from other sources. For a town of less than 30*000 population, all of the required information could usually be obtained in a single day# Larger cities required more time for an adequate survey# The maximum use had to be made of the few hours at the disposal of the inspecting team, with schedules arranged so as not to require an interview with municipal officials between 1200 and II4.OO hours. The first stage in the study of any community was to obtain a broad general idea of the area, including topography, population, industry and the degree of war damage suffered# As would be expected the sanitary problems in port cities were usually more acute than those in market towns and the industrial cities of Northern France and Belgium presented different problems than those encountered in Normandy# Information was secured on the number of United States troops located in the town, the nature of their quarters or bivouac and the estimated troop strength# The proposed future troop strength could rarely be predicted with any degree of certainty and the sur- veying officers were forced to the most unfavorable situation and to make their recommendations accordingly# The public -water supply was the subject of the most thorough investigation# As. in the United States, ownership of the water supply system was sometimes municipal and at other times private# The sources varied from rivers to shallow wells and in Northeastern France and Belgium springs and infiltration galleries were most common. Treatment of the water suppdy varied markedly# The most common defect was the failure to chlorinate adequately# Only exceptionally could a chlorine residual he determined in water from the distribution system# Bacteriological analyses when per- formed differed in procedure and interpretation compared with United States standards and the results were not always helpful in evaluating the quality of water# So few water systems showed an approach to the standards adopted for the theater that hope of rehabilitating them sufficiently for use by Advance Section troops without significant alterations was usually abandoned# The sewerage system was investigated in each community. Combined sewers were almost universal, carrying both sewage and 28 atom water® Of the towns surveyed, only three of forty made any attempt at sewage treatment® The disposal plant of one of these had been damaged and was not in operation; a second practiced sewage irrigation, while a third used sedimentation tanks® The normal procedure was to discharge the raw sewage into a nearby stream untreated® Very few cities were completely serviced by a public sewerage system® Cesspools, septic tanks, bucket latrines and common privies were found in varying numbers in different sections of the country® Barracks and schools to be used by American troops were commonly equipped with septic tanks or cesspools® A practical problem always to be anticipated was how to get them desludged® In some parts of France every town had a vidangeur who in normal times contracted for cleaning and desludging of cesspools and septic tanks® Whether such a contract was avail- able or not always had to be determined® In some localities field type latrines were recommended as the best expedient® In others, ordinary pit latrines were not feasible because of the nature of the soil and bucket latrines were recommended® In this event, satisfactory methods of disposing of the bucket contents had to be found® Garbage and trash disposal readily become a sanitary hazard where large numbers of troops are stationed® An effort was made to anticipate such a problem by selecting in advance a satisfactory method of disposal® Municipal incinerators in an operational condition were rarely found® The most popular method was to use garbage and litter in making sanitary fills® Before recommending a dumping ground, the site was inspected® The better sites were maintained by civilian employees who raked, leveled and covered the organic matter in the dumps® Only those so remote as not to be a nuisance were recommended for military use o Bathing facilities were surveyed in each town. Although it was not the function of the Medical Department to provide shower and other bathing facilities it was their responsibility to inspect such installations. In some areas Quartermaster Corps operated shower points were provided. In others existing public baths and showers were used* of which some were operated in a sanitary man- ner and some were not. In Belgium two of the principal cities were found to have modern natatoriums with equipment for treatment and recirculation of water. 29 The possibility of insect and rodent problems was always considered in each of the sanitary surveys. Fly breeding was a problem to a moderate extent in some coastal areas. Yellow jackets were a nuisance to the troops in the field during warm weather* Rats were observed but never became a serious menace. Food was scarce even in rural communities except for items produced locally* Sugar was scarce in Normandy and fats in northern France* Rationing was everywhere strict particularly in Belgium, but nowhere was starvation encountered and for this the credit was generally given by the informant to the black market* Communicable disease among civilians was carefully in- vestigated* The long period of German occupation, poor communi- cations and indifference had resulted in very meager and inadequate reporting of communicable disease in most of the towns and cities visited* Where records were available a high incidence of intestinal disease was usually determined* Diphtheria had been endemic in all communities and epidemic in many* Intensive campaigns for the active immunization of children had in the past year brought this disease reasonably well under control, even though the rates remained far higher among adults than were common in the United States. Scabies increased as the soap supply diminished. An attempt was made to trace to their source cases of typhus occurring within the previous year* On several occasions illnesses reported as typhus were found to have been typhoid fever. Information on the prevalence of prosti- tution and of the venereal diseases was not included in the sanitary survey since a separate venereal disease survey was made where indicated. The recommendations which concluded the reports of the sani- tary survey were worded in such a manner as to apply to unit commanders of troops in the particular town or city. The most common recommenda- tions were the prohibition of the use of water from the public supply for drinking or culinary purpose without further treatment; in respect to disposal of excreta and other wastes; explicit directions for the use of existing dumping ground for garbage and trash; and the use of public baths and showers* Special recommendations were added in some reports, such as the use of bathing beaches in one coastal area. The reports of sanitary surveys were forwarded through com- mand channels and information copies were sent to other services con- cerned* Where there was an area commander he received a copy. Copies were also transmitted to the appropriate Base Section to assume command when the area was released from control of the Advance Section. 30 The Monthly Sanitary Report A report to be submitted routinely by units engaged in active operations in the field must have demonstrated merit to warrant its justification,. The monthly sanitary report rendered by Surgeons of each separate unit was always considered a necessary part of operations and an essential source of health information,, While the reports were sometimes stereotyped and lacked interest, the majority contained facts of value in solving existing problems, in planning operations and in anticipating deve lopments „ The sanitary report was a document transmitted through command channels and consequently was slow in arriving at the headquarters levelo The delay was many times so great that it failed in the purpose for which it was originated, which was to act as a corrective a gent© To overcome this deficiency a procedure was adopted early in 19U3 whereby a carbon copy of the report was sent directly to the Office of the Chief Surgeon in addition to the regular report which followed through channels© It was under- stood that this information would not be used as a basis for of- ficial action but merely as a method for gathering information© It did lead to a well developed concept of general theater prob- lems and permitted the extent of common difficulties to be deter- mined at a time when remedial action could be undertaken to advantage © An individual record card was maintained in the Sanitation Branch of the Division of Preventive Medicine for each unit of the theater, on which note as made from material derived from the Sanitary Iteport of sanitary deficiencies or undue prevalence of communicable disease© Formal recommendations made when the official copy of the report was received were likewise recorded© If satis- factory action did not follow or if conditions failed to improve, field investigations were instituted either directly from theater headquarters or through Divisions of Preventive Medicine in base sections or other major commands of the theater to determine the reasons for failure or to stimulate action© Analyses were likewise made of theater practices in sanitation, to determine prevailing levels of accomplishment and fluctuations in results© For example each unit gave the results of the monthly bacteriological analysis of the water supply© Not only was this of value insofar as the particular 31 supply was concerned, but cummulative data demonstrated the trend of accomplishment in management of water supplies throughout the theaters The same system was employed with respect to other features of environmental sanitation and hygiene, and also for prevalence of the communicable diseases* When action by other agencies of the military organi- zation was required, or recorded items were of general import, the sanitary report was circulated to the appropriate division of the Office of the Chief Surgeon or to other arms and branches of the service* letters most commonly concerning the Corps of Engineers had to do with housing, bathing, water supply and sewage disposal* The Quartermaster was the responsible authority in a position to take corrective action for affairs connected with food, clothing, sanitary supplies and fuel* Material contained in the Monthly Sanitary Report was often of general value and interest and formed the basis for articles on sanitation and descriptions of new devices which were published in the monthly Medical Bulletin of the Office of the Chief Surgeon for dissemination throughout the theater* During the course of operations a report resembling in some essentials the Monthly Sanitary Report but containing more detail of professional interest came into being as a monthly re- port to the War Department* This was the Sssential Technical Medical Data report. The need for it developed from long delay of the ordinary sanitary report in transit to the Zone of Interior Tke Monthly Sanitary Reports from units of the theater were a common source of material for the report* Rodent Control The American forces in Britain were largely relieved of the responsibility of rodent control by reason of the energetic program of extermination maintained by British authorities through the course of operations* The British interest in rat control arose more from the need for food conservation than for control of communicable diseases* The Ministry of Food, the Ministry of Agriculture and the Ministry of Health joined in a comprehensive campaign against rats in most of the principal cities of Great Britain. Great stress was placed on public health education with popular campaigns and instructions to farmers and others in methods of combating rodents* Zinc phos- phide was the principal rodenticide employed, although red squill 32 was also used, but to a limited extent because of the difficulties of supplyo American Medical Officers in North Ireland encountered a novel method of attack on rats which made use of ferrets and dogs. The organization of this method had been brought to a high level, but was scarcely suitable for military practice0 Because of the general program of rat extermination, relatively little difficulty was experienced in American military installations in respect to rats* Measures wore instituted by military authorities as circumstances required, but more commonly the local rat extermination team of the county was called in aid* Instructions wore issued by the theater that authorities of all American military installations were to cooperate with the organized British effort, American personnel commonly made use of barium carbonate and trapping, but the joint effort was more commonly an application of the British method* As minimal as the rat problem had been in the United Kingdom, conditions on the continent were even better* The Monthly Sanitary Reports rarely mentioned the presence of rodents and no report from any source came to headquarters of an undue prevalence of rats, even in port areas0 Local situations occasionally demanded the attention of commanding officers but as a theater problem rodent, control did not enter into consideration* S Insect Control Provisions for the control of insects ivere among the earliest preventive measures established in the European Theater0 Medical entomological problems in the European area were not as numerous as those in subtropical and tropical areas, but laxity in recognizing and controlling the major difficulties which did exist could well have been disasterous to military operations* The principal effort was in louse controls, The care with which methods were developed and the plans made for putting them into action were evidenced by the very favorable results obtained in the control of a serious outbreak of typhus fever in 19i+5o The second major concern was that of mosquito and malaria control. The part that the entomological service placed in the control of these two important communicable diseases has been presented in detail in previous discussions. Opportunity will be taken here to discuss some of the minor 53 problems in insect control, the development of technical methods for insect control and to outline the procedures which became standard practice in the theater* Insect problems of the British Isles»--fintomologioal problems during the time that troops were stationed in the United Kingdom were of a minor nature* Flies-were prevalent in many localities to the extent that they created a nuisance* In the first year of the theater screening materials were not procurable and insecticidal sprays were available only in small quantities. That flies constituted a problem in England was not admitted by local health authorities* That they were present in many camps was evident by comments in sanitary reports# As the theater developed, screening was provided for buildings concerned with food preparation and ness halls with the result that the latter years in Great Britain saw improved conditions* Other than for sporadic infestations of pubic lice the troops were practically free of pediculosis* Periodic checks were made of troops newly arrived from the United States to determine whether in- festations of lice and scabies were being contracted on board trans- ports* No infestation was found among the troops examined* Investigation and assistance in the control of minor local outbreaks of roaches, bedbugs and harvest mites constituted the principal field activitieso Insect control on the continent•—The entomological service in the Preventive Medio1ne Division came into its own with the onset of active field operations, beginning with the first days of the cam- paign when problems of mosquito control developed in Normandy* Mosquito control continued an active interest throughout the course of activities* The nature of the problem and the methods employed are to be found in the discussion of malaria* The first indication of need for attention to the problems of infestation with lice came to the fore in the lull in fighting which preceded the November offensive* Isolated instances of louse infestation were reported from field armies, the circumstance of greatest extent involving some 100 men* This experience brought a request for attempted development of louse-proof underwear for combat soldiers because of the difficulty of keeping troops supplied individually with anti-louse powder* With limited materials obtained from British stocks experimental trial of the method was undertaken among soldiers of the Ninth Army but on too limited a scale to come to definite conclusions* 3h A survey of 1800 units in December and 1500 others in January including men of 23 and divisions respectively, showed that about 0,5% of units gave some evidence of infesta- tion with body lice but the total number of individual infesta- tions in all units was less than 100o The infestation usually occurred in combat troops who had slept in quarter* recently vacated by German soldiers or civilians., The great value of the educational work on louse control was exemplified by the fact that the few infestations which did appear among combat troops were quickly eradicated and only rarely did the same unit have infestations in successive months® These surveys during the winter months served to assure that when typhus appeared in areas occupied by American troops, no great danger of an epidemic of typhus need be feared because of the presence of such a low level of infestation® The real test of the methods which had been developed and the educational measures which had been practiced in respect to American troops came with the development of typhus fever in early March Despite residence and operations in an area with thousands of cases of typhus fever the United States Army practically escaped infection® The activities of the entomological service in the important feature of typhus control centering in the elimination of lice, has been discussed in the presentation of control measures used against typhus fever® The control of insectsThe many newly developed materials for the control of insects which came from the experience of the war served to introduce material changes in the course of operations, into practices which were followed in the European Theater* In 19U2 the entire emphasis in louse control was on methyl bromide fumigation and on MYL powdero Subsequently DDT powder became available and the whole procedure for louse control underwent fundamental change* The applicability of these materials to mosquito control soon became apparent and they were liberally applied in that field* The practical control measures now to be presented represent practice at the close of operations in the theater® Control of human lice,—Three species of lice attack man, namely the body louse, the head louse and the crab louse. Because of the wide differences in habit, each species requires special consideration in applying control measures. 35 Body Lice*—The body louse usually spends its life in the clothes* Accordingly in looking for body louse infestation, the clothing was examined along the seams amd folds and especially on the inside of the underwear; and control measures were directed largely toward the treatment of clothing* Louse powder with a principal component of DDT was the method of choice* The powder contained 10% of this chemical im an inert carrier* It was avail- able in two ounce sifter top cans for use by the individual and in bulk for application to large numbers of persons by means of mechan- ical dusting equipment* Application by individual*—Powder from the sifter top cams was sprinkled over the entire inner surface of the underwear with special attention paid to the seams* As the powder was applied it was rubbed in evenly with the hands* The seams on the inside of the shirt and trousers were treated in a similar manner* Approximately one ounce of powder was used for one application* The treatment was highly effective and complete lethal effect on lice was usually expected in 214. hours* The powder does not destroy eggs but. remains effective sufficiently long to kill the young lice as they hatch, and one application usually eradicated an infestation* Since the lasting effect of the powder was due to residual action of the powder remaining on the treated clothing it was necessary to reapply the powder when the underwear was changed* If a general infestation was detected every individual of the unit was treated at about the same time and powder was also dusted into the bedding between the sheets and blankets and in the mattresses* Persons not infected but mingling with lousey troops or civilians or living in infested quarters were required to apply the powder in the manner described as a prophylactic measure* Soldiers in the field often found it impractical to remove their clothing for treatment* In this ease good results could usually bo obtained by unbuttoning the shirt and trousers and dusting the inside of the underwear, shirt and trousers with the powder* Mass Treatment of Individuals with Dusting Equipment.-- When it was necessary to delouse large numbers of persons, bulk DDT powder and insecticide dusting powder were used advantageously* The procedure involved the following steps* The powder compartment of the duster was filled about three-fourth full of louse powder and the duster was always used with the delivery tube on the upper side* In using the duster the operator took particular care that the powder was distributed on the inner surfaces of the inner garments and on the skin itself* The seams of the clothes, about 36 the neck, am pits, waist and crotch were emphasized as being particularly important,, Approximately one ounce of powder was required per individual,, This routine was suggested to avoid missing parts of the clothing*: In the course of dusting the subject stood facing the operator with arms extended. The nozzle of the gun was in- serted under the clothing next to the skin at the wrist and p'owder was pumped up the sleeve to the shoulder, and the operation was repeated on the other arm. The nozzle of the gun was inserted at the waistline of males next to the skin and powder directed toward each hip and the pubic area0 The subject faced about ant the dusting operation was repeated at the neck and waistline. Females were treated in the same manner except that waistline dusting was not required. The hair on the head was dusted last. If a head covering was worn it was not removed but the nozzle was inserted underneath and the dust applied. If no head covering was worn the dust was pumped directly into the hair. In most instances the hair was ruffled in the hands to distribute the powder. If overcoats were worn, they were dusted lightly #n the inside particularly about the am pits. Control by use of spray on bodyand fumigation of garments.—In some situations it was desirable to eliminate all lice present on groups of individuals, hospital patients or prisoners within a short period. This was done by spraying the individuals with delousing insecticide spray, and destroy- ing lice and eggs in garments by methyl bromide fumigation or steam sterilization. The delousing spray was either an emulsion concentrate diluted with water, using five parts of water to one part of concentrate, or an alcohol solution. Both types were effective and were used in the same manner. The application of delousing insecticide spray for the control of lice and scabies was done by trained personnel of Quartermaster delousing units or the Medical Department. The delousing ©f individuals was accomplished by- stripping the individual and while the clothing was being do- loused, the person was given the spray treatments The spray was applied by means ©f a sprayer (liquid, insect, continuous spray) ©r a power sprayer with a paint spray nozzle, to the pubic and anal regions, under the am pits and on the other hairy portions of the body. It was also applied to the head for the control of head lice. During the application 37 the individual held his fingers ever his ©yes to p re rent the spray from getting into the eyes or under the eye lidso Individuals were not permitted te bath© for at least 21; hours after treatment,, The treatment destroyed lice and eggs and the residue destroyed any escaped lioe for from several days to a week after treatment. About 50 00 of spray was required for the treatment Delousing GarmentsLice and eggs can be destroyed by the usual methodsof steam sterilization or by the use of methyl bromide ampules in dalousing bagso Especially trained details should perform this work since high concentrations of the gas are dangerous0 Exposure to lew concentrations for short periods is not dangerouso Methyl bromide should be used only out of doors or in a structure without side wallso It wall net injur© clothing and equip- ment c The times required are* at temperatures of 60° Fahrenheit or over* three-fourths of an hour? at 50 to 59° temperature, en© and a quarter hours g at I4.O te I;9®p one and three-quarter hours % and at -9 to 390 the required time is two and a quarter hourso Fumigation by this nethed requires that a numbered fumigating bag and corresponding numbered identification tag be issued to eaeh individual to be deloueed© A duplicate tag was placed inside the fumigating bag© The operator inserted an ampule of methyl bromide and olosed the bag© The ampule of methyl bromide within the closed bag was broken and the bag allowed to lie on its side for the prescribed time© The bag «f fumigated slothing was then opened in the presence of the owner and emptied on the ground, personnel standing to windward at all times© After airing for five minutes each garment was shaken out thoroughly before being worn© A vault method utilizing a gas tight chamber was available for large scale disinfestation of clothing and equipment© Operation of the above required especially trained technicians and was done by the Quartermaster Corps© HeadLi®ee«-»The presene© of suspected presence of head lice was readily revealed by examining the hair for eggs or nits0 They were destroyed by use of delousing sprays or powders© Delousing in- secticide spray was applied with a sprayer or by hand© About 10 ml* to 15 ml© was required per person depending upon the amount of hair The material was applied as evenly as possible and thoroughly rubbed into the hair, since the eggs had to be con- tacted in order to be killed© The material was removed when the hair was washed in soap and water© The treatment destroyed all lice within a few hours, but preferably was allowed to remain in 38 the hair for as long as possible to prevent reinfestation from eggs in bedding, headgear and clothing which might hatch during the two weeks following treatment, The treatment was used as a preventive by persons doing delousing work or by troops mingling with infested natives, by applying the material at intervals of about two weekso The louse powder was also effective against head lioe0 It was thoroughly dusted into the hair and rubbed in with the hands» The hat or other headgear was also dusted, The eggs were not killed by the powder so a second treatment was made one week to ten days later, The head was not to be washed for at least 2l± hours after each treatment and preferably the powder was allowed to remain in the hair to aid in preventing reinfestation. Crab Lice o—The same treatment recommended for head lice was also used effectively against crab lice® It was highly important that the material be applied thoroughly. Since infesta- tions were frequently very general over the entire body, especially on hairy individuals, treatment was applied not only to the pubic regions and to the arm pits, but to the trunk, back, leg and arm areas where hair was presento The powder was sprinkled on the body and distributed by rubbing with the hands0 About one ounce was required par treatmento Bathing was avoided for 2U hours* A second application was made after seven to ten days© The delousing spray or liquid preparation was also used, thoroughly covering the body and allowing the material to remain for 2l+ hourso It was applied with a sponge, a piece of cotton, by hand or by means of a sprayer. About I4.O ml, to 50 ml, was re- quired for treatment and one treatment eliminated the infestation if all eggs were contacted with the material. The delousing sprays, particularly the emulsion type, were also effective against scabies. One application was effective and no bath was required. Control of Adult Mosquitoes, House Flies, Bed Bugs, Fleas and Cockroaches ,-«=■ DDT residual insect spray was used in controlling insects by leaving a residual insecticidal deposit on the walls and ceilings and other places where insects came in contact with ito It remained effective for several weeks and perhaps months after treatmento For this reason it was usually not necessary to apply the residual sprays oftener than about once a montho Methods of application,—Residual effect DDT insecticide spray was the prepared residual spray stocked by the Quartermaster and was recommended for general use, A similar spray could be 39 made by dissolving delousing larvicida dDT powder in kerosene or diesel or fuel oil when staining was not objectionable. A con- centration of five per cent., about 7 ounces per gallon, was normally usedo The solution was applied as a wet spray, giving the surface a thorough covering, but not applying so much that it ran off the surface,, Hand sprayers were used for small areas. Knapsack type sprayers were used, but the nozzle should be adjusted to make a fine spray. Care should be taken to avoid such a fine adjustment that a mist forms. A disc opening the sire of a No. 60 standard wire gauge is suggested. Power sprayers were used in the same manner. The ordinary paint spray nozzle produced too fine a mist and most of the spray fell to the floor or escaped into the air. If this was the only nozzlO available it was held close to the object to be sprayed in order that the liquid would remain as a spray deposit. Insecticide DDT emulsion concentrate, an aqueous emulsion, was sometimes used instead of the DDT kerosene solution. The same equipment and method of application was used. One part of con- centrate to four parts of water produced a 5% DDT spray and was the recommended strength for most purposes. The use of insecticide DDT emulsion concentrate was authorized only for the disinfestation of clothing for the control of body lice. Pests for which residual sprays are suggested®--The spray should be applied as protection against toosquitoes to the inside of dwellings, barracks, tents, latrines, mess halls and dugouts, under bridges and to any resting place for mosquitoes within the camp site® This may include the entire inside of the dwelling, especially in the darker places, such as under beds and behind objects and in comers; screens, if present, should be treated, preferably, by means of a paint brush® One quart will cover 250 to 500 square feet® For house flies the DDT residual spray should be used where the insects are concentratedo The interior of mess halls and kitchens, including the inside and outside of window screens and screen doors, latrines, garbage racks and other favorite resting places should be sprayed or painted® Both the inside and outside of latrine boxes should be thoroughly sprayed® To prevent fly breeding, residual spray should be applied to the fecal matter in the latrine pit at the rate of 2 ounces per latrine box hole or 1 ounce per 2 square feet of pit surface® 10 percent® DDT powder can also be used to prevent fly breeding in latrine pits by using 1 ounce per box hole or 1 ounce per i+ square feet of pit surface® The liquid or powder should be applied twice weekly at first until local experience reveals how often application need be repeated® Bed bugso—The spray was applied to beds and into the cracks and crevices in walls© In treating beds it was important to get com- plete coverage of the entire mattress and bedsteado The spray was directed particularly to the springs, joints and corners of the bed- steado Dark walls were treated to a height of about six feet with special attention to cracks and crevices© One treatment destroyed an infestation and prevented re infestation for several months., Where the spray was not available, effective control was obtained by applying the DDT louse powder to the bed, bedding and cracks in the wallso Fleas*—The spray was applied to the floor and about two feet up: on the walls for the control of fleas in buildings© In living quarters a light spray should also be applied to the beds and bedding© One gallon of 3% DDT in oil served to treat an area of from one to two thousand square feet© DDT louse powder was also used successfully© Cockroaches ©--DDT spray applied thoroughly in mess halls and kitchens gave promising results in the control of cockroaches© However, information on the value of the spray deposit and duration of effectiveness was not fully determined© The DDT louse powder applied to favored hiding places of roaches, such as crevices and behind objects, proved an effective means of control© Aerosol Insecticide Dispensers*,—The one pound aerosol insecticide dispenser provided an effective and convenient method of destroying mosquitoes in tents, barracks, billets and other somewhat confined spaces0 When possible the use of aerosol bombs in trenches, fox holes, bomb shelters and similar locations by front line troops was recomnended, und such bombs were reserved primarily for such purpose*, Directions for application were stamped on the bombs, and, since the bombs were frequently used in excessive amount, it was urged that such directions be carefully followed*, The bombs were also used to destroy mosquitoes in small outdoor areas such as around gun sites.. This was done by releasing the aerosol as the operator walked back and forth in the area being treatedo It should be released as close to the ground as possible, making swaths approximately 20 feet wide*, One bomb was sufficient to treat an area of from one to two acres. DDT Larvicides for Control of Anopheles and Other Mosquitoes*,—DDT proved to be a very effective mosquito larvicide0 Small quantities of the material controlled mosquito larvae over large areas*, It was used as a dust with inert diluents, in liquid form dissolved in oils or other solvents, or in an aqueous emulsion*, It was highly effective against both anopheline and culicine larvae<, Ui Control of Anopheles Larvae0--Preparation of petroleum oil solution of dissolving larvicide DDT powder was accomplished by adding this commercial grade of DDT in crystalline form to oilso At ordinary temperatures it dissolved in oil rather slowly,* It was, therefore, advisable to keep a reserve stock of such mixtures on hand* A 3% solution was prepared by adding DDT at a rate of 2 pounds for each 5 gallons of oil® Unless such heat as that provided by the exposure of the drum in sunlight was used to hasten the action, as long as 2l± hours was required for the DDT to go into solution® Kerosene, diesel oil, fuel oil, or crank case oil dissolved the material® This con- centrated solution was applied directly where coverage could be obtained with small quantities of oil, or it was used to make dilutions of the desired concentration® Application*—The material was poured or used from squirt guns* This method consisted of applying oil containing DDT to the water surface in the simplest manner possible* The oil was applied at different places to the pool or stream and the dispersion of DDT was dependent upon the spreading properties of the oil* Waste crank case oil was used, but diesel oil or fuel oil was recommended* The quantity of oil containing DDT needed per acre of surface was depend- ent upon the amount of vegetation and debris and on the area over which the oil would spread* It killed the larvae when present as a very light film* When the oils used spread readily, as little as one to two quarts of oil, containing 3% DDT per acre, was effective if applied at a number of points over the area* In some breeding areas oils did not spread sufficiently to make this method reliable* Spray equipment was considered most reliable under a wide range of conditions0 Owing to the remarkable toxic action of DDT the amounts needed were extremely small® This must bo realized to take full advantage of the potential saving in material and labor,, Whereas oil alone was usually applied at the rate of 15 to 35 gallons per acre in mosquito control operations, equally or more favorable control was obtained with 1% DDT oil solution properly applied at a rate of ap- proximately 5 quarts per acre® With a 3% DDT solution, even amounts as small as one to two quarts per acre were effective, if coverage could be obtained by using a low delivery of fine mist0 With the type of spraying equipment usually available, it was necessary to use a lower concentration and larger quantities of spray® The spray nozzle should be adjusted to liberate as fine a spray as possible, and at a slow rate, and the spray applied so as to obtain as much drift over the water as possible® A swath width of 50 feet was suggested, although this varied with the fineness and the wind volocityc By changing the aperture of decontamination sprayer discs 42 to about 3/6Uths of an inch (36 to 60 standard wire gauge), the delivery rate of standard spraying equipment was reduced and a finer spray, was obtainedo For residual toxicity, where wind and waves did not affect the surface, a dosage of one pound of DDT per acre was used© For this dosage two and one- half gallons of oil, containing 3% DDT, was required* Aqueous Emulsionso—Insecticide DDT concentrate emulsions wore used as mosquito larvicideo It had the advantage that it merely had to be diluted with water to the desired con- centration, thus simplifying the supply problem, The material had a tendency to remain concentrated on, or to rise to, the water surface when it was sprayed as a fine misto A mixture of one part concentrate to four parts of water gave a 3% DDT spray. Application was the same as with oil sprays. For initial kill a dosage of one-tenth of a pound of DDT per acre was recommended. At this dosage one pint of concentrate controlled anopheles larvae on two and one-half acres of breeding area. One part of DDT to a million parts of water in quiet pools prevented breeding for several weeks* This dosage re- quired approximately 11 pints of the concentrate per acre of water one foot deep* In applying heavy dosages concentrate was diluted to the desired concentration of DDT and applied as a coarse spray, which tended to cause the spray to mix throughout the water* Dosages higher than one part of DDT to ten million parts of water may prove fatal to fish life, and wore not normally recommended* In situations such as temporary pools, shell holes and barrow pits where fish life was not present heavy applications of DDT were recommended in order to reduce the frequency of application* DustForm,--Control of anopheles larvae can be obtained with one-tenth pound or less of DDT in dust form per acre, This material, listed as DDT dusting larvicide powder, contained 10$ DDT in an inert diluento It was applied at a rate of one pound per acre, but to get effective distribution it was sometimes necessary further to dilute the larvicide with any inert dust. Five pounds per acre of a 2$ dust proved satisfactory in most situationso Residual action was obtained in quiet breeding areas whore vegetation was dense with the application of one pound per acre , Other Methods of Applicationo—»The methods of application of DDT larvicide suggested above were the most common, However, 43 various methods may be ©mployedo DDT in oil solution or aqueous emulsion may be used in drip pans© Fine sawdust or other materials treated with oil containing DDT for broadcasting of the larvicide in the same manner as that used for paris green-oil combinations may be effective0 Use of DDT Against Culicine Larvae*—-The materials and methods of1'application already discussed gave satisfactory control of various species of culicine larvae© However, heavier dosages of oil solutions were recommended, such as the dosage per acre of one- half pound DDT in an oil solution© In using the aqueous emulsion, surface applications of from one-tenth to one-fifth pounds of DDT per acre for a dosage throughout the water of at least 0.05 parts per million was recommended© Applications of DDT as a dust wore not highly efficient against culicine larvae which feed below the water surface, and such method was not recommended© Repellents for Mosquitoes, Biting Flies, Fleas, Mites and Ticks0--Twro ounce bottles of insect repellent may represent any one oi* several chemicals or a mixture of them® The method to use is the same, regardless of the oorapoisition of the material© MosquitoesThe material was applied to the skin by shaking into one hand one-haIf to one teaspoonful of the repellent* The hands were rubbed together and the repellent applied in a thin layer to the face, neck, ears, hands and wristBo The repellent must be uniformly distributed over the areas to be protected as the insects will seek out and bite the areas where the application is too thin, or where the material has been rubbed off© Care should be taken not to apply the material too liberally on the forehead as it causes a stinging sensation if it gets into the eyes© The repellent gave protection for from one to five hours, depending upon a number of factors, such as the rate of application, the species of insect involved, the relative humidity, the amount of perspiration, and the rubbing of treated areas© There was also an unexplained variation in effectiveness among individual users0 The repellent was a solvent of paints and varnishes, and of many of the plastics, such as watch crystals and synthetic cloth, and was to be used with caution where these materials were presento Repellent applied to clothing repelled insects for a number of days© Trousers, shirts, socks, gloves, headnets and bednets were treated© Under field conditions, where no mechanical equipment was available, thorough protection was obtained from hand application© uu About 12 drops of the repellent should be shaken into one hand, the hands rubbed lightly on socks, shirts, or trousers, where bites occur. Hand or power sprayers were used to obtain more even A power spray is preferableo Two or four ounces should be used per suite Men can be sprayed with the clothing on, with care that they protect their eyes and do not breathe sprayed materialo Clothing may be sprayed after being removed, in which case the garment should be turned inside out and but- toned* One man can hold shut the opening of the sleeves and neck of the shirt, and bottoms of the legs of the trousers while another sprays into the bag-shaped garmento Fleas, Mites, and Ticks.-~For use against fleas, the repellent was applied to exposed skin and to clothing in the manner described above for mosquitoes. While it did not prevent fleas from alighting, the fleas left the treated surface almost immediately and did not bite. Repellent acted also against mites. It was applied to the skin of the legs and arms, but was most effective and longer lasting if applied to clothing. This was done as described for mosquitoes, but the simplest method was to draw the mouth of the bottle along the cloth, applying a thin layer one-half inch wide along all openings of the uniforms inside of neck, fly and cuffs of shirt, waist, fly and tops of trousers? socks above shoes; and all edges of leggings. Clothing was treated several days before it was worn, and one application was effective until the uniform was normally changed for laundering. In protection against ticks the repellent was applied as a spray at the rate of three to four ounces to the entire outer garment * It was highly effective against immature ticks, but less effective against adult ticks0 FIGURES 1. Elevated water tank build by British Contractors for U* So Forces, England, January 191+3* 2o Field demonstrations of pump and filter units of a portable water purification apparatus, England, December 19U2o 3* A portable purification unit and settling tank is operated by the llJffnd Engineer Group, Ninth Army, at Oulpen, Holland, March 191+5° I4.0 German Prisoners of War waiting to draw water, Germany, April, 191+5 ° 5® A water tower near the front lines, Haguenan Area, France, in January 191+5 ° 60 Testing beer before distribution to First Army troops in Belgium, November 191+i+o 7© Feces incinerator, British design, Bnglando 80 Sewage Disposal Plant under construction by British contractor, England, January 191+3• 9« Sewage Disposal Plant at Langford Ledge, North Ireland, January 191+5 o 10o Water for mess kit laundry is heated by immersion heater in the bivouac area of an armored division, France, September I9I+I+0 110 Improvised mess kit laundry unit at the Field Service School, England 191+3 ° l2o Artillery men pitch their tents beside their ’’self propelled 105” - Armored Division, St„ Vith, Belgium, January 191+3 0 13 o Lobs combe Corner Camp, Wiltshire, England? July 191+3® 11+o Prisoner of War Enclosure at Langenzenn, Germany, May 191+3® A HISTORY OF PREVENTIVE MEDICINE IN THE EUROPEAN THEATER OF OPERATIONS UNITED STATES ARMY 1941 - 1946 PART X - Military Occupational Hygiene by Colonel John E. Gordon, M. C, Chief of the Division of Preventive Medicine Office of the Chief Surgeon, ETO TABLE OF CONTENTS PART X Military Occupational Hygiene Page Functions and Policies • 1 Housing • • ••••••••• • •••••• 2 Scales of Accommodation 3 WAC Accommodations* ••••*•• •• •••••• 4 Billeting 4 Heating of Quarters and Other U. S* Army Installations. * * * * 5 Ventilation • •••••••• 6 Bathing and Ablution Facilities • • • • • • • • 6 Bathing Facilities on the Continent 7 Clothing and Equipment 8 Identification Tags * * 9 Chemical Health Hazards •*•••••••••• 9 Tetra-Ethyl Lead Gasoline • • * * * 9 Poisoning from Food Containers 11 Tetra-chlorethane ••«•••••••••••••• • 11 Methyl Bromide. •••••••••. •••.•••• 11 Poison Liquor •••• 11 Types of Poison Liquor. ..••••••••••••••••• 12 Incidence of Poisoning from Liquor. 14 Incidence Among Displaced Persons •••••«•••••.•• 14 Program of Prevention «••*•••• 16 Page Prevention and Control of Accidents, , . • 16 Annual Surveys of Causes of Non Battle Injury* 16 Unit Surveys * , * * , , . , , , , * * • 18 Motor Accidents c,,,****, a,,,*,***,*,** 18 Personal and Individual Health Problems * • 19 Trench Foot* c******** *•••••••* • 20 Sources of Statistical Information 20 Cold Injury in the ETO o***,****,•*.••.**. 21 Frostbite 0000***0,0, o,*,, *»•«•*,«•* 22 Cold Injury by Services, ,*« o.******.*..** 22 Trench Foot in the Armies* o**************** 23 Distribution by Regiments* •*****.•••••••••• 23 Factors Determining Incidence of Trench Foot ••••*••• 24 Methods of Control o****, o,,,,,,*,*,*** 24 Experiences of Other Armies with Trench Foot* «•*••*• 25 I Summary o,***,*,,,*,,,***, ,,,,*,,* 26 List of Figures List of Tables PART X Military Occupational Hygiene Ihe conception of military occupational hygiene as incor- porated in the program of preventive medicine in the European Theater was in analogy with the activities generally included under industrial or occupational hygiene in civilian practice. It was concerned with the disturbances of physiological hygiene in the individual that occur under military conditions, especially in relation to clothing, personal equipment and through the operation of mechanized and other military equipment. It dealt with the personal health hazards of military life which arose as a result of an occupation as a soldier. The Military Occupational Hygiene Branch of the Division of Preventive Medicine, Office of the Chief Surgeon, ETO was activated in July 1943, Military organization in preventive medicine gives full consideration to the community aspects of the prevention of disease and the maintenance of health. Environmental hygiene has probably reached its highest development under military conditions. The control of the communicable diseases has likewise received strong emphasis in army programs of prevention. The record of accomplish- ment has been uniformly good, and the contributions made to progress in the field have been outstanding. The current military activities saw nutrition come into its own. Perhaps the major criticism to be made of preventive medicine in the United States Army is that too little attention is directed to the problems of the individual soldier. The community aspects have received full attention. Comment has already been made on the progress that the Air Force has made in relation to the health of"the individual soldier. The Occupational Hygiene Branch in the Office of the Chief Surgeon was established in an effort to bring greater theater emphasis to the field. Functions and PoliciesThe functions and policies of the Occupational Hygiene Branch are more difficult to express with pre- ciseness than those of most parts of the Preventive Medicine program, by reason of the fact that the objectives in this field aim at an individualized contribution rather than to community attention to health matters, To an extent, purposes and aims can be formalized, because prime fields of endeavor do exist, A principal part of the work has to do, however, with functions frequently considered inconsequential and therefore often neglected, but none the less bearing importantly on health, welfare, and morale,, In functional charts of the Division the guiding principles were stated as followss (1) To collaborate closely with the Corps of Engineers in the provision of adequate housing of troops, with special attention to scales of accommodation, heating, and bathing and ablution facilitieso (2) To provide consultation and technical aid to the Quartermaster Corps in determining the design and allow- ances of clothing and personel equipment® (3) To collaborate with the Chemical Warfare Service in the study and investigation of chemical health hazards associated with operations of that service; and with other branches of the service where use of toxic solvents and heavy metals contribute health hazards® (4) To assist in the development of a comprehensive program for the control and limitation of accidents incident to military operations® (5) To determine by survey and study the individual health hazards of the several arms and services, and to formulate recommendations for preventive measures® Particular attention is to be paid to operation of mechanized and technical equipment® (6) To develop and institute a program of health education directed toward the general health needs of the command, with particular attention to currently important problems* Housing®-“Almost every conceivable kind of Facility was used for housing and sheltering American troops stationed in the European theater® Necessity was often the deciding factor® Prom the standpoint of comfort, shelter varied from the ope extreme of the soldier in a fox-hole at the front to the other of a famous continental hotel housing troops of a principal headquarters (Figure 1)® / 4P The ability of the American soldier to improvise as need demanded met full challenge in many of the housing situations he was called upon to face* Irrespective of the kind of shelter that fell to his lot he developed unexpected potentialities of comfort, given a few days time (Figure 2)0 The absence of building material did not deter him from making good use of crates and packing cases and other seemingly useless building material* Even the pup tent was reinforced and added to, to the extent that at times it was difficult to recognize the original equipment. The speed with which forces were built up in the Dhited Kingdom during the summer and early autumn months of 1942 made necessary the waiving of customary standards of accommodation® Troops were housed in hutments, billets, barracks and tents® Progress in the construction program and the embarkation of large numbers of troops for North Africa served to reduce the need for tented accommodations® As the weather became colder and by late October tents were no longer used for the housing of troops® Hutments were of various types, ranging from the double walled Nissen hut to those fabricated from tarred paper* Vertical walled huts were much used, and were constructed of bricks, concrete blocks, asbestos, wood and tarred paper* In general the huts made satisfactory quarters although overcrowding usually prevailed. Ventilation became worse especially in Nissen huts as longer and colder nights developed* 2 Figure 1 Soldiers on leave are quartered in resort hotels at the U. S. Recreational Center, Rivieria, France, April 1945. Figure 2 A Maginot line pillbox serves as quarters, 6th Armored Division, Kappel, Germany, December 1944. The barracks loaned to the American forces by the British also varied greatly in type and construction* Those of modem design consisted of wooden spider barracks with quarters, washing and latrine facilities, and drying rooms all under one roof* Older barracks which served the peace time British Army were also employed* Billets were provided by almost any building having walls and a roof, and included castles, manor houses, theaters, stores, armories, schools, and churches* Some had been severely damaged by bombing and in general remodeling and repairing were to some extent necessary before they served satisfactorily* Shortage of building materials and the need for shelter often required that these buildings be used before repair work could be done* Never- theless, most troops of the theater were adequately housed in permanent or semi-permanent installations during the first six to eight months of 1943, except for some engineer general service regiments and engineer aviation battalions which were quartered in tents, usually winterized* The great influx of troops during the latter part of 1943 necessitated the extensive use of tented camps during the winter of 1943-1944* Scales of Accommodation*—Obviously scales of accommodation prevailing in the Zone of Interior could not be applied in theaters of operation. In Great Britain there were just too many people in too small a country to give desirable accommodations for all* The British civilian population had its own housing problem because of the progressive losses by bombing* The British Army had to be housed, and with the American Army added to all this, it was completely necessary to scale down our standards of accommodation to a level approximating that under which the rest of the country lived* Some apprehension was originally felt as to the effect this would have on the health of American troops recently arrived in a country whose climate offered little comfort® The housing con- ditions, together with the shortage of fuel, suggested factors predisposing to high rates for upper respiratory disease® It was a matter of satisfaction that even under austere living conditions no undue effect on health was noted and the rates for respiratory disease, as has been demonstrated, were always favorable* Even during the influenza epidemic of 1943 the housing situation pre- cipitated no appreciable problem® Scales of accommodation were established by the theater through joint action by the Corps of Engineers and the Division of Preventive Medicine, to serve as a guide to new construction and for the alteration and remodeling of existing structures® Table 1 gives construction scales for both the United Kingdom and Continental operations* It is not to be assumed that the facilities stated were always providedo Shortage of time, materials and labor 3 often made that impossible, even for so-called fixed installations and particularly for those which involved the remodeling of old buildings* The original minimal basic allowance for hutted accommodations was 40 square feet of floor space per man* As the number of troops increased it was necessary to establish austerity scales which re- duced the area to 35 square feet per man* Double bunking was sub- sequently adopted for all types of housing except Nissan huts and covered asbestos huts, and a scale of 400 cubic feet per double bunk was used in place of the regular allowance* Tented scales were of two types, those prescribed for summer and those for winter use* Eight men were quartered in a 16x16 standard pyramidal tent under the summer arrangement, which allowed 32 square feet per man* Seven men were housed in winterized tents which gave an allowance of 35 square feet to each man* Winter tented scales were in effect during the period 15 October to 15 March and tents were used only in the absence of hutted accommodations. In the United Kingdom tents were winterized by constructing sidewalls of wood, celotex or similar material and providing floors* A standard United States Type M-41 tent stove provided heat. On the continent winterizing was not done, on the understanding that occupying troops would provide floors from locally available material. The M-41 stove or a suitable substitute was furnished* WAC Accommodations.—It was generally conceded that women required more space and sanitary facilities than men. Separate scales for the Womens Army Corps were therefore established according to which a minimum of 48 square feet of floor space was allotted each person and double bunking was not practiced. With respect to sanitary facilities, a four percent allowance of showers and three tubs per 100 personnel was allotted as compared with three percent of showers only for men. The provision of washbasins in the WAC scale of accommodations was fourteen per hundred personnel as compared with eight percent for men; and 12.5 percent toilets as compared with 5 percent. Billeting.—Developing limitations and commitments in transport, supplies and labor necessitated modification in the plans and construction standards made for housing and billeting troops. Troops were accorded facilities under billeting arrangements comparable to those of the austerity scale noted in Table 1* Theater policy provided for the billeting of Services of Supply and Ground Force troops, (excepting colored troops) whose combat efficiency would not be impaired by that arrangement* Where necessity demanded the use of billets without adequate bathing facilities, arrangements were made for the use of public baths* 4 Heating of Quarters and Other U© S© Army Installations*—|/ Difficulty in providing adequate heating of quarters and other IJ installations came from two sources, shortage of fuel and unsatis- factory stoves© The fuel situation was of first importance* Fuel was rationed both in the United Kingdom and on the continent and the allowances necessarily established were never liberal* In Great Britain temperatures were specified of such degree that no room was to be heated above 65° F* and no warehouse above 55° p* Maximum allowances of coal or coke were prescribed to accomplish these ends© From the first of May to the 22nd of October the al- lowance was three pounds of coal or coke per man per day* During the period 23 October to 1 May the allowance was eight pounds* Kindling wood was allowed in the proportion of one pound per 40 pounds of coal or coke© These allowances of fuel had to meet all purposes, in- cluding heating of quarters, provision of hot water, and cooking; except that no restriction was placed on hospitals© Provision was made that the fuel allowance for any organization could be increased by one-half upon written authority of the commanding officer, sup- ported by medical opinion as to need© While these allowances were small they proved sufficient from a health standpoint if not always in respect to comfort© The second principal difficulty in the United Kingdom in providing adequate heating came from the use of British type stoves* Ordinarily they were lined with fire clay and were without grates, which made it difficult to maintain a fire and to obtain the maximum heat from the allotted fuel© A study of the efficiency of various sizes and types was made in the summer of 1943 in collaboration with the Corps of Engineers, the results of which lead to the authorization of larger stoves in many types of installation© The United States Army tent stove, model M-41, was a better stove than any encountered in any country, but unfortunately sup- plies were limited and the equipment was never available in sufficient quantities at any time* Fuel was scarcer on the continent than it had been in Britain and rationing was necessary even for hospitals. During the season when heating of buildings was necessary, four pounds of coal or coke was authorized per man per day for all purposes, and 12 pounds per day for each hospital bed© The scale of prescribed temperatures for various types of installations provided a temperature of 62° for living quarters and mess halls, and a level of 65° for recreational buildings and officeso The permitted temperature for infirmaries was 70° and drying rooms for clothing were maintained at a temperature of 75 F© The prescribed temperatures were rarely maintained, and whether he was a genbral or a private the soldier*s remembrance of the winter of 1944-45 was of a mighty uncomfortable and foreboding situation© 5 Ventilation*—The maintenance of proper ventilation in living quarters met two important difficulties* In the first place the blackout interferred materially with normal arrangements and secondly, the limited provision of heat gave rise to a tendency on the part of troops to keep warm irrespective of proper ventilation* To obviate the first difficulty improved types of blackout devices were developed for windows and doors# In the early days, flat panels were used which rarely fitted properly when the window was closed# Louvre space was insufficient and the provisions for ventilation were negligible# Curtains were far superior in that if a breeze was even slight it would pass down and around the fabric and the air that was in the building had some opportunity to remain fresh# Shortages of cloth and other materials prevented the general adoption of this method# Despite the vigilence of commanding officers troops continu- ally blocked the ventilator openings of huts in order to keep warm# The limited fuel allowance, the restriction of fires to a few hours in the evening, and the type of building construction all contributed to excessive heat loss# ‘There was often good reason to consider warmth more desirable than fresh air# Because of the recognized deficiencies in proper ventilation of hutted installations a study was made in cooperation with British authorities whereby various types of ventilators were tried in huts actually occupied by troops. Demonstration Nissen huts with an allowance of 32 square feet of space per man were erected in Hyde Park, London, by the Ministry of Works and Planning in cooperation with the Royal Army Medical Corps# Blackout baffles installed on the outside of buildings were found to be a decided improvement# This measure together with the recommendation of the Division of Preventive Medicine for a standard one and one-half square foot inlet and outlet opening per ten men, led to improved ventilation of huts# Ventilation in Nissen cook houses was inadequate during the early months of the theater, and was a matter of importance because field ranges were often used in place of stoves# The toxic effects from incomplete combustion of gasoline were well known# Hooded ventilators were installed to remove gases and odors from kitchens# Ventilation of quarters and other accommodations on the continent can be dismissed with the statement that there was always too much of it* Housing accommodation was usually makeshift, a great proportion of troops were under canvas, and permanent camps were a rarity* Bathing and Ablution Facilities0—Bathing is one of the out- standing personal habitswhich suffers in any military operation* "Sven when facilities are available such factors as climate and military 6 assignments and not infrequently military necessity tend to interfer, and to deter troops from bathingo Sanitary orders of field commands usually stated that all men would bathe at least once weekly but bathing by roster was sometimes necessary to overcome the reluctance on the part of many because of the difficulties and the crudeness of facilities provided,, Scales of accommodation for fixed installations in Great Britain provided for three shower heads per hundred men, Ablution facilities allowed one nine-foot bench with four cold and four hot water taps per 100 men or if material were available eight wash basins per 100 menQ ihese scales were less than those provided in cantonments of the United states, but were sufficient to permit satisfactory cleanliness with reasonable comfort® The original construction standards provided by British en- gineers for camp buildings to be used by American troops directed the omission of bath houses where the water supply was limited, with the intent that water would be heated on Soyer stoves and used in tubs* The more extensive construction involved in providing bath houses was not believed justifiable for the time these accommo- dations would be used. Knowing that the American would neither accept nor adopt this method of taking a bath, the specifications were altered to state that tubs would be located only where an adequate water supply was available, which was a good international compromise® Stoves for heating bath houses were not provided in early specifications for construction of camps® It was soon apparent that the danger from exposure when taking a bath in winter out- weighed the hazards arising from no more than minor meticuluousness in personal cleanliness0 Bathing was abstained from so commonly that surveys by sanitary engineers served to demonstrate that heating of bath houses was a requisite to good health, and authorization of stoves followed® Similar action was taken in respect to ablution facilities in tented camps which afforded only partial shelter® Bathing Facilities on the Continent0—Bathing facilities on the continent were principally of"the field type0 Such provisions as existed in requisitioned buildings were used as they were, and in their absence improvisation by unit handymen was commonly practiced. If adequate facilities could not be brought about, army field equip- ment was operated by the Quartermaster Bath and Sterilization Companies, The ordinary provision of field bath equipment to troops of the line, quoting from the experience of the 9th Army, was one Bath and Sterilization Company to each corps, A company could serve an average of 5,000 men a week® Ihe experience of many field organizations indicated this provision to be insufficient, and it was a general opinion that a mobile or portable unit should by choice 7 be assigned to divisions or regiments* Shower facilities controlled by corps proved unsatisfactory, since frequently men were relieved and sent to rest areas where showers were not available during the time they were there. Troops again improvised all sorts of shower units as they did with most things (Figure 3), Some were of sufficient merit to deserve consideration in future planning for field installations* Among troops of the theater those of the Air Forces, Ordnance, and Engineer units usually fared best in bathing facilities since they had the advantage of trained mechanics and tools, and somehow found the materials with which to extemporise their own bathing facilitiei where regular provision did not exist. Clothing and Equipmento--The specifications for the uniform rovided United States soldiersin the European Theater originated with the War Department. The standard winter uniform was worn both winter and summer and for the climate of the region in which troops were stationed, that arrangement proved satisfactory. The uniforms supplied in the early years of the theater failed to meet the require- ments of the combat soldier and led to thorough review of the problem. A new winter uniform was developed in 1944 and first supplied to troops of the theater in late autumn of that year. It came into general use the following spring (Figure 4)« The shortcomings of previous equipment and the attendant difficulties have been discussed in detail in connection with cold injuries and trench foot. The Medical Department worked closely with the Quartermaster Corps in the minor and sometimes major requests for augmentation of clothing for special troops, or groups subjected •fco unusual degrees of exposure to cold and wet. Such instances were numerous and de- cision was based on individual circumstances. The basic allowances in general proved adequate and indeed liberal. The Division of Preventive Medicine directed special attention to the provision of drying rooms for clothing as perhaps the most important feature of clothing as a health consideration* The original building specifications for camps in the Baited Kingdom contained no provision for this important part of life in the field® It was generally given too little consideration by commanding officers of combat units® Much effort was expended in educational measures directed toward demonstrating the value and usefulness of drying rooms in furthering the comfort of soldiers, as well as in the prevention of respiratory infections. Most permanent camps and installations were eventually provided, on the basis of one square foot of drying room space per man. In combat units where fixed installations for this purpose did not exist, tents were turned to the purpose and served ade- quately when properly heated. 8 Figure 3 An improvised front line shower, 106th Infantry- Division, February 1945. Figure 4 New winter clothing is issued to the 8th Infantry Division, Hurtgen Forest, Germany, January 1945. Identification Tags® — The identification tag worn by all * / officers and enlisted men was a simple piece of equipment and yet \g several problems were associated with its use® It became evident early in the course of operations that the bodies of men involved in fatal accidents or casualties associated with fire, often failed of identification because the identification tag became separated from the body® The cloth tapes by which they were attached burned away, and caused confusion in group accidents, a circumstance first noted in airplane crashes in the Eight Air Force® Similar experi- ences could be anticipated among men of the Tank Corps, in the Chemical Warfare Service and in other arms and branches of the service® A representation was made to the War Department suggesting that metal chains be substituted for the cloth tapes, a matter which was accom- plished through publication of a new Army Regulation® The metal identification tag was not sufficiently large to accommodate the stamped record of the repeated stimulating doses of tetanus toxoido A request to the War Department for clarifi- cation led to a ruling that only the first reinjection was to be recorded on the tag0 Those administered subsequently were to be noted on the immunization records The recorded blood group on the identification tag was the most important piece of information to the soldier himself that the tag carriedo A survey of the reliability of the information demonstrated an error of about six percent in the recorded blood group® More than seven percent of soldiers were wearing no identi- fication tags at the time of survey and in some few instances no blood group had been recorded0 Action was initiated to remedy those deficiencies® Chemical Health Hazards©—A common conception exists that occupational or industrial hygiene is a matter wholly limited to poisoning by heavy metals or by organic solvents concerned with the daily work of an individualo The broader interpretation of the field that has already been stated would relegate these interests to a minor consideration, compared to the aspects of industrial or military life which bear directly on the everyday personal problems of the individualo Nevertheless, chemical poisonings do exist in military as well as civilian occupations, and the necessary attention was one of the interests of military occupational hygiene0 Tetra-ethyl Lead Gasoline® —The hazards connected with han< ling loaded gasoline warranted serious attention since the concen- tration of tetra-ethyl lead in this fuel was increased above levels formerly employed® The best available information was that a single application of this substance to the skin as a method of gas decontamination initiated no hazard of poisoning by lead® Inhalation of the vapors and the products of combustion were known to be detrimental to health® The rate of absorption by 9 inhalation under ordinary exposure was about three times more rapid than the rate of excretion so that the poison was cumulative® Only leaded gasoline was supplied to troops of the European Theater and this was the gasoline used in field ranges® Loaded gasoline had an octave rating of 60 as received and this was increased by adding lead tetra-ethyl to bring the rating to 80® An asbestos filter for the range was designed to catch the deposit of lead oxide formed by the decomposition of the tetra-ethyl® Actually it retained only about 40 percent of the products of decomposition and the remainder choked the feed line between the filter and the burner® This required replacement of the filter disk after four hours use of leaded gasoline® Contamination of the atmosphere or of food by lead would occur through distribution of lead oxide dust formed from tetra-ethyl not decomposed before reaching the filter disk or by tetra-ethyl which escaped during the five to ten minute period at the start of operations before a proper combustion temperature was attained® The flame of the range was luminous and oxidation was incomplete® The possibility of lead poisoning among cooks was remote in the case of ranges used in the open or in well ventilated rooms, but a hazard did exist in small poorly ventilated rooms® Poisoning with organic lead compounds had few of the essential clinical features of classical lean poisoning by inorganic lead salts<> The clinical reaction was essentially that of a generalized intoxicatiom combined with the manifestations of an encephalopathy® The onset may be insidious or abrupt, depending upon the nature of the exposure® If the onset is insidious, the first symptoms are lassitude, easy fatiguability, headache, and insomnia with sometimes more generalized constitutional symptoms® If the process progresses or if the onset is abrupt, the symptoms are predominantly mental, and those of a toxic psychosis, the pattern of which is determined by the previous personality of the patient® In- tractable insomnia is perhaps the most characteristic single symptom* There are few or no neurologic signs and none of the manifestations characteristic of poisinong with inorganic lead® The diagnosis should be suspected when a patient has been exposed to tetra-ethyl lead, is afebrile and presents minor or major symptoms of a disturbance of the central nervous system® The recommended preventive measures required provision of adequate ventilation when the field range was used indoors, the avoidance of excessive spillage of gasoline and if it occurred that it be removed by washing away with water or covering with earth® Care was taken to protect food from the fumes during the process of cooking® Food was not to be toasted or grilled directly over the fire of the field range® Field ranges were cleaned and filters replaced in accordance with the operating instructions issued for their use® Repeated contact of the gasoline with the skin was avoided and where such occurred the affected part was washed promptly with soap and water® 10 Poisoning from Food Containers®--Metal cans used as impro- vised food containers were found to be associated with danger of lead poisoningo The boiling of water and the cooking of food in terne or tin plated gasoline cans was specifically prohibited al- though storage of water was permittedo Lead and other metals were commonly used as substitutes for tin® The possibility of zinc poisoning following long contact of acid foodstuffs in zinc lined containers was well-knownc Action was initiated to limit accidental food poisoning due to these two heayy metals® Tetra-chlorethane®—“Tetra-ohlorethane presented an occupational hazard in the impregnation of clothing against gas0 Some dozen or so cases of poisoning had occurred at Edgewood Arsenal, with one death® Careful control of all employees engaged in this work was instituted® The effects of the chemical are principally on the lungs through inhalation, although absorption through the skin can take place® An adequate control of the process itself had been demon- strated as the best preventive measure, an important feature being the use of rakes to handle the wet clothing® The program for protection against this hazard in the European Theater impregnating plants included a careful selection of personnel to avoid those with indications of existing liver disturbances, adequate control of the process and finally periodic examinations of employes by icteric index, physical examination, and other indicated medical measures, in order that persons showing slight toxic effects might be early withdrawn from association with the chemical® Methyl Bromide*—The necessary measures for elimination of toxic effect from methyl bromide in disinfestation processes have been considered in the discussion of that method in the control / of lice* / Poison Liquor* — Only an occasional toxic effect from \f drinking liquor containing methyl alcohol or other harmful agent wa ever noted during the stay of .American troops in the United Kingdom* Such circumstances were no more common than in continental United Stateso For one thing, beer was everywhere available in the public houses of Britain and while it was war time beer, still the "mild and bitter" of Old England came to be almost as much favored by the American soldier as it was by the common man of the country0 Poisoning rarely results from beer0 Hard liquor of the class of brandies and whiskeys was decidedly scarce in Britain® Purchase by the bottle was almost impossible and while drinks by the glass could be obtained in re- cognized bars this was scarcely a source of danger of poisoning by methyl alcohol® It is the nondescript liquor of the bootlegger and the cheap bar or brothel that leads to accidents® 11 Conditions were otherwise on the continento Beer by- contrast was in relatively limited supply and not so easily obtainable, because troops were in the field and towns were off limits» France was a great wine producing country and the use of light wines was a part of every day life0 The temptation to reinforce them led to purchase or acquisition of alcohol of uncertain pedigree, and the alcohol most readily available was wood alcoholo While the difference between wood alcohol and grain alcohol was known to most soldiers, and the toxic effect of the former was generally appreciated, a certain carelessness or indifference was usual# The attitude of the combat soldier came strongly into con- sideration as a factor contributing to the frequency of poisoning by methyl alcohol# Life loses much of the established sense of values conditioned by a modern civilization, with the result that a soldier out of the line and with the first pass or furlough in weeks was in the mood to drink just about anything# As in most wine producing countries, distillates of wine were commonly produced and used in France# Lacking the potency of whiskey, which means hard liquor to most Americans, alcohol was often added# Local dealers and even farmers and small producers of wine were not averse to manufacturing artificial cognac and similar products through addition of flavoring and coloring materials to alcohols and wood alcohol or mixtures of wood and grain alcohol commonly formed the basis for such drinks# Poisoning by methyl alcohol came to observation soon after troops landed in France, but records of those early weeks were inde- finite and incomplete as they were for most health matters# The cases were associated with the favorite local drink of the Normandy peninsula, known as Calvados# The Surgeon of the Ninth Air Force gave the first authenticated report of death from poison liquor on 3 October 1944, with information of six deaths among men of that commando Four were from drinking Calvados while the unit was stationed in Normandy and the other two in September were related to cognac# Beginning 1 October 1944 records were maintained at theater headquarters of all incidents associated with this problem, and on the number of deaths that occurredo Types of Poison Liquor#—Poisoning many times came from just plain bad !TquoF7~the natureoT'which remained undetermined with a history almost invariably suggesting a shady or suspicious origin (Figure 5)# For example, an enlisted man of the 4199th Quartermaster Service Company died on 27 May 1945 and three others of the unit were seriously dll from drinking liquor obtained from a German civilian at Rheinberg# 12 Figure 5 Yanks capture a rathskeller in Borgel, Germany, January 1945. When samples of the liquor concerned with such events was obtained for laboratory examination, the reason for the difficulty was usually apparent0 Of thirteen samples of various alcoholic beverages examined in February 1945 by the central laboratory of the theater in Paris, seven contained methyl alcohol ranging from one to thirty percent by.volume„ The presence of aromatic extracts often made it impossible to detect by odor the presence of methyl alcohol. Of ten samples of blood of patients admitted to one General Hospital, three were found to contain methyl alcohol as well as ethyl alcohol. Death in some instances resulted from drinking straight methyl alcohol. An instance came from the 404th Fighter Group (SE) of the 9th Air Force* A private of the Air Force was found dead in bed at 0600 hours 24 October 1944* He had been drinking during the previous day and his associated stated that he obtained the beverage from a captured 50»gallon German barrel labeled "Methanal Giftig GEF 26-5-44'1* A half filled quart bottle of the liquid was found beside his bed* "While methyl alcohol was most commonly involved at least one instance is known where the trouble originated from diethylene glycol* Again, soldiers of a Quartermaster Truck company sold some antifreeze to a local cafe keeper in Belgium* Not only did such dangerous products come back to soldiers of the United States Army in the drinks they bought but a number of deaths of civilians occurred from the same cause* As bizarre as was the origin of poisoning from anti-freeze mixtures, it was perhaps exceeded by methyl alcohol poisoning from canned heat, a solid substance con- taining methyl alcohol and used for heating rations and other purposes* Several men from one of the field armies drank beer into which they had squeezed methyl alcohol from a cake of canned heat. One was admitted to the 59th Evacuation Hospital, several others were ill, and one had died that night* Methyl alcohol was determined as the cause of death* Buzz bomb fluid was another unusual substance, the ingestion of which led to poisoning. This substance was used by the Germans in launching their rocket bombs and large supplies were found in many parts of Germany. Three men from Battery B, 413th AAA. Battalion and one from the 1119th Military Police Company, Avn., gave a history of drinking buzz bomb fluid from a tank car at Eschwege. They were ad- mitted to the 56th Evacuation Hospital, where the staff was wholly familiar with the condition for they had already had four deaths from the same cause. While the appearance and taste of liquor often raised no suspicion of its content of methyl alcohol, it was almost past understanding how any one could be lured into drinking the concoction that led to the death of three soldiers and the evacuation of a 13 fourth to the Communications Zone with a diagnosis of ”poisoning, acute severe, caused by drinking questionable beverage.’* Two jugs hjad been found in a building where the soldiers were billeted, one labeled ’’methanol” and the other ”formaldehyde”. The contents were ixed and bottles filled from the jug© The liquid was diluted with ater before drinking© Laboratory analysis showed the presence of 10th methyl alcohol and formaldehyde© Incidence of Poisoning from Liquor<> — The number of oases f acute poisoning that occured before October 1944 from drinking bad .iquor is now known; but informal reports that came to the Office of the Chief Surgeon and through contact with medical officers of the theater, the estimate is at least a dozen© Records were available from October 1944 to the close of hostilities in June 1945« The number was not great during the autumn of 1944, An increase became apparent after the first of January© As the war drew to an end, reports became more and more frequent with no less than 82 deaths from this cause in May 1945© The total for the period of operations on the continent was 178, to give a mortality rate of 0.12 per 1000 strength per annum© The majority of cases and deaths from poisoning by methyl alcohol or other toxic agents in liquor, were among troops of the Ground Forces© The Air Forces were involved to a certain extent, but the troops of the Communications Zone relatively little; not that their judgment was probably any better, but their source of supply waso The seriousness of the problem among interests in Preventive Medicine becomes apparent when comparison is made between the number of deaths from poison liquor and those that resulted from acute communicable disease0 The number of deaths from the latter cause was 162; and deaths are included from primary pneumonia, tuberculosis, encephalitis of all forms, and meningitis both primary and secondary, as well as from the more commonly recognized communi- cable diseases© Even with this liberal interpretation the number of deaths and the mortality rates for alcohol poisoning were greater, 0.12 per thousand per annum compared with 0ollo (Table 2<) Incidence Among Displaced Persons.—The hazards of poison liquor were by no means limited to the American Army. Civilians participated and more particularly the group of displaced persons. A medical officer of the 2829th Engineer Combat Battalion was called to investigate the difficulties into which a group of Russian dis- placed persons had fallen. Men from a large camp at Landenprozetten obtained some liquor from Germans of the neighborhood on 11 April 1945 and forthwith indulged in a drinking bout. Several hours later the nearby German community called on the United states Army for help, insisting that the refugees were fighting, 1/Vhen a medical officer arrived in the Russian area, some ten men were found in severe convulsions, rolling on the floor, jerking at their throats. 14 calling out that their stomachs were on fire and having difficulty in breathing© The remainder of the men were under the care of their women folk who forced them to vomit and kept them walkingo Four were dead the following morning© Samples of the liquor were not available for laboratory examination because the Russian women had destroyed it© Only the men of the camp had drunk the liquor, the women refusing because "there was fuel oil in it©" The most outstanding of all incidents connected with poisoning from liquor occurred at the Handelar refugee displaced person camp® In all* there were 80 cases of poisoning® Sixteen displaced persons had died by the time an investigation was first instituted, and subsequently 42 others died in hospitals® Of the 80 patients only 22 survived of whom three were left totally blind* and three lost the sight of one eye® The 58 deaths represented a fatality of 72o5% among those known to have partaken of the liquor® Because of language difficulties the origin of the liquor was never determined precisely® The best that could be brought out was that it came from a factory building where it had been discovered by one of the displaced persons* and was poured by the leader from some form of large container into bottles as the men formed in line® The patients were admitted to hospitals in various stages of poisoning© The least affected group had no particular symptoms except for a tendency to lie quietly as if exhausted although still alert and oriented© Subjective symptoms were difficult to obtain because of language difficulty and because the patients were too ill to talk© The general complaint was of severe frontal headache, substernal burning pain, and pain in the epigastrium© A tendency to vomit was usual© The chief symptoms of a second group were severe abdominal pain and vomiting* so severe indeed that they writhed about and moaned continuously® They were semicomotose* had fixed pupils and a fixed stares rising out of their stupor only when the pain stopped or when they vomited a mahogany colored fluid* stringywith mucus and containing bile® In addition to abdominal pain and occasional vomiting, a third group of patients exhibited delirium bordering on mania, of such extent that mechanical restraint was often necessary© Generalized tremors and tonic and clonic convulsions were frequent© A fourth group were in profound coma or moribund® The skin was cold but not moist® They were cyanotic* and depending on the nearness of death# respirations were rapid* shallow, or slow irregular and convul- sive® A remarkable feature was that the pulse often slowed to 30 or 40 beats per minute along with the slowing of respirations# a symptom that was always terminal® Shortly before death the victim frequently manifested a generalized tonic or clonic convulsion® Death 15 was due to respiratory paralysis followed by rapid heart failure# Beginning respiratory difficulty was evidenced by an increased respiratory rate, cyanosis, rapid feeble pulse and falling blood pressure* Some of the first group proceeded through the several stages to ultimate death, so that the separations made apparently represent different stages in the process of poisoning rather than different levels of involvement* Those who recovered never exhibited the more serious symptoms of the last two groups* Program of Prevention*—Because of the nature of the problem, relatively little could be accomplished by formal directives from theater or other headquarters* Principal reliance was placed on popular education through the Army newspaper. Stars and Stripes, and on similar sources of disseminating information to the soldier himself* A more tangible contribution was made in providing the troops with a readily available, safe and innocuous beverage in the form of beer or soft drinks, through the program initiated in the autumn of 1944 with the Special Services Division and described in connection with sanitation* Prevention and Control of Accidents*—The statistical demonstration of the importance of non-battle injuries as causes of death and disability among troops of the European Theater is presented in the concluding section of this presentation, Iput no more than cursory familiarity with the problem is needed to appreciate that accidents and injuries rank well up among preventable disease conditions* The Medical Department had the obligation in safety programs of the theater to maintain statistical data with reference to the number, frequency, severity, and causes of injury to military personnel and to provide the Provost Marshall with adequate summaries of disabling injuries* Additionally the Provost Marshall was aided in the determination of doctrine and in the preparation of educational aids for safety training* Staff supervision of safety programs designed to limit the number of preventable accidents ms a responsibility of the Provost Marshall of the Theater* Fundamentally, the responsibility for the operation of a safety program for military and civilian personnel and prisoners of war rested with the commanding officers of unit installations (Figure 6)« Annual Surveys of Causes of Non Battle Injury* In furtherance of its obligation, the Division of Preventive Medicine prepared extensive analyses of non-battle injuries for the years 1942, 1943, and for the first half of 1944, the period immediately pre- ceding continental operations* The press of military activities and the major problems of trench foot and later of typhus fever so absorbed staff and facilities that detailed analyses for the continental period were 16 Figure 6 An accident due to a skid on an icy bridge in Luxembourg, January 1945, not made, although general features of accidents and injuries were abstracted, and detailed studies mad© of specific problems. It is not to be assumed that all non-battle injuries are preventable® Some classes definitely are amenable to improve- ment through safety campagins* others are not and there is a broad intermediate zone difficult to evaluate from the standpoint of preventability® Any separation of preventable and injuries must be wholly arbitrary® To accomplish the purpose at hand, the important causes of non-battle injury deemed preventable have been incorporated in Table 3® The frequency of preventable accidents is noted for two groups of Army personnel* those whose injuries were of sufficiently minor moment to permit return to duty* and those having injuries of such extent that return to the Zone of the Interior was necessary® The extent to which the listed preventable accidents entered into deaths from non-battle injury formed the second part of the analysis® Somewhat more than 20 percent of non-battle injuries among patients who eventually returned to duty were due to what have been considered preventable causes © It would appear that the more serious injuries* judged by the necessity to invalid the patients home* were due to preventable causes* in still greater proportions namely* 45 percent® The preventable conditions were easily the most highly represented among deaths from non-battle injury* to the extent of about 7Z%0 Stated differently* it would appear that a great many injuries occurred in military practice . which were not readily preventable* but that of those which resulted in death and more serious injury* a great proportion were preventable® The year 1943 may be taken in illustration of general experience with non-battle injuries during the period of training activities in Great Britain® During that time only the 8th Air Force was actually engaged in combato In the course of the year, 24,919 officers and men of the European Theater were admitted to hospital for non-battle injuries. Of these, 95,7% were returned to duty, ld% were evacuated to the Zone of the Inferior, and 3,2% died. The ten most frequent causes of injury are listed in Table 40 Accidental injury by falls was easily the most common cause of disability,, but was not far removed from those accidents which occurred in the course of athletics* sports* and recreation which accounted for 1006% of all non-battle injuries® The proportion due to motor vehicle accidents was 709^o 17 A relatively small proportion of patients suffering acciden- tal injuries developed disability of such extent that their return to the Zone of the Interior was necessary# The number was 275 or 1.1% of all non-battle injuries. Approximately one-fifth were the result of motor vehicle accidents, by which it may be judged that this was a common cause of serious accidents. About one-sixth resulted from accidental injury by falls. Ihe chief reasons for evacuation are set forth in Table 5. Most serious accidents. Judged by a result in death or evacuation to the Zone of the Interior, were due to air transport accidents. Of the 809 fatal accidents during 1943, 54.5% were air transport accidents, 13% due to motor vehicles, and 8.5% resulted from mishaps with fire arms. The major causes of accidental deaths listed in order of frequency are to be found in Table 6. #A sample of individual sick and wounded reports for the period January through March 1944, exclusive of deaths and those evacuated to the Zone of the Interior, were examined to determine which arms and branches of the service participated most frequently in this type of injury. The data are set forth in Table 7. The sample consisted of 1693 oases of what may be termed the minor accidental injuries of the theater and corresponding to about 20% of reported instances. The greatest numbers were noted for the infantry, but if the comparison is made on the basis of troop strength, the frequency of these conditions among the Air Force was generally high. The relatively great numbers for the Ordnance Department and the Corps of Engineers are to be noted. An analysis of deaths from these causes during the same period of time showed a disproportion between cases and deaths in respect to the infantry, in that fatal accidents were relatively few. By far the greater number of fatal accidents occurred in the Air Forces, and the proportion of deaths from accidents was also relatively great for the engineers. Table 8. Unit Surveys.—Aid was frequently furnished to units of the theater in analyzing the particular causes of injury in the unit as the basis for a unit safety program. Sometimes this was at the request of units, more commonly as a means of contributing constructive help rather than the usual criticism which comes from higher head- quarters to units with unfavorable rates. These special studies were most often related to engineer organizations and to infantry divisions. Motor Accidents.—In 1943 a special study was made of the situations concerned in automobile accidents, for use by the Services of Supply in a program designed to limit disabilities from that causeo Such problems are as readily amenable to epidemiologic analysis as are those related to communicable disease. 18 Motor accidents were separated into those resulting only in mechanical mishap, those causing personal injury as well, and finally those which resulted in death. Time and space relations were determined for accidents attended by personal injury, with briefer attention to such factors as fatigue, types of injury, causes of death and the kinds of vehicle involved. Under civilian conditions most automobile accidents oc- cur during the evening rush hour of five to six o’clock. In this military experience the greatest proportion was associated with night driving, the hour from 2300 to 2400 hours showing the highest accident rate. Personal and Individual Health Problems,—It is easy to develop enthusiasm aboutsuch tangible health problems of the individual soldier as those just discussed - poisoning by methyl alcohol, the trench foot problem and housing difficulties. The minor considerations add up to a total that is usually unappreciated, but important in determining the level of fitness of the individual, his sense of well-being and his quality as a soldier, This is the field which has been referred to as perhaps the most undeveloped in the practice of military preventive medicine. Personal hygiene as here considered in interpreted in the broad sense of including all matters having to do with the physical and mental and psychologic well being of the individual and is far removed from the too general interpretation of the field as one having to do with such things as brushing the teeth and washing the hands. Ihe interests of the neuropsychiatric service and those of Preventive Medicine have opportunities for enlarged and cooperative activities. The whole program of public health education could well be incorporated into this activity, instead of being left indiscriminately to various branches of preventive medicine as so commonly is done. The field warrants the full attention of at least one officer in any organized division of Preventive Medicine. No attempt will be made to list or discuss the various sources of interest which entered into this activity in the European Theater, but a few examples will serve to indicate types. The development by the Air Forces of a special division of work in Preventive Medicine called the Care of the Flyer was easily the best thing done in the theater in this particular activity. The functioning of the human mechanism, physically, mentally and psychologically was recognized as of equal importance to the mechanical performance of the aircraft he operated. The Army was setting out for France and an Army on the march would have foot troubles of a degree unassociated with normal 19 camp life* Much time was devoted to informing the soldier of the kinds of difficulty that feet encounter and what could be done about them. The common roller towel was a frequent inheritance of American units when they took over British quarters and it was surprising how frequently this relic of other days came to be observed in American installations. It was rooted out with diffi- culty, because of inability to supply the usual paper towels and the lack of another substitute. Public opinion was sometimes ahead of practical method, as in the request of a headquarters for recommendations on methods to sterilize mouth pieces of telephones. It was necessary to point out that available measures were useless, and to emphasize the lack of result from token efforts. The supply of socks provided troops from American sources was necessarily augmented by purchase of British supplies, so that at one time no less than four different kinds were provided American troops. The sizes were different, as manufactured in the two count- ries. It was a small matter to point out which items could logically be substituted for size and for intended usej and yet lack of that simple information gave rise to much foot trouble. These are small affairs but they remain neglected without the attention of some specificially designated officer of the Pre- ventive Medicine Service, The personal contribution to individual health and welfare which remedy often brings, serves to enhance the appreciation of the aims of the preventive program and to enlarge its support. It is good public health education. Trench Foot.—The outstanding event in preventive medicine in the European Theater, considering the whole course of the war, was a widespread and extensive prevalance of trench foot which began in November 1944 and continued throughout that winter (Figure 7). Because separate and independent consideration is given this subject in a medical monograph trench foot will be presented here only briefly. The material which follows is quoted in its entirely from the annual reports of the Division of Preventive Medicine for the years 1944 and 1945, Sources of Statistical Information,,—-In conformity with War Department directives trench foot, immersion foot and frostbite were made reportable diseases as of November 1944, using the Weekly Statistical Report Form 86ab. Form 323 gave earlier information because it was a daily report, but was less exact because of inherent duplications o Trench foot in previous years had been recorded in medical statistics as ’!cold injury,’1 The 86ab reports defined three forms 20 Figure 7 Cold Injury, 108th General Hospital, Paris, France, Decent) er 1945. of cold injury, trench foot and immersion foot which resulted from wet cold, and frostbite which arises from exposure to dry cold. Frostbite was further qualified as cold injury, ground type, and cold injury, high altitude type0 Because of previous practice a certain number of cases in this experience were reported simply as cold injury and others as cold injury, ground type<> These were all included in the analysis of data under the term trench foot. Only cases listed as frostbite were so recorded, irrespective of whether they were also qualified as high altitude or ground type. The disease on the continent was almost wholly of the ground type and originated in the Ground Forces0 Frostbite first appeared in the week ending 8 December 1944o Reported cases increased thereafter so that in one week the 3rd Army alone reported no less than 611 casese Ihe general term of cold injury, to include all three of the above categories was believed best suited to epidemiologic study and for statistical purposes generally. Differential diagnosis was difficult and it about came down to determing whether a given injury occurred above or below freezing temperature. Pathologically the several conditions were much the same and varied only in degree. The same contributing factors held in causation and much the same principles were involved in medical management. ■While separate records were maintained for frostbite, all three conditions were considered as a unit in the analyses to follow and were called cold injury*, Cold Injury in the ETO, Medical planning of the theater had long anticipated that cold injury would be a matter of major concern during operations on the continent. The problem entered actively into the plans for mounting continental operations. Methods for combating trench foot and for disseminating information on the subject were initiated in June and continued throughout the summer. Directives were issued in September, others in October and still others in November, Trench foot did not appear in the theater in appreciable numbers until about 10 November, this being coincident with the start of active offensive operations and the development of colder weather (Figure 8), The incidence of cold injury increased sharply at that time, almost in the manner of an outbreak of in- fluenza, and thereafter progressively declined so that in the early weeks of December the incidence was less than one-fourth what it was at the point of maximum occurrence about 15 November© This second general phase was followed by another major peak about the middle of December9 This again was related strongly 21 and definitely to military operations, the major counter-attack of the Germans (Figure 9). Trench foot in the First Army was at this time more common than during the November peak. There was an ap- preciable rise in incidence in the Third Army, while minor upward swings were noted in both the Seventh and Ninth Armies. Ihe next two or throe weeks again showed a well-marked improvement in the situation. The fifth general phase of the curve became evident in the second week of January with a sharp upward swing of cold in- juries as the weather became decidely more severe, with freezing temperatures and much snow. A large part of the increase was due to the appearance of frostbite. For the month of November the number of reported cases of cold injury wa« 9,328 and for December it was 13,024, a total of 23,352* The equivalent of two divisions of troops were lost from this cause* It was evident that more energetic control measures were necessary* These became active in January through institution of a control program based on that which had proved successful in combating malaria, a disease whose control likewise depends on personal and individual measures* The final peak in January and early February occurred at a time when the troops were engaged in bitter fighting over rough snow-covered terrain. Milder weather occurred about the first of February, the snow melted rapidly and the incidence of cold injury dropped precipitately. Table 9, Figure 10. The majority of cases of cold injury occurring in January and early February were of the type of frostbite, while those occurring later in the spring were predominantly trench foot. The number of cases reported by days for the four armies in the theater is also shown in Table 9* Rates per thousand strength per annum by weeks are set forth in Table 10* Frostbite. —Frostbite was no problem until early December, but thereafter the number of cases progressively increased* Table 11. Cold Injury by Services..--An analysis of cold injury as it affected the various major commands of the theater showed the condition to be far and away a problem of the Ground Forces* Almost no cases occurred in the month of November in the Ground Force Replacement Command, among Communications Zone and Air Force troops of the conti- nent o December showed an appreciable number in the Ground Force Reinforcement Command, largely due to patients released from hospital who returned to that organization and developed recurrence* There were few primary attacks* The numbers for the Communication Zone and the 9th Air Force continued minimal* The admissions per thousand per year were greater in December than in November* The data 22 Fi gur e 8 A Ninth Army tank bogged down by mud, November 1944. Figure 9 Heavy machine gun fire pins down a combat patrol of the 2nd Infantry Division, Ondenval, Belgium, January 1945. Cold injury, all armies, European Theater of Operations, daily admissions 1 November 1944 to 2? April 1945, inclusive. Figure 10 are presented in Table 12® Trench Foot in the AnniesThe above data indicate tnft cold injury was primarily a problem of the armies in the fieldo However, when reported cases were distributed according to armies it was apparent that the Third Army had been involved to a much greater extent than others, that the rates for that unit were fol- lowed closely by those of the First Army, and that the Seventh and Ninth Armies had been relatively little involvedo Figure 11© The same variations which were demonstrated between armies likewise became evident when distribution was made by divisions® In the Third Army, some divisions had a consistently bad experience, the 26th Infantry for example, while that of others had been uniformly good, for example the 95th Infantry Divisionc As a general rule the armored divisions had much less trench foot than infantry divisions® Figure 12, Table 13® The same behavior could be demonstrated for the First Army® Organizations such as the 30th Infantry were consistently free from trench foot® This was an old seasoned division that had long stressed the importance of trench foot as an infantry problem and had a well developed system of foot discipline® Their experience is to be contrasted with that of the 99th Infantry and the 106th Infantry® Here again the experience of armored divisions was satisfactory® The Seventh Army included three seasoned divisions, the 3rd Infantry, 36th Infantry and 45th Infantry© In general all had a fairly satisfactory experience with trench foot© This was to be contrasted with the experience of the 44th Infantry a relatively new division© Even the Ninth Army with relatively little trench foot as an army, showed the same variation among divisions® Distribution by Regiments0“~A number of studies were made of the variation in incidence oetween regiments of divisions© If a unit with a generally satisfactory rate was examined, such as the 3rd Infantry Division, it was demonstrated that under similar circumstances of environment the 7th Infantry Regiment had almost no trench foot while rates for the 15th and 30th Regiments were decidedly great© Many- similar examples could be cited© Finally, there was a great variation between the battalions of regimentso The 346th Regiment of infantry had many cases of trench foot during a short period of active operationso Almost all were among men of the 1st Battalion, with the 2nd and 3rd Battalions essentially free from the condition0 Ihe lack of uniform occurrence of the disease suggested that a variety of factors entered into the production of trench foot, because environmental and other conditions were so variable in respect to units© 23 Factors Determining Incidence of Trench Foots“-Four major considerations entered into the production of trench fo>t» These were military operations, weather, clothing and equipment, and foot discipline (Figure 13)G "Various subdivisions of these factors are set forth in the following lists 1 Operational conditions a0 Military duties Offensive operations Defensive operations Static operations Reserve and rest areas ho Terrain Mountains Swamps River Crossings Plains Co Environment and exposure Trench or fox holes Tents Buildings do Rotation of Combat duty 2 Clothing and equipment Foot gear Winter clothing 3 Weather Cold Wet 4 Foot Discipline Training Practice Command Control Early field investigations showed that excessive incidence could in rare instances be related to a single one of these factors, more commonly there were various combinations of two or three and sometimes all four were active. It thus became evident that the problems of a particular unit in respect to trench foot were more or less individualized and that the control of trench foot in the final analysis, and for a given unit, was largely a question of determining which factors were active and directing the necessary specific measures of prevention as indicated by such epidemiologic studieso To this end, groups of investigators were active in all four of the field armies0 Methods of Control0’—When trench foot first appeared in rapidly developing numbers,it came so suddenly and the situation was so confused by the secrecy incident to the major military operations then under way, that while it was known generally that trench foot was occurring in most of the armies, the actual units affected were not known, nor could the center of the principal difficulty be determined* Tie problem of control was like that of a water-borne epidemic of typhoid,, The immediate need was to insti- tute general meaures comparable to the chlorination of water* To accomplish this purpose action was taken along three lines. Energetic measures were taken by command to improve foot discipline* The 24 Figure 11 Cold injury. First, Third, Seventh and Ninth Annies, European Theater of Operations, daily admissions, 1 Novemoer 1944 to 27 April 1945, inclusive. Gold injury. Divisions of the Third Army, European Theater of Operations, rates per week, 3 November 1S44 to 27 April 1945, inclusive. (Divisions listed were assigned to Third Armv as of 1 February 1945.) Figure 12 Figure 13 Dry clothing is frequently an impossibility in front line fox holes, Ardennes Hills, February 1945. Quartermaster Corps bent its energies to placing all available stocks of clothing in the hands of front line troops (Figure 14), Ihe Medical Department undertook a campaign of public health edu- cation directed towards the individual soldier, making use of all available Army publications, such as Yank magazine, the Stars and Stripes, Army Talks and others; the use of posters, of the radio, and of movie shorts. As the situation became clarified, the line of attack became more specific. Measures were directed towards determining those organizations most involved, the conditions which were pro- ducing trench foot and the determination of the necessary remedial measures. This work was done by the various divisions of Preventive Medicine of Armies, aided by investigators from the Office of the Chief Surgeon, The attack on the disease thus became direct and specific in contrast to the initial measures which were general and inclusive. In January, Trench Foot Control Teams consisting of two officers, one from the line and one from the Quartermaster Corps, were established by each of the five field .Armies® The teams, in conjunction with Army surgeons, worked with all units of the respective command down to the regimental level, investigating their specific problems and making recommendations on the spot for avoiding cold injury® Provision was also made for non-commissioned Trench Foot Officers at company level, who instructed the troops of the unit in preventive measures and instituted improved foot discipline® Representatives of the theater division of Preventive Medicine visited all Armies and made careful studies of the basic causes underlying outbreaks of cold injury0 The chain of command at all levels became fully aware of the danger of cold injury and cooperated to the fullest in bringing it under controlo The Office of the Chief Quartermaster held a series of conferences in Paris with representatives of the Armies, Air Forces and other interested commands to decide upon types of winter clothing best suited for front line soldiers. Experiences of other Armies with Trench Foot®--The First French Army, with the Seventh Phited States Army, constituted the Sixth Army Group® They were located in much the same territory® Operations were of a similar pattern and weather conditions were much alike® Their experience with cold injury closely paralleled that of the 7th Army® Table 14® The British Army was singularly free from trench footo Prom the beginning of operations on the continent until 1 January only 44 cases were reported, of which six were in the Canadian Army and the balance among troops of the Second British Army0 The rate was so low as to make it worthless to present the data in detail. 25 Summary.--Trench foot developed in the European Theater of Operations in excessive numbers in November, and early energetic attack led to a marked reduction in incidence. The December counter- offensive of the German Army brought about a second wave of incidence. The number of cases was great and the causes lay in the general mili- tary situation. There was no doubt that the practice of preventive measures suffered because of the need of primary attention to combat activities. The latter part of December and early January showed a recrudesence of trench foot. This was in considerable measure due to the cold weather. It was also likely due in small part to acceptance of trench foot as an inevitable part of military operations in winter. More sustained and energetic control measures were indicated. Trench foot was a serious problem in the experience of the theater. Of each 100 battle casualties, 80 were expected to return to combat duty. Trench foot led to much greater loss of man power with the best estimates that not more than half returned to combat duty. In evaluating the various factors which gave rise to the disease during the winter of 1944 and 1945 it was the opinion of all that no one cause could be designated as the single exciting cause, but that several factors were inter-related and each of a different force under the varying circumstances under which it operated. It was a practical impossibility to single out any one. There was no magic cure or prevention. Trench foot control involved a combination al all relevant factors. With the type of warfare and under the con- ditions experienced in the ETO by the American Army, trench foot in a substantial amount was believed to have been an .unavoidable hazard of war. The incidence could be reduced but not eliminated under the adverse conditions faced in Europe that winter. Under less severe conditions where fighting was leas active, it might be possible with careful discipline, rotation of troops and suitable supplies to reduce trench foot to the point of almost complete elimination. 26 Figure 14 Parachute infantrymen of the 101st Airborne Division search for their size of overshoes, Bastogne, Belgium, January 1945. Facilities Amm&dss?le Wlnti6)?igfed Summer Tented WAAC Scale Living Quarters Officers, Sr. Officers, Jr. Sergeants Other Ranks 150 s.r. (1) 75 s.r. (2) 75 s.f. (2) >to s.r. (5) (27) (25) 72 S.F. 72 S.F, 35 S.F, 35 S.F. (2) (2) (7)(25) (7)(25) 6U S.F. 6H S.F. 35 S.F. 35 S.F. J W(9) (T)(9) (T)(10) (T)(10) 50 S.F. (T)(6) 50 s.r. Type of accident Cases Percent Accidental injury by falls 3719 14 o9 Accidents occurring in athletics. sports and recreation 2652 10 06 Motor vehicle accidents 1963 7 <»9 Running, jumping, twisting turning, lifting, slipping, etcD 1937 7 08 Bicycle accidents 1259 6 ol Accidental injury by crushing 983 3 o9 Accidents occurring in drilling or marching 917 3 o7 Striking on object 855 3 o4 Fighting 768 3 ol Heat ; 716 I 2 o9 - - : :r•: Sources Division of Medical Records, Office of Surgeon, European Theater of Operations the Chief , UoSo Army„ Table 5 Chief Reasons for Evacuation of Mon-Battle Injuries to the Zone of Interior*, European Theater of Operations*, r Uo So Army*, 1943« Type of Accident Case Motor vehicle accidents 62 Accidental injury by falls 43 Bicycle accidents 21 Accidents occurring in athleticsa exercises*, sports and recreation 15 Accidents involving inarching 15 Air transport accidents 15 Other accidents 104 Total 275 Sources Division of Medical Records*, C )ffice of the Chief European Theater of Operations*, Uo So Army Table 6 Major Causes of Accidental Deaths, European Theater of Operations, U* S. Army, Number and percent of total deaths, 1943, Type of accident Number Percent of total deaths Air transport accidents 411 54.5 Motor vehicle accidents 105 13,0 Accidental injury by firearms 69 8.5 Accidental drowning 20 2.6 Other and unspecified road transport accidents 18 2.2 Accidental injury by falls 15 1.9 Water transport accidents 14 1.7 Other accidents 127 15.7 Total 809 100.0 Source: Division of Medical Records, Office of the Chief Surgeon, European Theater of Operations, U.S, Army, Table 7 Uon~battle Injuries, Exclusive of Fatal Cases and E-vacuations to the Zone of Interior, by Arm or Service, European Theater of Operations, U0 S0 Army, 20 percent sample of individual sick and wounded records, January to March 1944, inclusive Arm or Service Cases Adjutant General’s Department 1 Military Intelligence 2 Women’s Army Corps 2 Air Force, general or unspecified 94 M {| combat units 142 11 ” transportation units 25 auxiliary units 6 t! n service units 106 Medical Department, enlisted men 74 " 11 officers 1 H " Army Nurse Corps 13 Infantry, general or unspecified 265 " airborne 1 n parachute troops 65 " Rangers 6 Ordnance, general or unspecified 99 n ammunition 11 M aviation 11 Cavalry, general or unspecified 6 armored troops 2 tt other organized units 18 Coast Artillery, anti=aircraft units 41 Engineers, general or unspecified 178 n combat 28 ” bridge pontoon units 8 Field artillery 54 Chemical Warfare Service 32 Armored Forces* 51 Tank Destroyer Forces* 18 Military Police 38 - Quartermaster Corps 125 Signal Corps 60 Transportation Corps 47 Unassigned or not recorded 64 Total ~T693~ * Incomplete information Sources Division of Medical Records, Office of the Chief Surgeon, European Theater of Operations , U0Se Army® Table 8 Accidental Deaths, by Arm or Service, European Theater of Operations, U.S. Army, January to March 1944, inclusive Arm or Service Deaths Adjutant General*s Department 1 Finance Department 1 Air Force, general or unspecified 40 *' ” combat units 135 n transport units 30 n ” auxiliary units 5 ” ” service units 15 Medical Department, enlisted men 7 Infantry, general or unespecified 19 11 airborne 2 n parachute troops 4 " Rangers 1 ” mechanized units 2 Ordnance, general or unspecified 7 " ammunition 1 M aviation 1 Cavalry, general or unspecified 1 ” armored troops 1 other mechanized units 1 Coast artillery, anti-aircraft units 6 Engineers, general or unspecified 31 combat units 38 Field Artillery 17 Armored Forces* 5 Tank Destroyer Forces* 5 Military Police 8 Quartermaster Corps 23 Signal Corps 8 Transportation Corps 3 Unassigned and not recorded 5 Total 423 * Incomplete information Sources Division of Medical Records , Office of the Chief Surgeon, European Theater of Operati ons, U. So Army* Table 9 COLD INJURY Armies of the European Theater of Operations Admission by days November 1944 to April 194 5 * inclusive Date Total* 1st Army 3rd Army 7 th Army 9th Army L5th Army 194-4” 28 Oct, 28 0 28 29 26 0 26 30 16 0 '' 16 31 39 0 39 1 No' 33 6 27 2 34 6 28 3 26 5 20 1 Total 202 17 184 1 1 4 Nov, 44 7 37 0 5 41 14 26 1 6 43 15 21 7 7 37 7 21 9 8 103 34 11 52 6 9 199 110 21 59 9 10 347 135 129 70 13 Total 814 322 161 286 45 11 Nov, 601 118 387 83 13 12 738 132 501 86 19 13 683 | 203 432 33 15 14 820 324 424 61 11 • 15 1086 247 719 109 11 16 829 146 543 122 18 17 606 154 350 91 11 Total 5363 1324 3356 585 98 18 Nov, 479 ”l38~ “ J&8 94 19 19 399 ! 137 163 53 46 20 286 i 133 102 19 32 21 262 138 82 13 29 22 358 171 103 47 37 23 498 164 157 31 146 24 640 171 192 108 169 Total T9ir~ 1052 rwr 365 478 25 &ov. 468 139 " 136 ~ 85 109 26 384 108 125 83 68 27 359 71 138 86 64 28 316 61 120 77 58 29 295 76 119 62 38 30 285 64 131 33 57 1 Dec, 320 79 135 39 67 Total 2427 598 ~953~~ 465 T~ 46T ■ 1 " ~ Table 9 - Cold Injury» (Continued) Date tfotal* 1st Army 3rd Army 7th Army 9th Army 15th Army 2 Deco ~T39 5l 95 53 w 3 215 57 76 38 44 4 194 57 56 32 49 5 254 62 83 34 75 6 300 93 127 29 51 7 303 127 101 45 30 8 203 77 71 31 24 Total 1708 524 609 262 313 9 Dec o 307 129 87 65 26 10 230 87 43 66 34 11 310 144 79 58 29 12 403 161 146 86 10 13 478 158 201 105 14 14 458 265 103 72 18 15 728 507 142 69 10 Total 2914 1451 801 551 141 16 Deco 521 146 592 73 8 17 407 240 117 43 7 18 308 146 100 50 12 19 330 212 71 45 2 20 425 225 143 51 6 21 409 199 133 76 1 22 329 154 77 94 4 Total 2729 1322 933 434 40 53 t>eco 458 146 "176 llO 2& ~ 24 547 232 177 95 43 25 624 300 212 72 40 26 537 . 285 127 90 35 27 369 133 129 78 29 28 280 80 102 58 40 29 326 113 137 51 25 Total '3141 '1589" loe'o 554 538 30 Deco 193 51 79 40 23 31 184 66 75 29 14 1945 1 Jan0 202 79 65 49 9 2 241 72 57 101 11 3 267 87 58 113 9 4 254 92 37 122 3 5 > ’ 341 158 73 102 8 Total 1682 605 444 556 77 Table 9 - Cold Injury<, (Continued) Date Total* 1st Army 3rd Army 7 th Army 9 th Army 15 th Army 6 Jaru TOT**" ~T88 57 ns 13 7 291 132 60 96 3 8 416 168 102 132 14 9 485 241 143 94 7 10 561 333 128 90 10 11 545 216 192 130 7 12 591 209 242 130 10 Total 3384 1487 924 815 64 94** 13 Jan® 512 190 “255“ “TIT” 7 14 473 228 150 76 19 15 646 282 217 125 22 16 595 377 121 88 9 17 601 309 187 93 12 18 405 175 128 97 5 19 420 103 234 78 5 Total 3652 » 1664 1242 667 79 0 20 Jan® 441 228 133 75 5 21 505 214 172 117 2 22 432 208 145 76 3 23 537 272 120 139 6 24 445 163 133 142 7 25 448 121 144 178 S 26 505 85 169 247 4 Total 3313 j 1291 ” 1016 974 0 27 Jan® 464 43 119 289 18” 28 386 53 185 142 6 29 307 48 102 153 4 30 303 118 47 134 4 31 397 126 50 190 31 1 Feb® 445 238 27 172 8 2 499 347 37 108 7 Total 2*80lT 973 567 1188 73 1** 3 f'ebo 700 484 27 153 36 n 4 502 343 36 112 11 5 439 250 28 139 22 6 307 165 29 100 13 7 337 154 67"' 101 15 8 255 101 49' 101 4 9 311 125 91 89 6 Total 2851 1622" 327 795 107 0 Table 9 » Cold Injury0 (Continued) Date Total* 1st Army 3rd Army 7 th Army 9th Army 15th Army iff* Febo 287 103 99 69 5 11 11 219 59 102 44 5 9 12 288 81 147 47 4 9 13 307 67 189 46 1 4 14 178 72 77 22 4 3 15 151 66 64 17 1 3 16 103 34 37 17 8 7 ~~T?otaI “IBS* 485 ns— 565 T SB— 17 F©b» 66 16 54 55 T 0 18 62 11 32 19 0 0 19 82 16 30 36 0 0 20 69 14 26 27 2 0 21 75 20 28 22 5 0 22 80 18 34 27 1 0 23 116 22 65 22 7 0 Total" ’ 550“ I!? 5Ss 178 ' Is T TTTibT 85 9 47 54 5 0 25 108 38 40 15 15 0 26 115 35 38 8 34 0 27 106 23 56 10 16 1 28 101 34 53 8 6 0 1 Mar0 78 26 40 8 4 0 2 108 51 46 10 1 0 Total 701 “516 320 83 81 "T 3 Maro 107 45 “ 46 ' 5 17 0 4 87 33 36 9 8 1 5 131 55 47 25 3 1 6 166 63 77 18 8 0 7 137 40 78 16 3 0 8 112; 37 65 10 0 0 9 118 36 67 12 3 0 Total 858 rw ' 4l0 IT IT TT 10 Mar0 217 24 176 15 2 0 11 " 88 42 25 20 1 0 12 66 34 24 6 2 0 13 49 24 16 8 1 0 14 53 23 20 10 0 0 15 42 19 15 7 1 0 16 56 2 17 36 1 0 Total 571 168 593 l02 8 0 Table 9 - Cold Injury <> (Continued) Total CO t-1 (—i (—1 1 |_i 1-1 O to O) S O Ol > *"d o Total H HHH W M H O O 03 S! *rJ o Total 05 04 U1 W M H H o o t-3 o p M 05 to CO co to to CO O to ® s o> CJ1 9 o Total N N N N H H H 05 N H O tO CD >5 9 *1 C S’ £ 22 1 CO H Ol N M C o> k-* |«J ImJ | ! O W N O O M cn CO M » Ol a M tfk CD 05 M M H* M 05 |M~* to M Ol H to 05 05 05 H H W Q -5 S Ol o> m O to tn a i-3 O P H * 05 i—» (—• 05 O O O M 05 cn O M M Cl M cn oo L 92 M CO CD M 05 O M O M rf* '5 H O H O H 27 M H W COM CO O >3 on ct !> 3 •< 05 O O H-* M M O O 05 O O O O O M to 05 o to O O O O M 05 M M O O CO to O 05 OQ H N H CO l-j to CO 05 cn 05 3rd Array CO rf* 03 O H H M to OJ CO 05 O w o Ol o» Oi CO 05 h tn cn cn h w 05 -a 05 |— • to 05 O to 05 co CD to 05 to M f-» co 05 05 H w to OD 03 C» 7th Army | O o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o j-) O O O O O M o CO £ > O o o o o o o o o o o o o o o o _ o o o o o o o o to O O 1—1 O O H* o o o o o o o o o 15th Army Table 9 - Geld Injury* (Continued) ftate Total* 1st Army 3rd Army 7 th Army 9th Army 15th Army 21 Apr o 6 3 1 2 0 0 22 3 0 0 3 0 0 25 2 1 0 1 0 0 24 2 0 0 2 0 0 25 4 2 0 2 0 0 26 10 0 8 2 0 0 27 8 6 0 2 0 0 Total 35 “IF” 9 14 TT" "TT” Total 44228 16953 15439 9767 2423 146 * Cases among troops assigned and attached to Headquarters, Sixth and Twelfth Army Groups not included 0 ** Daily distribution not available,, Sources Division of Preventive Medicine, Office of the Chief Surgeon European Theater of Operations, U« S, Army. Table 10 COLD INJURY Armies of the European Theater of Operations Rates per 1000 strength per annum, by weeks, November 1944 to April 1945, inclusiveo Week ending: Total* 1st Army 3rd Army 7 th Army 9th Army 15th Army 1944 3 Nov« 12 o 3 3.1 51.9 0.4 10 46.4 55.7 32.7 75.5 14.7 17 260o0 184 ol 591.7 152.0 25.0 24 160.2 172 o 7 214.8 94.9 135.7 Total 127.7 110o9 224.4 94 o 5 47.5 1 tec. IsoTTl 98o5 i86'.S 116.8 124.6 8 9202 85.3 127.5 67.8 83.8 15 154.0 223.2 168.3 127.7 39.2 22 142 .0 192 03 190.8 100.6 12 o 7 29 154 o 7 214.1 174.6 116.1 69.3 Total 135.2 164.0 170.0 106.4 67.8 194F~ 5 Jan. 7906 96.1 66.8 112.8 23.7 12 15802 238.0 141.9 166.7 19.1 233.0 19 170o9 1 270.6 i 184.6 130.9 23.6 ai c=» 26 J.49.3 213.0 149.3 165.0 9.5 no n fotal fL39.8 2'0$'o'9 135.9 144.7 18.9 187.5 2 F*Qbe 124.4 168.6 86.1 ~l92'„l 3'. 7 9 123.9 299.5 53.7 126.1 22.4 cr » 16 66.5 88.0 1 119.6 42.1 5.6 136.0 23 24.1 21.5 40.9 31.3 2.9 ■= ** Total 84 o 9 144.5 75.4 99.3 11.7 49.0 2 Mar. 29.0 35.6 52.4 “13.7 1.4 9 34 © 6 50.8 66.7 17.7 7.0 1.8 16 22 .0 27.5 49.2 16.1 1.3 - 23 12 04 4.4 10.6 36.4 0.2 <= ~ 30 3.5 2.3 1.0 11.0 . 0-0 . 1.0 fotal 17 o 3 ' ~~ 35.9 “T97T~ 4.3 L - 6 Apr* 1.9 4.3 .5 3.9 13 2.3 5.9 .5 3.9 0.0 20 lei .9 .4 4.0 0.0 27 1.2 1.9 1.3 2.3 0.0 fotal lo6 “3.2: o7 3.5 o OS o GRAND TOTAL]76.1 106.8 99.8 72.2 20.2 “lOr ♦ Cases among troops assigned and attached to Headquarters, Sixth and Twelfth Army Groups not included0 Source: Division of Preventive Medicine, Office of the Chief Surgeon, European Theater of Operations, U. S. Army. Table 11 Frostbite All Armies, European Theater of Operations, Cases and rates per 1000 strength per annum, by weeks, November 1944 to April 1946 inclusive Week Ending Cases Rate 1944 • 3 November 0 0 10 0 0 17 0 0 24 0 0 1 December 0 0 8 1 oa 15 22 1.2 22 1 0.1 29 41 2.0 1945 5 January 142 6.7 12 392 18.3 19 1024 47.9 26 1135 51.1 2 February 788 35.0 9 1186 52.4 16 388 14.7 23 68 3.0 2 March 58 2«4 9 91 3.7 16 34 1.3 23 17 0.6 30 0 0 6 April 2 0.1 13 8 0.3 20 11 0.4 27 9 0.3 Total 5368 9.14 Source: Division of Preventive Medicine, Office of the Chief Surgeon, European Theater of Operations, U.S. Army. Ground Forces GFHC Com T Z Air Force Total Continent * Month Cases Rate Cases !fiate Cases Rate Cases Rate Cases Rate “ “ 1 1. “-.■u November 9328 125.2 2 0,3 10 0c3 10 0.7 9350 75.1 December 1302*4 132.2 115 17.0 57 1.5 20 1.0 13216 80,7 January 121*40 136.0 236 33.1 122 3.5 *±8 3.1 125*46 85.3 February 801? 83**4 176 25.0 159 U.3 13 0.8 8365 53.1 March 2593 18.6 86 8.3 12 0.3 2 0.1 2693 12.2 April 181 1.6 19 lo9 8 0.2 22 1.2 230 2.1 Total t- - U5283 75«9 63U 13,2 368 1.8 115 1.1 *46*400 *46.6 Sources T Divisions of Preventive Medici ne and Medical Statistics, Office of the C hlef Surgeon, European Theater of Operations, U. S , Army. Cold Injury- Major Commands on the Continent, European Theater of Operations, U. S. Army Cases and Rates per 1000 Strength per Annum, hy Months November 19UU to April Inclusive Table 12 Entfng b. 26th Inf. 76th Inf. 80th Inf. 87th Inf, 2nfh 9Uth Inf. ?&h Uth Arm* d 6th Arm'd 8th Arm'd 9th. Arm'd 11th Arm * d 17th A/B I9IA 17 Nov 10.11 0 66.1+8 0 0 0 0 0 0 .08 0 2k « 8.73 1U.11 13.82 1.89 5.72 0 3.59 3^3 3-81 .17 0 1 Dec 9.U9 1.06 8.7>+ 10.55 0 9.01 .25 7.UU 6.27 U.7g .17 0 8 « 6.UU 1.59 11.00 3.87 0 2.11 •51 1.69 5-*13 3.59 .89 0 15 " u.93 *26 6.31 1.U5 2U.60 18.21 .76 •9^ 2.06 1.01 .71 0 0 22 * 1.7U .11 1.65 .57 2.82 .57 .50 •75 .17 .6U 0 0 29 " 5 0 57 6.36 13.28 12.31 H.87 .71 ,70 .31 11.11 .08 .39 .09 0 19*15 5 Jan 1.52 .66 12. ho 6-79 8.21 .18 .Ik .18 6„69 9.*19 .51 20.*^9 1.01 12 " 2.UU .31 12.77 lM 12.5*1 19.73 1.27 M 6.58 iu.36 0 .11 12.02 80.0U 19 * 2.63 iM n.99 9.U3 3.52 32.77 .*19 .5* 2.77 11.98 97 2.60 16.85 28.80 26 « 13.16 7.07 U.U? 1.32 U.27 3.13 12.95 8.87 .36 .51 8.33 .36 .99 3.66 23. *13 2 Feb 7.26 1.75 3.9U 1.90 10.21 M5 9.U5 12.90 ■^.23 •17 5*. 66 0 1.87 IM 9.3*1 9 H 9.63 1.38 i .58 1.63 1.99 u.59 6.3U 8.55 .25 .70 1.28 .09 .75 11.18 11.32 16 « 10.03 6.61 .90 7.7*1 6,82 1.65 10.38 12.2k 0 .17 5.07 .09 .09 6.20 .2^ 23 " 3-^3 2.95 •* .90 2ol2 1.50 1.67 5**15 .18 .09 1.30 ,09 0 3.97 0 Cold Injury Divisions of the Third Army,* European Theater of Operations Rates per 1000 Strength per Week, 3 November to 27 April 19^5» Inclusive Table n Week kth 5th 26th 76th 80th 1 87th 90th 9*Hh 95th 1 Uth 6 th gth 9th XI th 17th Ending Info Inf „ Infe Info [Inf, Info Inf, L_Inf 0 Arm9d Arm11 d __ Arm9 d Arm9d — — Arm8 d A/B "1965 ■ r" ~ 2 Mar M 0 U0?g l05B 1.58 n.97 0 .92 .9^ ,08 0 »• 0 9 H SM .75 .^5 .95 ,20 U„65 .70 5.32 ,06 .35 lo0k oUl .77 1c62 0 16 * .6U .25 ,06 i0^6 o06 ,82 0 3.09 0 .95 0 oOg 2.55 2oOU 0 23 M .57 .06 0 .13 1,70 c06 ,26 0 .17 0 0 0a2k ?g6 0 30 * Oo6 0 0 0 0 0 0 0 0 .17 0 0 o2U 0 oOg 6 Apr 0 0 0 .07 ,06 0 0 0 0 0 0 0 0 O' 0 13 * 0 0 0 0 0 0 0 0 0 0 0 0 ~0 i> ,2U 20 * 0 0 0 0 0 0 0 0 0 0 0 0 0 oOg 0 27 " Oo6 0 0 0 0 0 --=*H 0 0 0 0 0 0 0 0 0 •Divisions und er Third Army Command as of 1 Febru tary 19*+5. ••No Report, Source s Division of Preventive Medecine, Office of the Chief Surgeon, European Theater of Operations, United States Armyc • Cold Injury- Divisions of the Third Army,* European Theater of Operations, Hates per 1000 strength per Week, 3 November 19^+» to 27 April 19^5» inclusive„ Table 13 (Cont'd) Table 14 Cold Injury- First French Army, Sixth Army Group, European Theater of Operations, Cases and Rates per 1000 Strength per Annum, by Weeks, 5 October 1944 to 1 February 1945, inclusive Week Ending Cases Rate 1944 5 October 31 9.5 12 110 30.0 19 330 82,7 26 171 43.8 2 November 123 29.8 9 105 24.5 16 662 158.0 23 907 219,6 30 285 69.2 7 December 426 103.8 14 497 118.7 21 574 137,7 28 582 245,3 1945 4 January 346 82.0 11 323 71.0 18 377 83.0 25 1362 299,0 1 February 1355 341.0 Source: Division of Preventive Medicine, Office of the Chief Surgeon, European Theater of Operations, U, S, Army. FIGURES lo Soldiers on leave are quartered in resort hotels at the U#So Recreational Center, Rivieria, France, April 1945* 2* A Maginot Line pillbox serves as quarters, 6th Armored Division, Kappel, Germany, December 1944* 3. An improvised front line shower, 106th Infantry Division, February 1945* 4* New winter clothing is issued to the 8th Infantry Division Hurtgen Forest, Germany, January 1945* 5* Yanks capture a rathskeller in Borgel, Germany, January 1945. 6* An aooideilt due to a skid on an icy bridge in Luxembourg, January 1945© 7* Cold Injury, 108th freneral Hospital, Paris, France, December 1944* 8* A Ninth Army tank bogged down by mud, November 1944* 9* Heavy machine gun fire pins down a combat patrol of the 2nd Infantry Division, Ondenval, Belgium, January 1945. 10* Cold Injury, all Armies, European Theater of Operations, daily admissions, 1 November to 27 April 1945, inclusive. 11* Cold Injury, First, Third, Seventh and Ninth Armies, European Theater of Operations, daily admissions, 1 November 1944 to 27 April 1945, inclusive* 12* Cold Injury, Divisions of the Third Army, European Theater of Operations, rates per 1000 strength per week, 3 November 1944 to 27 April 1945, inclusive* (Divisions listed were under Third Army command on 1 February 1945.) 13* Dry clothing is frequently an impossibility in front line fox holes* 14* Parachute infantrymen of the 101st Airborne Division search for their size of overshoes, Bastogne, Belgium, January 1945. TABLES lo Scales of Accommodation for housing© DoS© Army Personnel in War Office Accommodations in the British Isles© 2© Deaths due to Alcohol Poisoning and Acute Communicable Dis- eases, all troops on the continent, European Theater of Op- erations, UoSo Army, number by months and rates per 1000 strength per annum, October 1944 to June 1945, inclusive© 3© Selected Preventable Causes of Non-battle Injuries, Euro- pean Theater of Operations, Uc So Army, February 1942 to March 1944, inclusive© 48 Ten most frequent causes Of Non-battle Injuries, European Theater of Operations, TJ0S© Army, cases and rates per 1000 strength per annum and percent of total injuries, 19430 50 Chief reasons for Evacuation of Non-battle Injuries to’the Zone of Interior, European Theater of Operations, DoS© Army, 1943 o 6© Major causes of Accidental Deaths, European Theater of Opera tlons, UoSo Army, 1943© 7© Non-battl© Injuries, exclusive of fatal cases and evacua- tions to the Zone of Interior, by Arm or Service, European Theater of Operations, (J0S0 Array, twenty percent sample of individual sick and wounded records, January to March, 1944, inclusiveo So Accidental deaths, by Arm or Service, European Theater of Opperations, U©So Army, January to March, 1944, inolusive0 9o Cold Injury, Armies of the European Theater of Operations, admissions by days, November 1944 to April 1945, inclusive© 10o Cold Injury, Armies of the European Theater of Operations, rates per 1000 strength per annum, by weeks, November 1944 to April 1945, inclusive0 11© Frostbite, all armies, European Theater of Operations, cases and rates per 1000 strength per annum, by weeks, November 1944 to April 1945, inclusive © 12o Cold Injury, Major Coifimands on the Continent, European Theater of Operations, U0S0 Army, oases and rates per 1000 strength per annum, by months, November 1944 to April 1945, inclusiveo 15o Cold Injury, Divisions of the Third Army, European Theater of Operations, rates per 1000 strength per week, 3 November 1944 to 27 April 1945, inolusiveo (Divisions listed were under Third Army command as of 1 February 1945o) 140 Cold Injury, First French Army, Sixth Army Group, European Theater of Operations, cases and rates per 1000 strength per annum, by weeks, 5 October 1944 to 1 February 194t, inclusive,, A HISTORY OF PREVENTIVE MEDICINE IN THE EUROPEAN THEATER OF OPERATIONS UNITED STATES ARMY 1941 - 1945 PART XI - The Integration of Preventive Medicine with other Military and Civilian Activities by Colonel John E. Gordon, M.C. Chief of the Division of Preventive Medicine Office of the Chief Surgeon, ETO TABLE OF CONTENTS PART XI The Integration of Preventive Medicine with Other Military and Civilian Activities Page Division of Professional Services ........ 1 Corps of Engineers 3 Quartermaster Corps 3 Office of the Provost Marshal 5 Civil Affairs ••••....••. . . 5 United States Navy ...... 7 British Military Organizations 7 Civilian Agencies of the United States ..... 8 British Civilian Agencies , . . . . 9 Civilian Health Agencies in France ... 10 Belgian Civil Health Authorities . , 11 American Red Cross 12 Professional Education in Preventive Medicine , , , , , , • 0 13 Committees . 14- List of Figures PART XI The Integration of Preventive Medicine with other Military and Civilian Activities A consideration of common interests between the organized service for preventive medicine in the Medical Department and the many other agencies both in and out of the United States Army which, had a part in that work, involves an appreciation of the fundamental philosophy that governs activities designed for the prevention of disease and the maintenance .of health,, Preventive medicine is no independent discipline in the sense of chemistry or physics, nor even to the extent of physiology or anatomy among medical scienceso It is an intimate part of the whole structure of medical practice, and its accomplishments are largely determined by the extent and satisfactoriness with which its efforts are integrated with other branches of medical practice and into the whole fabric of military life., A preventive medicine service of itself has the responsi- bility to develop methods for the limitation of disease; and to apply* direct, and supervise preventive measures within the com- munity, be it military or civilian,, To an appreciable extent it is a coordinating agency, for much of the work of prevention is neces- sarily and desirably done by organisations other than those concerned primarily with preventive medicine® This concept of preventive medicine led inevitably to a close association of the Preventive Medicine Division in the European Theater with other professional and administrative di- visions of the Office of the Chief Surgeon, with numerous other branches and arms of the service and with civilian agencies in public health® The closest relationship rightfully held with the Division of Professional Services in the Chief Surgeon's Office® Division of Professional Services® —The practice of medicine perhaps functions most closely to the ideal when the physician is equally concerned with the care of the sick and the protection of the well® Even with specialized interest? in either preventive or internal medicine, no sharp dividing line xa desirable and in consideration of the two disciplines, it should be impossible to determine just where preventive medicine leaves off and where good curative medicine begins® "While it is desirable administratively that the organization for the two be separate, still a unity of pro- fessional interests is essential if the objective, the health of the command, is to be attained® Much of the success of a working arrangement that endured throughout the course of operations came from an understanding reached in the earliest days of the theater, between the Chief Medical Con- sultant of the Division of Professional Services and the Chief of the Preventive Medicine Division; an understanding and a definition of principles that came out of an afternoon in a British garden on the first Sunday in the life of the newly established headquarters in rural England„ Certain fields where treatment entered strongly into the program of control lent themselves to a fairly definite division of interests between medical management and preventive activities. Among these fields was that of venereal diseases (see Part V). Malaria was another example; the Professional Services Division was responsible for clinical management of patients and the application of suppressive treatment, and the Division of Preventive Medicine for mosquito control, the protection of hospitals from infestation, and for proper isolation precautions. The tuberculosis program like- wise stressed the clinical features involved in case finding, and the preventive measures applied were directly under the supervision of the consultant in tuberculosiso Interests such as trench foot were predominantly a matter of preventive medicine, but clinical study and clinical management as a means of limiting disability were so closely coordinated with the preventive program by the Chief Surgical Consultant that the term Division of Preventive Surgery, at first lightly expressed, to designate the surgical personnel of the Professional Services Division, came to approach reality as it desirably shouldo Other mutual interests were less sharply divided., Diphtheria showed a measurably increased prevalence and a higher death rate in early 1945* The principal cause contributing to greater numbers of deaths was determined to be not so much an enhanced virulence of the infectious agent as too late recognition of the disease, and, as a consequence, of treatment that was too long delayedo The preventive measures were definitely related to improved clinical methods<> On the other hand, no better illus- tration of a primary stimulus to epidemic control that originated from the clinical side could be brought forth than the observation by clinicians of a changing character in upper respiratory disease In 1943 which gave the first indication of a nascent influenza epidemic days Defore it became statistically apparent., These pertinent and outstanding examples were wholly aside from the continuing but less significant affairs which entered into 2 the work of the day to such an extent that the services of each department were constantly called upon by the other and informal conferences between tnem close to a daily occurrence, Colonel William So Middleton, whc served as Chief Medical Consultant in the aurooean Theater for three years, has expressed the opinion that professional practice in the Theater demonstrated an inte- gration of clinical and preventive interests which might well find broader application, a statement in which the writer joins with no reservations0 Corps of Engineerso—An outstanding feature of the practice of preventive medicine in this war was the extent to which non-medical specialists entered into the worko Prominent among these were sanitary engineers and nutritionists.. Possessing a kind and quantity of training and experience in fields that were more or less foreign to the physician, they contributed to an improved per- formance in the control of water supplies, in waste disposal, mess management, nutrition, and in the general management of environ- mental sanitation., (Figure 1) These achievements in preventive medicine were attained, however, through close association with a number of other technical branches of the service, especially the Corps of Engineers and the Quartermaster Corps, The operation of systems for water supply, sewage dis- posal and for general disposal of wastes was a function of the Corps of Engineers, The interest of the sanitary engineers in the preventive medicine service in these facilities was expressed through continuous consultation concerning specilications for their construction and in the program for their operation. Many of the matters connected with military occupational hygiene (see Part X) were fundamentally related to activities of the Corps of such things as housing, heating, ventilation, and other factors related to the personal comfort and health of troops. The changing requirements in scales of accomodation to meet altered conditions of military operations were always a joint consideration of Preventive Medicine and the Engineers, Specific control measures for some of the communicable diseases depended primarily upon the activities of the Engineers, such as rat control programs and operations for elimination of mosquitoes. Quartermaster Corps,—If a man is well fed and well clothed, much has been accomplished in assuring that he remains healthy. These two objectives were responsibilities 3 of the Quartermaster Corps„ In the accomplishment of their obligation, their relationships with the Medical Department were frequent and funda- mental o The time is long since passed when the responsibility of a unit commander for the nutrition of his troops ends with seeing that they have what the Quartermaster allots* and the Quartermaster has extended his interests far beyond the question of supply<> Quartermaster food laboratories have been developed, and Subsistence Divisions have extended their activities to mess management,, The Nutrition Branch of the Preventive Medicine Division in the European Theater was concerned with the analysis and scientific appraisal of the ration, as well as with its palatability, with mess management and the avoidance of food wastage„ The overlapping interests of the two organizations gave opportunity for much common and correlated effort, a circumstance which contributed pertinently to the high level of attainment in nutrition in the European Theater, The development of a new winter uniform for the European Theater by tne Quartermaster oorpf was as well an intimate concern of the Division of Preventive Medicine„ Clothing and equipment had a lot to do with the prevention of trench foot and influenced the rates for respiratory infection,, The long series of conferences by members of the Quartermaster Corps which led to the final specifi- cations were participated in by the Medical Department„ The medical aspects were considered jointly with the technical details of supply, sizes, materials, and the many other considerations which entered into this major undertaking„ Perhaps the closest collaboration of the two services was in the field of louse control„ The whole scheme of delousing under- went a fundamental change in method just before the problem of typhus fever developed, with the result that the careful planning which had entered into the project had to be in large part discarded because of the emergence of new and superior methodso This involved for the Quartermaster Corps not only the usual supply problem, but the train- ing of Quartermaster units in the new methods which substituted, for the troops, dusting with DDT powder in place of bathing and, for the disinfestation of equipment, the same chemical in a liquid or powder form in lieu of methyl bromide» (Figure 2) The training of Steri- lization and Bath units in these methods was accomplished through the joint efforts of experts from the preventive medicine service, and the Quartermaster officers in charge of the units9 The success of the project was demonstrated in the control of an epidemic of typhus fever in Germany, where these Quartermaster Corps units contributed to the limitation of the disease to an extent which has received too little credito 4 Figure 1 Construction of a sewer line by the Engineer Corps, Wilton, England, 1943. Figure 2 DDT powder for the prevention of the spread of typhus, 345th Quartermaster Depot Company, Herbesthal, Belgium, December 1944. Office of the Provost Marshal,—-Control of the venereal diseases has passed from a police activity to emphasis on education and the application of epidemiologic methods* in similar manner to the attack on the communicable diseases in general. However, to assume that the police functions have no longer a place in modern venereal disease control* discounts the material dielo secured from the Office of the Provost Marshal in application of tne off limits policy* and its aid in the management of prostitutes, (Figure 3) In time of active military operations, battle casualties assume a far greater importance than do non-battle injuries or even the need to control epidemics0 A situation arises where attention to such prosaic affairs as automobile accidents and other commonplace hazards of Army life seems fa.r apart from the main issue0 The losses in manpower resulting from accidents nevertheless have been material„ The problem of accident prevention is not alone an obligation of the Provost Marshal as too many officers* both medical and other* are prone to assume. Accident prevention is definitely a part of a well conceived preventive medicine program. The Provost Marshal's department in the European Theater, although appreciating its primary responsibility in the matter* gave genuine cooperation to the limited efforts in the field that were made by the Preventive Medicine Division, Both organizations* however* might well have directed more energy to eliminating causes of disability from non-battle injuries* the results of which numbered essentially three fifths of the losses that came from battle casualties. Civil Affairso—The Public Health Section of the Civil Affairs Division was the preventive medicine organization for that part of Army activities directed towards the maintenance of health among civilians of liberated countries., As the Public Health Section of Military Government* it served a similar purpose for the civilians of conquered countries» (Figure A) No inconsiderable discussion arose in the course of operations* and again after the war was over., on the nature of a health organization to accomplish the obligations associated with military occupation of conquered countries.. There is serious reason for combining into a single organization two activities—preventive medicine for troops and public health for civilians who become the wards of the army—which are identical in their aims and differ only in the populations to which they apply, 5 When this is not done, however, the closest cooperation between the two activities is necessary* The obligation to troops of protection from typhus fever cannot be accomplished satisfactorily if an epidemic among the civilians who surround the army is disre- garded* Venereal disease is not a problem of an army but of a com- , plete population* The army and civilians live in the same area and the environmental hygiene of that area is as closely related to the one as to the other. The planning stage of civil affairs operations in England was characterized by much cooperative effort to develop preventive medicine procedures among displaced persons, refugees and the general civilian populations of liberated and occupied countries that would fit into the methods and supply programs of the Army* Once operations began on the continent, the civil affairs organization more or less went its own way„ Little was known in the Preventive Medicine Division about the activities of the Public Health Section of Civil Affairs, ETO, despite a conscientious liaison officer in the Office of the Chief Surgeon, whose duty it was to effect coordination between public health and preventive medicine in the two organizationsc He was usually as uninformed as the rest of the Office of the Chief Surgeon,, The contact that did exist with civil affairs personnel was not on the operational plane at theater headquarters but at the policy making and supervisory level of Supreme Headquarters* SHAEFo The common efforts that came into play operationally* were exerted through the G~5 Section of the 12th Amy Group and the corresponding staff sections of armies, and were largely brought about on an informal basis„ Policies governing vehereal disease control, typhus control, the management of displaced persons, and many other features of civilian public health were some of the interests which brought together the Division of Preventive Medicine and the Public Health Section of G-5 SHAEF* Most directives issued at that level were first coordinated with the Office of the Chief Surgeon* The venereal disease control officer of G-5 .SHAEF was for some months assigned on temporary duty to the Office* All in all, the arrangements that existed were satisfactory and gave suggestion of the possibilities that could have eventuated had the same situation held in all echelons* The fault doubtless lay in both directions but at least there was too general an attitude that each was independently created and intended to function that way. 6 Figure 3 The military police and gendarmes patrol the streets of Cherbourg, France, July 1944. Figure 4 An Allied Civil Affairs unit, Verdun, France, September 1944* Operationally, the preventive medicine service took a considerable- oart in th*> training of army and army group civil affairs organizations ir oreparation for typhus control, but other man that wiere -was little joint effort. When typhus actually broke out, practical help was provided by the Meal cal Department to 0-5 organizations of armies, but the limitations in personnel and other factors were such that effective typhus control broke down and it became necessary for the Medical Department through all echelons to take direct responsibility for the control of all communicable diseases among civilians, an arrangement which per- sisted to the end of hostilities. The staff and resources of the Public Health Section came under direct control of Surgeons at the several levels of command' and the standard of performance improved. United States Navy,—The most cordial relations existed between the headcuarters of the Navy and of the Army in the European Area but in preventive medicine the number of common interests was minimal. The part of the Navy in the European Theater was relatively small, compared with that taken in other theaters of operation A few such affairs as the sanitary control of ports required joint decision, but mutual interests were more or less limited to exchange of opinion on professional subjects as they influenced individual problems of the two services. British Military Organizations,—Among the differences in organization between the Royal Army Medical Corps and the Medical Department of the United States Army was the separation of the area covered by preventive medicine as it existed in the American forces, into two divisions in the British Army, the Department of Pathology and the Department of Hygiene, The Department of Pathology had to do among other things with immunization and with laboratory interests, ‘ine Department of Hygiene carried responsibility for essentially ail activities in preventive medicine as interpreted in American practice, other than those named. Thorough-going conferences and reviews of policies and experience were held by both these departments at about six month intervals, A representative of the American Division of Preventive Medicine was regularly included in the meetings of the advisory councils possessed by both organizations, not as an observer or visitor but with every expectation that he would constitute a part of the group, participate lully in discussions, be con- sulted in technical procedures, and evaluate practices. No finer collegial relationship could have developed. 7 In the detailed planning of joint operations naturally the British and American specialists in preventive medicine devoted much effort to coordination of governing policies and opinions0 The material help afforded the United States forces during the early months of the theater deserves special mention• Members of the American forces* both officers and enlisted men were received at the Army School of Hygiene at Aldershot for courses of instruction in field methods of sanitation* along with British colleagues. Technical help was furnished on many occasions by laboratories at Everleigh and the Army Medical School. Supplies and equipment so often lacking at that time were provided from British sources. This satisfactory relationship between the two services came in large part through the activities of the British liaison officer regularly assigned to the headquarters of the European Theater. He was accepted as a part of the American organization. The frequent opportunities for comparison of British and American experiences were made possible by the free access to British information and British opinion which came through the liaison officer. The similarity in practices and in attitudes towards preventive medicine arising from the close cultural unity of the United States and its neighbor to the north gave a common under- standing and a close coordination of interests between the De- partment of Hygiene of the Canadian Army and the Division of Preventive Medicine in the American forces. Among these was the control of the venereal diseases» As with the British* Canadian prophylactic stations were open to the soldiers of all allied forceso The Red Army arranged for liaison with the United States forces in medical affairs, but no medical officer of the Russian Army was stationed regularly with the American forces. Periodic visits of a senior medical officer served to keep our Russian ally informed of the medical problems encountered by the American forces and the methods employed in their management. Civilian Agencies of the United States.—An early visit to Great Britain in 1941 by Surgeon General Parran of the United States Public Health Service, served to establish a working arrangement between that agency and the United States military forces. Later the Public Health Service stationed an officer of its corps at the embassy in London, largely charged with in- tegration of civilian interests in public health of the two 8 countries, but nevertheless frequently concerned with purely military affairs in preventive medicine„ Technical opinion and advice from the National Institute of Health was drawn on freely in the conduct of military preventive medicine in the theater,, The Office for Scientific Research and Development maintained an office at the United States Embassy from 1941 until the end of hostilities„ The organization was interested in all scientific objectives having a connection with the war effort* The files of that office were a fruitful source for the Division of Preventive Medicine in obtaining information necessary to the conduct of operations in Europe and sometimes impossible or diffi- cult to obtain through military channels * In many instances, the Office instituted special inquiries through its facilities in the Zone of the Interior which gave information and opinions essential to solution of military problems* In turn, the Division of Pre- ventive Medicine contributed information on events and circum- stances which had a bearing on developmental projects close to the interests of the Office for Scientific Research and Develop- ment in America* Many health measures having to do with members of the merchant marine were effected through cooperation with the War Shipping Administration office in London0 The part this agency played in the development of satisfactory measures for the sanitary control of ports was material =, British Civilian Agencies Our own national health service was no closer nor more helpful in furthering the interests of the United States Amy than was the British Ministry of Health,, The association of the army preventive medicine personnel with this agency antedated the outbreak of war, for prior to that event the subsequent Chief of the Pre- ventive Medicine Division served with the Ministry of Health as liaison officer with American public health authorities,. When the United States entered the war and the American liaison officer was transferred to the Amy, the same professional relationship continued,, The confidential reports of the Ministry on health conditions in Britain were regularly supplied to the Division of Preventive Medicines Statistical information on the incidence of disease came weekly from all major jurisdictions of the United Kingdom,, When the United States Amy lacked laboratory facilities in the early days cf the war, the full facilities of the Emergency Public Health Laboratory Service of the Ministry were made available„ Specialized help in laboratory procedures 9 was always provided in handling problems which extended beyond the facilities of an army in the fieldo Many epidemiologic investigations involving the civilian population and the U,, S» Army were joint undertakings<> No common interest outweighed in importance the venereal diseaseso Support was obtained from the Ministry in the development of a program of control which made extensive use of epidemiologic methods through case finding„ The co- operation that arose from local health authorities was in large measure due to the, good auspices of the Ministry,, Indeed, few problems in public health failed to touch the common interest of the U. So Army and the Ministry of Health* The facility with which they were satisfactorily settled was due in no small degree to the fact that the Chief of Preventive Mecb - cine was included as a regular member of the staff council of the Ministry, whose weekly meetings provided excellent opportunity for exchange of information, settlement of difficulties, and mutually determined action0 Numerous British scientific institutions had a part in furthering work in preventive medicine in the United States Army„ The Medical Research Council, through its National Institute for Medical Research laboratory at Hampstead gave long collaboration to the Eighth Air Force in experimental tests of aerosols for the control of respiratory disease„ The facilities of one of the outstanding laboratories of the world were available to the Uo So Amy Medical Department in problems associated with in- fluenza o The activities of the London School of Hygiene were largely suspended during the war but the aid of its faculty was freely furnished in regard to problems associated with louse control, management of scabies, housing and ventilation, and a variety of other fields0 Civilian Health Agencies in France. —The French Ministere de la Sante Publique was one of the first governmental agencies with which contact was established by the Preventive Medicine Division when Paris was entered by the United States forceso In accordance with the precedent set in Great Britain, the Division was made the liaison Detween the Ministiy and the Medical Department,, Little actual information was at hand on the health conditions of the city or of the nation,, The rapid sani- tary survey made of Paris and the surrounding territory at that time was possible through the energetic collaboration of the French authorities, themselves just returning to their posts and 10 undertaking the reorgardzation of facilities after the German occupation,, The reporting of the communicable diseases was fragmentary at the time but such information as the Ministry possessed was promptly placed at the disposal of the Preventive Medicine Division of the American Army* The venereal diseases were a prominent interest of both the Army and the Ministry„ The plans which were made, the support which the Ministry of Health solicited from the French police, and the cooperation obtained from local health authorities did much to produce the satisfactory rates for these diseases experienced by the United States Army, and in the end led to appreciable improvement in the control of prostitution in France, an objective which had long been sought by forward looking French health authorities® The Office Internationale d'Hygiene Publique promptly put in the hands of United States military health authorities reports of that office on sanitary conditions of ports and the movement of the quarantinable diseases in the European area® The Ins*1 tut Pasteur housed the central laboratory of the United States Army for many months0 It provided anti- rabic vaccine and other biologic products for the use of the Armyo Most valuable of all were the consultation and advice given by the staff of this famous research institute« The Institut Arnold Fournier occupied a similar position in respect to problems associated with syphilis and the other venereal diseases,, Belgian Civil Health Authorities®—-The number of United States troops stationed in Belgium was relatively small but the community of interests in health affairs be- tween the local officials and the army was no less close than in other countries where American soldiers were stationed® A new venereal disease law came into being as a result of common endeavor by civilian and Amy health workers® Parti- cular mention is made of the fact that the first use of penicillin as a measure for eliminating foci of infection of the venereal diseases was in Liege® A center was established for the treatment of infected prostitutes by the Health De- partment of the city, was supplied with the necessary drug through American help, and supervision and field work was contributed by public health nurses of the Amy® This pioneer effort led to the development of a system which later received large scale application in occupied cities of Germany® 11 American Red Cross„--Much emphasis has been placed in preceding discussions on the first of the stated objectives of the preventive medicine service, which was the maintenance of health*, The efforts extended in military occupational hygiene were largely devoted to accomplishing the second aim, the physical well-being of the soldier*, The service in preventive medicine had an initimate concern with the work of the American Red Cross as it affected the third function, the morale of the Army*, The obli- gations of a number of military organizations were related to the morale factor, the Special Services Group, the Corps of Chaplains and others| and working with the Army to that end were civilian organizations such as the United Services Organization and the American Red Cross0 (Figure 5) The Red Cross hostels were the home of the soldier on pass or furlough; the clubs were his place of relaxation after duty hours„ The Medical Department consequently had a deep interest in helping toward achievement of the ends for which the Red Cross organization in the theater was established,, The preventive medi- cine service had the obligation of assuring that the sanitary facilities and the provisions for maintenance of health in Red Cross installations were equivalent to those provided by the Amy,. Primarily for this reason the Amy assigned an officer of the Medical Corps as a liaison health officer to work with the Red Cross in furthering the joint interests of that organization and of the Army0 The liaison officer took up his duties in March 194-3 under an arrangement which continued throughout the period of principal activities in Britain and until the main body of troops left for the continent in 1944» A secure system of sanitary inspection and control of housing facilities in clubs and hostels was early developed under his direction,, Messing arrangements*, general sanitation of premises, control of food handlers and the manifold interests of Amy housekeeping entered into the program,, To further this work, the Array assigned a group of eight public health nurses who served Red Cross headouarters for several months during the early develop- ment of activitieso As the details of essential sanitary procedures became apparent, a sanitary order to govern Red Cross institutions was prepared by the liaison health officer with the help of the nurses who had made most of the sanitary inspections, and this was adopted by the American Red Cross as standard operating procedure„ Great credit accrues to the American Red Cross for the serious effort made to bring sanitary conditions in Red Cross clubs to a standard approximating that of the Amy, It was one 12 Figure 5 The American Red Cross at a rest camp for combat troops, Belgium, October 1944. thing to accomplish that end under military conditions, with the favorable situations of discipline, supplies and trained personnelj and wholly another to attempt the same standards with untrained civilian staffs, drawn largely from another nation. Cooperative effort in the control of the venereal diseases between the American Red Cross and the Army deserves special mention, Conditions in Great Britain limited the useful- ness of the usual system of station prophylaxis, Prophylactic stations could not be found in the blackout, The wide dispersal of troops acted against ready availability.. The American Red Cross clubs were where the troops lived while on pass or fur- lough, They were continuously the center of social activities. Everyone knew where they were. The ready agreement of the over- seas organization of the American Red Cross to permit installa- tion of prophylactic stations in their clubs was both broad- minded and indicative of the present day realistic attitude toward these conditions* which basically looks upon them as just part of a number of communicable diseases susceptible to the same fundamental measures used for communicable disease control in general. Professional Education in Preventive Medicine.—Under military conditions, the part of preventive medicine in general medical practice was so much greater and received so much more emphasis than is ordinary, that courses of instruction in military medicine gave unusual consideration to this subject. The American School Center was established at Shrivenham, England in March 1943 as a general array school, but a goodly part of its activities were medical. A course of one month in field methods of medical practice was repeated regularly during the period of training for operations in France. When operations became a reality the school was transferred to the Continent and resumed activities at Etampes, near Paris. The course of instruction included full consideration of the control of the communicable diseases, of water supply, environmental sanitation, nutrition, venereal disease control and the control of insects. Members of the theater Division of Preventive Medicine augmented the regular teaching staff of the school and practical instruction in sanitation was furtnered by a demonstration sanitary area designed and built by members of the Sanitation Branch of the Office of the Chief Surgeon. 13 The need for instruction in special laboratory disci- plines and for the training of laboratory technicians led to establishment of a training school for officers and enlisted men at the first Medical General Laboratoryo The British Post-Graduate Medical School gave a series of courses in war medicine throughout the war years, participated in by many officers of the Canadian and American armies, as well as those of the Royal Amy Medical Corps for whom it was primarily intendedo A number of the senior officers of the United States Army medical corps, including members of the Division of Preventive Medicine served on the faculty. The course of instruction was sponsored by the War Office of Great Britian® Specialized and intensive instruction in military hygiene was provided by the British Amy School of Hygiene at Aldershot, through which many officers and men of the United States Amy had the advantage of contact with British ideas and British procedures* Committees*— Both in France and in Great Britain, medical officers of the United States Amy participated in the work of many comnattees that dealt with a variety of medical subjects, mostly related to the war effort but not invariably so, for physicians generally entered intimately into the medical life of the country in which they were living* Among these bodies were a Joint Committee on the Control of Venereal Diseases and a.Committee on Social Impli- cations of the Venereal Diseases* The first committee was organized by the British Ministry of Health to develop procedures for co- ordinated effort between civilian health authorities and those of all services, British, American and Canadian, to the end of facili- tating improved conditions in relation to both civil and military populations* The Committee on Social Implications of the Venereal Diseases was organized by the British Social Hygiene Council and was primarily concerned with civilian interests on a long term basis* The Jaundice Committee of the Medical Research Council in- cluded representatives of the United States Amy* The special in- vestigations conducted under the auspices of this group led to material contributions in this developing field* Other special groups were concerned with problems of water supply, louse control, typhus fever, tuberculosis and other interests sufficiently numerous to include the major fields of preventive medicine* u A Committee on Social and Preventive Medicine, of which the Chief of the Preventive Medicine Division was a member, was formed in 1942 by the Royal College of Physicians. The Committee was one of the first groups to emerge in the field of post war planning. Its deliberations extended over three years and led to clarification of the objectives and aims of preventive medicine in present day practice, A method of presentation to future medical students was defined. The work of the committee was illustrative of the possibility of main- taining interest in fundamental problems of medicine under war conditions and of the community of interests of physicians irrespective of nationality and individual concern. 15 FIGURES !• Construction of a sewer line by the Engineer Corps, Wilton, England, 1943* 2. DDT powder for the prevention of the spread of typhus, 345th Quartermaster Depot Company, Herbesthal, Belgium, December, 1944. 3. The military police and gendarmes patrol the streets of Cherbourg, France, July 1944. 4. An Allied Civil Affairs unit, Verdun, France, September 1944* 5# The American Red Cross at a rest camp for combat troops, Belgium, October 1944. A HISTORY OF PREVENTIVE MEDICINE IN THE EUROPEAN THEATER OF OPERATIONS UNITED STATES ARMY 1S41 - 1945 PART XII - The Health of the Command Colonel John E. Gordon, M. C. Chief of the Division of Preventive Medicine Office of the Chief Surgeon, ETO TABLE OF CONTENTS PART XII - The Health of the Command Pag© Introduction,) ooooooocoo eooooooeoe.e* X Monthly Admissions for the Theater as a Whole. . • „ • • • • 1 Non-battle Injuries ooooo.oo.oooo.o...#. 1 Battle Casualties o * oooooooooooocop.oo. 2 Admissions for All Causes * * » * . * . . . ««•••• 2 Monthly Admissions - Operations in Continental Europe . • • 2 Disease, All Fo rms ooooooooooeooe.e.... 2 Neuropsychiatric Conditions « o » <> « * «, „ * <» « 2 Non—battle Injuries ooooooooooo.o.o..... 3 Battle Casualties in Great Britain* • ••••«••••»• 3 All CaUSeS ooooooooooooooooooooeoos. 3 Deathsooooooeoooooooooo.oooooe... 3 Non-effective Rates o oeoooooooo.ooo«oo.« 3 Comparison vrith Other Theaters* 4 List of Figures List of Tables PART XII - The Health of the Command Throughout the many weeks of operations in Europe, and from a variety of headquarters, the Chief of the Division of Preventive Medicine was accustomed to submit to the Chief Surgeon of the Theater a review of the principal events of the week in Preventive Medicine, epidemiologic notes, and a tabulated summary of cases and deaths from disease, non-battle injury, and battle casualtieso The statistical summary that concluded the report was designed to give the factual data upon which opinion was based as to the health of the commando The same procedure would seem a fitting way to conclude this more pretentious history of the events that took place during the whole time that the United States Army functioned in Europe as the European Theater of Operationso (Figures 1 - 7)0 Monthly Admissions for the Theater as a Whole©—Both admissions to hospital and to quarters are included in these data which are derived from the weekly Statistical Health Reports© All DiseasesThe conditions classified as disease were the commonest cause of admission to hospital or quarters, with an average admission rate for the whole period of operations of 546 per thousand strength per year© The best year was 1944 although the six month period of 1945 was almost as good© The highest average annual rate for any year, that of 837 in 1943, was largely due to increased rates for respiratory disease0 In all years, the monthly distribution of admissions reflects the same influence© Table 1© In the course of the discussion devoted to epidemiology full attention has been given to the principal causes of admission to sick report as a result of infectious diseases© That information will not be reviewed© Other than infectious diseases, admissions because of neuropsyohiatric disturbances were a strong contributing factor to the total disease admission rates© The data are presented in Table 2© Non-battle Injuries©-“The average rate for the period of operations was 105 per 1060 strength per year and no great variation occurred from year to year© The rates for 1945 were greatest, 115 per thousand, as would be anticipated for the period of most active operations; but even in that year the rates did not greatly exceed the established average© No characteristic monthly distributions were evident, but the outspoken influence of field operations and of intensified training are well demonstrated© Table 3© Battle Casualties0— The first battle casualties of the European Theater recorde724 115 Casualties 395s488 124 166 2 2s 242 9 235s113 160 157s967 115 Total 2P466s196 775 59s070 812 249s817 946 Is 103s751 749 Is 053 c558 768 Source; Mec Was lical Statistics D 3hington9 D0 C© ivisions Office of $ CD CO s Ger leralp War Departments Admissions to Hospitals and All Causes European Theater of Operations0 Ua S0 Army- Cases and Rates per 1000 Strength per Annum February 1942 to June 1945 0 Inclusive Table 5 Table 6 Admissions to Hospitals and Quarters, All Diseases Continental Europe and United Kingdom, European Theater of Operations, U0 S» Army Cases and Rates per 1000 strength per annum, by months September 1944 to June 1945 Inclusive, Month Total United Kingdom Continent Cases Rate Cases Rate Cases Rat© 1944 Sep® 49860 305 26415 400 23445 240 Oct® 64984 467 19563 470 45421 466 Nov® 82114 538 19513 476 62601 562 Dec o 127798 564 27652 460 100146 601 1S45 Jan® 118465 605 25861 525 92604 631 Feb® 118862 577 21084 446 97778 616 Mar,, 140201 530 23151 458 117050 547 Apr o 102541 469 17177 444 85364 474 May 117630 531 15146 507 102484 535 June 140168 532 * * Total 1062623 518 195562** 461 726893** 535 * Ho data avallat>le3 ** June not inciudedo Source! Medical Statistics Division, 01*rice or the Surgeon General, War Department, Washington, D« C® Table 7 Admissions to Hospitals and Quarters, Neuropsychiannc Diseases, Continental Europe and United Kingdom European Theater ot* Operations, Uc S« Array, Cases and Rates per 1000 strength per annum, Dy months, September 1944 to June 1945, inclusive Month Total United Kingdom | Continental Europe Cases Rate j Cases Rate Cases Rate J 1944 September 6546 40 1 3387 t 51 ‘ 3159 32 October 9099 65 ! 3554 85 5545 i 57 November 12939 85 | 4736 •115 8203 74 December 16226 72 j 5006 83 11220 67 1945 January 9929 51 | 2075 42 7854 54 February 7455 36 | 492 10 6963 44 15a rch 10250 39 560 11 9690 45 April 6730 31 462 12 6268 35 May 3297 15 478 16 2819 15 June 3437 13 546 12 2891 13 ' '— - ""I Total 85908 42 21296 45 64612 41 —- — Sources Medical Statistics Division, Orrice of The Surgeon General, War Department, ’Washington, Dc 0o Table 8 Admissions to Hospitals and Quarters, Non-tattle Injuries, Continental Europe and United Kingdom, European Theater of Operations, Uc S„ Army, Cases and Rates per 1000 Strength, by Months, September 1944 to June 1945, Inclusive Month Total United Kingdom Continental Europe Cases Rate Cases Rate Cases Rate 1944 September 11931 73 4520 68 7411 76 October 12119 87 3250 78 8869 91 November 16124 106 3055 75 13069 117 December 30816 136 3698 62 27118 163 1945 January 34163 174 4933 100 29230 199 February 23489 114 2336 49 21153 133 March 27640 104 2620 52 25020 117 April 24717 113 2303 59 22414 124 May 24819 112 1764 59 23055 120 June 22896 87 * * * Total 228714 ! 111 28479** 67 177339** 130 * No data available® ** June not included® Sources Medical Statistics Division War Department, Washington, Office D0 Co of The Surgeon General Table 9 Admissions to Hospitals and Quarters® Battle Casualties® Continental Europe and United Kingdom European Theater of Operations® U<, Sr Army® Cases and Rates per 1000 Strength per annum® by months® September 1944 to June 1945® Inclusive Month Total | L _ J United Kingdom Continental Europe Cases Rate | Cases Rate Cases - Rate 1944 September 33200 —.———j. 203 ! | 15388 233 17812 183 October - 19300 1 139 | j 3668 88 15632 160 November 42400 278 1 i 11425 279 30975 278 December 48200 ■ 213 | | 46 1 48154 289 1945 January 42373 216 | f 1 j 1391 28 40982 279 February 26481 129 | 433 9 26048 164 March 49784 1 138 i 396 f \ 8 49389 231 April 34096 156 j 556 14 33541 186 May 4813 22 ; 23 23 i 4790 25 June 420 2 1 * * L j Total 301067 147 | 1 33324** 78** 267323** 196** —.——— — _ I , —1 _ , , Source % Medical Statistics Division® Office of The Surgeon General® War Department® Washington® D„ C © *Data not **June not available© included© Table 10 Admissions to Hospitals and Quarters, All Causes, Continental Europe and United Kingdoms European Theater of Operations*, U0 S0 Army, Cases and Rates per 1000 Strengths per annuiris by months, September 1944 to June 1945, Inclusive Month Total United Kingdom Continental Euro pe Cases Rate Cases Rate Cases Rate 1944 September 94991 581 46323 701 48668 499 October 96405 693 26481 636 69922 717 November 140658 922 33993 830 106645 957 December 206814 913 31396 523 175418 1053 1945 January 195001 995 32185 653 162816 1109 February 168832 820 23853 504 144979 913 March 217625 822 26166 518 191459 895 April 161354 738 20035 517 141319 784 May 147262 665 16933 567 130329 680 June 163484 621 * * Total 1592404 776 257365** 606** 1171555** 859** *No data available«, **June not includedo Sources Medical Statistics Office of The Surgeon Generali; War Washington f De C» Total 1942 1943 1944 1945 Causes Deaths } Rate Deaths Rate Deaths Rate Deaths Rate Deaths Rate Disease* 1594 o5 ' 36 ' ’ 75 In <>4 590 857 c6 Non-battle Injuries* 9085 2*9 199 2*7 768 2*9 3900 2*6 4218 3® 1 Died of Wounds** 16251 5*1 * 25 o3 65 *2 10781 7o3 5380 3o9 Killed in Action** Declared and Reported Dead While Missing 107258 33*7 147 2o0 2799 10c 6 38856 460? 35456 25e 9 in Action Died While Prisoners 9012 208 134 lo8 2162 8o 2 5363 3*6 1353 loO or Internees*** 895 o3 7 — 7 ©2 603 • 4 241 o2 Total 144095 45 * 3 L, 1 548 : . „ 7* 5 5949 22o 5 90093 61*0 47505 34* 7 Sources Medical Statistics Division* Office of The Surgeon General* War Department* Washington* DcC, * ~ Figures for 1942 and 1943 based on Individual Medical Recordss for 1944 and 1945* on the Statistical Health Report (WD AGO Form 8-122* formerly WDMD Form 86ab)» ** - Data taken from Records Branch* ”Battle Casualties of the Army*" Office of The Adjutant General* 1 July 1946* prepared for WDGS by Machine *** - Does not include 190 persons who died of wounds while prisoners of war or deaths are included in "Died of Wounds” above* internee s'o These Deaths from all Causes European Theater of Operations - U0 So Army With Rates per 1000 Strength per annums by YearsD February 1942 to June 1945x, Inclusive Table 11 Table 12 Deaths from Infectious Diseases, European Theater of Operations, U, S# Army Number by Diagnosis and Years, February 1942 to June 1945, Inclusive Infectious Diseases Total 1942 1943 1944 1945 Common respiratory 6 1 5 Pneumonia* primary 64 2 30 32 Pneumonia., primary atypical 45 1 3 8 33 Pneumonia, secondary 32 1 2 /6 23 Influenza 1 1 ‘Meningitis, meningococcal 99 6 13 40 40 Meningococcal infection, other 2 2 Scarlet fever 4 2 2 Streptococcal sore throat 1 1 Rheumatic fever 3 . 2 1 Diphtheria 34 5 29 Poliomyelitis 8 1 4 3 Chickenpox 1 1 German measles 1 1 Mumps 2 2 Tuberculosis 53 2 5 20 26 Encephalitis 3 3 Malaria 6 4 2 Fever of undetermined origin 1 1 Hepatitis* infectious 68 2 22 44 Weilcs disease 1 1 Common diarrhea 3 1 2 Dysentery, amoebic 1 1 Dysentery* bacillary 1 1 Syphilis 2 1 1 Tetanus 1 1 Gas gangrene 15 6 9 Mycotic Dermatoses 1 1 Total 459 10 33 159 257 Source: Medical Statistics Division, Office of The Surgeon General* War Department, Washington, Dt Ce Table 13 Average Daily Non-effective Rates per 1000 Strength European Theater of Operations * U, S, Army., By February 1942 to June 1945 s Inclusive Month 1942 1943 ! 1944 1945 r !L U. . January 37a7 30«3 75a3 February llol 42 o 4 30a5 72a8 March 10o9 43a 1 290 4 62a3 April 14o6 36 o 6 26a8 64a4 May 17o4 30a6 23a6 42 0 9 June 24o0 26a3 2606 28a8 July 26c0 23c7 39a 4 1 v- August 260 5 20a4 49a2 September 27 o 4 21a 8 50 a 5 October 27o 7 24a 0 55o4 November 30© 1 27a3 57a7 December 26 a 1 j 32 a 2 67a7 1 n 1 1 Total 26n6 — 1 29o 1 J 44o6 56a5 Total 1942 - 1945 48 a Sources Medical Statistics Divisions Office of The Surgeon Generals War' Departments Washingtons D0 Cc Table 14 Average Daily Non-effective Rates per 10C0 Strength, For Disease, Non-battle Injury and Battle Casualty, European Theater of Operations, U. S, Army, January 1944 to June 1945, Inclusive Month Disease Non-battle Injury Battle Casualty 1944 January 24,9 5.4 .4 February 25.1 5.0 .4 March 23.9 5.1 .4 April 21.1 5.2 . 4 May 17.7 5.5 . 4 June 14.4 5.4 6.8 July 12.8 5.1 21.5 August 12.8 5.0 31.4 September 12.6 5.5 32.4 October 16.8 6.7 31,9 November 20.4 7.7 29.6 December 25.1 9.7 32.9 1945 January 29.1 12.3 33.9 February 27.3 15.4 30.1 March 23.4 12.5 26.4 April 26.9 11.2 26.5 May 20.5 8.1 14.3 June 18.2 6.2 4.4 Total 21.3 8.5 20.7 Sources Medical General, Statistics Division, Office War Department, Washington, of The Surgeon D. C. Theater Total 1942 1943 1944 1945 Cases ______— Liai9.j Cases 2047606 i Rate | Cases | Rate Cases Rate Cases Rat© Total Array 14120214 667 r— 671 1 5163760 j 768 P4550658 606 2358190 1 608 Total Overseas 5541949 690 j 348472 679 1370172 860 1 2288868 654 ! 1534447 i 631 North America 90663 534 : 27248 672 39285 548 18226 433 5904 382 Europe 17352S3 546 | 50881 700 221078 837 726437 492 737867 538 Alaska 155041 571 | 33564 568 71615 624 39766 478 10096 431 Pacific Ocean Area 626954 600 72812 494 239851 813 22145? 561 92834 448 Continental United States 8578285 353 1699X34 669 3793588 739 2261800 534 825743 571 Latin America 235832 376 j 84864 825 82748 684 46448 540 21772 558 Mediterranean 1146934 849 9618 451 406619 943 558051 346 174646 726 Southwest- Pacific 1117120 926 55751 832 204267 1046 465289 840 39181-3 1006 China-Burma- India 308806 929 j 1 5951 1046 45636 991 171716 1077 85503 707 Africa-Middle East 123336 j 9*6 1 7783 1356 59073 110? 42468 896 14012 587 Source; Medical Statist! Y/ashingtonp Do G cs Division*, Office of The Surgeon General*, War Department*, o Admissions to Hospitals and Quarters,, All Diseases, Total Army, Continental United States and Theaters of Operations, Uc S„ Army? Cases and Rates per 1000 Strength per annum, by years, January 1942 to June 1945, Inclusive Table 15 Theater Total 1942 1943 1944 1945 Cases | Rate | Cases j Rate [ Cases Rate J_ Cases Rate ssssssss 89 Cases l535996~~ Rate Total Army ’ 192£342 I 91 294288 r 624849 93 666209 ' 87 Total Overseas 934-179 [ 116 63922 ; 126 212194 133 395673 113 262390 108 Continental United States 987163 75 230366 91 412655 80 270536 67 73606 51 Latin America 32308 93 11180 109 12754 105 5995 70 2379 61 China-Burma- India 31541 95 460 81 3893 84 15385 96 11803 98 European 33544.5 105 8023 110 26497 100 143201 97 157724 115 Pacific Ocean Area 111366 107 15379 104 33590 114 43648 111 18749 90 Africa-Middle East 14679 115 928 162 7469 140 4712 99 1570 66 North America 21160 325 6330 156 9747 136 4065 96 1018 66 Mediterranean 179581 133 2040 96 64075 149 91063 138 22403 93 Southwest Pacific 166758 138 11963 178 33317 171 77046 139 44432 114. Alaska 41341 152 7619 152 20852 182 10658 127 2312 99 L.. — Source: Medical Statistics Divis Washington* D. C0 ion* Office of The Surgeon General* War Department* Admissions to Hospitals and Quarters* Non-battle Injuries Total Army* Continental United States* and Theaters of Operations* Ue S0 Army* Cases and Rates per 1000 Strengths per annum*, by years.? January 1942 to June 1945* Inclusive Table 16 Theater Total 1942 194 :3 1944 1945 Cases Rate Gases Rate Cases Rate Gases Rate Cases Rate - - ■ ’ - -- —— •: - .. . Total Army 638913 30 4135 lo4 41862 6.2 355624 47.3 237292 61 Total Overseas r , 638913 79 4135 sa 41862 26.3 355624 101.6 237292 98 Continental United States 0 0 0 0 0 North America 1 0.005 » o 0 0 0 0 0 1 o 06 . Latin America 2 0o005 0 0 1 .01 1 .01 0 Africa-Middle East 364 3 38 6.6 293 5.49 28 .59 5 o 21 Alaska 1307 5 60 1.2 1238 10.8 8 .1 .04 China-Burma- India 3980 12 16 2.8 295 6.4 2854 17.9 815 7 Pacific Ocean Area 41911 40 740 5o0 4502 15.3 12040 30. 5 24629 119 Southwest Pacific 65158 54 1596 23.8 2234 11.45 18885 34a 42443 109 Mediterranean 130702 97 1519 71.2 31057 72.0 86695 131.4 11431 47 European 395488 124 166 2.3 2242 8.5 235113 159.6 157967 115 Sources Medical Statistic Washingtons D. C. s Division# Office of The Surgeon General# War Depa rtments Admissions to Hospitals and Quarters* Battle Casualties Total Army* Continental United States* and Theaters of Operations* Ue Se Army Cases and Rates per 1000 Strength per annum* by years* January 1942 to June 1945* Inclusive Table 17 Admissions to Hospitals and Quarters All Causes* Total Army* Continental United States* and Theaters of Operations* U*S* Army Cases and Rates per 1000 Strength per annum, by years January 1942 to June 1945, Inclusive Theater Total 1942 1943 1944 1945 Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Total Army Total 16680469 788 2346029 769 5830471 867 5572491 742 2931478 756 Overseas 7115041 885 416 529 811 1624228 1019 3040155 869 2034129 837 Worth America 111824 659 33578 828 49032 684 22291 529 6923 447 Alaska Continental 197689 728 41243 821 93705 817 50332 605 12409 530 United States Pacific Ocean 9565428 728 1929500 760 4206243 819 2532336 631 897349 622 Area 780231 747 88931 603 277943 942 277145 703 136212 657 Latin America 268142 769 96044 934 95503 789 52444 610 24151 619 European China-Burma- 2466196 775 59070 812 249817 946 1103751 749 1053558 768 India Africa-Middle 344327 1036 6427 1130 49824 1081 189955 1191 98121 811 East 138379 1062 8749 1525 66835 1253 47208 996 15587 653 Mediterranean Southwest 1459217 1079 : 13177 618 501751 1164 735809 1115 208480 866 Pacific 1349036 1119 69310 1035 239818 1228 561220 1013 478688 j 1229 Source: Medical Statistics Division, Offl ce of The Surgeon Genera 1* War De partment , Washington, D* C« Table 18 FIGURES la The maintenance of health is a function of command* General Dwight D* Eisenhower, Supreme Allied Commander, examines the field jacket of a soldier at the 16th Reinforcement Depot, February 1945* 2* Medical care of the sick and wounded is the first obliga tion of the Medical Corps0 The 45th Field Hospital at Weissenee, Germany, April 19450 3» Good hospital care decreases non-effectiveness* A patient with a lung wound in the shock ward of an evacuation hospi- tal, France, July 19440 4* The prevention of disease limits hospital admission* Drink- ing water is tested for its chlorine residual, 26th Infantry Division, Luxembourg sector, January 1945o 5* Medicine Is many sided* Dental care in the 26th Infantry . Division, Germany, February 1945* 6o The protection of the food supply is fundamental to pre- vention of disease0 Inspection of frozen poultry by an army veterinarian at a cold storage plant in Paris, Feb- ruary, 1945o 7* Precision furthers accomplishmento Laboratory service at the 5th General Hospital, Northern Ireland, November 1942* 8c Causes of death in World Wars I and II, troops of the AEF and of the European Theater of Operations, U0S* Army, average rates per 1000 strength per annum0 90 Average daily non=>effective rates per 1000 strength, Euro- pean Theater of Operations, UoSo Army, by months, February 1942 to June 1945, inclusive0 lOo Average dally non=effeotive rates per 1000 strength* disease, non-battle injury and battle casualty, European Theater of Operations, U0S0 Army, January 1944 to June 1945, inclusive* TABLES 1*, Admissions to hospitals and quarters, all diseases, European Theater of Operations, UQ S0 Army, cases and rates per 1000 strength per annum, by months, February 1942 to June 1945, inclusive o 20 Admissions for neuropsychiatric conditions, hospitals and quarters, European Theater of Operations, U<> So Army, cases and rates per 1000 strength per annum, by months, February 1942 to June 1945, inclusive0 30 Admissions to hospitals and quarters, non-battle injuries, European Theater of Operations, Uc S„ Army, cases and rates per 1000 strength per annum, by months, July 1942 to June 1945, inclusive*. 4C Admissions to hospitals and quarters, battle casualties, European Theater of Operations, Uc Sa Army, cases and rates per 1000 strength per annum, by months, August 1942 to June 1945, inclusive*. 5c Admissions to hospitals and quarters, all causes, European Theater of Operations, U« So Army, cases and rates per 1000 strength per annum, February 1942 to June 1945, inclusive*, 6o Admissions to hospitals and qua.rters, all diseases. Continental Europe and United Kingdom, European Theater of Operations, U„ S0 Army, cases and rates per 1000 strength per annum, by months September 1944 to June 1945, inclusive0 7„ Admissions to hospitals and quarters, neuropsychiatric diseases. Continental Europe and United Kingdom, European Theater of Opera tions, U0 So Army, cases and rates per 1000 strength per annum, by months, September 1944 to June 1945, inclusive0 So Admissions to hospitals and quarters, non-battle injuries. Continental Europe and United Kingdom, European Theater of Operations, U*, S*> Army, cases and rates per 1000 strength, by months, September 1944 to June 1945, inclusive*. 90 Admissions to hospitals and quarters, battle casualties. Continental Europe and United Kingdom, European Theater of Operations, U0 S0 Amy, cases and rates per 1000 strength per annum, by months, September 1944 to June 1945, inclusive0 10o Admissions to hospitals and quarters, all causes, Continental Europe and United Kingdom, European Theater of Operations, U0 So Army, cases and rates per 1000 strength per annum, by months, September 1944 to June 1945, inclusive*, 11o deaths from all causes, European Theater of Operations, U0S0 Army, number and rates per 1000 strength per annum, by years, February 1942 to June 1945, inclusive0 12o Deaths from infectious diseases, European Theater of Operations, Uo So Army, number and rates per 1000 strength per annum, by years, February 1942 to June 1945, inclusiveo 13o Average daily non-effective rates per 1000 strength, European Theater of Operations, U0 S0 Army, by months, February 1942 to June 1945, inolusive0 14o Average daily non-effective rates per 1000 strength for disease, non-battle injury and battle casualty, European Theater of Operations, U0 S0 Army, January 1944 to June 1945, inclusive0 15o Admissions to hospitals and quarters, all diseases. Total Army, Continental United States and Theaters of Operations, U0 So Army, oases and rates per 1000 strength per annum, by years, January 1942 to June 1S450 16o Admissions to hospitals and quarters, non-battle injuries. Total Army, Continental United States and Theaters of Operations, U„So Army, cases and rates per 1000 strength, per annum, by years, January 1942 to June 1945o 17o Admissions to hospitals and quarters, battle casualties, Total Amy, Continental United States and Theaters of Operations, Uo So Amy, cases and rates per 1000 strength per annum, by years, January 1942 to June 1945, inclusive,, 18o Admissions to hospitals and quarters, all causes, Total Army, Continental United States and Theaters of Operations, U0 So Army, cases and rates per 1000 strength per annum, by years, January 1942 to June 1945, inclusive0