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Chapter XXIX

Contents

The Medical Department Of The United States Army in The World War

CHAPTER XXIX

DEPARTMENT OF SANITATION AND PUBLIC HEALTH, GERMAN OCCUPIED TERRITORYa

The office of the department of sanitation and public health for civil affairs in German occupied territory was established pursuant to the provisions of General Orders, No. 1, advance general headquarters, A. E. F., Treves, Germany, December 13, 1918; however, the organization of the office had been begun by verbal orders issued by the commander in chief, A. E. F., about one week previously. It was the duty of this department to supervise and control the civil sanitary service in the occupied area with a view of protecting the health of the troops of the American Army of occupation and of guaranteeing to the civil population adequate medical service. The personnel of the department consisted of 12 officers, 4 nurses, and 9 enlisted men.

DISTRIBUTION OF TROOPS

The army of occupation, i. e., the third Army of the American Expeditionary Forces, consisted of eight divisions organized into three corps, with headquarters at Coblenz. These troops occupied an area west of the Rhine along the Moselle River, roughly 80 miles from southwest to northeast, from Treves to Coblenz, and about 50 miles in width, together with the northern half of the Coblenz bridgehead east of the Rhine. This territory included the kreise (circles) of Prum, Bitburg, Treves, Saarburg, Daun, Wittlich, and Berncastel, in the Government district of Trier, and Adenau, Ahrweiler, Cochem, Mayen, Coblenz, and Neuweid, in the Government district of Coblenz, with most of the Government administrative area of Montabaur, in Hesse Nassau. The estimated civil population of the territory occupied, and with whose sanitary control this division was charged, totaled 835,000.

GERMAN PUBLIC HEALTH SERVICE

Information was obtained concerning the personnel and organization of the German public health service by personal interviews with the civil officials in Treves and Coblenz and by a study of published regulations and reports of the service. It was found that it was administered by civil officials appointed by the Minister of the Interior. In each of the Government administrative areas, a civil medical officer was charged directly with the supervision of sanitary matters within his area; he was responsible to the administrative head of the district. As health officer of the community, he was the technical adviser of the administration with reference to all sanitary and public health matters. In general he supervised water supply and sewage disposal; received reports of communicable diseases and saw that lawful measures against their spread were

aBased on: Report on the Department of Sanitation and Public Health, Civil Affairs, Treves, Germany. Period Dec. 7, 1918, to May 28, 1919, dated Nov. 1, 1919, by Col. Henry A. Shaw, M. C. On file, Historical Division, S. G. O.


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enforced; made sanitary inspections of food supplies, including milk, meat, etc.; supervised the sanitation of schools and the medical examination of public prostitutes. He could not initiate sanitary regulations, but he kept in touch with all matters affecting the health of the community, and was held responsible for making proper and timely recommendations for the prevention of disease and the general improvement of sanitary conditions. He made weekly reports of communicable diseases and yearly reports of general health conditions to the administrative head of the district.

COORDINATION OF THE CIVIL AND MILITARY SANITARY SERVICE

As the German public health service appeared to be adequate and sufficient for the needs of the civil population, the manifest policy was to continue the organization in force, with such supervisory control and assistance by the American Military Establishment as might be found necessary. This was satisfactorily effected by directing division commanders to supervise the administration of the civil sanitary service within their divisional limits. As these areas corresponded fairly closely with administrative areas, division surgeons were enabled to cooperate effectively with the local health officer, obtaining from him information concerning the health of the civil population and the sanitary conditions of the country and at the same time giving him information concerning the health conditions of the military units. In this the work of the civil and military organizations was coordinated, each reporting to the other essential data affecting public health.

Reports from division surgeons of cases of communicable disease in both civil and military populations reached the office of the chief sanitary officer through the chief surgeon, Third Army. Weekly reports of communicable diseases in the civil community were also received from the chief German sanitary official of the district of Treves and of Coblenz. Cases of typhoid fever were in addition reported from the director of the German laboratory at Treves. Division surgeons made a special monthly report to the chief sanitary officer through channels regarding important matters pertaining to public health and sanitation in the civil population, a separate report being rendered for each administrative area. Thus, reports were received and tabulated from both civil and military sources enabling the chief sanitary officer to keep in touch with health conditions in both communities.

MEDICAL SERVICE FOR THE CIVIL POPULATION

One of the first endeavors of the office was to get in touch with the German civil sanitary officials both in Trier and in Coblenz for the purpose of obtaining information concerning the adequacy of the established public health service with respect to personnel and material, and also to learn whether the needs of the civil population were satisfied as to medical attendance, hospital and laboratory facilities, and medical supplies and drugs. Though the public health service, as noted above, was found to be generally adequate and competent, it was reported that there were insufficient German physicians to care for the civil population in the occupied territory.


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HOSPITALS

All hospitals were under the administration of the Minister of the Interior of Prussia and made regular reports concerning the number of beds, the character of patients, the number of admissions and discharges, and the causes of death. In the entire district of Coblenz there were reported to be 39 institutions for the care of the sick, with a total of 3,825 beds, and of these only 2,282 were occupied. In the Treves district there were 2,214 beds available, this number being sufficient to care for the needs of the civil population. The total number of beds in Coblenz was approximately 5 per cent of the population and in Treves 2.2 per cent. In both districts the number of hospital beds had been increased during the war to care for soldiers and was larger than the number that sufficed in time of peace.

The civilian authorities were informed that in emergency, and also in case of communicable disease, where isolation could not be promptly obtained by German civilians, such patients would be admitted to American military hospitals.

LABORATORIES

A well-equipped laboratory under the control of the public health service had been established in Treves and was found to be very efficiently administered.

MEDICAL SUPPLIES AND DRUGS

Reports from hospitals, laboratories, public health officials, physicians, and druggists showed that many of the essential medical supplies and drugs were either exhausted or to be found in extremely limited quantities. Such were gauze, cotton, and soap for surgical work; rubber articles; certain drugs, as iodine and the iodides, sulphur, boric acid, camphor, and the vegetable cathartics. Estimates were made of the needs of the population based on the number of hospital beds, and recommendation made that certain enumerated supplies and drugs be furnished by the Medical Department, United States Army, to German hospitals and laboratories in the occupied area. These recommendations were approved in substance, and the necessary measures taken to carry them into effect. The cost of the supplies was charged to the German Government.

HEALTH CONDITIONS

A comprehensive study was made of the health of the civil community in Germany during the war and particularly in the occupied area, the material for which was drawn from official reports from civil and military sources, from interviews with German physicians and civil officials, from vital statistics published by the German Government, and from personal examination of various groups of the German population.

VITAL STATISTICS

Births.-The average birth rate for this region during several years previous to the war had been about 30 per thousand; in 1914 it was 23.8; in 1917, 15.6, and in 1918, 16.1. Illegitimate births in the occupied area in Germany showed little variation in the rural districts before and during the war, but in the cities the rate was about doubled in 1917 and 1918 as compared with 1915.


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Deaths.-In the occupied area the death rate for several years previous to the war averaged 15 per thousand inhabitants; in 1915 it was 20.5 and in 1918, 27.2.

Communicable diseases.-There had been a marked increase in the number of communicable diseases in Prussia in 1914 and 1915. This was to be expected on account of war conditions involving rapid mobilization of troops and billeting with civilians; many localities were left with insufficient medical personnel. In the American area the most notable increase in these diseases had been in typhoid fever, tuberculosis, diphtheria, and especially dysentery; previous to the war this disease had been almost negligible in this region, but it appeared in Trier in 1914 and in Coblenz in 1915, increasing during the following years; in Coblenz there were over 700 cases in 1917, and in Treves more than 1,000 in 1917, and nearly 1,900 in 1918.

Among the civil population of Germany, tuberculosis in all its forms had more than doubled during the war, a fact shown chiefly in death statistics, as living cases were not reported. A corresponding increase of tuberculosis among the living was indicated by the fact that the Government insurance offices in the cities of Trier and Saarbrucken paid benefits to 48 cases of pulmonary tuberculosis in 1914; the number rapidly increased during the war and in 1918, 208 persons received insurance for this disease. Of all the etiological factors entering into this increase the shortage of food was most important. This increase had been much less marked among the comparatively well-fed rural population than among the city dwellers who were more strictly rationed.

FOOD PROBLEM

One of the most interesting matters for investigation was the food problem in Germany, since this question in one form or another was met with at every turn.

To solve the problem of a diminished food supply, Germany proposed national rationing. This was begun early in 1915, first in regard to bread and then extended in the same year to potatoes and meat and finally to nearly every essential food product. The rationed articles could be obtained only on tickets, in specified amounts and at prices fixed by the Government. After the failure of the potato crop in the fall of 1916, food conditions went from bad to worse, so that before the end of the war the ration allowances in most parts of Germany were less than half the usually accepted estimates for physiological requirements for health. In general, it may be stated that the allowances in 1914 averaged about 3,000 calories for various localities; in 1915, about 2,000 calories; in 1916 and 1917 about 1,500 calories, and in 1918 between 1,200 and 1,500 calories. In December, 1918, the allowances for Cologne were 1,480 for Coblenz 1,490, and for Treves 1,408 calories. The rationed articles for this period in Treves were as follows for one week:

Grams

Calories

Cost in marks

Bread, whole rye, 4-pound loaf

2,000

4,800

0.96

Potatoes, 1 pound per day

3,500

3,073

.63

Sugar

156

620

.18

Meat, including 25 grams sausage

150

260

.18

Fat (margarine)

50

450

.43

Marmalade, cereals, dried soup, etc.

594

650

.81

Total

6,450

9,853

3.63

Per day

11.8

1,408

.52

1Pounds.


825

Because of illicit traffic in food supplies, hoarding was practiced by farmers and by the wealthy, and among these there was not so great inconvenience and distress as among the poor in the large cities.
 FOOD VALUE OF THE RATION

That the ration allowance during the latter months of the war was pitifully inadequate is shown by a glance at the following figures:

Average diet

Treves ration

Protein

per cent

12-15

8.3

Fat

.do.

18-20

10

Carbohydrates

.do.

60-65

81.7

Total calories

3,000

1,408

The ration was diminished both relatively and absolutely in protein and fat, and in caloric value reduced almost one-half in carbohydrates, and more than half in total amount. The dietary of the poor people was somewhat augmented by the addition of such vegetables as cabbage, carrots, beets, and greens, which could be purchased during the winter in open market at very reasonable prices. While these vegetables added to the bulk of food, its caloric value was probably not increased much more than 175 or 200 units.

EFFECTS OF FOOD SHORTAGE

It was difficult to estimate the effect on the civil population of this inforced reduction in diet; in any event, the results related only to a limited portion of the inhabitants. In general, farmers and country people had enough for their own needs and more; the well-to-do always found ways to procure an abundance of food. Those who suffered real physical privation were the poor in the cities; this class has been estimated from 10 to as high as 25 per cent of the total population; the lower figure was probably nearer the truth.

This loss of weight was not an unmixed evil, as there was evidence, at the time of our occupation, of improved physical condition of the obese and overfed, the gouty and the diabetic.

Children of school age, 6 to 13 years, were found to have suffered directly as the result of improper and insufficient nourishment. Two thousand five hundred children in Treves and vicinity were found in general to be under the average normal height and weight of German children during peace times. A large number were found to be small in stature and thin in build, pale and anemic and with poor nutrition; these conditions were found most frequent and most marked among the poor. Reports to the same effect were received from numerous sources in Germany.

In a comprehensive psychiatric survey of the school children of Treves, it was found that, chiefly as the result of malnutrition, there was a lowering of the whole standard of school work; loss of nervous energy exhibited by 40 per cent of the children; an increase in the number of border-line defectives of not more than 1 per cent of the total school population; and an increase in the number of children failing to pass their grades from 8 per cent in pre-war


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years to 15 per cent in 1917 and 1918. These conditions were, however, not found in nearly so marked a degree in the cities of Cologne, Bonn, and Coblenz.

War edema so commonly seen throughout Germany was very generally attributed to insufficient nourishment. The British, it was learned, noted that it appeared when fat was markedly reduced in the dietary, and that the symptoms cleared up when fat was added.

As a result of the food survey which this office began early in January, the following report (in part) was made January 31 to the officer in charge, civil affairs:

The evidence at hand indicates undernourishment of babies and young children. Nursing mothers are not properly nourished, and their babies do not gain in weight as they should. Bottle-fed babies can not be properly fed on account of the lack of milk. Children are undernourished mainly by reason of the lack of fats and milk. In regard to the sick, one of the most important considerations is a proper diet. There is ample evidence that sick are dying or that convalescence is greatly lengthened on account of lack of a nourishing and easily digestible diet. White bread, rice, milk, and some easily digested fats are essential.

With regard to the general population, there is no doubt that the middle class and poorer people who can not afford to pay exorbitant prices for food are undernourished, and in many cases resistance is thereby lowered so that they become more susceptible to disease. As it is manifestly impossible to secure a perfectly even distribution of all the food available in the American area, it is almost certain that some of the essential articles of diet in the ration allowance will before the next harvest become exhausted in certain localities, such as the industrial centers, and that it will be impracticable, perhaps  impossible, to supply such districts from German food stocks. It is therefore believed that our Government should have on hand the necessary supplies to make good these deficiencies and should be able to control the distribution. It is probable the first serious cry for food will be for bread. The present dietary is deficient in protein and fat. The deficiencies would be made up by wheat, which is rich in protein, and by pork, which in addition to protein is rich in fat. Potatoes will probably be demanded in certain localities, as this vegetable is even more of a staple than bread. Rice is an excellent substitute for potatoes. In addition, bacon or margarine might be economically issued to replace the deficient fat. Canned beef or canned salmon would form valuable additions to the present dietary and if on hand in excess might be used to advantage.

The following recommendations were made at the same time:

That steps be taken to increase the dietary of nursing women, children, and the sick by the addition of wheat flour, rice, condensed milk, and butter or margarine.

That the United States Government be prepared to issue to the general population wheat flour (preferably whole wheat), meat (preferably pork), bacon or margarine, and rice.

The food situation in the American area remained practically unchanged during the winter of 1918-19 and early spring of 1919. The component parts of the ration varied somewhat from time to time, the general situation getting rather worse than better, until with the opening of spring and the advent of a wealth of green vegetables conditions began to improve. On April 20, 1919, the first American food was brought in and sold to German civilians, increasing the ration to about 2,100 calories. Articles on sale consisted of flour, rice, canned milk, bacon, canned beef, and canned salmon, but unfortunately the prices were so high that very little of the food reached those who were most in need of it.

An investigation of the physique of school children in Treves indicated that many of the physical defects noted and much of the suffering and hardship


827

endured by them were due to the unhygienic surroundings in which they lived. With a view of obtaining definite information as to the living conditions of the poorer portion of the population, a house-to-house survey, including over 1,000 families, was made by American Army nurses accompanied by German social welfare nurses. This survey showed that because of overwork, neglect of homes and children, and especially because of the war ration, disease, especially tuberculosis, had increased among the poor people in the city of Treves. The following facts in their report are quoted:

Average number of persons per family

7.1

Average number of rooms occupied per family

3.52

Average number living children per family

4.08

Average number dead children per family

2.07

Number of families with sickness at time of visit

757

Number of families with history of tuberculosis

282

Number of families with some member tuberculous

379

Average earnings per family per week, marks

61.02

Average cost of living per family per week, marks

51.89

(At the time of this survey, the value of the mark was about 8 cents.)

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