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Chapter I

Communicable Diseases, Table of Contents

CHAPTER I

TYPHOID AND THE PARATYPHOID FEVERS

Typhoid and paratyphoid fevers were of but minor importance as causes of sickness in the United States Army during the World War. This negative condition, however, is of all the more present interest in view of the fact that in previous wars, as is shown below, our experience with typhoid fever was quite different. Prior to the World War enteric fever (typhoid) was one of the greatest scourges of armies mobilized for war. In the British Army in the South African War (1899-1901), approximately 59,750 cases of typhoid fever occurred (average annual strength, 209,404), with a case mortality rate in excess of 10 per cent (8,227 deaths.)1 During the Spanish-American War (1898), with a mean annual strength of 147,795 men, there were reported 20,926 cases of typhoid fever in our Army, with 2,192 deaths.2

Prior to the development of the fairly simple laboratory technique (Widal reaction) for the identification of the B. typhosus, the diagnosis of typhoid fever was based on clinical manifestations. Consequently, the medical statistics of the Army prior to and even during the Spanish-American War, as well as all other statistical records for like periods, whatever their source, are not accurate in so far as typhoid fever is concerned. They are sufficiently reliable, however, to justify their use in reviewing, for comparative purposes, the prevailing trend of the disease. Since the Spanish-American War the Medical Department has devoted special attention to the prevention of typhoid fever, and the regulations for many years have provided that its diagnosis, for record purposes, must be based on the clinical picture, confirmed by laboratory findings. During the World War, when it became necessary to mobilize approximately 4,000,000 men within a relatively short period of time, it manifestly was impracticable to confirm all clinical diagnoses of typhoid and paratyphoid fevers by laboratory methods; but the laboratory and clinical investigations were quite searching, and the probability of error in recorded diagnoses was undoubtedly small; however, the recorded mortality rates during the World War are somewhat exaggerated. The explanation for this is that in tabulating causes of death during the World War, it was the practice in the Surgeon General's Office, to charge deaths to the primary cause of admission. Thus, individuals who were admitted to hospital for typhoid fever, and who developed influenzal pneumonia concurrently, during the pandemic of influenza, and who actually died of that complication, were recorded as having died of typhoid. Careful studies of a large series of cases occurring in the American Expeditionary Forces, demonstrate that the case mortality did not exceed 11 per cent,3 whereas the basic statistical tables of the Surgeon General's Office, which are used in Volume XV of this history, indicate that it was approximately 13.7

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


16

per cent. Some mild cases of typhoid fever also were overlooked, having been confused with the intestinal type of influenza prevailing so generally during the late fall and early winter of 1918. The morbidity rates in the tables presented herein are slightly less, therefore, than the actual rate of occurrence of typhoid fever, and mortality rates are considerably in excess of the actual death rate.

As the subject matter herein deals principally with the limited occurrence of diseases of this group, rather than their fairly common occurrence, and with the facts underlying and accounting for such limitation, the material reviewed is analyzed principally from an epidemiological point of view.

CHART I

TYPHOID FEVER IN THE UNITED STATES ARMY PRIOR TO THE WORLD WAR, AND AS COMPARED WITH WORLD WAR INCIDENCE

In so far as the earliest records of the American Army are concerned typhus fever was the disease with which typhoid fever was most frequently confused,4 and it was not until 1851 that the nomenclature used by the Medical Department of the Army separated the two and accepted the diagnosis "febris typhoides." Furthermore, in the first few months of the Spanish-American War, Army surgeons failed clearly to separate typhoid fever and malaria, and it was only when the disease assumed the proportions of an epidemic that its character was understood.5 It is quite evident, therefore, that, as stated above, the Army typhoid statistics prior to the Spanish-American War are not accurate and the grouping together of admissions and deaths from both typhoid and typhus fever will more nearly approximate the actual prevalence of typhoid fever in the Army. This method of presentation, therefore, has been adopted in discussing the prevalence of typhoid in the Army prior to the World War.


17

The trend of typhoid fever in the Army from 1820 to 1919, is plotted on logarithmic scale in Chart I.

Records are not available from 1832 to 1837, nor for a part of the period of the Mexican War (1846-1848). Prior to 1910 the admission rates, although irregular, were high, ranging-except for war periods-from 2 to 10 per 1,000 per annum, and the death rate ranged from about 0.30 to 1.50 during the same period.

The very low ratio recorded for 1844 is inexplicable, notwithstanding a careful search of War Department records. The mean strength of the Army during 1844 was about 8,500 men and the reported admissions for all diseases were less than for the year 1843. But few troops were on field duty during 1844, the Florida Indian War having come to an end during 1842.

Two striking and significant peaks of occurrence are shown in Chart I, the first marking the Civil War and the second the Spanish-American War. From an epidemiological and practical point of view the fact of greatest importance shown in the chart is the precipitate downward trend in typhoid admission rates which commenced in 1909. This reduction coincided with the introduction of typhoid vaccine in the Army, as a preventive measure, the value of which is more clearly visualized in Chart II.

As typhoid rates always increase markedly during war periods, it will be well to examine in greater detail, the rates in the Army during such periods. The admission and death rates for typhoid fever during the Civil, Spanish-American, and World Wars are shown in Table 1; comparable rates for the British Army during the South African War also are included for purposes of discussion.

TABLE 1.- Typhoid fever. United States Army by war periods; also the British Army (South African War), showing admissions and deaths. Absolute numbers, rates per 1,000 per annum, and case mortality ratesa

War

Average annual strength

Admissions

Deaths

Case mortality rate 
(per cent)

Absolute numbers

Rates per 1,000 per annum

Absolute numbers

Rates per 1,000 per annum

Civil War (1861-1866)-All troops Northern Army

532,198

79,462

29.86

29,336

11.02

36.92

Spanish-American War (1898)-U.S. Army

147,795

20,926

141.59

2,192

14.83

10.47

South African War (1899-1901)-British Army (2.5 years)

209,404

59,750

114.13

8,227

15.72

13.77

World War (1917-1919)-U.S. Army (2.75 years)

1,501,265

1,529

.37

277

.05

14.85

aSource of information: (1) Medical and Surgical History of War of the Rebellion, Part I, Medical Volume. (2) Report of the Surgeon General of the Army, 1900, p. 402. (3) Official History of the War, Medical Services Diseases of the War, Vol. I, London, His Majesty's Stationery Office, 11. (4) Monthly sick and wounded reports, Office of the Surgeon General, 1917-1919.

The recorded morbidity rates for the Civil War do not give a true picture of the actual occurrence of the disease. Experience has taught that the case mortality rate for typhoid fever ordinarily is about 10 per cent. Calculation of the case mortality rate from the recorded morbidity and mortality for the Civil War gives a case fatality rate of 36.9 per cent which, manifestly is much too high. Reversing the process and calculating the morbidity rate from the


18

CHART II


19

recorded mortality statistics on the basis of a case fatality rate of 10 per cent, gives an admission rate for the Civil War period somewhat in excess of 100 rather than one of 30.5 per 1,000. This rate undoubtedly approximates more nearly the actual prevalence of the disease.

CHART III

The incidence rate of 141.59 per 1,000 per annum for the Spanish-American War (1898) doubtless is quite accurate, as the case mortality rate calculated from recorded morbidity and mortality is 10.47 per cent. The Spanish-American War was of short duration and the vast majority of the 20,000 or


20

more cases of typhoid fever occurred within a comparatively short period of time during the summer and fall of 1898.

The recorded morbidity rate for the British Army during the South African War probably is somewhat less than was the actual occurrence of the disease, as the case mortality rate, based on recorded morbidity and mortality, is somewhat higher (13.77 per cent) than that ordinarily to be anticipated.

The incidence rate of 0.37 per 1,000 per annum for American troops during the World War is in striking contrast with all previously recorded war-time rates and demonstrates in a very telling manner that epidemics of typhoid fever can be prevented in armies. The recorded case mortality rate for American troops during the World War was approximately 14.85 per cent, which is considerably in excess of the case death rate ordinarily to be anticipated. As explained above this high recorded death rate in all probability is due in large part to the fact that deaths were charged to typhoid fever that actually were due to influenzal pneumonia. A comprehensive special investigation of typhoid fever in the United States Army in France, made at the time the disease was prevailing, which is given fuller consideration below, demonstrated very clearly that the case death rate was not in excess of 11 per cent of the individuals attacked.3

COMPARISON OF DEATH RATES FOR TYPHOID FEVER IN THE UNITED STATES ARMY AND IN THE CIVIL POPULATION

From Table 2 it is possible to gain a definite conception of the comparative prevalence of typhoid in American civil communities and in the Army. The statistics incorporated in Table 2 are presented graphically in Chart III.

TABLE 2.-Typhoid fever. Deaths by years, 1890 to 1919, white enlisted men, United States Army, and estimated rates for male civilian population, ages 20 to 34. Annual rates per 1,000

Year


Death rates per 1,000 per annum

Year

Death rates per 1,000 per annum


White enlisted men

Male civilians, 
ages 20-34

White enlisted men

Male civilians, 
ages 20-34

1890

0.55

0.59

1905

0.30

0.40

1891

.48

.64

1906

.28

.38

1892

.56

.57

1907

.32

.37

1893

.67

.55

1908

.34

.35

1894

.87

.53

1909

.25

.31

1895

.56

.55

1910

.18

.33

1896

.74

.51

1911

.09

.27

1897

.30

.38

1912

.03

.24

1898

15.26

.46

1913

---

.24

1899

2.52

.44

1914

.04

.20

1900

1.67

.57

1915

---

.16

1901

.84

.49

1916

.02

.16

1902

.95

.46

1917

.04

.15

1903

.47

.44

1918

.05

.13

1904

.36

.42

1919

.06

.09

It may be noted that for the years 1900 to 1903, inclusive, the Army rate was considerably in excess of that for the registration area of the United States, with so marked a downward trend for the Army rates that the two differed but slightly for the last year of the four-year period. For the years 1904 to 1909, inclusive, the rates for the two groups were very nearly the same.


21

From 1910 onward, however, while the rate for the civil population had a very considerable downward trend, comparable rates for the Army were at an extraordinarily low level, and this decline took place within a period of three years (1910-1912). During the period, 1910 to 1919, the civil population was not subjected to any unusually adverse environmental conditions and the reduction of the mortality rate by more than one-half during the 10-year period can be attributed primarily to improvements in environmental sanitation plus an unknown but probably quite considerable amount of prophylactic vaccination during the later years of the period.

In so far as the Army is concerned, the high rates for the years 1900 to 1903 were due to conditions approximating those of war. It was during this period that considerable numbers of troops were operating in the Philippines. Profiting by the experience gained during the Spanish-American War (1898) and the immediately following Philippine insurrection, the Medical Department of the Army redoubled its efforts to prevent typhoid fever in Army personnel. No very noticeable reduction in rates was attained, however, until 1910. During 1910 and 1911 the rates were cut in half and in 1912 the reduction was so marked that the death rate was only one-tenth of that which prevailed prior to 1909. It was in the latter part of 1909 that prophylactic typhoid immunization was introduced in the Army as a voluntary measure,6 and in 1911 it was made mandatory for all military personnel.7

The typhoid mortality rates for the civil population tabulated in Table 2 are crude rates, and when corrected for age and sex the results attained in the Army in the prevention of typhoid fever during the World War become more striking. With minor exceptions the military personnel in active service during the World War (1917-19) ranged between 20 and 34 years of age. The death rate from typhoid fever for males of the civilian population of that age group for the period averaged about 0.117 per 1,000 per annum, as compared with a rate of 0.05 per 1,000 per annum for military personnel.

OCCURRENCE OF TYPHOID FEVER IN THE ARMY DURING THE WORLD WAR

Armies are much more apt to become seeded with typhoid bacilli brought in by recruits from civil life during periods of hurried mobilization than during the more orderly and leisurely recruitment incident to times of peace. If, therefore, typhoid fever is of common occurrence in civilian communities it may be anticipated that it will gain a foothold and spread with great rapidity in armies during periods of mobilization, provided preventive measures are not effective.

When mobilization was ordered in 1917 typhoid fever prevailed to a much less degree throughout the United States than was the case at the beginning of the Spanish-American War. It was of very common occurrence in the civil population of our country in 1898, was introduced into all mobilization camps, and spread with great rapidity.8

During the 15 or 20 years preceding the World War there had been so marked and continuous a reduction in typhoid rates in the civil population throughout the United States that the likelihood of the wholesale introduction of the disease into our mobilization camps in 1917, by incoming recruits, was


22

somewhat remote. As a matter of fact, a total of only 546 cases of typhoid fever occurred among enlisted men in camps in the United States during the World War, and in a large proportion of these cases the disease was contracted prior to reporting at camps.

When we turn, however, to comparable conditions confronting our troops on the Western Front in France, the picture is a different one. The water supplies, as a rule, were not above suspicion of contamination, typhoid fever was of no uncommon occurrence in the civilian population, it was known to have occurred in troops occupying sectors in which most of our divisions operated,9 large numbers of cases of typhoid fever occurred in the relatively unprotected British Expeditionary Force in France during the early stages of the war,10 and the rates of incidence in the partially protected French armies for the first two years (1914-15) of the war were very high.9 The possibility of acquiring the disease from outside sources in France therefore, was, almost unlimited, and had our preventive measures not been effective the disease undoubtedly would have prevailed quite extensively.

TOTAL NUMBER OF CASES

It is necessary to have clearly in mind that this discussion relates to the occurrence of typhoid fever in individuals who had been protected against the disease by prophylactic vaccines, in so far as it was possible to carry out this procedure efficiently during the stress of hurried mobilization. In a considerable number of instances the service records of individuals failed to bear notation that three doses of antityphoid-paratyphoid vaccine had been given; but investigation of the administrative procedures adopted in carrying out this protective measure and the safeguards instituted to prevent troops going overseas without such vaccinations, warrants the statement that but few individuals received less than three doses of the saline vaccine or one of the lipovaccine. Prior to July 1, 1918, it was the custom to administer three doses of saline vaccine and after that date either three doses of saline vaccine or one of lipovaccine.11 All drafted men received protective vaccines immediately after reporting at mobilization camps.

Examination of Table 3 indicates that during the World War (April, 1917, to December, 1919) the aggregate of the mean annual strength of our military forces was 4,128,479; during the same period, 1,529 primary admissions for typhoid fever were reported, the typhoid rate per 1,000 of strength being 0.37. The progress made in the control of typhoid fever since the Spanish-American War can be visualized more clearly when it is realized that, whereas during the Spanish-American War the total typhoid rate was 141.59 per 1,000, during the World War it fell to 0.37 per 1,000, the relative proportions being approximately 382 to 1.


23-24

TABLE 3.-Typhoid fever and typhoid vaccination-Admissions, deaths, discharges for disability, and days lost from duty, officers and enlisted men (white, colored, and native troops), United States Army, April 1, 1917, to December 31, 1919. Absolute numbers and ratios per 1,000 per annum

 

Total mean annual strengths


Typhoid fever


Admissions

Deaths

Discharges for disability

Days lost

Absolute numbers

Ratios per 1,000

Absolute numbers

Ratios per 1,000

Absolute numbers

Ratios per 1,000

Absolute numbers

Non-
effective rates per 1,000

Total officers and enlisted men, including native troops

4,128,479

1,529

0.37

227

0.05

24

0.01

109,374

0.07

Total officers and enlisted men, American troops

4,092,457

1,527

.37

227

.06

24

.01

109,315

.07

Total officers

206,382

49

.24

77

.03

---

---

4,367

.06

Total enlisted American troops:

 

 

 

 

 

 

 

 

 

    

White

3,599,527

1,348

.37

182

.05

24

.01

97,104

.07

    

Colored

286,548

68

.24

25

.09

---

---

3,904

.04

    

Color not stated

---

62

---

13

---

---

---

3,940

---

         

Total

3,886,075

1,478

.38

220

.06

24

.01

104,948

.07

Total native troops enlisted

36,022

2

.06

---

---

---

---

59

.00

Total Army in the United States (including Alaska):

 

 

 

 

 

 

 

 

 

    

Officers

124,266

18

.14

3

.02

---

---

1,132

.02

    

White enlisted

1,965,297

483

.25

54

.03

11

.01

25,020

.03

    

Color enlisted

145,826

45

.31

17

.11

---

---

2,435

.05

         

Total enlisted

2,111,123

528

.25

71

.03

11

.01

27,455

.04

         

Total officers and men

2,235,389

546

.24

74

.03

11

.00

28,587

.04

United States Army in Europe, excluding Russia:

 

 

 

 

 

 

 

 

 

    

Officers

73,728

27

.37

4

.05

---

---

2,844

.11

    

White enlisted

1,469,656

776

.53

123

.08

13

.01

68,407

.13

    

Colored enlisted

122,412

23

.19

8

.07

---

---

1,469

.03

    

Color not stated

---

59

---

13

---

---

---

3,929

---

         

Total enlisted

1,592,068

858

.54

144

.09

13

.01

73,805

.13

         

Total officers and men

1,665,796

885

.53

148

.09

13

.01

76,649

.13

Officers, other countries

8,388

4

.48

---

---

---

---

391

.13

United States Army in Philippine Islands:

 

 

 

 

 

 

 

 

 

    

White enlisted

16,995

---

---

---

---

---

---

---

---

    

Colored enlisted

4,456

---

---

---

---

---

---

---

---

         

Total enlisted

21,451

---

---

---

---

---

---

---

---

United States Army in Hawaii:

 

 

 

 

 

 

 

 

 

    

White enlisted

16,161

50

3.09

4

.25

---

---

3,305

.56

    

Colored enlisted

3,319

---

---

---

---

---

---

---

---

         

Total enlisted

19,480

50

2.57

4

.21

---

---

3,305

.47

United States Army in Panama, white enlisted

19,688

---

---

---

---

---

---

---

---

United States Army in other countries not stated:

 

 

 

 

 

 

 

 

 

    

White enlisted

---

38

---

---

---

---

---

343

---

    

Color not stated

---

3

---

---

---

---

---

11

---

         

Total

14,232

41

2.88

---

---

---

---

354

.07

Transports:

 

 

 

 

 

 

 

 

 

    

White enlisted

97,498

1

.01

1

.01

---

---

29

.00

    

Total enlisted

108,033

1

.01

1

.01

---

---

29

.00

Native troops enlisted:

 

 

 

 

 

 

 

 

 

    

Philippine Scouts

18,576

1

.05

---

---

---

---

8

.00

    

Hawaiians

5,615

---

---

---

---

---

---

---

---

    

Porto Ricans

11,831

1

.08

---

---

---

---

51

.01




Typhoid vaccination


Admissions

Discharges for disability

Days lost

Absolute numbers

Ratios per 1,000

Absolute numbers

Ratios per 
1,000

Absolute numbers

Ratios per 
1,000

Total officers and enlisted men, including native troops

35,552

8.61

5

0.00

156,548

0.10

Total officers and enlisted men, American troops

35,149

8.59

5

.00

155,614

.10

Total officers

593

2.87

---

---

2,325

.03

Total enlisted American troops:

 

 

 

 

 

 

    

White

30,915

8.59

4

.00

129,713

.10

    

Colored

3,606

12.58

1

.00

23,277

.22

    

Color not stated

35

---

---

---

299

---

         

Total

34,556

8.89

5

.00

153,289

.11

Total native troops enlisted

403

11.19

---

---

934

.07

Total Army in the United States (including Alaska): 

 

 

 

 

 

 

    

Officers

564

4.54

---

---

2,220

.05

    

White enlisted

30,080

15.30

4

.00

121,528

.17

    

Colored enlisted

3,562

24.42

1

.01

22,885

.43

         

Total enlisted

33,642

15.94

5

.00

144,413

.19

         

Total officers and men

34,206

15.30

5

.00

146,633

.18

United States Army in Europe, excluding Russia:

 

 

 

 

 

 

    

Officers

14

.19

---

---

72

.00

    

White enlisted

363

.25

---

---

6,633

.01

    

Colored enlisted

11

.09

---

---

306

.01

    

Color not stated

34

---

---

---

298

---

         

Total enlisted

408

.26

---

---

7,237

.01

         

Total officers and men

422

.25

---

---

7,309

.01

Officers, other countries

15

1.79

---

---

33

.01

United States Army in Philippine Islands:

 

 

 

 

 

 

    

White enlisted

39

2.29

---

---

189

.03

    

Colored enlisted

12

2.69

---

---

19

.01

         

Total enlisted

51

2.38

---

---

208

.03

United States Army in Hawaii:

 

 

 

 

 

 

    

White enlisted

230

14.23

---

---

656

.11

    

Colored enlisted

21

6.33

---

---

67

.06

         

Total enlisted

251

12.89

---

---

723

.10

United States Army in Panama, white enlisted

41

2.08

---

---

122

.02

United States Army in other countries not stated:

 

 

 

 

 

 

    

White enlisted

10

---

---

---

95

---

    

Color not stated

1

---

---

---

1

---

         

Total

11

.77

---

---

96

.02

Transports:

 

 

 

 

 

 

    

White enlisted

152

1.56

---

---

490

.01

    

Total enlisted

152

1.41

---

---

490

.01

Native troops enlisted:

 

 

 

 

 

 

    

Philippine Scouts

86

4.63

---

---

275

.04

    

Hawaiians

17

3.03

---

---

91

.04

    

Porto Ricans

300

25.36

---

---

568

.13

RELATIVE IMPORTANCE OF TYPHOID FEVER AS A CAUSE OF ADMISSION TO HOSPITAL FOR DISEASE AND OF DEATHS FROM DISEASE

The fact that typhoid fever, comparatively speaking, was of minor importance as a cause of admission to hospital for disease during the World War is well shown in Table 4.


25

TABLE 4.-Typhoid fever. By country of occurrence, showing percentage relationship to total admissions and deaths from disease, and relative standing among the 30 most common causes of admissions and deaths, April 1, 1917, to December 31, 1919

 


Admissions

Deaths


Percentage relationship to total diseases

Relative standing among 30 most common diseases

Percentage relationship to total diseases

Relative standing among 30 most common diseases

Officers:

 

 

 

 

    

United States

0.02

---

0.35

22

    

Europe

.07

---

.71

11

Total officers (including other countries)

.04

---

.47

15

American enlisted men, United States

.02

---

.21

19

    

Europe

.10

---

.69

10

    

Hawaiian Islands

.42

---

10.26

2

Total enlisted (including other countries)

.04

---

.39

13

Native troops:

 

 

 

 

    

Filipino

.01

---

---

---

    

Porto Rican

.01

---

---

---

Total native troops

.01

---

---

---

Total, U.S. Army

.04

---

.39

13

Typhoid fever contributed only 0.04 per cent of the total admissions to hospital for all diseases, and in no country in which our military forces served did it prevail to such degree as to give it a rating in the list of the 30 diseases of most frequent occurrence. Of all deaths from disease during the World War only 0.39 per cent were attributable to typhoid fever, and in the list of the 30 diseases most frequently resulting in death, in order of importance (1 to 30), it occupied the thirteenth place.

DISTRIBUTION BY GRADE (COMMISSIONED AND ENLISTED PERSONNEL)

The admission rate for commissioned personnel was appreciably lower than for enlisted-officers, 0.24, and American enlisted, 0.38 per 1,000. This is explicable on the basis of better education, higher degree of intelligence, a more comprehensive knowledge of personal hygiene and sanitation and their corollaries, more intelligent compliance with instructions and orders, and better personal hygienic and environmental sanitation.

RACIAL DISTRIBUTION

The morbidity rate for white enlisted personnel was considerably higher than for colored-white American, 0.37; colored American, 0.24 per 1,000. The most probable explanation of the higher rate in white American troops is that it was due to the fact that a relatively larger proportion of white troops were engaged in operations in highly contaminated areas (combat areas), with a correspondingly greater exposure to infection.

DEATH RATE

The general death rate from typhoid was 0.05 per 1,000 per annum. The recorded case fatality rate was approximately 15 per cent. For the reasons pointed out elsewhere this is considerably higher than actually occurred.


26

Complete investigation of localized outbreaks and comprehensive studies of large groups of cases indicate that the case fatality rate was approximately 11 per cent and were exact data available it doubtless would be found to have been less than 10 per cent.

DISCHARGE ON ACCOUNT OF DISABILITY

A total of 24 men were discharged from the service on account of disability resulting from an attack of typhoid. Of the total number of individuals discharged for disabilities resulting from diseases, only 0.014 per cent were discharged for disabilities incident to typhoid, and in the list of the 30 diseases most frequently resulting in discharge for disability typhoid does not appear.

NONEFFECTIVE RATES

A total of 1,529 primary admissions for typhoid were reported and these men were absent from duty a total of 109,374 days. The average loss of time from duty per case of typhoid was, therefore, 72 days.

SEASONAL DISTRIBUTION

In general, the seasonal distribution in troops during the World War conformed to the well-known seasonal distribution of typhoid fever in temperate and cold climates-highest incidence in the late summer and fall months, particularly for cases developing in the United States. In Europe, however, a very considerable proportion of the cases arose during the winter months- November, 1918, to March, 1919, inclusive-due, doubtless, to increasingly constant exposure to massive doses of the infective agent.

GEOGRAPHICAL DISTRIBUTION

The recorded mortality rate for the civilian population of Manila, Philippine Islands, for the period 1917 to 1919, inclusive, was 1.8412 per 1,000 per annum, while that for American and Filipino troops serving in the Philippines during the same period of time was practically nil (1 case, or 0.05 per 1,000, for the period).

The admission rate per 1,000 for total enlisted strength for the period was 2.57 for Hawaii, 0.54 for Europe, and 0.25 for the United States. Expressed in comparative ratios these figures mean that for every one case of typhoid fever occurring in troops in the United States approximately two cases occurred in troops in Europe and ten cases in troops serving in Hawaii.

TYPHOID FEVER IN HAWAII

An explosive outbreak of typhoid fever, definitely traced to the water supply, occurred at Schofield Barracks, Hawaii, in the fall of 1917. The following abstract summarizes the epidemiology of this outbreak:13

Schofield Barracks, the largest Army station in Hawaii, is located on the northern end of the island of Oahu, about 23 miles from Honolulu. The regular water supply for the station was obtained from two sources. The old section of the station was supplied mainly with water collected in tunnels and brought down through a system of tunnels and pipes from a range of mountains adjacent


27

to and to the west of the station. The new section of the station, about 1 mile distant, was supplied by a gravity system having its main intake in the Koolau Mountain Range in the headwaters of the fork of the Kaukonahua River on the opposite side of the island. This supply was not subject to contamination except that certain sections of the tunnels in the upper reaches were open. Overflow and additional small streams came together, below the intake for the regular supply, forming a stream at the bottom of the ravine. On this stream, below the intake for the permanent water supply, was located a pumping station to augment the permanent supply, when necessary. This auxiliary supply was not supposed to be used without previously informing the sanitary authorities, through whom instructions would emanate as to the proper treatment of the water. At times water from the auxiliary supply for the new post also was pumped to the old post to augment the permanent supply, but at no time was this done during the course of the epidemic to be reviewed. The pumping station for this auxiliary supply was located at the lowest point of the watershed and the water itself was subject to constant contamination from camps of Japanese laborers engaged in construction work on the water supply system at the time the outbreak of typhoid occurred. These camps were on the hillside below the water mains and about 45 feet above and 55 to 100 yards distant from the bed of the stream constituting the auxiliary supply.

In the early days of August, 1917, a Japanese laborer arrived at one of the camps and, though he did not report for treatment, it was learned at a later date that he was ill for some time with a continued fever that doubtless was typhoid. While ill, he was visited by a Japanese friend (Mizusawa) employed at one of the construction camps. Mizusawa had not been inoculated against typhoid fever and came down with typhoid fever during the latter part of August. He worked for several days after he became ill, continuing to live at the camp, and he failed to report for treatment. He stopped work on September 1, but remained at camp until September 7. He was admitted to hospital in Honolulu on September 15 and was having hemorrhages from his intestines at that time. This patient was interrogated at the time the epidemic was under investigation and examination of his blood gave a positive agglutination reaction with B. typhosus in high dilution. While at the quartermaster construction camp this man had used an insanitary privy located on the drainage shed of the stream constituting the source of the auxiliary water supply for the new section of Schofield Barracks.

From the middle of August to the middle of September, 1917, the rainfall on the watershed of the regular water supply system for the newer part of the post was so low that it became necessary, more or less constantly, to supplement the regular supply with water from the auxiliary system. The sanitary authorities at Schofield Barracks had no knowledge of the fact that this was being done. On September 13 and 14 rather heavy rains occurred on the watershed used as an auxiliary water supply and following these rains it was noted at Schofield Barracks that the water from the source was quite muddy. Within 10 days after these heavy rains fell cases of typhoid fever began to appear, and within a comparatively short period of time 100 cases had occurred. All individuals who contracted the disease gave a history of drinking the contaminated water


28

within the incubation period of the disease. Of the total population-military and civilian-exposed to infection, 4,087 had been vaccinated with antityphoid-paratyphoid vaccine and 812 had not been so protected. No persons living in the older section of the post contracted typhoid except an occasional individual who gave a definite history of drinking water in the newer section of the post on the evening of September 14 or the following day. The comparative morbidity and mortality rates from typhoid fever in these two groups are shown in Table 5.

TABLE 5.-Typhoid fever. Schofield Barracks, Hawaii. Vaccinated and unvaccinated groups, population, admissions and deaths. Absolute numbers, with rates per 1,000 and case fatality

Groups

Population


Admissions

Deaths

Case fatality per cent


Absolute numbers

Rate per 1,000

Absolute numbers

Rate per 1,000

Vaccinated groups

4,087

55

13.46

4

0.98

7.27

Unvaccinated groups

812

45

55.42

7

8.62

15.56

aSource of information: Russell, F. F.: Typhoid fever in the American Army during the World War. The Journal of the American Medical Association, Chicago, lxxii, Dec. 20, 1919, 1863.

These statistics demonstrate conclusively the protective value of prophylactic vaccination, the relative morbidity rate for the nonvaccinated to vaccinated being approximately 4 to 1. They show also that the complete eradication and prevention of typhoid can be accomplished only by a combination of prophylactic vaccination and efficient environmental sanitation and personal hygiene. The lower case mortality rate in the vaccinated group is confirmatory of other observations that appear in medical literature.

TYPHOID FEVER IN EUROPE (RUSSIA EXCEPTED)

The greater frequency of occurrence of typhoid in American troops on active service in France than in the United States justifies a somewhat detailed discussion of the epidemiology of the disease in the former area of activity. In the United States many of the cases occurred in unvaccinated individuals, but all troops in Europe presumably had been vaccinated; in the United States environmental sanitation in mobilization camps was excellent, while in Europe many defects existed, particularly so in the battle areas where the military objectives necessary of attainment prevented proper attention to sanitation; and general exposure to typhoid infection was much greater in France than in the United States.

The prevalence of typhoid fever in American Expeditionary Forces for the period of the World War is shown in Table 3. The total number of cases recorded as primary admissions was 885 (0.53 per 1,000). The occurrence of the cases by months is presented graphically in Chart IV.

The data incorporated in Chart IV pertain to all bacteriologically proven, as well as clinically diagnosed but not bacteriologically proven, cases of typhoid fever reported to the chief surgeon 's office, A. E. F. They include also cases reported as primary admissions for typhoid fever as well as cases of typhoid


29

CHART IV


30

complicating, or concurrent with, other diseases or battle injuries, and represent very closely the actual prevalence of typhoid fever in France. This chart shows that, prior to June, 1918, practically no typhoid fever occurred in American troops in France (there was a total of nine cases only); that an increase in the disease occurred in June, 1918, bringing the morbidity rate up to 0.03 and that again in December, 1918, and January to March, 1919, increases in rates occurred. The various elevations of the morbidity curve referred to above correspond with the occurrence in a few organizations located in various parts of France and more particularly the somewhat widespread but limited occurrence of the disease from November, 1918, to January, 1919, inclusive, in certain of the divisions that had taken part in the Meuse-Argonne operation.

That the origin and spread of typhoid fever in the American Expeditionary Forces were due to defects in sanitation that usually operate to initiate and disseminate the disease is well shown in the review of the epidemiology of the more important of the outbreaks, namely, those occurring in- 

 


Cases

Company No. 4, Camp Cody replacement unit, July, 1918

95

77th Division, December, 1918, to January, 1919

122

79th Division, December, 1918, to March, 1919

61

88th Division, January, 1919, to March, 1919

21

Medical Department units at Curel, December, 1918, to January, 1919

72

Motor Transport Camp, Marseille, March, 1919

64

TYPHOID FEVER IN COMPANY No. 4, CAMP CODY REPLACEMENT COMPANY

On June 15, 1918, three replacement units left Camp Cody, Deming, N. Mex., for Camp Merritt, N. J., en route to France.14 Company No. 4, with an enlisted strength of approximately 248 men, was a provisional one, both commissioned and enlisted personnel being made up of individuals casually attached by transfer. All three companies arrived at Camp Merritt, N. J., on June 21, and none reported any serious illness. Company No. 4 was the only one of the three in which typhoid fever occurred.

Company No. 4 sailed for England on June 28, arriving in Liverpool on July 11. During the passage across the Atlantic many cases of so-called seasickness were reported, of which doubtless a considerable proportion were in reality typhoid fever. The company left Liverpool on July 11 and arrived in St. Aignan, France, via Cherbourg, shortly thereafter. During this trip, typhoid suspects transferred to hospital were as follows: July 11, Liverpool, England, 3; July 12, Romsey, England, 4; July 14, Southampton, England, 34; July 15, Cherbourg, France, 17; July (date unknown), St. Aignan, France, 3. Men continued to be taken ill for a period of 10 days after the arrival of the company at St. Aignan, the last case of typhoid having been admitted to hospital on July 28.

The following information is summarized from reports of investigation of the outbreak in England14 and France.15

The incubation period of a large proportion of the cases was of such length as to indicate that most of the men contracted the disease while traveling by train from Camp Cody, N. Mex., to New York. The three companies traveled on the same train, but cases of typhoid arose in Company No. 4 only. So far as could be ascertained by inquiry, general sanitary conditions on the train were alike for the three companies.


31

The data on the service records and other evidence obtained indicated that antityphoid-paratyphoid vaccines had been given to all men in Company No. 4 at Camp Cody. Two of the men first taken ill in England stated that they had not felt well prior to their departure from Camp Cody, but had not reported themselves to a medical officer because of their eagerness to go to France. One of these men developed a severe diarrhea, with cramps, while en route to New York. The other man who did not have typhoid during the outbreak was later proven to be a typhoid bacillus carrier. A kitchen car was used in common by Companies No. 3 and No. 4, the personnel of one company being located in tourist sleeping cars in front of the kitchen car and that of the other company behind the kitchen car. The drinking water used by Company No. 4 was distributed from the usual type of water tank used on American railway cars and was not readily subject to contamination on the train. There was, however, a supplementary supply for Company No. 4, consisting of a large open barrel filled with water and placed in the vestibule between two of the sleeping cars. This could very easily have become contaminated, as the only means for obtaining water was by dipping the tin cup or canteen in the barrel. Washing and toilet facilities aboard the train were taxed to the limit.

Available evidence suggests that two of the men in the company were in the early stages of typhoid during the railway trip, that there was one bacillus carrier in the company, and that in all probability the unprotected drinking water in the open barrel was grossly contaminated by an individual or individuals in the early stages of the disease or by carriers of the organism. Certain it is that the defects in environmental sanitation were more marked during the railway trip than at any other stage of the journey to France.

In no other instance during the World War did such a large number of cases of typhoid fever occur in any one company, and in no other outbreak was the spread of the infection so sharply restricted. Ninety-five cases occurred in an organization with a total strength of 248 men and the case death rate was 8.3 per cent (8 deaths). The outbreak in this organization was most carefully studied both clinically and bacteriologically and the diagnosis was confirmed bacteriologically in a large proportion of the cases.

TYPHOID AND PARATYPHOID FEVERS IN THE 77TH DIVISION

This division took an active part in the Meuse-Argonne operation. Typhoid fever was known to have prevailed previously in endemic form in this sector, having been reported in both allied and enemy troops. The initial cases of typhoid fever in the division appeared during November, 1918, and failure to enforce sanitary discipline resulted in further spread of the disease during December, 1918, and January, 1919. An epidemiological investigation of the occurrence of typhoid and paratyphoid fevers in this division was made,16 the report of which is the source of the following summary:

During the period November, 1918, to January, 1919, inclusive, a total of 97 cases of typhoid and 25 of paratyphoid fevers occurred in the division. Eighteen of the cases appeared in November, 1918; 79 in December, 1918; and 25 in January, 1919. So far as could be determined, typhoid-paratyphoid


32

vaccine had been administered to the entire division. Of the total number of cases of typhoid and paratyphoid fevers, 74 occurred in one regiment, namely, the 307th Infantry, and most of the cases arising in this regiment were reported from the 2d and 3d Battalions. These two battalions, after the armistice, were stationed in small towns along the river Aube. These valley towns were flooded during the entire period from December, 1918, to January, 1919, and great difficulty was experienced in providing proper latrines, particularly in the town of Clairvaux, at which place it was necessary to move one of the latrines four times because of high water. All organizations of the divisions, except the 2d and 3d Battalions, 307th Infantry, and Company E, 305th Infantry, were located on somewhat higher and better drained ground during this period.

Investigation of the outbreak indicated that sanitary discipline in the division was poor, that some units were without company water bags for several days, and that after water bags were obtained and the water was chlorinated many men continued to use water from unauthorized sources, claiming that the water furnished was overchlorinated and unpalatable. Inspection of the chlorination of water supplies used by the division disclosed the fact that in 35 per cent of the supplies no trace of excess chlorine could be demonstrated and in approximately 20 per cent of the water bags such great excess of chlorine was present as to render the water unpalatable.

The evidence collected indicated that a few men in this division picked up typhoid or paratyphoid in the Argonne, that after the armistice the division was stationed in areas of typhoid endemicity, that the gradual spread of the disease was due to poor sanitary discipline, and that in the organizations in which lowered morale and poor discipline were most evident and sanitary defects were most difficult to remedy the disease gained greatest headway and was most difficult to eradicate.

TYPHOID FEVER IN THE 79TH DIVISION

Diarrhea prevailed somewhat extensively in the 79th Division during October and November, 1918, diminishing during December and January. All regiments were involved, particularly the 315th and 316th Infantry.17 Troop movements of the division are of interest as during the latter part of October and the first part of November the regiments occupied territory around Etraye, Reville, Crepion, and Gibercy. This region had been occupied by German troops, and that diseases of the intestines were common in this area is shown by the fact that the German hospital near Damvillers had special latrines reserved for "intestinal cases." All regiments of the division, at one time or another, occupied the Etraye and Crepion areas. The 313th Infantry was removed from this locality on November 23 and the 314th on November 11, while the 315th and 316th remained until December 26, 1918.

While in action during the first part of November the troops drank water from shell holes, springs, wells, and surface water wherever found. Diarrhea became so general that 50 per cent or more of the personnel of the division was affected and 61 of the cases were diagnosed definitely as being typhoid fever.

An investigation for typhoid carriers was undertaken in the 315th Infantry, the cooks and permanent kitchen police (336) being examined. Of these, 57 gave a history of diarrhea. Nine carriers were found (eight typhoid


33

and one paratyphoid A). Samples of water from various sources in and about Crepion, Etraye, and Reville gave positive tests for B. coli. The evidence gathered indicated that the initial cases were acquired by drinking contaminated water and that the spread of the disease was due mainly to carriers. Sanitary discipline in this division was not good.

TYPHOID FEVER IN THE 88TH DIVISION

An outbreak of typhoid fever occurred in the 88th Division in the early part of 1919, limited very largely to the 2d Battalion, 350th Infantry, located at Morlaincourt.17 A total of 12 cases occurred, the highest number for a single week having been reported during the week February 12-18, 1919. The investigation of this outbreak disclosed the fact that there were three sources of water to which this organization had access. One source was found to be potable, and no cases of typhoid fever arose among the men using this water exclusively. The two remaining sources were found to be grossly contaminated, one of them arising as a spring under a house in which there was a case of typhoid fever. There were at least 27 cases of the disease among civilians, and soldiers were billeted in a number of houses in which cases of typhoid were present. Eleven soldiers living in such houses contracted the disease.

TYPHOID FEVER IN MEDICAL DEPARTMENT UNITS AT CUREL, FRANCE

In December, 1918, and January, 1919, there occurred among troops billeted at Curel (Haute Marne), France, an outbreak of typhoid fever with 72 cases.18 Twenty-one deaths occurred, but it is known that a large number of secondary pneumonias developed as complicating factors, and the case mortality rate from typhoid itself was not excessive.

The troops stationed at Curel numbered about 70 officers and 1,782 men, constituting the personnel of Evacuation Hospitals Nos. 25, 31, 32, 33, 34, and 35; Mobile Hospitals Nos. 100, 101, 102, 103; and the 106th, 113th, and 301st Sanitary Trains, the first and third of these being skeletonized. All had one or more cases of typhoid fever except Mobile Hospital No. 101 and the skeletonized sanitary trains. Evacuation Hospital No. 33 had 28 cases, 39 per cent of the total, and Evacuation Hospital No. 25, 15 cases, or 21 per cent of the total.

The first organization arrived in this area November 29, the others continuing to arrive until December 8, 1918. Water was not chlorinated from November 29 to December 9 because of lack of supplies of hypochlorite. The supply of hypochlorite was again exhausted December 20, and did not again become available until December 27.

The water supply of the village was from four springs and many wells. No sanitary survey of the water supply was made by American medical authorities until after the epidemic was under way; a survey made at that time indicated that all the village water was nonpotable in its raw state. The chief source of water supply for the troops was a spring, within a radius of 125 feet of which were six privy vaults, four being on ground higher than the spring. All were overflowing with fecal matter.


34

Some cases of diarrheal disease were reported among the inhabitants of Curel, but no typical typhoid fever was seen. There was no diarrhea or gastrointestinal disturbance among any of the organizations prior to their arrival at Curel and none of the organizations stationed there had seen service in any of the front areas. Approximately 75 per cent of the troops suffered with diarrhea during their stay at Curel. Gastrointestinal disturbance commenced a few days after arrival of each contingent and persisted until January 7, when it began to diminish, finally disappearing altogether on January 18. As a rule, the diarrhea was not severe in character, persisted for a few days only, the stools were not bloody, and there was no fever.

Cases of typhoid fever began to appear on December 19, reaching the maximum in number on January 2, declining thereafter but persisting until January 15. No contact relationships could be established. The organizations having the largest number of cases were billeted in sections of the village far distant the one from the other.

The individual service records of the personnel and other information available indicated that all men had been vaccinated against typhoid and paratyphoid fevers. Some of the men were among the later draftees and had received lipovaccine, but there appeared to be no relationship between the prevalence of typhoid fever in the various units and the type of vaccine used or the length of time elapsing since vaccination. The general character of the epidemic, its rapid rise to a peak and sharp decline, with no definite remissions, pointed to a water-borne epidemic. Confirmatory of this interpretation is the fact that the incubation period for most of the cases indicated that infection was acquired during the time when the water was not treated. When regular and continuous chlorination of the water was begun, on December 27, the incidence rate dropped rapidly and the outbreak came to an end.

TYPHOID FEVER IN THE MOTOR RECEPTION PARK, MARSEILLE

Typhoid fever occurred in motor reception park No. 752 in Marseille from the latter part of February to the latter part of April, 1919.19 There were 64 cases with 7 deaths (case mortality, 11 per cent). The epidemic was clearly proved to be of water-borne origin. The camp was divided into three sections, A, B, and C. All cases occurred in section C. The water supply for sections A and B was the regular supply used by the city of Marseille, which passed through a central sedimentation plant before use. It was probably not above reproach, but the sedimentation process reduced the contamination to a minimum. The water supply for section C was an offshoot from the regular city supply. It was piped into camp from an open canal which wound for many kilometers through villages, past farm houses, and country roads. Along the banks of this canal deposits of human feces frequently were observed. These disappeared after rainstorms, being washed into the canal. The water as it arrived at camp was full of worms, snail shells, and much organic sediment. Three open taps were installed in section C, for the purpose of washing trucks and filling their radiators. On investigation it was found that 31 of the first 33 patients admitted having drunk the raw water from these taps more than half the time, despite warnings issued against drinking this raw water and ready access to Lyster bags in which was an abundance of treated water. Correction of existing defects in the water supply in section C brought the outbreak to an end.


35

MINOR OUTBREAKS OF TYPHOID FEVER

Of minor outbreaks of typhoid fever that occurred in various parts of France the following were the more important: In an Engineer detachment at Bazoilles,20 15 cases, August, 1918; 323d Infantry, 81st Division, 10 cases, December, 1918; Battery E, 321st Field Artillery, 82d Division, 22 cases, January and February, 1919. These and other minor outbreaks were carefully investigated and their epidemiology was of like nature to that of the outbreaks reviewed above.

In the American Third Army in Germany

-The discussion of typhoid fever in our armies in Europe would be incomplete without brief reference to its occurrence in the American Third Army in Germany, which is summarized in the following quotation:21

Typhoid fever has been present in the Third Army since its formation, but the incidence of this disease has fallen off noticeably since the army has settled down and opportunity has been afforded for the establishment of improved sanitation. During the interval, December 22 to March 11, 63 cases of typhoid fever were reported from organizations of the Third Army. An analysis of these cases with reference to date of onset of the disease brought out the fact that in the majority infection was acquired either during the march to the occupied territory or in the days immediately following the arrival of organizations at their destinations. Since that time the incidence of typhoid fever in the army has been in no sense alarming, and in one or two instances the infection was known to have been acquired outside the occupied territory. Revaccination of the army with lipovaccine was commenced in March.

TYPHOID FEVER IN THE UNITED STATES

The total number of cases of typhoid fever recorded as primary admissions in the United States during the World War was 546 (0.24 per 1,000 strength). The morbidity rates for all the large mobilization camps are tabulated in Table 6.

TABLE 6.-Typhoid fever. Admissions, enlisted men, by camps, September 1, 1917, to December 31, 1918. Absolute numbers and rates per 1,000

Camps


1917 (September-December)

1918

Camps

1917
(September-December)

1918


Absolute numbers

Rates
per
1,000 strength

Absolute numbers

Rates per 1,000 strength

Absolute numbers

Rates
per
1,000 strength

Absolute numbers

Rates per 1,000 strength

Beauregard, La.

2

0.51

3

0.19

Logan, Tex

3

0.33

2

0.11

Bowie, Tex.

13

1.78

4

.24

MacArthur, Tex

19

2.53

2

.11

Cody, N. Mex.

---

---

1

.06

McClellan, Ala.

10

1.03

2

.10

Custer, Mich.

---

---

4

.15

Meade, Md.

---

---

8

.23

Devens, Mass.

1

.12

---

---

Mills, N. Y.

---

---

1

.07

Dix, N. J.

20

3.15

2

.06

Pike, Ark.

4

.47

10

.28

Dodge, Iowa

1

.16

2

.07

Sevier, S. C.

4

.56

4

.20

Doniphan, Okla.

7

.98

1

.05

Shelby, Miss.

1

.14

9

.43

Fremont, Calif.

---

---

2

.13

Sheridan, Ala.

9

1.52

5

.27

Funston, Kans.

1

.10

4

.10

Sherman, Ohio

1

.11

1

.04

Gordon, Ga.

1

.13

8

.25

Syracuse, N.Y.

---

---

1

.30

Grant, Ill.

1

.14

1

.03

Taylor, Ky.

4

.60

8

.25

Greene, N. C.

---

---

11

.54

Travis, Tex.

7

.82

7

.23

Hancock, Ga.

4

.45

---

---

Upton, N.Y.

---

---

3

.11

Jackson, S. C.

2

.25

8

.28

Wadsworth, S.C.

1

.11

5

.23

Johnston, Fla.

---

---

3

.14

Wheeler, Ga.

---

---

1

.05

Lee, Va.

2

.26

17

.42

         

Total

120

.48

145

.19

Lewis, Wash.

2

.19

5

.16

aSource of information: Annual Reports of the Surgeon General, U. S. Army, 1918, pp. 118, 119, and 1919, pp. 922, 923.


36

The tabulation includes the years 1917 September to December and 1918 only, as many of the mobilization camps were closed by the early months of 1919. No cases whatsoever of typhoid fever occurred in one-third (10) of the camps listed in Table 6 during 1917 and in one-fifteenth of the camps in 1918. In 33 per cent of the camps less than three cases were reported in 1917, while 44 per cent of the camps reported less than three cases during the year 1918. More than 50 per cent of the cases recorded in this table occurred in individuals who reported at mobilization camps in the incubatory stage of the disease.

The conclusion to be drawn from the information set forth in this table is that, compared with our experience during the Spanish-American War, scarcely any typhoid fever occurred in our mobilization camps. It also evidences the fact that very rapid progress has been made in the eradication of typhoid fever in the civil population throughout the United States of America since the Spanish-American War.

The other very important reversal of our Spanish-American War experience is that while one or more cases of typhoid fever occurred in all camps-Camp Kearny, Calif., excepted-at some time during the World War, the disease did not become disseminated throughout the commands as was so universally the case during the Spanish-American War.

That a large proportion of the 546 individuals who had typhoid fever in the United States had contracted the disease before protection could have been afforded by vaccination is evident from the following abstracts from reports on file in the Office of the Surgeon General of the Army. The surgeon at Camp Devens, Mass., reported that the case of typhoid fever reported from that camp in 1917 occurred in a drafted man five days after his arrival at camp.22 The surgeon at Camp Dix, N. J., reported that the 14 cases of typhoid occurring in that camp during October, 1917, were probably brought in by the September increment of drafted men.23 The surgeon at Camp Sherman, Ohio, reported that the one case of typhoid fever in that camp in 1917 was contracted by the soldier at Prospect, Ohio, and the man never had been vaccinated.24 The same surgeon reported 12 cases (not included in Table 6, as the cases arose prior to federalization) in Company H, 3d Ohio Infantry, that were charged to sources other than those for the camp. None of the men had been protected by vaccination, and had probably contracted the disease by drinking water from a condemned well at Springfield, Ohio. There were seven cases at Camp Travis in 1917, all brought in from outside sources. The triple vaccine offered general immunity.25 The 10 cases reported at Camp McClellan in 1917 occurred in the 5th New Jersey Infantry. The cases were brought into the camp, and examination of the individual service records of the command showed that in practically every instance protective inoculation had not been completed.

The camp surgeon at Camp Gordon, Ga., reported that a few cases of typhoid fever were treated in the hospital during 1918, but it was possible to establish in every instance the fact that the individual brought the infection to camp with him.26 The camp surgeon at Camp Shelby, Miss., reported that this relatively rare disease in the Army camps was introduced in this camp when there appeared 4 cases in July and 4 cases in August who were either


37

suffering from clinical typhoid fever when they entrained or gave manifestation of the disease after being in the camp only a few days.26 Among the 8 cases of proved typhoid fever, 4 cases had received no typhoid inoculation, 2 cases only one dose, and 2 had two inoculations. The camp surgeon at Camp Greene, N. C., reported that typhoid fever occurred in a small number of cases, particularly in a small epidemic in June and July, 1918, and mostly in recruits who had not been inoculated.26

Of 74 deaths from typhoid fever among enlisted personnel serving in the United States, 41, or 55 per cent, occurred in individuals who had been on active service for less than two months and these doubtless were deaths from typhoid fever in individuals who either had not been given protective inoculations or in whom no active immunity had been produced for one reason or another.

In so far as the military forces serving in the United States are concerned there is ample justification for the statement that no epidemics of typhoid fever occurred throughout the period of the war. This triumph in preventive medicine is attributable to three factors-antityphoid inoculation; excellent environmental sanitation; and the progress made in the gradual elimination of typhoid fever from the civil population during the two preceding decades.

The one outbreak of typhoid fever among civilians under governmental but nonmilitary control in the United States that assumed epidemic proportions occurred at one of the camps for interned enemy aliens at Hot Springs, N. C., in the summer of 1918.27 The essential epidemiological features of this outbreak are as follows:

The epidemic, consisting of a total of 183 cases, was limited to enemy aliens in the internment camp, and the cases were transferred for treatment to United States Army General Hospital No. 12, located at Biltmore, N. C., about 50 miles distant. The epidemic was directly traceable to accidental contamination of the water supply of one section of the camp, which was connected, for fire-prevention purposes only, with an intake from the French Broad River, afterward found to be contaminated.

The epidemic began July 1, 1918, when 4 men became ill with typhoid fever. During the month of July, 88 cases occurred and during August, 95. August 23 marked the onset of the last case. At the beginning of the epidemic none of the interned aliens had been protected by inoculation against typhoid. Prophylactic inoculations with antityphoid vaccine first were offered as a voluntary measure, but the response was so poor that it was decided to make the vaccination compulsory. This was done August 1.

The cases studied in this epidemic fall into four groups: The first consisted of uninoculated, 70 patients; the second of 73 who had received 1 inoculation; the third of 21 who had received 2 inoculations; and the fourth of 4 cases with 3 inoculations. The degree of protection furnished by the belated effort to immunize men at the internment camp at Hot Springs is uncertain. Efforts were made to determine the relative degree of protection afforded by vaccination during the epidemic, the comparative study being based on the four groups mentioned above. The average duration of fever in uncomplicated cases


38

in the first group (unprotected) was 37 days, in the second group (1 inoculation) 31 days, and in the third and fourth groups 24 and 29 days, respectively.

In the first group 18 per cent of the cases developed complications, in the second group only 12 per cent, and in the third and fourth groups no complications appeared. In the 13 noninoculated cases with complications the average duration of fever was 80 days, and in 9 patients with complications who had received 1 inoculation the average duration of fever was 64 days.

OCCURRENCE OF TYPHOID FEVER IN THE ARMIES OF SEVEN OF THE NATIONS PARTICIPATING IN THE WORLD WAR

A comparison of the rates of prevalence of typhoid in the armies of the various nations engaged in the World War (Great Britain, France, Italy, Belgium, Germany, Austria, and the United States) is of more than passing interest, particularly if analyzed from the viewpoint of the preventive measures initiated by the armies of each nation. Complete statistical data are not available; however, sufficient information is at hand to warrant its tabulation and discussion. This information is given in Table 7.

TABLE 7.-Typhoid fever. By years of occurrence in the armies of seven of the important nations involved in the World War, showing number of cases and deaths with ratios per 1,000 per annum, and case fatality rates, 1914 to 1919

Country


1914

1915


Cases

Deaths

Case fatality (per cent)

Cases

Deaths

Case fatality (per cent)


Absolute numbers

Ratio per 1,000

Absolute numbers

Ratio per 1,000

Absolute numbers

Ratio per 1,000

Absolute numbers

Ratio per 1,000

United States

7

0.07

3

0.03

42.86

8

0.08

---

---

---

Great Britain

388

---

47

---

12.11

2,351

4.00

130

0.22

5.53

France

45,450

---

8,170

---

17.98

64,561

---

6,312

---

9.78

Italy

---

---

---

---

---

18,665

18.01

---

---

---

Belgium

524

6.14

121

1.42

23.09

1,900

10.30

324

1.76

17.05

Germany

---

---

---

---

---

43,681

---

7,964

---

18.23

Austria

7,188

---

844

---

11.74

125,771

---

13,573

---

10.79

Country


1916

1917


Cases

Deaths

Case fatality (per cent)

Cases

Deaths

Case fatality (per cent)


Absolute numbers

Ratio per 1,000

Absolute numbers

Ratio per 1,000

Absolute numbers

Ratio per 1,000

Absolute numbers

Ratio per 1,000

United States

25

0.23

3

0.03

12.00

297

0.44

23

0.03

7.74

Great Britain

2,568

2.02

30

.02

1.17

1,166

.61

33

.01

2.83

France

12,656

---

484

---

3.82

1,659

---

135

---

8.14

Italy

28,142

11.95

---

---

---

7,773

2.58

---

---

---

Belgium

335

1.72

22

.11

6.57

240

1.13

13

.06

5.42

Germany

31,180

---

1,892

---

6.07

16,571

---

623

---

3.76

Austria

24,292

---

1,570

---

6.46

9,551

---

748

---

7.83

Country


1918

1919


Cases

Deaths

Case fatality  (per cent)

Cases

Deaths

Case fatality (per cent)


Absolute numbers

Ratio per 1,000

Absolute numbers

Ratio per 1,000

Absolute numbers

Ratio per 1,000

Absolute numbers

Ratio per 1,000

United States

768

0.30

133

0.05

17.32

467

0.47

71

0.07

15.20

Great Britain

334

.12

20

.01

5.99

---

---

---

---

---

France

665

---

110

---

16.54

---

---

---

---

---

Italy

3,881

1.31

---

---

---

---

---

---

---

---

Belgium

187

.89

24

.11

12.83

31

---

19

---

61.29

Germany

20,932

---

926

---

4.42

---

---

---

---

---

Austria

4,799

---

664

---

13.84

---

---

---

---

---


TOTAL FOR THE PERIOD

Country


Cases

Deaths

Case fatality (per cent)


Absolute numbers

Ratio per 1,000

Absolute numbers

Ratio per 1,000

United States

1,572

0.35

233

0.05

14.82

Great Britain

6,807

1.02

260

.04

3.82

France

124,991

14.86

15,211

1.81

12.17

Italy

58,451

6.24

---

---

---

Belgium

3,217

3.59

523

.57

16.26

Germany

112,364

---

11,405

---

10.15

Austria

171,601

---

17,399

---

10.14

aSource of information: (1) Monthly sick and wounded reports of the Surgeon General, for the years 1914 to 1919, inclusive. (2) Official History of the War, Medical Services, Diseases of the War, vol. 1, p. 11. (3) Dopter, M.: Les Maladies Infectieuses pendant la Guerre, Librairie Felix Alcan, Paris, 1921, p. 45. (4) Document on file in the historical division of the Surgeon General's Office. (5) Document on file in the historical division of the Surgeon General's Office, (6) Handbuch der Arztlichen Erfahrungen im Weltkriege, Band iii, Inner Medizin, Leipzig, 1921 87. (7) Document on file in the historical division of the Surgeon General's Office.


39

The interpretation of the data compiled in the table is somewhat complicated by the fact that the figures given for France and Italy include not only typhoid but also the paratyphoid fevers, while those for the remaining five nations are confined to typhoid. It may be assumed, however, that the vast majority of the cases occurring in both the French and Italian Armies were typhoid. A further complication arises from the fact that Italy did not engage in hostilities until 1915 and the United States not until the spring of 1917. It should be noted, however, that the statistics for the United States Army include the cases occurring during 1919, while those for the armies of the other nations (except Italy and Germany) cover the period 1914-1918, inclusive.

It may safely be assumed that the armies of all the nations concerned were well acquainted with the generally accepted principles that form the basis for the control and prevention of the enteric group of fevers, and that all well-known general preventive measures were enforced in so far as military necessity would permit. We will limit ourselves, therefore, to an inquiry as to the extent to which anti-typhoid-paratyphoid vaccines were used as a prophylactic measure by the armies of the various nations and the degree of success-prevention of typhoid fever-attending their use.

UNITED STATES ARMY

The United States Army was the only one of the seven under consideration in which the policy, initiated several years previous to our entrance into the World War, was continued and actually carried into effect, of making mandatory the vaccination of all military personnel immediately after their entry into the service and of using a triple vaccine-typhoid-paratyphoid A and paratyphoid B-for protective purposes.

Our admission (morbidity) rate per 1,000 for typhoid fever was the lowest attained by the armies of any of the nations participating in the conflict.


40

Approximately one-fourth of the cases arose after the cessation of hostilities, and the assumption is justified that though an exceedingly high degree of protection was afforded our troops by this measure the immunity was not a lasting one. It follows, therefore, that even though three consecutive doses of vaccine are given for protective purposes the repetition of the series of inoculations may become necessary or desirable in time of war at less than three-year intervals. This procedure was actually adopted by our Army in the early months of 1919 and approximately 350,000 men were revaccinated in France.

BRITISH ARMY

During the course of the war (1914-1918), among approximately 4,970,90228 British (excluding colonials) called to the colors, about 20,149 cases were recorded as having had the typhoid fevers.1 Leishman10 reported that the British were able to inoculate, with a single dose of vaccine, about 25 to 30 per cent of the original expeditionary force before they crossed the channel, and that it was not long before the inoculation strength of their troops in France rose to a figure that fluctuated between 90 and 98 per cent.

The regulations of the British Army at the outbreak of the war in 1914 provided for antityphoid inoculation for troops embarking for foreign service.29 In consequence of the existing emergency, the first expeditionary force of 100,000 troops dispatched to the Western Front had been incompletely protected and soon after arrival in France typhoid fever began to appear. In 1915 and thereafter approximately 90 per cent of the troops dispatched for foreign service had received protective inoculations. Prior to departure from home territory it was the custom to give two consecutive doses of vaccine and repeat the series every two years. At no time was the use of this protective measure made mandatory for all troops. During 1914 and 1915 the vaccine consisted of typhoid bacilli alone, but the undue prevalence of the paratyphoid fevers A and B in troops in various theaters of activity made necessary the addition of the paratyphoid organisms, and from the beginning of 1916 to the end of the war the vaccine in use was a triple one (B. typhosus, and B. paratyphosus A and B).

As will be seen from Table 7 the rate of prevalence (morbidity per 1,000) decreased from year to year and, while in 1915, 4 men in every 1,000 had typhoid fever, by 1918 the rate had been reduced to 0.12 per 1,000. This reduction coincided with an increasingly widespread use of antityphoid vaccines as a preventive measure, and there is ample justification for the statement that the gradual elimination of typhoid fever from the British armies was attributable to protective inoculation.

FRENCH ARMY

Since no official figures from the French War Office relative to the prevalence of typhoid and the paratyphoid fevers, or with reference to the status of protective inoculations with typhoid-paratyphoid vaccines during the World War, are available, the data used herein were obtained from a report made by Dopter;30 the statistics include both typhoid and the paratyphoid fevers. During the course of the war approximately 8,410,00031 men were called to active service by France, and during the same period of time approximately 125,000 cases of typhoid and the paratyphoid fevers occurred in the


41

French Army30 (approximate rate per 1,000 for typhoid and the paratyphoids for the period, 14.86).

Antityphoid vaccine as a prophylactic measure was used in the French Army to a certain extent at the outbreak of the war (1914) but was not a compulsory measure for all troops. On account of the existing emergency only a small percentage of the military personnel was given protective inoculations during 1914, and as a consequence approximately 45,000 cases of typhoid and paratyphoid fevers occurred, most of which were typhoid.30 Until September, 1915, an antityphoid vaccine was used, but a large proportion of the troops still were unprotected. It was noted in 1915 that, while some progress was being made in the control of typhoid, the cases of paratyphoid fever were increasing rapidly. In consequence of this fact a triple vaccine containing typhoid and paratyphoid A and B organisms was adopted and used from September, 1915, to the end of the war.

During the first two years of the war, and particularly so during 1914, when a considerable proportion of the French military forces had not received protective inoculations of antityphoid vaccine, large numbers of cases of typhoid occurred. Subsequent to September, 1915, however, when a triple vaccine was adopted and when military conditions permitted its more widespread use, both typhoid and the paratyphoid fevers were gradually brought under control, as is evidenced by the fact that during the first two years of the war (1914 and 1915) there were approximately 110,000 cases of these fevers, whereas during the last two years the total was approximately 2,000 cases.

ITALIAN ARMY

During the World War approximately 5,615,000 Italian subjects were called for active service with the Italian Army,31 and of this number approximately 65,000 had typhoid or the paratyphoid fevers.32 (Approximate rate per 1,000 for typhoid and the paratyphoid fevers for the period 6.24.) The use of antityphoid vaccine as a preventive measure was technically obligatory for the Italian Army when Italy entered the war in 1915, but it was found to be not feasible to carry it into effect during that year on account of the rapidity and urgency of mobilization. During 1916 and 1917 somewhat similar conditions obtained and though some progress was made a large proportion of the forces still remained unprotected.32 During 1918 still greater efforts were made to inoculate the new drafts and not until that year were the enteric fevers controlled to any marked extent. Though during 1915 the vaccine consisted of the typhoid bacillus alone, from 1916 to the end of the war both typhoid and paratyphoid vaccines were used.

BELGIAN ARMY

During the course of hostilities approximately 267,000 Belgian subjects were called to the colors with the army,31 and of this number approximately 3,200 had typhoid or paratyphoid fevers.33 (Approximate rate per 1,000 for typhoid and paratyphoid for the period 13.1.) Approximately 90 per cent of the cases were typhoid and 10 per cent paratyphoid.

Prophylactic vaccination was not carried out in the Belgian Army prior to or at the beginning of the war in 1914, but was introduced in 1915, and by the end of that year 10 per cent of the forces had been protected.33 During 1914 and


42

1915 approximately 2,500 cases of typhoid and the paratyphoid fevers occurred. From 1916 onward to the end of the war about 96 per cent of the personnel was protected, and during this three-year period approximately 1,000 cases were observed as compared with 2,500 for the preceding year and a half.

GERMAN ARMY

From 1915 to the end of the war approximately 112,000 cases of typhoid fever occurred in the German Army.34 No information is available to us as to the extent to which prophylactic vaccines were used, the content of such vaccines, or the prevalence of the paratyphoid fevers in the German Army. Total mobilized forces amounted to 11,000,000 men.31 

AUSTRIAN ARMY

From the beginning of the war in 1914 to the end of 1918 approximately 171,000 cases of typhoid occurred35 among the 7,800,000 men Austria mobilized for the war.31 The extent to which paratyphoid prevailed is not known nor is there available information concerning the extent to which prophylactic vaccination was practiced, or the type of vaccines used.

The data outlined above demonstrate most conclusively the value and importance of prophylactic vaccines (typhoid-paratyphoid) in the prevention of the enteric fevers and the very great importance of carrying this measure into effect at the time that troops are called to the colors.

PREVENTIVE MEASURES INAUGURATED IN THE ARMY DURING THE

WORLD WAR

The general and special preventive measures carried out in the American Army for the control of typhoid fever and other communicable diseases are considered in detail in the volume on sanitation of this history; therefore, only brief reference is made to them in this chapter.

In so far as general preventive measures are concerned, it may be said that instruction in hygiene was made a matter of routine and every effort was made to safeguard the environment in accordance with modern conceptions of disease prevention.36 To protect against the intestinal group of infections-typhoid, dysentery, and diarrhea-special attention was directed to the proper disposal of excreta and to the supply of potable drinking water. In the field the pit latrine system with fly-proof box seats was used generally, except in the battle areas. To each company or other organization of like nature was to be issued one or more canvas water-sterilizing bags, capacity 30 gallons, for the storage and distribution of drinking water. Sealed ampules of calcium hypochlorite were available for use in sterilizing supplies of water for drinking purposes. Investigation of outbreaks of typhoid and medical inspections of organizations frequently disclosed the fact that organizations either had no water-sterilizing bags or no calcium hypochlorite, or were provided with neither. Many company commanders apparently failed to appreciate the importance of having water-sterilizing bags and tubes of calcium hypochlorite always with the organization. In France the general distribution of tubes of calcium hypochlorite was a difficult problem and very unsatisfactorily solved until about the date of the signing of the armistice, when this item was issued as part of the ration. There


43

also was wide variation in the quantity of calcium hypochlorite in the tubes and the amount of available chlorine in the individual tubes varied within wide limits. Had all organizations in France had water-sterilizing bags and chlorine constantly available, together with good water discipline, and in addition, had it been possible to supply each soldier with a sterilizing agent to be carried on the person and to be used in emergency for the sterilization of water in the canteen, it is extremely doubtful if more than a hundred or so cases of typhoid would have occurred among the nearly 2,000,000 men in the American Expeditionary Forces.

The experiences of the Army with vaccines in the World War have their lessons for the future. The history of this subject may therefore be divided into several periods. In this connection it should be remembered that this account relates only to the manufacture of vaccines and does not correspond exactly to the actual use of the various products.

INTRODUCTION OF THE USE OF VACCINES (1908-16) 

MONOVALENT SALINE VACCINE

After the experience of the Army with typhoid fever during the Spanish-American War, the officers of the Medical Corps in charge of the bacteriological laboratories of the Army Medical School devoted much attention to the problems of the prevention of the spread of typhoid. In 1908, Russell37 took up the problem of typhoid vaccination on account of its sound theoretical basis and because of partial success of the use of vaccines in the British and German Armies. He worked out the technique of the production of a vaccine for subcutaneous injection, using the agglutinating power of rabbit's serum as an index of immunity. The procedure finally decided upon was a modification of the English broth vaccine and the German agar vaccine methods. The aim was to change the typhoid bacillus as little as possible by killing it at a minimum temperature of 53° C. for one hour. The organisms were suspended in salt solution and 0.25 per cent tricresol was added to prevent contamination. This amount of antiseptic was found not to injure the antigenic properties of the vaccine. The English strain "Rawlings," from a soldier of the Boer War, was selected from several strains as being most suitable for vaccine purposes.

The strength of the vaccine was 1,000 million bacilli per cubic centimeter as determined by the Wright method of counting. The doses were 0.5 c. c., 1.0 c. c., and 1.0 c. c. at 7 to 10 day intervals.

PARATYPHOID A AND B SALINE VACCINES (1916-17)

During the first period, while cases of typhoid were exceptional, several cases of paratyphoid A and B occurred each year in troops along the Mexican border, and these cases seemed to indicate a lack of cross immunity and the possible necessity of a mixed vaccine. In 1916 this problem became more acute as a small epidemic of paratyphoid A infections occurred in the Mexican expeditionary forces and also in the National Guard units stationed in Texas.38 Paratyphoid B infections also occurred, but were less numerous. Under these conditions, several cultures were sent from the Army laboratories at Fort Sam Houston, Tex., and El Paso, Tex., to the Army Medical School, where they


44

were tested for suitability as vaccine strains. Paratyphoid A vaccine No. 1 was made on September 10, 1916, 1,000 million per cubic centimeter, for local use of our troops in Texas and Mexico. Six of the strains were used at first in different proportions in different lots. The first paratyphoid A and B mixed vaccine was made in 1916.37 Two hundred million paratyphoid B organisms were added to the paratyphoid A vaccine. The reactions were reported as severe and from January 20 to May 22, 1917, only a paratyphoid A vaccine was issued.

In the meantime, the British had been suffering from paratyphoid infections in France for two years and had finally adopted a mixed vaccine. The cultures used were sent to the school by our observer with the British Army. "Mears" A and "Rowland" and "Cools" B were tried out experimentally.

THE PERIOD OF THE WORLD WAR (1917-18)

SALINE TRIPLE TYPHOID VACCINE

After the declaration of war by the United States on April 6, 1917, it was decided to use paratyphoid vaccine, and at first, on account of fear of severe reactions, a separate vaccine was introduced, made up chiefly of "Rogers" and "Mears" A and "Rowland" and "Cools" B. The strength of this vaccine was 750 million per cubic centimeter of each fraction, a total of 1,500 million per cubic centimeter. The administration of 6 doses of vaccine, 3 of monovalent typhoid, and 3 of paratyphoid seriously complicated the training schedules and the possibility of a mixed triple vaccine was again taken up. Such a vaccine, consisting of 1,000 million typhoid and 750 million each A and B, a total of 2,500 million per cubic centimeter, was made up and tested at Fort Leavenworth, Kans.39 The reactions were not severe and the agglutination response was satisfactory. The vaccine was made of "Rawlings" typhoid, "Rogers" and "Mears" A, and "Rowland" and "Cools" B. The first lot was made on July 11, 1917, and this kind of vaccine constituted the bulk of the vaccine used in the war.

LIPOVACCINE (SEPTEMBER 30, 1918, TO MARCH 12, 1919)

In 1916 several French workers reported on the use of oils in the place of salt solution as a medium for bacterial vaccines. The advantages claimed for this method were, slow absorption, larger dosage with less reaction, and especially the efficiency of a single dose. These claims attracted the attention of the director of laboratories at the Army Medical School, Washington, D. C., and he, with his assistants, in the spring of 1918, conducted preliminary experiments in the manufacture and use of lipo-triple-typhoid vaccine.40 Their experience apparently confirmed the claims, and the single dose was an especially strong administrative argument in preparing the Army quickly for action in France. In the fall of 1918 lipovaccine was officially adopted by the Surgeon General's Office.41 The first lot was made on May 23, 1918, of para B.

The technique, briefly, was to grow the organisms in the regular way in Kolle flasks; the growth was washed off in a minimum of salt solution and centrifugalized to collect the bacteria. After November, 1918, a Sharples centrifuge was used for this purpose, and the organisms were grown in tryp-


45

broth. The centrifugate was collected and dried in a hot-air oven at 60° C. It was then weighed, ground up in a ball mill to a fine powder, and olive oil was used for suspension. The doses were in milligrans of dried organisms. The dose was 1 c. c. Each cubic centimeter contained 0.3 mg. of typhoid, para A and para B bacilli, representing a total of 7,500 million organisms. The plant at the school was greatly enlarged by a special apparatus for this work.

After the armistice was signed, and there was enough leisure to study the subject more thoroughly at the school, it was found that to prepare an entirely sterile product on a large scale was most difficult. Some of the typhoid organisms were not killed, and contaminating organisms from the air were difficult to exclude. It was also found that absorption was not slow; the organisms were rapidly extracted from the oil by the body fluids. Even more important, it developed that a single dose did not give the antibody response that follows the use of two and three injections.

On March 1, 1919, therefore, a return was made to saline vaccine, and the following circular letter was issued from the Surgeon General's Office:42

1. Beginning with date of receipt of this letter, saline triple typhoid vaccine and saline pneumococcus vaccine, Types I, II, and III, will be used in place of the corresponding lipovaccines used to date.

2. Lipovaccincs were adopted as a war measure on account of their obvious advantages and have served their purpose. The technique of manufacture, however, needs further improvement, and the duration of their protective power as compared with that of saline vaccines needs further investigation. Saline vaccines will therefore be used as a routine and lipovaccines will be reserved for emergencies.

*    *    *    *    *    *    *

LOCAL AND SYSTEMIC REACTION FOLLOWING PROPHYLATIC VACCINATION

There is nothing to indicate that any permanent disability followed the vaccination of troops during the war. Furthermore, the temporary disability produced by the triple typhoid vaccine was not great. Of the approximately 4,000,000 men who were mobilized for our war Army, all of whom were inoculated with typhoid vaccine soon after enlistment, only 35,552 were admitted to sick report for reactions following vaccination.

Foster, working at Camp Meade, Md., made an exhaustive study, from the clinical point of view, of the effects of triple typhoid vaccine on a large number of troops in that camp and reported as follows on the unusual reactions to typhoid and paratyphoid vaccination:43

The reaction which is usually experienced from prophylactic doses of typhoid vaccines amounts only to a slight discomfort. At worst the subject is seldom more uncomfortable than he would be with an acute tonsilitis, and he has the consolation that 18 to 24 hours will mark the termination of the symptoms. There seems to be a consensus of opinion, however, that vaccination with the mixed typhoid-paratyphoid culture is not so apt to be passed unnoted as vaccination with the single typhoid strain. The symptoms commonly varying somewhat in degree, are slight fever, chilliness, muscular pains and backache; not so usual, but still relatively frequent, are severe headache, vomiting or diarrhea, or both, epistaxis, and bronchitis, which last may continue for days or even a couple of weeks. This list includes all the symptoms which occur in the average cases, and from these deviations are not unusual. Occasionally, of course, bizarre cases are noted due, perhaps, to some accident in technic.


46

Differentiated from the above-mentioned majority, of over 40,000 vaccinated troops, was found a group of cases, admitted to the wards of the base hospital at Camp Meade on account of rather severe symptoms. These symptoms at least suggested certain specific diseases. On account of the diseases simulated this group may be subdivided into meningeal, appendiceal, and purpuric types. These cases were sufficiently frequent to afford opportunity for study, and because of the diagnostic embarrassment which we experienced in the beginning no little attention was given to them. The reaction which bore resemblance to appendicitis was most common. At least 50 of these cases were studied, and of the other types a somewhat smaller number.

The meningeal type of reaction is alarming because of the resemblance to meningitis. When, as happened with two cases, there were in addition to other signs a few fine purpuric spots on the body, the resemblance to an early stage of "spotted fever" was complete. The usual course of events with my cases was initiated by headache, commencing a few hours after vaccination and gradually increasing to an almost unbearable intensity. With severe headache photophobia is the rule. There was pyrexia up to 102° F. and sometimes vomiting. When put in bed the patient assumes the meningitis posture-lying on the side, knees up, and head thrown a little back. On examination one finds invariably with these cases some stiffness of the neck, a positive Kernig sign, and a mild hyperæsthesia. In the absence of history, diagnosis can hardly be made without lumbar puncture. When lumbar puncture is done the cerebro-spinal fluid is found under considerable increase of pressure, often dropping too fast to be counted. The fluid is clear and normal. There is no significant cell increase. Withdrawing 10-15 c. c. of fluid almost invariably relieves the headache. In brief, the condition is one of meningismus.

The appendicitis picture is definite enough as a clinical picture with localized pain and tenderness, slight fever, and some increase in the leucocyte count (due to vaccine). A number of these cases were operated upon. The appendices removed, however, did not present the conditions expected, and an agreement between the surgeon and the pathologist on this point was impressive. With this experience a conservative attitude developed and none of the cases of this type was operated upon. At a somewhat later period, while at General Hospital No. 14, I found that Lieut. Col. Edward Martin had become interested in the surgical aspect of this problem but had come to a different conclusion in that with his cases the appendix did show more evidence of acute inflammatory change. Colonel Martin's cases gave a history suggesting repeated attacks of appendicitis in the past, and it has been proposed in explanation that the vaccination excited an acute process in an individual thus predisposed. Neither the immediate practical question involved nor the underlying one of scientific principle can be clarified by evidence now available. It will be recalled that shortly after typhoid vaccination began to be somewhat extensively used among our civil population in the cities the statement was made and repeated that latent tuberculous foci in the lungs might be thus fanned into activity. Some scattered attempts were made to ascertain the truth, but these studies bear analysis as badly as the statements to be examined. At present there are opinions, but little evidence. Similar opinions are current as to the effects of vaccination on latent chronic urethritis, arthritis, and some other conditions. The whole subject requires careful reexamination. It is of interest in passing to recall that vaccines made from typhoid cultures have been advocated for the treatment of some of these conditions-arthritis, urethritis-which we are now assured are aroused into activity by the same measure.

There is so much obscurity surrounding the etiology of purpura that the cases following vaccination had for me an especial interest. The first of these cases to receive recognition was admitted from a regimental infirmary on account of epistaxis. * * * On the morning of admission to hospital he had epistaxis, and for this reported at sick call. The epistaxis was obstinate and required "packing." Examination showed a purpuric eruption covering the body. The spots were small and discrete, varying from one-sixteenth inch to one-eighth inch, and purplish in color. There was no bleeding of the gums; no blood found in urine or feces. We had not at this time facilities for exact measurement of clotting time, but no abnormality was noted by means of improvised apparatus. The bleeding time and cell counts were normal. The rash gradually faded to a tawny brown stain, and the patient was returned to duty.


47

On inquiry, stimulated by this case, it was found that a number of cases had been admitted to the otology service of the hospital because of epistaxis following vaccination, and it was recognized that many of these had hematuria and a few had purpuric eruptions. A number of cases of varying degrees were studied subsequently in both these services. Epistaxis with transient hematuria was not uncommon. Some of these showed also hemorrhages and purpuric rashes. In one case there was violent epistaxis, hematuria, melena, and extensive purpura and hemorrhage into some of the joints. The left elbow had later to be opened and the clot removed. All of these cases made perfect recoveries.

Since an understanding of this condition would be helpful for an understanding of purpura, examinations were made of blood in respect to the clotting and bleeding times, cell counts, and platelet counts. So much normal variation was found in the platelets that no evidence could be recured in this direction. The other estimations were normal, except a slight leucocytosis observed in many cases after vaccination without special symptoms.

Statistical tables of the Surgeon General's Office for the World War period show that five soldiers were discharged from the Army for disability following triple typhoid vaccination. A further investigation of the clinical records of these cases, however, revealed an error in tabulation; although some temporary disability resulted from vaccination, a careful search of the records failed to reveal any cases that terminated in permanent disability or death.

The use of typhoid vaccine as a protective measure having been a routine procedure in the United States for a number of years prior to the World War, the American military authorities appreciated the fact that the reactions following its administration not infrequently (approximately 10 per cent) were moderately severe during a period of from 24 to 48 hours after inoculation. For this reason it was the custom to recommend that all personnel be excused from all duties, except the necessary roll calls, for a period of 24 hours after vaccination. The experience gained in the vaccination of 4,000,000 men during the World War further confirms the wisdom of carrying this procedure into effect, and it is now required by Army Regulations.

FACTORS THAT MAY BE RESPONSIBLE FOR THE OCCURRENCE OF TYPHOID IN INDIVIDUALS PRESUMABLY PROTECTED BY VACCINATION

As noted, a large proportion of the cases of typhoid in troops in the large mobilization camps in the United States occurred in individuals who had not been protected by prophylactic vaccines. Approximately 885 cases occurred in approximately 1,900,000 men serving in France, and it is highly improbable that any appreciable number of these men were uninoculated. Vaughan,3 in a careful study of the records of 270 cases of proven typhoid in France, found that all had received prophylactic inoculations, and that in 207 of the 270 cases there was a record of the dates of vaccination and types of vaccine used. Why did prophylactic vaccination occasionally fail to protect against typhoid? Concerning this matter we have no definite information. Vaughan, who gave it considerable attention, made the following comments on this phase of the problem:3

1. Absence of vaccination, either total or partial.-By this I refer to failure not because of impotent vaccine but because of failure to react in certain individuals. It is well known that after the same doses of vaccine different persons form different amounts of agglutinins. But agglutinin titer is not a measure of immunity. We have no criterion that will tell


48

us when an individual is actually immunized, nor have we any means of determining the degree of immunity present.

2. New strains of the organisms against which the vaccine does not immunize.-Serologic and cultural determinations made in the various laboratories have not consistently produced anything to suggest such a condition.

3. Failure of proper inoculation.-Among the cases of true typhoid studied, vaccination had been performed in 50 different camps and posts in the United States. This fact, combined with the really excellent results in most individuals vaccinated, renders such a possibility rather remote.

4. An overwhelming dose of the infecting organism.-Absolute immunity to human disease does not exist in man. The highest immunity that can be produced by artificial methods will protect against the antigenic virus only up to a certain limit. I am of the opinion that the greater number of cases of typhoid and paratyphoid in France occurred as a result of massive infection with a dose great enough to overwhelm the forces of immunity. This, I presume, was most frequently associated also with the first cause enumerated, "absence of vaccination, either total or partial," in that it occurred in those possessing a lower degree of immunity than their more fortunate comrades. As Bernard has so succinctly expressed it, vaccination raises against the typhoid bacillus a great barrier-high, but not insurmountable.

5. "Back-handed typhoid," "antibody exhaustion," or "immunity exhaustion."-I include the second designation of this condition as being the most readily comprehensible in view of the existing nomenclature and conceptions of immunity, while I prefer the third as being more scientifically correct. I developed the first term as I recognized more and more of this type in the field, and it has the particular advantage that it emphasizes the assumption that the successive stages of typhoid infection are therein, in a manner, reversed.

The present-day conception of typhoid is that it is of primary systemic infection. The organisms entering by way of the gastrointestinal tract are absorbed into the circulation and do not primarily grow as saprophytes in the alimentary canal. After passing through the gastrointestinal mucosa, the organisms reach the liver through the portal circulation, where they may be excreted through the bile; or some may pass into the general circulation, where they multiply and, after the usual period of incubation, cause typhoid fever. The organism excreted in the bile may lodge in the gall bladder and there, growing, produce the carrier condition, even though the host has not had typhoid fever.

In a vaccinated person, the organisms entering the portal circulation are either broken up and destroyed by the body ferments or excreted into the bile, or both. In the gall bladder they may find lodgment and continue to grow, in reality outside the body organism, multiplying profusely even though the host be highly immune. The number of organisms that are continually discharged in the bile and resorbed through the intestinal mucosa call on the immunity mechanism for constant and exhausting action. There may be superimposed on this local enteritis caused by one of the typhoid-colon group or any other organism, or even by the typhoid member of the group itself. This subacute or chronic condition rendering toxic absorption more facile, serves gradually to undermine the constitution. Finally, added to all this, are the hardships of war and army life-exposure, food not always well balanced, fatigue, and perhaps at last some intercurrent infection-and all the conditions required to wear out a body immunity are then present.

It is this reversed process-a local infection or carrier state followed by systemic disease instead of the usual typhoid followed by a carrier condition-that I have chosen to call "back-handed typhoid." Overwhelming doses of the infecting organism and this exhaustion reaction were in my opinion two of the chief causes of typhoid among our troops.

From the nature of the condition it has been impossible to obtain convincing experimental evidence of its presence in France; but a certain amount of indirect evidence appears to warrant our assuming its presence. Our first case occurred in a colleague who, preceding his illness, had been billeted with a French family and who had been drinking unchlorinated water while at his billet. For two weeks or more he had been complaining of general malaise and a moderate diarrhea, but not sufficient to keep him from his work. At the end of two or three weeks the illness became acute, the usual symptoms of typhoid developed, he became progressively worse, and he died within one week from the onset of the exacerbation.


49

These cases present the usual clinical histories of ambulatory typhoid, with the definite addition of a local gastrointestinal pathologic condition and symptoms preceding the disease proper. Otherwise there is nothing unusual about the symptomatology. Especially frequent was this syndrome among the men who had seen active service at the front. From nearly all, a history was obtained of having drunk whatever water they could get, even from the stagnant mud of the shell holes.

To check up on the impression I had gained, I questioned 104 patients as to previous history of chronic local gastrointestinal disturbance. All were straight typhoid cases. Forty-four denied attacks of diarrhea antedating the diarrhea of the disease itself. Thirty-nine admitted a continuous preceding enteritis varying from one week to three months in duration, and of these, 23 had it for over a month. Fifteen had had diarrhea for from one week to three months while at the front, which had subsided and from which they had been free for from two to three months. Seven additional patients admitted having had a transient diarrhea of from one to five weeks duration in the two months preceding their disease.

Subacute diarrhea is not a necessary, or the usual, antecedent of typhoid fever. The disease begins frequently even with constipation. I would compare the foregoing figures, in which more than 60 per cent had been afflicted with enteritis, with the statements of the Typhoid Commission in the Spanish-American War, that in that epidemic "More than 90 per cent of the men who developed typhoid fever had no preceding intestinal disorder." I do not believe that the figure of 60 per cent would hold for all men attacked by this malady in the American Expeditionary Forces, but do assert that it was the case in a representative number of those who had been at the front.

There is no proof that these men were harboring the typhoid bacillus in their intestinal tract previous to coming down with the disease. It is here that my hypothesis fails of absolute proof. Such proof would have necessitated a survey of the stools of all members of a division, to be followed by weeks or months of watching to see whether the carriers discovered would develop the disease. Moveover, had this been done, the carriers would have been hospitalized and treated, thus defeating the object of the experiment. But corroborative evidence is not lacking. Several observers have reported the finding of typhoid bacilli in the stools of patients a few days or more previous to the onset of the disease, while Battlehner has reported four cases in whose excreta the bacilli were discovered from 21 to 117 days before the onset of the disease. These had been considered as healthy carriers. I have a record of one patient who one and a half months previous to admission cared for a typhoid patient and shortly thereafter developed diarrhea, which persisted for six weeks until the typical acute onset of typhoid. In the discussion of typhoid carriers I have called attention to 10 out of the 32 carriers, with history of diarrhea, none of whom had had preceding typhoid, and one carrier with no history of typhoid and no diarrhea, who nine months previously, at Camp Dodge, had had negative stools for the typhoid group.

I have shown, then, that carriers have been produced in France; that diarrhea is often associated with the carrier condition; that among 104 men, diarrhea preceded the disease in 60 per cent; that in one instance exposure to the disease was followed by enteritis which persisted for six weeks, until the onset of typhoid. Before absolute proof of back-handed typhoid is produced, I must show that all these facts find sequence in individual cases.

6. Unsatisfactory vaccine, either as regards antigenic properties or number of doses administered.-Considerable experimental evidence has accumulated to show that with increasing numbers of inoculations the immunity increases. Four inoculations confer a greater degree of immunity than do three. One of the advantages of the method in use in the United States Army is that the men nearly all receive the same vaccine in the same dosage and with the same number of inoculations. Observers in other armies were sometimes forced to draw their conclusions from patients who had received different kinds of vaccine and all numbers of injections, from one to four or more. The fact that our vaccine did protect in the great majority of the cases demonstrates the efficiency of our preparation and of the dosage. It may not be ideal, but it is thoroughly practical.


50

CLINICAL COURSE OF TYPHOID FEVER IN THE VACCINATED INDIVIDUAL

The general impression prevailed at the outbreak of the World War that the clinical manifestations of typhoid fever in the vaccinated individual differed from those found in the unvaccinated. The statement is made by Gay44 that not only is the mortality rate decreased but the disease itself is found to undergo a very distinct modification when it occurs in the vaccinated individual, so much so, that it frequently is so mild as to offer great difficulty in diagnosis. Vaughan, in a study of a series of 373 cases occurring in vaccinated individuals in the American Expeditionary Forces, France,3 found that the most striking feature of the disease in the inoculated was its almost classical resemblance to the old typhoid fever as one knew it in the unvaccinated individual. Not only was this resemblance noted in the clinical history but also at the bedside. In the majority of cases in which the typhoid bacillus was isolated there was no difficulty in the clinical diagnosis. Typhoid facies, coated tongue, rose spots, palpable spleen, rigid and slightly tender abdomen, and dicrotic pulse were the rule rather than the exception; however, as in the uninoculated, all gradations of the disease were found. One has long been acquainted with mild and ambulatory cases, with difficulty in diagnosis on account of the mildness of the disease, and frequent absence of many of the usual symptoms of typical typhoid fever. Many such cases probably occurred among our troops in France and remained undiagnosed. It is further possible that the number of cases that would fall under this class had been greatly increased by previous inoculation. But of those patients whom we have seen sick in hospital there could be no doubt as to the clinical diagnosis.3

Leucopenia was not as marked as in the classical typhoid fever. The average white count on successive days was about 7,000. In a few cases from 2,000 to 4,000 white cells per cubic millimeter were noted. The above average agrees with the report by Hawn, Hopkins, and Meader.14 The average white count during hemorrhage was 4,500; in perforation, 6,000; in lobar pneumonia complicating the disease, 12,000, and in bronchopneumonia 9,000. These figures, however, agree with those occurring in typhoid fever in the unvaccinated.3

What has been said relative to the white blood count applies to the febrile course of the disease; that is, the type of fever in vaccinated patients did not differ remarkably from that in unvaccinated. The average day of cessation of fever was 26.9; relapse occurred in 10 per cent of the cases and the average date of onset was the 35th day. Death occurred in 11 per cent of 270 of the cases studied and the 21st day was the average day of death.

The foregoing clinical findings are in accord with those reported by other observers. Labbé45 remarks that the symptomatology has nothing characteristic and the same elements are present and appear in the same order among vaccinated and unvaccinated individuals. The onset is not marked by special symptoms and during the fastigium, diarrhea has the usual occurrence. However, it may be that this symptom occurs somewhat less frequently in the vaccinated. Bernard and Paraf,46 in describing the clinical symptomatology among French troops, remarked that typhoid fever among the vaccinated has no particular characteristic which might indicate a modification of the disease.


51

The different classical forms are seen with their usual characteristics. Campani and Gallotti47 reported that in a series of cases of typhoid and paratyphoid fevers occurring in 144 nonvaccinated civilians and 341 vaccinated soldiers on the Italian front the case mortality rate from typhoid fever in the vaccinated patients was 8.6 per cent and in the paratyphoid A and B cases 4.6 and 7.8 per cent, respectively. Among the unvaccinated the case death rate for typhoid was 20 per cent and for the paratyphoid cases nil. They found that in both groups about 42 per cent of the patients had a febrile period lasting into the fourth week and that the average duration of fever was, among the soldiers, 24.5 days and among civilians 28 days. They state that the febrile curve instead of being irregular and low in the vaccinated, was high and decidedly more regular than among the nonvaccinated. Splenomegaly and nervous phenomena were more frequent among the vaccinated. These workers concluded that vaccination had lessened both the mortality and the severity of the disease.

Freund48 reported typhoid infection in the German Army and concludes that among the vaccinated cases there were more remissions and intermissions as well as a great number of mild cases. The fever was milder but the total duration of the disease was not shortened. No change in the frequency of the complications or relapses resulted on vaccination, and mortality given among the vaccinated was 8.3 per cent.

Hawn, Hopkins, and Meader,14 in describing the 38 cases studied in an outbreak among American troops in England, found clinical symptoms similar to the cases described by Vaughan. The initial chill occurred in 16 per cent, diarrhea in 58 per cent, constipation in 21 per cent, abdominal pain in 6 per cent, and epistaxis in 2.6 per cent. Rose spots were described in 19 cases, splenomegaly in 9 per cent. Blood cultures were positive in 12 cases and the mortality was 13.15 per cent.

There was a somewhat progressive increase in severity with lapse of time after inoculation in individuals to whom vaccine had been administered from one to six months before the patient was taken sick (11.6 per cent severity). When from 13 to 18 months had elapsed, 15.9 per cent were classified as severe. It appeared that the average severity of the disease was fairly constant throughout the first eight months following inoculation, after which it gradually increased. The proportion with relapse did not appreciably differ.

COMPLICATIONS, SEQUELÆ, AND CONCURRENT DISEASES

The complications and sequelæ of typhoid fever during the war afforded nothing new from either a clinical or pathological point of view. Among the more important of these were 4 cases of general septicemia, with 4 deaths; 2 cases of acute endocarditis, with 2 deaths; and 7 cases of myocardial insufficiency, of which 2 resulted fatally. Important complications of the respiratory tract were 26 cases of bronchitis, with 6 deaths; 59 cases of bronchopneumonia, with 39 deaths; 29 cases of pneumonia, of which 24 terminated fatally; and 18 cases of pleurisy, with 6 deaths. Hemorrhage was recorded in 11 instances, with 8 deaths; and diarrhea as a complication in 5 cases, of which 3 terminated fatally. Enteritis and colitis occurred in 12 instances, with 2 deaths; and peritonitis in 8, with 7 deaths. There were 2 deaths among the 4 cases of acute


52

nephritis. Altogether 209 complications were deemed as being of sufficient importance to be reported, with 151 deaths.

Typhoid fever was reported as concurrent with other diseases in 368 instances. Of these, 60 terminated fatally, giving a case mortality of 16 per cent. The more important diseases with which it was concurrent are given in Table 8.

TABLE 8.-Typhoid Fever. Concurrent with other diseases, enlisted men, United States Army,serving in the United States and Europe, April 1, 1917, to December 31, 1919


Primary cause of admission

Absolute numbers

Deaths

Case mortality

Primary cause of admission

Absolute numbers

Deaths

Case mortality

Influenza

162

33

20.37

Enteritis and colitis

25

4

16.00

Tuberculosis of the lungs

4

3

75.00

Intestines, other diseases of

5

2

40.00

Bronchitis

29

1

3.45

All others

98

6

6.12

Pneumonia, broncho-

29

6

20.69

Total associated

368

60

16.30

Pneumonia, lobar

16

5

31.25

CARRIERS

Nichols,49 who made a somewhat exhaustive study of the "carrier" state during the World War, classified carriers as "incubationary," "convalescent," and "contact." The percentage of cases that develop the carrier state of one class or another has been variously estimated as being from 9 to 50 per cent, women constituting the majority, three-fourths of the carriers being of the intestinal type.

The bacteriological examination of the stools and urine of food handlers at stated intervals, and examination of convalescents from typhoid for the carrier state prior to their discharge from hospital, was a matter of routine during the World War, and by means of this administrative procedure a few carriers were detected. According to Nichols, the results of examination of about 30,000 food handlers during the war demonstrated less than 0.1 per cent carriers among healthy males. Gay44 states that 7,500 carriers are being added to the civilian population in the United States each year. There were 64 recorded carriers among the primary admissions to hospital during the war.

Instructions governing medical officers, A. E. F., in the determination of a carrier state were as follows:50

*    *    *    *    *    *    *

Typhoid and paratyphoid patients excrete the bacilli, frequently with their urine and practically always in their feces. This is most likely to occur during the third and fourth week of the disease, the condition may persist throughout convalescence and not infrequently longer. It is, therefore, important not to release the convalescent typhoid or paratyphoid fever patient until he ceases to excrete these bacilli.

Three negative cultures of the urine and feces at six-day intervals should be required before release of patient, the first not earlier than one week after temperature curve has become normal.

Some persons who have never had a clinical history of the disease may excrete typhoid or paratyphoid bacilli. It is important to detect such carriers in any occupation, but especially among cooks and handlers of foodstuffs. In such a carrier survey, two examinations should be done on each individual.


53

No definite lesions were found in incubationary and contact carriers. The liver and kidney showed lesions in convalescent carriers. In intestinal carriers with lesions in the gall-bladder, bile-ducts, or both, the organism was demonstrable in the stools. In urinary carriers the focus was found in the kidney, especially in the pelvis.

According to Nichols,49 carrier strains did not differ from others and could not be differentiated by cultural or other tests. In determining the carrier state serological examinations were suggestive, as more than 50 per cent gave positive agglutination tests. Such examinations, however, were of little value in the case of convalescents from the disease or in the recently vaccinated subject. The organism was found in the duodenal contents or feces in the intestinal type of carriers and in the urine in urinary carriers. It was the custom to require at least three consecutive examinations of the feces and urine of convalescents from typhoid before dismissing the possibility of an existing carrier state.

In the United States it was the policy to collect all chronic typhoid carriers in the Army at the Walter Reed General Hospital, Washington, D. C., for further observation and treatment.51 At the time the armistice went into effect arrangements also had been completed for the establishment of a special hospital in France, near Dijon, for the treatment and study of chronic "carriers" of all types in the American Expeditionary Forces.

An essential in the successful treatment of typhoid carriers was location of the focus of infection which, though usually single, sometimes was multiple. Where the focus was a single one, as for example, the gall-bladder, treatment by excision usually effected a cure. Where the foci were multiple, as for example in the gall-bladder and in the bile-ducts, removal of the gall-bladder did not result in a cure.

Nichols, Simmons, and Stimmel52 reported on the surgical treatment of typhoid carriers at the Walter Reed General Hospital in 1919. Seven cases are included in this report; 6 were intestinal carriers and 1 urinary. Four of the former were cured by removing the infected gall-bladder, and the urinary carrier was cured by removal of the infected kidney. In two of the intestinal carriers failure was attributed to the gall-duct being infected as shown by cultures of the duodenal contents. Operation was not recommended for at least six months after recovery from the primary disease, as in many instances the carrier state was of temporary duration. Henes53 reported favorably upon the surgical treatment of typhoid bacillus carriers at the United States Army General Hospital No. 12 during the war.

In spite of all known methods of treatment, some chronic carriers continued to excrete bacilli. The commanding officer of the Walter Reed General Hospital reported several such cases to the Surgeon General in April, 1919.54 These cases had been operated upon, but foci of infection remained. The procedure followed in such instances was to discharge the individual from the Army, at the same time notifying the State board of health having jurisdiction.55


54

DIAGNOSIS

For many years, particularly since prophylactic vaccination was made mandatory, the Medical Department of the Army has stressed the importance of the scientific and early diagnosis of typhoid fever. Before we entered the World War it was required that the diagnosis be based on isolation of the organism and that a culture of the isolated organism be sent to the Army Medical School at Washington for confirmation. This practice was continued during the World War except that organisms isolated in France were sent for confirmation to the central medical department laboratory at Dijon.

A prompt report of cases of enteric fevers was insisted upon by the chief surgeon, A. E. F.56 For purposes of classification a division was made into proven cases, clinical cases, suspects, convalescents, and healthy carriers. Diagnoses were reported by telegram to the chief surgeon, A. E. F. With the development in France of several foci of infection-December, 1918, and January, 1919-the chief surgeon, A. E. F., issued a special circular letter relating to the typhoid and paratyphoid fevers. The following notes on diagnosis were incorporated in this letter:50

In individuals previously vaccinated against typhoid but who have completely lost their immunity, infection similar to that found in the unvaccinated occurs, giving rise to the symptom complex * * * characteristic of typhoid fever.

Infections occurring in the vaccinated individuals who still possess a certain degree of resistance to infection results in the appearance of atypical clinical pictures, such as abortive types of typhoid and paratyphoid in which the constitutional symptoms are mild but with slight febrile reaction of atypical type and few if any rose spots. The onset may be either insidious, with headache, loss of appetite, and fatigue, or acute and associated with chills, vomiting, intestinal cramps, and diarrhea. Fever may be wholly absent or evanescent in character and determined only if observations are made within the first 48 to 72 hours. A low type of temperature, with daily fluctuations of from 98.6° to 100.4°, suggestive of the presence of tuberculous disease, may persist for a week or 10 days. It is in this class of cases that blood cultures taken early in the course of the disease, and repeated if negative, frequently give definite information concerning the nature of the infection. Ambulatory types of typhoid are not uncommon and the first indication of the existence of the disease may be furnished by the occurrence of intestinal hemorrhage or perforation.

The vaccinated individual protected against general systemic infection may still act as a carrier of typhoid infection and frequently shows clinical manifestations of local disease of some portion of the gastrointestinal tract, while the characteristic symptom complex of typhoid fever due to general infection, namely, continued fever, rose spots, and enlarged spleen, may be wholly absent. * * *

Atypical modes of onset.-(a)

Acute onset with symptoms simulating meningitis. Lumbar puncture differentiates. (b) Acute onset with intense, usually generalized bronchitis or symptoms suggestive of lobar or bronchopneumonia. (c) With chills, fever, vomiting, cramplike pain in abdomen, sometimes localized in right iliac fossa and suggesting appendicitis. (d) With symptoms of acute nephritis. Attack begins suddenly, with nausea, vomiting, pain in lumbar region, diminution in secretion of urine, which is highly colored and contains albumin and casts. (e) Special mention should be made of the ambulatory type of typhoid in which the symptoms are slight, consisting simply of headache and lassitude associated with mild gastrointestinal disturbances. The patient is at no time confined to his bed, and intestinal hemorrhage or perforation may furnish the first clue with regard to the existence of typhoid. (f) In the above atypical modes of onset early blood cultures are of importances in differentiation. * * *

In the differential diagnosis influenza, acute miliary tuberculosis, sepsis, and malarial fevers must be differentiated. Local and unexplained gastrointestinal derangements, as


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gastritis, diarrhea, dysentery, enteritis, appendicitis, and inflammation of the bile passages, occurring with or without fever should be regarded with suspicion when cases are admitted from commands in which cases of typhoid or paratyphoid fever have occurred.

Laboratory diagnosis of typhoid and paratyphoid fevers.

-Bacteriological procedures are of great value (1) for the certain and early diagnosis of suspected cases; (2) to determine carrier state in convalescent positive cases; (3) to detect carriers in otherwise normal individuals.

Blood cultures offer the most certain method for early diagnosis of undetermined fevers, and it should be kept in mind that the earlier in the disease the blood culture is taken the more likely is the result to be positive; thus, in positive typhoid fever the chance of successful blood culture declines from 90 per cent during the first week to 40 per cent during the third week. In paratyphoid A fever, because of the frequently short and mild febrile period, the prompt and early blood culture is all the more necessary. Relapses are more common in paratyphoid than in typhoid, and taken at such a time, blood culture yields positive results in every case.

The following method of blood culture is recommended as being suitable in all cases of fever of undetermined etiology.

(a) When laboratory facilities are at hand, take 10 c. c. of blood from a vein at the elbow. Place 3 c. c. in each of two flasks containing 100 c. c. of plain broth. Place 1 c. c. in tube of agar (melted and cooled to 45° C.); immediately mix and pour plate. Place remainder of blood in dry sterile test tube to separate serum for such serological tests as may be suggested.

The two flasks and plate are incubated and examined the following day. Transplants are made to plain agar slants, or, better, Russell's double sugar agar. In cases of development of Gram-negative motile bacilli on agar slants, emulsions should be made and agglutination tests done with immune sera for final identification.

Frequency of nonagglutinability of recently isolated typhoid cultures should be kept in mind. Negative blood culture in suspected typhoid fever means little. Repeat if clinical conditions indicate.

(a) If the blood culture specimen can not be taken directly to the laboratory, filtered sterile ox bile is most useful, 5 c. c. in a tube. To such sterile ox bile 5 c. c. of blood is added, the tube closed with a sterile paraffin cork, carefully packed, and sent for examination to the nearest laboratory. Bile medium is furnished in chest No. 1, transportable laboratory, United States Army, expeditionary force model. Additional supply of this medium may be obtained as needed from central Medical Department laboratory, A. P. O. 721.

Bacteriological examination of feces is second only to blood culture as an important means of positive diagnosis. It is especially important in paratyphoid B fever. * * *

The Widal test-

In view of previous vaccination with T. A. B., vaccine has been generally held of little or no value; however, it should be stated that the determination of agglutinin titer of patient's serum at intervals of one week and the demonstration of progressive and marked increase of agglutinin content of the blood offer, especially in the absence of positive blood culture, excellent evidence as to the etiology of the disease. Thus, in typhoid fever an agglutinin titer (Widal test) of 1 to 40 during the first week of the disease may advance to 1 to 1280 during convalescence. In paratyphoid B fever the titer frequently advances to 1 to 2,560; however, in paratyphoid A fever it may not reach 1 to 640. Formalinized and standardized bacterial suspensions of B. typhosus B, paratyphosus A and B, paratyphosus B may be obtained on request from the central Medical Department laboratory, A. P. O. 721.

In the series of cases studied by Vaughan,3 blood cultures were made from 274 cases and typhoid or paratyphoid bacilli were isolated in 180 cases, or 65.7 per cent. Of these 180 positive results, 143 were positive on the first culture, 25 on the second culture, 3 on the third, 9 on the fourth, and none on the fifth, showing the value of repeated culturing. In the case of the epidemic occurring in the Camp Cody replacement unit, 32 per cent of the blood cultures taken in England were positive and 88 per cent of those taken at Cherbourg; in the Prauthoy epidemic 16 per cent were positive; in the Curel epidemic 88 per cent; and in the Marseille epidemic 28 per cent were positive. This is a


56

very wide range of positive cultures and indicates, in the low percentages, either delay in resort to laboratory diagnosis or lack of skill on the part of the laboratory personnel. A blood culture is manifestly of much greater value than a stool or urine culture. In the Curel epidemic, which was handled promptly by a skilled laboratory force, the per cent of positive blood cultures was high (88 per cent); consequently, it was necessary to resort to cultures of the urine and stools and there were reported only 14 per cent positive feces and 3 per cent positive urine. In the case of the Marseille epidemic with a low percentage of positive blood cultures the gravity of the situation was not at first appreciated. The local laboratory personnel was reinforced and subsequently there were reported 53 per cent positive stool and 14 per cent positive urine culture. Likewise in the Nevers epidemic and for the same reason there were but 15 per cent positive blood and 38 per cent positive stool and 31 per cent positive urine cultures.

Marris,57 of the British Army, during the course of an extended study of typhoid patients, developed the so-called atropin diagnostic test. He held that when the human body is so invaded by bacilli of the typhoid group as to exhibit typhoid, paratyphoid A, or paratyphoid B fever, a toxin is formed which effects the heart in a peculiar manner; the presence of this toxin can be detected by observing the abnormal yet characteristic reactions of such hearts to a certain drug, notably atropin. This reaction consists in the failure of acceleration of the pulse beat more than 15 beats per minute after the hypodermic injection of a large dose (one thirty-third gram) of atropin. Marris based his observations on 111 cases of proved typhoid or paratyphoid. The test was positive in 92 per cent of cases in the first week of the disease; 89 per cent in the second week; 83.7 per cent in the third week; 88 per cent in the fourth, and in the later stages the reaction was not characteristic. He found the test to be negative in the case of typhoid carriers and in a list of other diseases such as trench fever, meningitis, bronchitis, pneumonia, tuberculosis, dysentery, malaria, influenza, etc. The same results were noticed with amyl nitrate and adrenalin as with atropin.

In Vaughan's3 series the atropin test was made in a small number of cases and was usually found to be positive, more markedly so during the first week, when the pulse was slow. It was often negative after the pulse rate increased. In 38 cases reported from England14 an acceleration of pulse rate occurred in 33 cases, a decrease of rate occurred in 1, and no alteration in 2 cases. Of the 33 showing acceleration, 23 showed a positive reaction. The earliest day on which the test was performed in this positive group of 23 cases was the seventeenth day; the latest the thirty-first day. The positive reaction for the group was 68 per cent. Of the 10 cases showing a negative reaction, the test was performed after the twenty-first day of the disease-seven of them being after the thirtieth day of the disease. If the seven cases occurring in the later stages of the disease, when the reaction is not supposed to be characteristic, are eliminated, the result would stand, as 81.5 per cent positive tests. Friedlander and McCord,58 at Camp Sherman, Ohio, tested the effect of atropin in other diseases than typhoid and found that in 170 cases, 62, or 36.5 per cent, gave a positive reaction. Their list of diseases included measles, influenza, scarlet


57

fever, and pneumonia. These investigators are of the opinion that a test which gives such a high percentage of positive results in other diseases than typhoid can not be depended on.

The statement is justified that the Widal reaction is of somewhat doubtful value in the diagnosis of typhoid fever in the recently vaccinated. This contention is supported by Hamilton59 and Fennel.60 Dreyer, Walker and Gibson,61 and Davison62 present arguments in support of their opinion that microscopic Widal tests, with a standardized agglutinable culture, made at intervals, to demonstrate fluctuations upward or downward, in agglutinin content, have a definite diagnostic value. It may be stated that agglutination tests in the vaccinated, while suggestive of the presence or absence of specific infection, can not replace in diagnostic value the recovery of the specific organism from the blood, urine, feces, or bile. The agglutination reactions performed in the Army followed the Dreyer technique closely.63

In Vaughan's3 series of 206 cases, in which the tentative or provisional diagnosis was noted, 120 bore a diagnosis of respiratory disease, while only 49 were diagnosed as gastrointestinal. This is in accordance with previous knowledge of the disease, the initial symptoms being not local but the general symptoms of acute infection frequently with a concomitant bronchitis. The pandemic of influenza prevailing at the time also tended to render difficult a proper diagnosis.

Vaughan's report that the onset was generally gradual and misleading is confirmed by a study of the period elapsing between onset and hospitalization. In the 123 cases occurring in the 77th Division, the cases were hospitalized on an average of 8.1 days after the onset of the disease, the extremes being 1 to 57 days. The laboratory diagnosis was made on an average of 19.6 days after the onset, the extreme being 7 and 60 days. This gives an average of 11.5 days spent by a case in the hospital before a laboratory diagnosis was made. In the 38 cases occurring in England (infected in the United States en route to England) the average date on which the cases were hospitalized was 13½ days after initial symptoms; in the Prauthoy epidemic it was 52.5 days.

THE PARATYPHOID FEVERS

Recognition of the paratyphoid group of fevers (A and B) as disease entities is a fairly recent development of scientific medicine, antedating the World War by only a few years. The experience of the Medical Department of the United States Army with this group of fevers prior to the World War was limited very largely to a sharp outbreak of paratyphoid fever A in National Guard troops on active duty on the Mexican border of Texas during 1916 and the early part of 1917, and an outbreak of paratyphoid A that occurred in the expeditionary force of the Regular Army dispatched into Mexico during the summer of 1916.38 These epidemics were very quickly brought to an end by the use of paratyphoid A vaccine. As paratyphoid fevers were being reported as of not uncommon occurrence in all allied armies in France when the United States entered the war, steps were immediately taken to incorporate the paratyphoid A and B organisms in prophylactic vaccines to be used by the American Army. This group of fevers was a negligible factor as a cause of illness in the United States Army, as is indicated in Table 9.


58

TABLE 9.-Paratyphoid fevers. Officers and enlisted men, April 1, 1917, to December 31, 1919, by country of occurrence, admissions, and deaths. Absolute numbers and rate per 1,000 per annum

Country


Total mean annual strengths


Para A

Para B


Admissions

Deaths

Admissions

Deaths


Absolute numbers

Rate per 1,000

Absolute numbers

Rate per 1,000

Absolute numbers

Rate per 1,000

Absolute numbers 

Rate per 1,000

United States

2,235,389

32

0.01

---

---

11

0

1

0

Europe

1,665,796

95

.06

6

0

56

.03

4

0

Other countries

227,294

7

.03

---

---

11

.05

---

---

    

Total primary cases

4,128,479

134

.03

6

0

78

.02

5

0

Additional cases as associated diseases

---

41

---

5

---

17

---

1

---

    

Grand total

---

175

---

11

---

95

---

6

---

The death rate for cases occurring in the United States is the more reliable one. Most, if not all, of the deaths from paratyphoid recorded for troops in Europe actually were due to causes other than paratyphoid, but were charged back to the paratyphoids for the reasons stated elsewhere (p. 15).

The clinical characteristics of the paratyphoid fevers as they occurred in American troops during the World War can be summarized as follows: On the whole, the disease followed a much milder course than did typhoid. The individual case could not be distinguished from typhoid fever by clinical manifestations alone. Both diarrhea and initial constipation were somewhat more common than in typhoid cases. No relapses were reported, and the duration of the febrile stage was approximately the same as for typhoid. The only certain method of differentiation was identification of the causative organism.

REFERENCES

(1) Official History of the War (British) Medical Services, Diseases of the War. His Majesty's Stationery Office, London, 1922, Vol. I, 11.

(2) Annual Report of the Surgeon General, U. S. Army, 1900, 402.

(3) Vaughan, Victor C., jr.: Typhoid Fever in the American Expeditionary Forces. The Journal of the American Medical Association, Chicago, 1920, lxxiv, No. 16, 1074.

(4) Annual Report of the Surgeon General, U. S. Army, 1856, 6.

(5) Ibid., 1899, 273.

(6) Ibid., 1910, 46.

(7) General Orders, No. 76, W. D., June 9, 1911; also General Orders, No. 134, W. D., September 30, 1911.

(8) Annual Report of the Surgeon General, U. S. Army, 1900, 223 and 347.

(9) Emerson, Haven: General Survey of Communicable Diseases in the A. E. F. The Military Surgeon, 1921, xlix, No. 4, 389.

(10) Leishman, W. B.: Enteric Fevers in the British Expeditionary Force, 1914-1918. The Glasgow Medical Journal, Glasgow, 1921, xcv, 81.

(11) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1254.

(12) Annual Reports, Philippine Health Service, Manila, 1917, 1918, 1919.

(13) Annual Report of the Surgeon General, U. S. Army, 1918, 228.

(14) Hawn, C. B., Hopkins, J. D., and Meader, F. M.: Outbreak of Typhoid Fever Among American Troops in England. The Journal of the American Medical Association, Chicago, 1919, lxxii, No. 6, 402.


59

(15) Van Valzah, S. L.: Report of an Epidemic of Typhoid Fever in Company 4, June Automatic Replacement Draft, Camp Cody, September 7, 1918. On file, Historical Division, S. G. O.

(16) Neal, Marcus, P., Maj., M. C.: Investigation of an Epidemic of Typhoid-Paratyphoid Fever in the 77th Division, U. S. Army, December 22, 1918, to February 25, 1919, May 10, 1919. On file, Historical Division, S. G. O.

(17) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1541.

(18) Taylor, R. M., Capt., M. C., and Bailey, Wm. H., Capt., M.C.: Report upon Epidemic of Typhoid Occurring among Troops Billeted at Curel (Haute Marne) March 20, 1919. On file, Historical Division, S. G. O.

(19) Effler, Louis R.: History of Typhoid Epidemic at Motor Reception Park 752, Base Section No. 6, Marseille, A. E. F., May 23, 1919. On file, Historical Division, S. G. O.

(20) Neal, Marcus P., Maj., M. C.: Report upon an Investigation of Typhoid in the 81st Division, A. E. F., December, 1918, April 8, 1919. On file, Historical Division, S. G. O.

(21) Annual Report of the Surgeon General, U. S. Army, 1920, 371.

(22) Ibid., 1918, 54.

(23) Ibid., 1918, 56.

(24) Ibid., 1918, 65.

(25) Ibid., 1918, 88.

(26) Ibid., 1919, Vol. I, 916.

(27) Garbat, A. L.: Typhoid Carriers and Typhoid Immunity. Monographs of the Rockefeller Institute for Medical Research No. 16, New York, May 10, 1922, 1.

(28) Statistical Report No. 169, Statistics Branch, General Staff, War Department, Washington, April 9, 1921.

(29) Official History of the War (British): Op. cit., 55.

(30) Dopter, M.: Les Maladies infectieuses pendant la Guerre, Librairie Félix Alcan, Paris, 1921, 50.

(31) Military Casualties-Certain Countries-World War, Special Report No. 178. February 25, 1924. Statistics Branch, General Staff, War Department. On file, Historical Division, S. G. O.

(32) Occurrence of Typhoid and Paratyphoid Fevers in the Italian Army, Special Report. On file, Historical Division, S. G. O.

(33) Occurrence of Typhoid and Paratyphoid Fevers in the Belgian Army, Special Report. On file, Historical Division, S. G. O.

(34) Goldscheider, Alfred: Typhus Abdominalis. Handbuch der Ärztlichen Erfahrungen im Weltkriege. Band III, Innere Medezin. Verlag von Johann Ambrosius Barth in Leipzig, 1921, 64.

(35) Occurrence of Typhoid and Paratyphoid Fevers in the Austrian Army, Special Report. On file, Historical Division, S. G. O.

(36) Report on the activities of the chief surgeon's office, A. E. F., May 1, 1919, from the chief surgeon, A. E. F., to the Surgeon General. On file, Historical Division, S. G. O.

(37) Russell, F. F.; Nichols, H. J.; and Stimmel, C. O.: Directions for Making Triple Typhoid Vaccine. The Military Surgeon, 1920, xlvii, No. 4, 359.

(38) Annual Report of the Surgeon General, U. S. Army, 1917, 68.

(39) Craig, Charles F.: Triple Typhoid Vaccine. Journal of the American Medical Association, 1917, lxix, No. 12, 1000.

(40) Whitmore, E. R.; Fennel, E. A.: and Peterson, W. F.: An Experimental Investigation of Lipo-vaccine. Journal of the American Medical Association, 1918, lxx, No. 7, 427.

(41) Circular Letter, Surgeon General's Office, November 4, 1918.

(42) Circular Letter, Surgeon General's Office, March 12, 1919.

(43) Foster, N. B.: Unusual Reactions to Typhoid-Paratyphoid Vaccination. Contributions to Medical and Biological Research, Paul B. Hoeber, New York, 1919, i, 491.

(44) Gay, F. P.: Typhoid Fever. The MacMillan Company, New York, 1918, 188.

(45) Labbé, Marcel: Les Infections Typhique et Paratyphiques chez les Vaccinés. Annales de Médecine, Paris, 1916, iii, 13.


60

(46) Bernard, L., and Paraf, J.: Les Infections Typhoides chez Les Sujets Vaccinés contre la Fièvre Typhoide. Annales de Médecine, Paris, 1914, ii, 443.

(47) Campani, A., and Gallotti, A.: Confronto fra il decorso clinico del tifo nei vaccinati e nei non vaccinati. Giornale di Medicina Militare, Roma, 1918, 66, 614.

(48) Freund, Ernst: Ueber den Verlauf des Bauchtyphus bei Schutzgeimphten. Wiener Klinische Wochenschrift, Wien, 1916, xxix, No. 39, 1232.

(49) Nichols, Henry J., Maj., M. C., U. S. A.: Carriers in Infectious Diseases. Williams & Wilkins Company, Baltimore, 1922, 45.

(50) Circular Letter, chief surgeon's office, A. E. F., 1919.

(51) Letter from the Surgeon General, U. S. Army, to the commanding officer, Walter Reed General Hospital, April 14, 1919, subject: Typhoid carriers. On file, Record Room S. G. O., 710 (Typhoid Carriers, W. R. G. H.) (K).

(52) Nichols, H. J.; Simmons, J. S.; and Stimmel, C. O.: The Surgical Treatment of Typhoid Carriers. The Journal of the American Medical Association, Chicago, 1919, lxxiii, No. 9, 680.

(53) Henes, Edwin, jr.: The Surgical Treatment of Typhoid Carriers. The Journal of the American Medical Association, Chicago, 1920, lxxv, No. 26, 1771.

(54) Letter from the commanding officer, Walter Reed General Hospital, to the Surgeon General, April 7, 1919, subject: Typhoid carriers. On file, Record Room, S. G. O., 710 (Typhoid Carriers, W. R. G. H.) (K).

(55) Letter from the State health commissioner, Richmond, Va., April 8, 1919, to Col. S. J. Morris, M. C., Office of the Surgeon General, subject: Typhoid carriers. (Letter from the Department of Health, State of Maryland, Baltimore, March 24, 1919, to Col. S. J. Morris, M. C., Office of the Surgeon General. On file, Record Room, S. G. O., 710 (Typhoid Carriers).)

(56) Circular No. 69, Office of the Chief Surgeon, A. E. F., February 17, 1919. On file, Historical Division, S. G. O.

(57) Marris, H. F., Capt., R. A. M. C.: A Report upon the Use of Atropine as a Diagnostic Agent in Typhoid Infections. Medical Research Committee. Special Report Series, No. 9, His Majesty's Stationery Office, London, 1917.

(58) Friedlander, A., and McCord, C. P.: The Atropin Test in the Diagnosis of Typhoid Infections. The Journal of the American Medical Association, Chicago, 1918, lxx, No. 20, 1435.

(59) Hamilton, C. D.: The Effect of Typhoid Vaccination on the Widal Reaction. The Journal of the American Medical Association, Chicago, 1915, lxv, No. 22, 1873.

(60) Fennel, E. A.: Agglutinin Response after Army Triple Typhoid Vaccination. The Journal of the American Medical Association, Chicago, 1918, lxx, No. 25, 1915.

(61) Dreyer, G.; Walker, E. W. A.; and Gibson, A. G.: Typhoid and Paratyphoid Infection in Relation to Antityphoid Inoculation. The Lancet, London, 1915, i, 324.

(62) Davison, W. C.: The Superiority of Inoculation with Mixed Triple Vaccine (B. Typhosus, B, Paratyphosus A, and B, Paratyphus B). The Archives of Internal Medicine, Chicago, 1918, xxi, No. 4, 437.

(63) Dreyer, G., and Inman, A. C.: Persistence of Antibodies in the Blood of Inoculated Persons as estimated by Agglutination Tests. The Lancet, London, 1915, ii, 225, and Fennell, E. A.: The Dreyer Method of Agglutination. The Journal of the American Medical Association, Chicago, 1918, lxx, No. 9, 590.