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Chapter XVIII

Communicable Diseases, Table of Contents

CHAPTER XVIII

THE MALARIAL FEVERS

COMPARISON OF MALARIAL RATES FOR THE WORLD WAR WITH PREVIOUS

AND SUBSEQUENT MALARIAL RATES, UNITED STATES ARMY

Prior to the World War, malaria in the United States Army had been controlled with a high degree of efficiency, as shown in Table 81. Satisfactory as had been the reduction in morbidity and mortality from malarial fevers, most apparent in our troops serving in the Philippine Islands, Panama, and Porto Rico, the results obtained by our medical officers and sanitarians in the prophylaxis of these fevers during the World War were much better, despite the fact that many of our great camps were located in regions where endemic malaria was severe.

TABLE 81.-Malarial fevers. Admissions and deaths, enlisted men, United States Army,1911 to 1920. Ratios per 1,000

Year


White enlisted

Colored enlisted

Porto Rican

Filipino


United States

Philippine Islands

Hawaiian Islands

Panama

United States

Philippine Islands

Porto Rico

Philippine Islands


ADMISSIONS

 

 

 

 

 

 

 

 

1911

15.47

75.56

6.95

53.92

0.68

---

131.03

242.12

1912

14.65

186.35

6.22

120.31

4.42

45.89

52.72

241.91

1913

8.82

126.27

9.05

145.55

7.67

38.65

31.99

193.49

1914

11.05

48.60

1.44

208.96

---

30.35

12.73

201.80

1915

12.86

68.43

2.24

87.57

6.56

21.63

18.34

80.11

1916

22.43

60.74

2.40

66.50

10.56

87.83

269.63

43.38

1917

7.50

50.24

3.54

109.23

5.85

81.68

26.65

56.63

1918

3.91

22.11

---

75.67

4.48

44.09

57.28

46.47

1919

3.58

14.68

---

82.18

1.22

45.46

45.41

41.12

1920

7.54

8.37

.80

55.13

2.06

51.36

24.79

26.32

DEATHS

 

 

 

 

 

 

 

 

1911

---

.08

---

---

---

---

---

.57

1912

-

.36

---

---

---

---

---

.55

1913

---

.21

---

---

---

---

---

.57

1914

---

---

---

---

---

---

---

---

1915

.03

---

---

---

---

---

---

---

1916

.02

---

---

---

---

---

---

---

1917

.01

.11

---

.25

---

.66

---

---

1918

.01

---

---

.24

.04

---

.24

.18

1919

.01

.26

---

.20

.04

---

.48

.12

1920

---

---

---

.23

---

---

---

---

1Includes National Guard officers.
2Includes officers.

There was a marked decrease in the admission rates for malaria for white enlisted men during the period 1911-1920, in the United States, the ratio for 1916 being 22.43 per 1,000; in 1917, 7.50 per 1,000; in 1918, 3.91 per 1,000; and in 1919, 3.58 per 1,000, the latter rate having been obtained despite the fact that during 1917 and 1918 hundreds of thousands of untrained and susceptible recruits were mobilized in camps situated in regions of malaria endemicity. The admission rates for malarial fevers in the Philippine Islands, Panama, and Porto Rico (all classes) were also reduced, although to a lesser extent, the lower reduction in these countries being due undoubtedly to continuing greater

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


512

exposure to infection, in spite of the rigid sanitary measures taken to prevent infection.

The rise in the United States malarial rate in 1920 was probably due to the necessity of curtailing the antimosquito work in camps during the latter part of 1919 and in 1920, owing to the lack of funds.

ADMISSION AND DEATH RATES DURING THE WORLD WAR

In the period from April 1, 1917, to December 31, 1919, inclusive, the total number of admissions for malaria was 15,555, this number including officers and enlisted men of both American and native troops. There were 36 deaths recorded as due to malaria and 28 discharges for disability. The total loss of time recorded as caused by the malarial infections (primary cause of admission) was 194,529 days.

The malarial fevers were not included among the 30 leading diseases for our Army, as a whole, either for admissions, deaths, discharges for disability, or time lost. However, in Panama they ranked second for admissions, third for deaths, and second for time lost, for American enlisted men. Among Filipino troops, the malarial fevers ranked third for admissions, eleventh for deaths, and fourth for time lost, while for Porto Ricans (Porto Rico and Panama) these fevers ranked eighth for admissions, third for deaths, and seventh for time lost.

The greatest number of cases of malaria occurred in the United States, but the highest admission rate was in American troops serving in Panama. The native Porto Ricans furnished the next highest admission rate and the highest death rate.

The admissions, deaths, and discharges for disability for malaria, with ratios per 1,000, are given in Table 82.

TABLE 82.-Malarial fevers. Admissions, deaths, and discharges for disability, officers, and enlisted men, United States Army, April 1, 1917, to December 31, 1919. Absolute numbers, ratios per 1,000, per cent of total diseases, and relative standings

Rank and country


Admissions

Deaths

Discharges for disability

Absolute numbers

Ratios per 1,000 strength

Per cent of total diseases

Relative standing among diseases1

Absolute numbers

Ratios per 1,000 strength

Per cent of total diseases

Relative standing among diseases

Absolute numbers

Ratios per 1,000 strength

Per cent of total diseases

Relative standing among diseases

Officers:

 

 

 

 

 

 

 

 

 

 

 

 

    

United States

328

2.64

0.45

---

1

0.01

0.12

---

---

---

---

-

    

Europe

60

.81

.16

---

---

---

---

---

---

---

---

---

    

Total (including other countries)

437

2.12

.38

---

1

.00

.07

---

---

---

---

---

American enlisted men:

 

 

 

 

 

 

 

 

 

 

 

 

    

United States

10,182

4.82

.43

---

23

.01

.07

---

25

0.01

0.02

-

    

Europe

890

.56

.10

---

2

.00

.01

---

---

---

---

---

    

Philippine Islands

639

29.79

3.27

10

2

.09

2.74

12

---

---

---

---

    

Hawaiian Islands

24

1.23

.20

---

---

---

---

---

---

---

---

-

    

Panama

1,739

88.34

11.30

2

3

.15

9.38

3

---

---

---

-

    

Total (including other countries)

13,674

3.52

.41

---

30

.01

.05

---

26

.01

.02

---

Native troops:

 

 

 

 

 

 

 

 

 

 

 

 

    

Filipino

843

45.38

6.93

3

2

.11

1.71

11

2

.11

.56

0.12

    

Porto Rican2

600

50.72

3.87

8

3

.25

2.42

3

---

---

---

---

    

Hawaiian

1

.18

.30

---

---

---

---

---

---

---

---

---

         

Army total

15,555

3.77

.44

---

36

.01

.06

---

28

.01

.02

---

1Thirty leading diseases; a dash indicates a standing below 30.
2Served in Panama as well as Porto Rico.

bOnly primary admissions are taken into account until Table 88 is considered.


513

DISTRIBUTION IN THE ARMY

Of the total 15,555 primary admissions for malaria in the United States Army, no less than 10,510 were in the troops serving in the United States. Only 950 admissions are recorded as occurring in our troops serving in Europe, while 1,482 admissions were in the Philippine Islands, 1,739 in Panama (American troops), 600 in Porto Rico and Panama (Porto Ricans), and 24 in the Department of Hawaii. In addition to the above, 249 admissions for malaria were among officers and enlisted men serving in other countries.

Of the 36 deaths reported as due to malaria, 24 occurred in the United States, 2 in Europe, 4 in the Philippine Islands, 3 in the Canal Zone (American), and 3 in Porto Rico and Panama (Porto Ricans).

The rate of admissions per 1,000 for officers serving in the United States was 2.64 and for enlisted men, 4.82; in Europe, for officers, 0.81, and for enlisted men, 0.56; in Panama, for white enlisted men the ratio per 1,000 was 88.34; in the Philippine Islands 29.79, and in the Hawaiian Islands, 1.23. For native troops the ratio per 1,000 was highest for Porto Ricans, i. e., 50.72 and lowest, for Hawaiians, i. e., 0.18 per 1,000. The ratio per 1,000 for native Filipino troops was 45.38.

The low rate for troops serving in the Hawaiian Department is explained by the fact that the malarial fevers are not present in the Hawaiian Islands except as imported cases, there being no well-authenticated instance of a case of malaria originating in the Hawaiian Territory. All malaria infections occurring in our troops in these islands were, therefore, relapses of infections acquired elsewhere.

The malarial fevers caused 11.3 per cent of the sick admission rate in American troops serving in Panama, 6.93 per cent of that in the Philippine Islands, and 3.87 per cent of the admission rate in Porto Rican troops. In the United States malaria caused less than 0.45 per cent of the total admission rate for disease in the Army, while in Europe these infections caused less than 0.15 per cent of our total admission rate for disease.

It is evident that in countries in which the chances for infection were greatest, as in Panama, the Philippine Islands, and Porto Rica, the incidence was greatest, but even in such regions the rates, on the whole, were low when compared with the pre-war rates.

RACIAL DISTRIBUTION

The admission rate per 1,000 for officers was 2.12; for American enlisted men, 3.52; and for native troops, 40.09. There was, however, a great difference in geographical situation, native troops all serving in highly malarious countries.

The absence of immunity to malaria in native troops appears to be established by a comparison of the ratio per 1,000 for American and Filipino troops, both serving in the Philippine Islands, where the ratio per 1,000 for American enlisted men was only 29.79 as compared with a ratio of 45.38 for enlisted Filipinos.

However, caution should be used in drawing the conclusion from these data that native troops possess no immunity to the malarial infections. In the absence


514

of information regarding relative exposure to infection between the two groups and whether the native troops had been exposed previously to malaria, it is impossible to state definitely that the native troops were more susceptible to malarial infection than white troops; but it is fair to assume, in view of these figures, that such immunity as the native troops possessed in the Philippine Islands was of little worth in protecting them from the infection and could not be depended upon as of any practical value in military operations. The experience of our Army in this respect is similar to that of other armies and demonstrates that there is no such thing as a true racial immunity to the malarial infections.

TABLE 83.- Malarial fevers. Admissions, deaths, discharges for disability, and days lost, by race, enlisted men, United States Army, April 1, 1917, to December 31, 1919. Absolute numbers and ratios per 1,000

 


Absolute numbers

Ratios per 1,000

Admissions

Deaths


Discharges for disability

Days lost

Admissions

Deaths

Discharges for disability

Non-
effectivenes

White

12,690

24

24

155,683

3.53

0.01

0.01

0.12

Colored

861

5

2

15,299

3.00

.02

.01

.15

Filipino

843

2

2

9,120

45.38

.11

.11

1.35

Hawaiian

1

---

---

5

.18

---

---

.00

Porto Rican

600

3

---

7,092

50.72

.25

---

1.64

Color not stated

123

1

---

1,926

---

---

---

---

    

Total Army (enlisted men)

15,118

35

28

189,123

3.85

.01

.01

.13

In comparing American and native troops, the ratio per 1,000 of admissions for malaria shown in Table 83 was greatest for Porto Ricans and smallest for colored soldiers. For the former it was 50.72 per 1,000 and for the latter only 3 per 1,000. The ratio per thousand for Filipino troops was 45.38; for Hawaiian soldiers 0.18, and for white soldiers 3.53. While this table illustrates what actually happened so far as such statistics can show, it should not be interpreted as proving any racial susceptibility to malaria, for both Porto Rican and Filipino troops were serving in malarial countries, while the vast majority of our white troops were not exposed to malaria, and the troops composed of native Hawaiians in Hawaii were absolutely unexposed, malaria not being present in the Hawaiian Islands owing to the absence of anopheline mosquitoes.

DISTRIBUTION IN WHITE TROOPS IN THE UNITED STATES, PANAMA, PHILIPPINE ISLANDS, AND
HAWAIIAN ISLANDS

An inspection of Table 84 demonstrates that the admission and death rates from malaria for white enlisted men for the World War period was highest in Panama and lowest in Europe. In Panama the ratio per 1,000 for malaria was 88.34; in the Philippine Islands, 25.48; in the United States, 4.89; in the Hawaiian Islands 1.48, and in Europe, 0.47.

The malarial fevers were far more prevalent in white enlisted men serving in Panama than in those serving in the Philippine Islands, the ratio per 1,000 for the former being 88.34 as compared with 25.48 for the latter. Thus, the


515

ratio per 1,000 for Panama was over three times that for the Philippine Islands. Without accurate knowledge of the local conditions affecting the exposure of the men in the two countries, it would be unwise to attempt to draw any conclusions as to the cause of the much higher ratio in Panama. However, it is evident that during the period of the World War our white enlisted men serving in Panama were three times as apt to contract malaria as those serving in the Philippines, as shown by the actual ratio per 1,000 of malarial infections. The cases of malaria recorded for the American Expeditionary Forces doubtless were relapses of infection acquired in the United States as no evidence was obtainable that original infections were acquired in France.

TABLE 84.-Malarial fevers. Admissions, deaths, discharges for disability, and days lost, by countries of occurrence, white enlisted men, United States Army, April 1, 1917, to December 31, 1919. Absolute numbers and ratios per 1,000

Country


Absolute numbers

Ratios per 1,000

Admissions

Deaths


Discharges for disability

Days lost

Admissions

Deaths

Discharges for disability

Non-
effective

United States

9,617

18

23

115,181

4.89

0.01

0.01

0.16

Europe

697

1

---

15,930

.47

.00

---

.03

Philippine Islands

433

2

---

5,982

25.48

.12

---

.96

Hawaiian Islands

24

---

---

282

1.48

---

---

.05

Panama

1,739

3

---

16,867

88.34

.15

---

2.35

    

Total Army (white enlisted men)1

12,690

24

24

155,683

3.53

.01

.01

.12

1Includes figures for "Transports."

DISTRIBUTION IN WHITE AND COLORED ENLISTED MEN, BY CAMPS, IN THE UNITED STATES

From Table 85 it may be seen that the greatest number of admissions for malaria was at Camp Beauregard, La., (726); the second greatest number at Camp Pike, Ark., (703); the third (469) at Camp Jackson, S. C.; the fourth (356) at Camp Travis, Tex.; the fifth (344) at Camp Shelby, Miss.; the sixth (233) at Camp Johnston, Fla.; the seventh (223) at Camp Wheeler, Ga.; the eighth (206) at Camp Sevier, S. C.; the ninth (203) at Camp Gordon, Ga.; the tenth (163) at Camp Logan, Tex.; the eleventh (161) at Camp Taylor, Ky.; the twelfth (122) at Camp Eustis, Va.; the thirteenth (115) at Camp McClellan, Ala.; the fourteenth (113) at Camp Bowie, Tex.; while a smaller number occurred at the other camps in the United States. Only one admission for malaria was reported at Camp Forrest, Ga., and one at Camp Greenleaf, Chickamauga Park, Ga.

While the camps mentioned stand in the above order as regards the actual number of admissions for malaria in the troops serving within them, a study of the ratios per 1,000 admissions in these camps results in a very different relative standing. Considered in this way, the camps mentioned stand in the following order: (1) Camp Beauregard, La.; (2) Camp Shelby, Miss.; (3) Camp Pike, Ark.; (4) Camp Jackson, S. C.; (5) Camp Eustis, Va.;c (6) Camp Wheeler,

cOccupied only a part of war period.


516

Ga.; (7) Camp Johnston, Fla.; (8) Camp Travis, Tex.; (9) Camp McClellan, Ala.; (10) Camp Sevier, S. C.; (11) Camp Taylor, Ky.; (12) Camp Gordon, Ga.; (13) Camp Humphreys, Va.; and (14) Camp Logan, Tex. It should not be deduced from these statistics that the malarial infections all actually originated in these camps, as they do not distinguish between infections contracted in the camps and those due to relapse of previously acquired malaria.

TABLE 85.-Malarial fevers. Large camps, United States. Admissions, deaths, and discharges for disability, white and colored enlisted men, April 1, 1917, to December 31, 1919. Absolute numbers and ratios per 1,000

Camps


Admissions

Deaths

Discharges for disability

White

Colored

White

Colored

White


Colored

Absolute numbers

Ratios per 1,000

Absolute numbers

Ratios per 1,000

Absolute numbers

Ratios per 1,000

Absolute numbers

Ratios per 1,000

Absolute numbers

Ratios per 1,000

Absolute numbers

Ratios per 1,000

Beauregard, La.

694

34.35

32

75.83

---

---

---

---

---

---

---

---

Bowie, Tex.

112

4.44

1

1.05

---

---

---

---

---

---

---

---

Cody, N. Mex.

34

1.50

---

---

---

---

---

---

1

0.04

---

---

Custer, Mich.

4

.11

3

2.21

---

---

---

---

---

---

---

---

Devens, Mass.

21

.46

6

2.70

---

---

---

---

1

.02

---

---

Dix, N. J.

56

1.25

7

1.45

---

---

---

---

---

---

---

---

Dodge, Iowa

28

.84

4

.69

---

---

---

---

---

---

---

---

Doniphan, Okla.

82

3.07

---

---

---

---

---

---

---

---

---

---

Eustis, Va.

121

19.13

1

2.19

---

---

---

---

---

---

---

---

Forrest, Ga.

1

.11

---

---

---

---

---

---

---

---

---

---

Fremont, Calif.

43

2.79

---

---

---

---

---

---

---

---

---

---

Funston, Kans.

75

1.50

20

3.24

1

0.02

---

---

---

---

---

---

Gordon, Ga.

185

4.86

18

2.64

---

---

---

---

1

.03

---

---

Grant, Ill.

8

.19

14

2.02

---

---

---

---

---

---

---

---

Greene, N.C.

33

1.26

4

1.13

---

---

---

---

1

.04

---

---

Greenleaf, Ga.

1

.08

---

---

---

---

---

---

---

---

---

---

Hancock, Ga.

84

2.31

3

1.88

2

.05

---

---

---

---

---

---

Humphreys, Va.

40

4.10

9

2.92

---

---

---

---

---

---

---

---

Jackson, S.C.

414

11.22

55

10.72

---

---

---

---

---

---

---

---

Johnston, Fla.

115

5.79

18

7.46

---

---

---

---

1

.05

---

---

Kearny, Calif.

28

1.10

---

---

---

---

---

---

---

---

---

---

Lee, Va.

45

.88

2

.30

---

---

---

---

2

.04

---

---

Lewis, Wash.

55

1.16

---

---

---

---

---

---

---

---

---

---

Logan, Tex.

163

6.11

---

---

1

.04

---

---

---

---

---

---

MacArthur, Tex.

56

2.30

3

3.15

1

.04

---

---

1

.04

---

---

McClellan, Ala.

97

3.66

18

8.45

---

---

---

---

---

---

---

---

Meade, Md.

47

1.12

14

1.74

---

---

---

---

1

.02

---

---

Mills, N.Y.

83

3.62

2

1.59

---

---

---

---

---

---

---

---

Pike, Ark.

639

15.64

64

7.34

2

.05

---

---

1

.02

1

0.11

Sevier, S.C.

199

7.60

7

4.36

---

---

---

---

---

---

---

---

Shelby, Miss.

317

11.01

27

16.34

---

---

---

---

---

---

---

---

Sheridan, Ala.

79

3.08

5

5.65

---

---

---

---

2

.08

---

---

Sherman, Ohio

15

.41

8

1.38

---

---

---

---

---

---

---

---

Syracuse, N.Y.

4

1.19

---

---

---

---

---

---

---

---

---

---

Taylor, Ky.

140

3.29

21

4.79

2

.05

1

0.23

---

---

---

---

Travis, Tex.

327

8.72

29

4.41

---

---

---

---

---

---

---

---

Upton, N.Y.

22

.55

8

1.71

---

---

---

---

---

---

---

---

Wadsworth, S.C.

43

1.43

2

1.79

---

---

---

---

---

---

---

---

Wheeler, Ga.

213

8.91

10

5.51

---

---

2

1.10

---

---

---

---

Others

---

---

3

8.85

---

---

---

---

---

---

---

---

DISTRIBUTION BY STATES

It does not follow that every man inducted or enlisted in a particular State was a native of that State; nevertheless, it is true that the majority were and that practically all had been residing in the State from which inducted or enlisted long enough to contract malaria infection if it were present. That this supposition is correct is borne out by the data shown in Table 86, which agree with the well-known distribution of the malarial infections in the United States.


517

TABLE 86.- Malarial fevers. Admissions, deaths, discharges for disability, by State of induction, white and colored enlisted men, United States Army, United States and Europe, April 1, 1917, to December 31, 1919

State


White enlisted men


United States

Europe

Total United States and Europe


Absolute numbers

Absolute numbers

Absolute numbers

Ratios per 1,000


Admissions

Deaths

Discharges

Admissions

Deaths

Discharges

Admissions

Deaths

Discharges

Admissions

Deaths

Discharges

Alabama

815

2

1

47

---

---

862

2

1

19.57

0.05

0.02

Alaska

1

---

---

---

---

---

1

---

---

.50

---

---

Arizona

9

---

---

---

---

---

9

---

---

.89

---

---

Arkansas

622

---

1

23

---

---

645

---

1

15.37

---

.02

California

116

---

---

6

---

---

122

---

---

1.17

---

---

Colorado

15

---

---

2

---

---

17

---

---

.52

---

---

Connecticut

32

---

---

4

---

---

36

---

---

.78

---

---

Delaware

6

---

---

---

---

---

6

---

---

1.03

---

---

District of Columbia

10

---

---

3

---

---

13

---

---

1.16

---

---

Florida

204

---

---

7

---

---

211

---

---

11.21

---

---

Georgia

570

1

3

29

---

---

599

1

3

12.88

.02

---

Idaho

9

---

---

---

---

---

9

---

---

.52

---

---

Illinois

555

2

---

28

---

---

583

2

---

2.59

.01

---

Indiana

220

---

---

12

---

---

232

---

---

2.54

---

---

Iowa

110

---

---

15

---

---

125

---

---

1.38

---

---

Kansas

93

1

7

---

---

---

100

1

---

1.74

.02

.06

Kentucky

326

---

---

21

---

---

347

---

---

5.75

---

---

Louisiana

480

---

---

42

---

---

522

---

---

15.57

---

---

Maine

17

1

---

1

---

---

18

1

---

.79

.04

---

Maryland

65

---

---

2

---

---

67

---

---

1.80

---

---

Massachusetts

103

---

---

11

1

---

114

1

---

.95

.01

---

Michigan

96

---

1

15

---

---

111

---

1

.91

---

.01

Minnesota

70

---

---

9

---

---

79

---

---

.86

---

---

Mississippi

1,279

1

2

57

---

---

1,336

1

2

49.04

.04

.07

Missouri

360

---

---

27

---

---

387

---

---

3.47

---

---

Montana

4

---

---

1

---

---

5

---

---

.15

---

---

Nebraska

41

---

---

8

---

---

49

---

---

1.13

---

---

Nevada

1

---

---

---

---

---

1

---

---

.21

---

---

New Hampshire

9

---

---

---

---

---

9

---

---

.66

---

---

New Jersey

116

1

---

7

---

---

123

1

---

1.29

.01

---

New Mexico

21

1

1

1

---

1

22

1

1

1.02

.08

.08

New York

319

---

1

42

---

---

361

---

1

1.87

---

---

North Carolina

241

1

---

13

---

---

254

1

---

5.28

.02

---

North Dakota

10

---

---

---

---

---

10

---

---

.41

---

---

Ohio

157

---

1

26

---

---

183

---

1

1.01

---

.01

Oklahoma

153

---

1

9

---

---

162

---

1

2.30

---

.01

Oregon

20

---

---

2

---

---

22

---

---

.79

---

---

Pennsylvania

223

---

1

19

---

---

242

---

1

.92

---

---

Rhode Island

25

---

---

4

---

---

29

---

---

1.69

---

---

South Carolina

161

---

---

8

---

---

169

---

---

6.82

---

---

South Dakota

20

---

---

1

---

---

21

---

---

.75

---

---

Tennessee

473

2

---

32

---

---

505

2

---

9.33

.04

---

Texas

626

2

3

32

---

---

658

2

3

5.32

.02

.02

Utah

1

---

---

2

---

---

3

---

---

.19

---

---

Vermont

8

---

---

1

---

---

9

---

---

.91

---

---

Virginia

134

---

1

5

---

---

139

---

1

3.08

---

.02

Washington

13

---

---

1

---

---

14

---

---

.34

---

---

West Virginia

50

---

---

4

---

---

54

---

---

1.15

---

---

Wisconsin

70

---

1

8

---

---

78

---

1

.85

---

.01

Wyoming

---

---

---

---

---

---

---

---

---

---

---

---

Others or not stated

538

3

5

103

---

---

641

3

5

---

---

---

    

Total

9,617

18

23

697

1

1

10,314

19

23

3.29

.01

.01

 


518

TABLE 86.-Malarial fevers. Admissions, deaths, discharges for disability by State of induction, white and colored enlisted men, United States Army, United States and Europe, April 1, 1917, to December 31, 1919-Continued

State


Colored enlisted men


United States

Europe

Total United States and Europe


Absolute numbers

Absolute numbers

Absolute numbers

Ratios per 1,000


Admissions

Deaths

Discharges

Admissions

Deaths

Discharges

Admissions

Deaths

Discharges

Admissions

Deaths

Discharges

Alabama

54

1

---

8

---

---

62

1

---

2.60

0.04

---

Arkansas

38

---

---

4

---

---

42

---

---

2.55

---

---

District of Columbia

1

---

---

---

---

---

1

---

---

.23

---

---

Florida

23

---

---

1

---

---

24

---

---

2.00

---

---

Georgia

75

2

---

9

---

---

84

2

---

2.71

.06

---

Illinois

2

---

---

1

---

---

3

---

---

.32

---

---

Indiana

1

---

---

---

---

---

1

---

---

.23

---

---

Iowa

1

---

---

---

---

---

1

---

---

.82

---

---

Kansas

---

---

---

1

---

---

1

---

---

.49

---

---

Kentucky

10

---

1

3

---

---

13

---

1

1.19

---

0.09

Louisiana

73

---

1

8

---

---

81

---

1

3.09

---

.04

Maryland

5

---

---

2

---

---

7

---

---

.77

---

---

Massachusetts

1

---

---

---

---

---

1

---

---

.84

---

---

Minnesota

---

---

---

1

---

---

1

---

---

2.05

---

---

Mississippi

70

---

---

21

---

---

91

---

---

4.16

---

---

Missouri

6

---

---

---

---

---

6

---

---

.70

---

---

Nebraska

2

---

---

---

---

---

2

---

---

3.25

---

---

North Carolina

28

---

---

4

---

---

32

---

---

1.67

---

---

Ohio

4

---

---

---

---

---

4

---

---

.53

---

---

Oklahoma

2

---

---

1

---

---

3

---

---

.55

---

---

Pennsylvania

3

---

---

---

---

---

3

---

---

.21

---

---

South Carolina

62

---

---

4

---

---

66

---

---

2.84

---

---

Tennessee

27

1

---

2

---

---

29

1

---

1.75

.06

---

Texas

57

1

---

---

---

---

57

1

---

1.87

.03

---

Virginia

9

---

---

3

---

---

12

---

---

.56

---

---

Wyoming

2

---

---

---

---

---

2

---

---

22.22

---

---

Others or not stated

9

---

---

2

---

---

11

---

---

---

---

---

    

Total

565

5

2

75

---

---

640

5

2

1.85

.01

.01

As regards the absolute number of admissions for malaria, a study of Table 86 shows that Mississippi led the States in the number of admissions (1,427), and this is also true as regards the ratio per 1,000. Arranged in order of relative total admissions for malaria the States showing the greatest number stand in the following order: (1) Mississippi, 1,427; (2) Alabama, 924; (3) Texas, 715; (4) Arkansas, 687; (5) Georgia, 683; (6) Louisiana, 603; (7) Illinois, 586; (8) Tennessee, 534; (9) Missouri, 393; and (10) New York, 361.

Though the various States of the Union stand in the above order as regards the absolute number of admissions for malaria occurring in the enlisted men inducted or enlisted from them, the true incidence of the malarial infections can be determined only by a consideration of the ratio per 1,000 of inducted or enlisted men from each State. A study of the table shows that the States stand in the following order as regards the actual percentage or ratio per 1,000 for malaria, the figures applying only to white enlisted men, the small number of infections in colored troops being negligible for the present purpose: (1) Mississippi, 49.04; (2) Alabama, 19.57; (3) Louisiana, 15.57; (4) Arkansas, 15.37; (5) Georgia, 12.88; (6) Florida, 11.21; (7) Tennessee, 9.33; (8) South Carolina, 6.82; (9) Kentucky, 5.75; (10) Texas, 5.32.


519

The relative prevalence of malaria in enlisted and inducted men, as shown in the above list of 10 States, agrees almost perfectly with what is known regarding the relative prevalence of malarial infections in the civil population of the United States. It is noted that inducted and enlisted men from the States of Mississippi, Alabama, Louisiana, and Arkansas showed the highest ratios per 1,000 for malaria, and it is well known that malaria is more prevalent in these States than in any other States of the Union. It will also be noted that the ratio per 1,000 for men from Mississippi is three times that for men from any other State, and this also agrees with other observations regarding the relative frequency of malaria in the Southern States of the Union. The ratios per 1,000 shown for the other States in the above list agree well with what was known regarding the distribution of malaria in the United States before the World War, and it can not be said therefore that our records have added anything new to our knowledge as to the distribution of malarial infections in this country. While this is true, the data are of value in demonstrating what may be expected as regards the incidence of malaria in men enlisted or inducted from the various States in the Union. It is certain from Table 85 that a very considerable proportion of the malaria occurring in our camps was not due to local infections but to relapses of infections contracted before arrival in the camps. These relapses occurred in men coming from States well known to be heavily infected with this disease. Therefore it is evident that a considerable amount of malaria, in the form of relapses, must be expected in troops recruited in the States of Mississippi, Alabama, Louisiana, Arkansas, and other Southern States, while practically no malaria will occur in the form of relapses in troops recruited in New Hampshire, Wyoming, Arizona, Nevada, and other States of the northern and western groups. It must also be remembered that most of the relapse cases are "carriers" of malarial infection. This subject, so important from the standpoint of prophylaxis, will be considered below.

SEASONAL PREVALENCE

Malarial fevers were present in our troops throughout the year, but were most prevalent during the summer and autumn months (Table 87). In 1917 and 1918 the greatest prevalence of malaria was in May, June, July, August, and September, the highest ratio per 1,000 occurring in 1917 in June (14.31), and in 1918 in July (8.36). In 1919, the highest ratio per 1,000 occurred in November (15.64), probably due to the fact that the majority of relapses occurred at this time.

Due to climatic conditions in the States whose men showed the greatest number of admissions for malaria, it may be stated that most of the cases admitted during the months of November, December, January, February, March, and April were relapses of infections contracted during the other months of the year. It is also undoubtedly true that a certain proportion of the cases admitted during May, June, July, August, and September were "relapse" cases; admitting these facts, however, the table demonstrates beyond question that there was a great increase in malaria in our troops, commencing in May and reaching its acme in 1917 in June; in July in 1918; and in November in 1919. The higher prevalence of the malarial infections in November, 1919, is probably


520

partially due to the fact that prior to that time funds for the prosecution of antimosquito work had been greatly curtailed coincident with demobilization of the Army.

As a whole, Table 87 demonstrates that malarial infections in our troops were most prevalent during the months of June, July, August, and September, and this agrees perfectly with what was previously known regarding the seasonal prevalence of these infections in the parts of the United States in which our various camps were situated.

TABLE 87.-Malarial fevers. Admissions by months, white and colored enlisted men, United States, April 1, 1917, to December 31, 1919. Absolute numbers and ratios per 1,000

 


White

Colored

Total


Absolute numbers

Ratios 
per 1,000

Absolute numbers

Ratios 
per 1,000

Absolute numbers

Ratios 
per 1,000

1917

 

 

 

 

 

 

April

151

9.86

1

2.46

152

9.67

May

222

10.85

1

2.06

223

10.65

June

375

14.55

---

---

375

14.31

July

414

10.83

1

1.80

415

10.95

August

428

9.13

6

8.45

434

9.10

September

921

14.23

9

11.48

930

14.20

October

858

9.97

15

8.26

873

9.94

November

349

3.95

32

9.79

381

4.15

December

156

1.66

9

2.93

165

1.70

1918

 

 

 

 

 

 

January

118

1.29

8

1.89

126

1.32

February

117

1.28

4

.96

121

1.27

March

233

2.48

7

1.53

240

2.43

April

287

2.95

12

2.44

299

2.92

May

567

5.68

39

5.34

606

5.66

June

813

7.48

47

6.32

860

7.41

July

919

8.30

93

8.92

1,012

8.36

August

761

7.11

124

8.83

885

7.31

September

592

5.38

81

5.90

673

5.43

October

178

1.59

20

1.31

198

1.56

November

107

1.02

13

1.04

120

1.02

December

48

.61

10

1.15

58

.67

1919

 

 

 

 

 

 

January

31

.55

4

.70

35

.57

February

33

.84

3

.55

36

.80

March

36

1.06

3

.81

39

1.04

April

53

1.87

2

.81

55

1.79

May

44

1.81

7

4.04

51

1.96

June

44

2.14

2

1.29

46

2.08

July

102

5.69

2

1.20

104

5.31

August

134

10.26

3

2.00

137

9.41

September

117

9.40

4

4.24

121

9.04

October

153

13.13

1

1.32

154

12.40

November

182

16.49

2

2.73

184

15.64

December

74

6.56

---

---

74

6.15

     


     Total

9,617

4.89

565

3.88

10,182

4.82


MORTALITY

In the period between April 1, 1917, and December 31, 1919, 36 cases of malaria were reported as having died. These figures include all deaths from this cause (primary admission) in the entire Army, and it is believed that never before in the history of the world has so small a number of deaths from the malarial infections been recorded in any army in time of war.

PREVENTIVE MEASURES

The principal prophylactic method employed in the United States Army, and the one that gave the best results, was the prevention of the breeding of


521

mosquitoes.d The efforts of the medical officers of the Army in this direction were ably seconded by those of the officers of the Sanitary Corps and, in the extra-cantonment area, by those of the United States Public Health Service. An immense amount of time, labor, and money was expended in ditching, dredging, draining, and filling in, but the results obtained well repaid the effort and the funds expended, as shown by the low malaria rates in our training camps which were situated in infected localities.

In certain camps mosquito control was never complete, and other prophylactic measures were employed. Thus, at Camp Beauregard, La., where mosquito control was not satisfactory, it was found that the proper treatment of "carriers" and of cases contributed greatly to the control of the disease.1

RELATIVE EFFICIENCY OF PROPHYLACTIC MEASURES

The relative efficiency of the various methods of prophylaxis employed for the prevention of malaria has always been a subject of controversy. No data of value in the settling of this question are available in our records of the World War, as only two methods of prophylaxis were extensively employed in the Army; i. e., the prevention of mosquito breeding and screening. Our excellent results were due then almost entirely to the prevention of the breeding of the mosquitoes transmitting malaria in this country, plus screening. By reason of the magnitude of our antimosquito operations and their success, the experience of our Army probably furnishes the most striking example of the efficiency of antimosquito prophylaxis of malaria on record, an experiment so gigantic and so successful that it should end for all time any doubt as to the value of this form of prophylaxis in the prevention of malarial infection.

PRESENT STATUS OF PROPHYLACTIC MEASURES

As stated, the measures directed toward the prevention of the breeding of mosquitoes, plus screening, proved to be the most efficient in the control of malarial infections, but it should be remembered that our experience with the use of other methods was very limited, too much so to be of any real weight in the evaluation of the various methods generally employed. Screening and the treatment of "carriers" of malaria resulted in almost absolute protection at Ebert Field,2 and had it been possible to apply these methods on as great a scale as the antimosquito methods were applied, it would be possible for a definite statement to be made regarding their relative value.

The following extracts from a report on the prophylaxis of malaria at Ebert Field, Ark., are of great interest as showing the value of quinine treatment of "carriers" and screening in the prophylaxis of these infections:

The control of malaria at Ebert Field, Ark., represented an unusually difficult problem due to the extensive area, the high rate of malaria among natives, and particularly the problem of the rice fields which extended for many miles around the camp. It can truly be said that malaria was controlled in this zone, but that mosquitoes were not under control.

The total number of cases of malaria reported from Ebert Field was 33. On these no cases were contracted in camp. The results on malaria control are indicated as follows:

Control of mosquito production being humanly impossible so long as the rice fields were within flight distance of any and all parts of the area, it is interesting to compare the mortality

dSee Vol. VI, Sanitation, Chap. X. V.


522

and the history incidence of malaria in 1917 with the case reports, mortality, and September check index of 1918. In 1917 there occurred 4 deaths from malaria in the control area as against none in 1918. The history incidence index, 29 per cent, or expressed in the number of cases, 522, the only available record for 1917, when compared with the actual development of only one case in 1918, is conclusive proof of the efficiency of the control.

Since, in spite of the attempt to control production, A. quadrimaculatus, recognized as an efficient transmitter of malaria, was present in large numbers about the residences of the community, this diminution of malaria can be ascribed only to screening and the sterilization of the human "carriers"-the latter being probably the main factor.

*    *    *    *    *    *    *

The use of 10 grains of quinine sulphate by mouth for sterilization of the blood of malaria carriers is evidently sufficient for one malaria season if used actively over a period of 30 days.

British experience in Macedonia showed3 that the best results in the prophylaxis of malaria were obtained when antimosquito measures and prophylactic quinine were combined, owing to local conditions which made anti-mosquito measures impossible. So far as the prevention of breeding places was concerned, Wenyon states4 protection from the bites of mosquitoes was the most efficient prophylactic measure; he found that it was impossible to get rid of the mosquitoes and that the following were the most effective methods of prophylaxis under the existing conditions:

Evacuation of infected individuals -The evacuation of infected individuals-i. e., those that showed by their history that they had a persistent infection-reduced the number of cases by removing the most heavily infected and also removed the "carriers" of the infection, thus preventing the infection of mosquitoes. The results of this measure alone he estimates as reducing the admissions by from 60 to 70 per cent. Over 25,000 men were thus evacuated, and he believes it no exaggeration to state that had these men remained they would have caused at least from fifty to sixty thousand additional admissions to hospital from malaria.

Quinine prophylaxis -In his experience this method was disappointing, due to poor application. The dosage varied greatly in different commands and was generally insufficient, and no proper methods were adopted to see that the men actually took the drug distributed to them.

Mosquito nets - Of all the methods tried, Wenyon regards the mosquito net as by far the most efficient in preventing infection. Head nets and gloves are also valuable.

When troops are engaged actively in campaign in a malarial region the main effort should be to protect the men from the bites of mosquitoes; the mosquito net, properly used, will accomplish this.

No data accumulated during the World War have changed our views regarding the relative value of the methods of malaria prophylaxis. The prevention of the breeding of the transmitting mosquitoes and protection from their bites are still the most efficient methods of prophylaxis, while prophylactic quinine, the segregation and proper treatment of "carriers," and the proper treatment of initial malarial infections are all considered valuable methods which should be combined with antimosquito measures. Especially important in malaria prophylaxis is the detection and treatment of "carriers" and the treatment of initial infectious in order that the "carrier" state may be prevented.


523

ETIOLOGY

Despite the considerable amount of research work connected with the etiology of malaria that was accomplished by our medical officers and sanitarians during the period of the World War, no new facts of fundamental importance were discovered regarding the etiology of these infections.

THE SPECIES OF MALARIA PLASMODIA

Our experience with malaria during the World War was confirmatory of the existence of at least three species of the malaria plasmodia; i. e., Plasmodium vivax, the benign tertian plasmodium; Plasmodium malario, the quartan plasmodium; and Plasmodium falciparum, the estivoautumnal or malignant tertian plasmodium. There was a tendency among some observers in the British and French Armies to urge the unity of all malaria plasmodia, basing their arguments upon the apparent merging of one type of malarial infection into another, with a corresponding change in the morphology of the plasmodia observed in the blood of the patients. However, there is nothing in the published observations of any of the adherents of this theory that would indicate that mixed infections with more than one species of plasmodium could be eliminated, and at the present time it may be stated that no observations made during or since the World War have shaken, in the least, the evidence upon which is based the generally accepted belief in the plurality of species among the malaria plasmodia.

As regards the existence of more than one species of estivoautumnal plasmodium, little that is new was added to our knowledge as a result of the war.

In March, 1921, some new data were published by the writer regarding the species of the estivoautumnal plasmodia secured from the study of material from malarial patients in some of our camps.5 These data were confirmatory of the existence of more than one species of this plasmodium and of the previous conclusions of the same writer that the estivoautumnal plasmodium should be divided into two types, one the species known as Plasmodium falciparum and the other, a subspecies, which this writer, in 1909, called Plasmodium falciparum quotidianum.6 The evidence that these two forms exist rests upon distinct differences in morphology, in the length of the life cycle in man, and in the clinical picture of the infections which are produced by them. The morphological differences are as constant and distinctive as those between Plasmodium vivax and Plasmodium malario, while the striking difference in the temperature curve still further serves to differentiate them. 

SPECIES OF ANOPHELES CONCERNED IN THE TRANSMISSION OF MALARIA IN CAMPS IN THE UNITED STATES

Early in the war the Surgeon General directed that collections be made of the prevailing mosquitoes in the training camps in the United States, and these collections were forwarded to the entomologist of the Army Medical Museum for diagnosis and preservation.7 These collections were not carefully made in many instances, so that it is impossible to state what species of anopheline


524

mosquitoes were most prevalent in certain of our camps, but the following list gives the anopheline mosquitoes common to certain camps in which malaria was most prevalent:

Camp Beauregard, La.

Anopheles quadrimaculatus.
Anopheles punctipennis.
Anopheles crucians.

Camp Dix, N.J.

Anopheles punctipennis.
Anopheles quadrimaculatus.
Anopheles crucians.
Anopheles walkeri.

Camp Eustis, Va.

Anopheles quadrimaculatus.
Anopheles crucians.
Anopheles punctipennis.
Anopheles barberi.

Camp Gordon, Ga.

Anopheles punctipennis.

Camp Greene, N.C.

Anopheles punctipennis.

Camp Jackson, S.C.

Anopheles crucians.
Anopheles punctipennis.

Camp Logan, Tex.

Anopheles quadrimaculatus.

Camp McClellan, Ala.

Anopheles puntipennis.

Camp Pike, Ark.

Anopheles quadrimaculatus.
Anopheles punctipennis.
Anopheles crucians.

Camp Travis, Tex.

Anopheles pseudopunctipennis.

Camp Wheeler, Ga.

Anopheles quadrimaculatus.
Anopheles punctipennis.
Anopheles crucians.

Of these mosquitoes, Anopheles punctipennis is the least active as a carrier of malaria, and where it is noted as occurring alone it is probable that other more active species also occurred but were not included in the collections. Anopheles quadrimaculatus is the most active transmitter of malaria of the anophelines reported, with Anopheles crucians second in importance in this respect. Anopheles walkeri and Anopheles barberi have not been recorded as hosts of the malaria plasmodia.

THE LENGTH OF FLIGHT OF ANOPHELINE MOSQUITOES

The question of the length of flight of anopheline mosquitoes has always attracted much attention because of the importance of an accurate knowledge of this subject in prophylaxis. Craig,8 in 1906, was the first to call attention to the fact that anopheline mosquitoes will fly over 2 miles in order to obtain a feeding of blood, although at that time it was generally believed by entomologists that anophelines did not fly for a greater distance than half a mile. It was not until the observations upon the Isthmus of Panama regarding the long-distance flight of anophelines that these findings were confirmed. During the World War some interesting and valuable observations along this line were conducted at Ebert Field, Ark.2 The experiments consisted in catching and staining anopheline mosquitoes, liberating them at various distances from the camp, and then recatching as many as possible. During the time covered by the experiments there were only light air currents, so that the distances covered by the mosquitoes could not be explained by their being carried by winds. More than 5,000 mosquitoes were experimented with, and recatching was done at 37 different stations. It was found that the distances covered by the flight of anophelines varied all the way from one-quarter of a mile to 2 miles, the


525

greatest number being caught at distances of from one-half to 1 miles. The conclusion was that in this locality a flight distance of at least 1 mile could be expected, but the range of Anopheles quadrimaculatus, the most common mosquito caught, could be as much as 2 miles.

The observations detailed above amply confirm those made in 1906,8 which were received at that time with incredulity by entomologists and sanitarians, and render it evident that little dependence can be placed upon prophylactic methods based upon the supposed short-flight distance of anophelines.

THE "CARRIER"

The importance of the "carrier"-i. e., the human being apparently well but whose blood contains the malarial gametocytes-was demonstrated again and some work was done, especially at Ebert Field, showing the importance of discovering and treating "carriers" in the prophylaxis of malaria. It was demonstrated also that "carriers" may be freed from their infection by persistent quinine treatment.

SYMPTOMATOLOGY

Nothing new was added to our knowledge of the symptomatology of malarial infections by observations made during the World War.

ASSOCIATION WITH OTHER DISEASES

The association of malaria with other diseases is shown in Table 88. A study of this table indicates that it possesses little scientific value as proving that any of the diseases in which malaria was secondary predispose to the latter infections to any great extent or that the malarial infections are more often associated with any one particular disease in any event. The number of cases is too small to base any important conclusions upon them, and the table is chiefly of interest as demonstrating that malaria actually was associated with the conditions mentioned.

TABLE 88.-Malarial fever, secondary to other diseases. Enlisted men, United States and Europe, April 1, 1917, to December 31, 1919. Absolute numbers, ratios per 1,000, and percentage rates

Primary diseases


Absolute numbers of secondary malarial fevers

Case rates (secondary)

Death rates (secondary)

Fatality rates (secondary)


Cases

Deaths

 

 

 

 

 

Per cent

Measles

47

---

0.50

---

---

Influenza (epidemic)

366

11

.50

0.01

3.01

Meningitis, cerebrospinal

5

3

1.08

.65

60.00

Mumps

72

---

.33

---

---

Typhoid vaccination

41

---

1.20

---

---

Tuberculosis of lungs

24

1

.77

.03

4.17

Acute miliary tuberculosis

2

2

8.40

8.40

100.00

Syphilis (all)

22

---

.35

---

---

Gonococcus infection

80

---

.33

---

---

Tonsillitis, acute

40

---

.24

---

---

Pharyngitis, acute catarrhal

21

---

.43

---

---

Bronchitis

172

---

.73

---

---

Pneumonia:

 

 

 

 

 

    

Broncho

20

2

.65

.06

10.00

    

Lobar

62

7

1.44

.16

11.29

Intestines, other diseases of

21

---

.35

---

---

All others

380

8

---

---

2.11

    

Total malarial fevers (secondary)

1,375

34

---

---

2.47

Total malarial fevers (primary)

11,072

25

2.99

.01

.23

 


526

PATHOLOGY

There were no new contributions to our knowledge of the pathology of malarial infection by our medical officers during the period of the World War.

DIAGNOSIS

During the war the diagnosis of malaria was based, in the vast majority of cases, upon the results of microscopic examinations of the blood of the infected individual. This is the first time in the history of our Army in war that the diagnosis of the malarial infections was made by an examination of the blood, for in our previous wars, with the exception of the Spanish-American War, such a method of diagnosis was not feasible, as the malaria plasmodia had not been discovered. In the Spanish-American War, as a matter of fact, the diagnosis of malaria was very largely based upon clinical symptoms, with the result that our statistics concerning the actual occurrence of malaria during that war are very inaccurate. During the Philippine insurrection the use of the microscope in the diagnosis of malaria became more general, but owing to lack of facilities and trained observers it did not become a general practice there except in our larger hospitals. However, for several years prior to the World War the diagnosis of malaria in our Army had been based entirely upon the results of blood examinations, and this wise practice was continued during the war. Every home camp was furnished with a splendidly equipped laboratory and specially trained officers and men, so that it was always possible to diagnose malaria by the examination of the blood. Conditions in this respect were equally favorable abroad.

No new method of diagnosis of malarial infections was evolved during the war by our medical or sanitary officers.

TREATMENT

In our Army, as well as in those of other nations, quinine continued to be the drug par excellence in the treatment of malarial infections, and no new substitute for quinine had been discovered. There was some difference of opinion as to the best method of administering this drug, but in our Army it was generally given by the mouth, with excellent results. In cases exhibiting pernicious symptoms the drug was administered intravenously.

In the British Army in Macedonia many medical officers favored the intramusculur use of quinine, but this method was rarely used by our medical officers. It is very questionable if the intramuscular injection of quinine should be adopted in preference to intravenous administration and our medical officers found that the administration of the drug by the mouth answered all purposes in the vast majority of the malarial infections that they encountered.

Some pessimistic papers were written during the war period by medical officers of the British Army as to the value of quinine in the treatment of malaria. The opinion is expressed that this spirit of doubt regarding the efficiency of quinine as a specific is entirely due to the results that have followed its administration in a faulty manner or to individuals who did not absorb the drug from the stomach when administered by the mouth. The opinion is also expressed that quinine properly administered and continued for a sufficient


527

period of time, will cure any case of malarial infection, provided the patient can take the drug; the experience of the British in treating invalided soldiers for malaria and returning them to duty is proof of this assertion.

REFERENCES

(1) Reports on mosquito control at Camp Beauregard, La. On file, Record Room, S. G. O., Correspondence File, 725.11 (Camp Beauregard) (D).

(2) Report on the activities of the malaria control section, division of sanitation, S. G. O., February 20, 1920, by Maj. George R. Bascom, Sanitary Corps. On file, Record Room, S. G. O., 725.11-1.

(3) Proceedings of the medical conference, held at the invitation of the Committee of Red Cross Societies, Cannes, France, April 1-11, 1919. Published by the League of Red Cross Societies, Geneva, Switzerland, 1919, 132.

(4) Wenyon, C. M., and Anderson, A. G.: Malaria in Macedonia, 1915-19, Journal of the Royal Army Medical Corps, London, 1921, xxxvii, 81.

(5) Craig, C. F.: The Classification and Differential Diagnosis of the Aestivo-autumnal Malarial Plasmodia. American Journal Tropical Medicine, Baltimore, 1921, 1, No. 2, 57.

(6) Craig, C. F.: The Classification of the Malarial Plasmodia. Boston Medical and Surgical Journal, 1909, clx, 677.

(7) Cir. Letter, Surgeon General's Office, March 21, 1918.

(8) Craig, C. F.: Observations upon Malaria; latent infection in natives of the Philippine Islands; intracorpuscular conjugation. Philippine Journal of Science, Manila, 1906, 1, 523.