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Chapter 16 - Coccidioidomycosis

Contents

CHAPTER XVI

Coccidioidomycosis

Charles Edward Smith, M. D.

HISTORICAL NOTE

Before World War II, there was little thought that coccidioidomycosis, an almost unknown disease, could ever become a military problem. The infection was first reported from Argentina in 1892 1 and was described 2 years later in California.2 At that time, the etiologic agent was believed to be a protozoon related to Coccidium, and it was therefore named Coccidioidis immitis .3

The mycotic nature of the organism was established in 1900.4 Further study revealed the diphasic form-the "parasitic" endosporulating spherules in man and the "saprophytic" mycelial form in cultivation. Coccidioides immitis was believed to cause serious illness or death in at least half of those who were infected. The disseminated infection, notable for its mimicry of tuberculosis and termed "coccidioidal granuloma," was thought to occur only rarely. In fact, before World War I, most of the recognized cases were reported individually in the literature as they occurred. Apart from Argentina, the disease seemed to be restricted to California, whence the name "California disease" and, even more specifically, "San Joaquin Valley disease." In short, coccidioidal granuloma was a medical curiosity and presented no military problems before World War II.

Between World War I and World War II, the knowledge concerning coccidioidal infections greatly increased. An important advance was the recognition that the disease occurred very frequently-in a benign form, coccidioidal erythema nodosum, with negligible mortality.5 Moreover, the fungus

1 (1) Posada, A.: Un Nuevo Caso de Micosis Fungoidea con Psorospermias. An.d. Circ. Med. Argent. 15: 585-597, 1892. (2) Wernicke, R.: Ueber einen Protozoenbefund bei Mycosis fungoides. Centralbl. f. Bakt. 12: 859-861, 28 Dec. 1892.

2 Rixford, E.: A Case of Protozoic Dermatitis. Occidental M. Times 8: 704-707, December 1894.

3 Rixford, E., and Gilchrist, T. C.: Two Cases of Protozoan (Coccidioidal) Infection of the Skin and Other Organs. Johns Hopkins Hosp. Rep. 1: 209-267, 1896.

4 Ophüls, W., and Moffitt, H. C.: A New Pathogenic Mould (Formerly Described as a Protozoon; Coccidioides immitis Piogenes); Preliminary Report. Phila. M. J. 5: 1471-1472, 30 June 1900.

5 (1) Gifford, M. A.: San Joaquin Fever. In Annual Report Kern County Health Department for Fiscal Year July 1, 1935 to June 30, 1936, pp. 22-23. (2) Gifford, M. A., Buss, W. C., and Douds, R. J.: Data on Coccidioides Fungus Infection, Kern County, 1901-1936. In Annual Report Kern County Health Department for Fiscal Year July 1, 1936 to June 30, 1937, pp. 39-54. (3) Gifford, M. A.: Coccidioidomycosis in Kern County, California. Proc. Sixth Pacific Science Congress 5: 791-796, 1942. (4) Dickson, E. C.: "Valley Fever" of San Joaquin Valley and Fungus Coccidioides. California & West. Med. 47: 151-155, September 1937. (5) Dickson, E. C.: Coccidioidomycosis; Preliminary Acute Infection With Fungus Coccidioides. J. A. M. A. 111: 1362-1365, 8 Oct. 1938. (6) Dickson, E. C., and Gifford, M. A.: Coccidioides Infection (Coccidioidomycosis); II. The Primary Type of Infection. Arch. Int. Med. 62: 853-871, November 1938.


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was recovered from the soil and was shown to cause natural infection in cattle and sheep as well as in man.6 Thus, it came to be appreciated that coccidioidomycosis is an exceedingly common infection, rather than a rare one, and that its disseminated form, coccidioidal granuloma, is the exception rather than the rule.

Studies completed just before World War II indicated that a very high infection rate occurs among newcomers to endemic areas.7 This fact suggested that a significant medical problem could arise if large military installations were to be established in these areas and susceptible adults were to be stationed there. The studies indicated that the endemic areas, while still ill defined, probably extended into some arid regions of southern California, Arizona, and west Texas. However, no methods of preventing acquisition of coccidioidal infections or of minimizing the disseminating form were even suggested. Indeed, the idea that a health problem even existed was largely a conjecture, since the newly suspected, extended endemic area enjoyed high favor for its salubrious climate.

INCIDENCE OF COCCIDIOIDOMYCOSIS

It has not been possible to obtain accurate information as to the incidence of clinical coccidioidal infection in military personnel during World War II. The Medical Statistics Division of the Surgeon General's Office has furnished provisional estimates based on sample tabulations of individual medical records. Table 48 shows that there was a total of 3,809 cases for the 4 years, 1942-45, and table 49 shows 39 deaths attributed to coccidioidomycosis for the same period. Unfortunately, there could be no breakdown by Army Ground Forces as compared with Army Air Forces. Provisional data based on summaries of the statistical health report provide a distribution of cases in the United States by service command. While this source is subject to underenumeration for this diagnosis (coccidioidomycosis was a writein entry only), the over-all statistics are of interest. Of the 2,889 cases reported from 1942 through 1945 in the United States, 2,717 (94 percent) were in the Ninth Service Command, 86 (3 percent) were in the Eighth Service Command, and the remainder was distributed among all the other service commands, except the Sixth, for which no cases were reported. The fact that more than 700 cases of coccidioidomycosis, or 18 percent of the reported Army total, were hospitalized in only 4 station hospitals in the San Joaquin Valley (author's personal records) indicates that 3,809 cases is a gross understatement of actual incidence of the disease.

6 (1) Stewart, R. A., and Meyer, K. F.: Isolation of Coccidioides immitis (Stiles) From the Soil. Proc. Soc. Exper. Biol. & Med. 29: 937-938, May 1932. (2) Giltner, L. T.: Occurrence of Coccidioidal Granuloma (Oidiomycosis) in Cattle. J. Agrie. Research 14: 533-541, 16 Sept. 1918. (3) Beck, M. D.: Occurrence of Coccidioides immitis in Lesions of Slaughtered Animals.Proc. Soc. Exper. Biol. & Med. 26: 534-536, March 1929. (4) Beck, M. D., Traum, J., and Harrington, E. S.: Coccidioidal Granuloma; Occurrence in Animals-Reference to Skin Tests. J. Am. Vet. M. A. 78: 490-499, April 1931. (5) Beck, M. D., Dickson, E. C., and Rixford, E.: Coccidioidal Granuloma.California State Health Dept. Spec. Bull. 57, June 1931. (6) Davis, C. L., Stiles, G. W., and McGregor, A. N.: Coccidioidal Granuloma in Calves.J. Am. Vet. M. A. 92: 562-563, April 1938.

7 Smith, C. E.: The Epidemiology of Acute Coccidioidomycosis with Erythema Nodosum ("San Joaquin" or "Valley Fever").Am. J. Pub. Health 30: 600-611, June 1940.


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It will be seen from table 48 that an insignificant number of cases of coccidioidomycosis occurred overseas. Apparently, the disease appeared only in troops who had acquired their infections in the arid southwestern United States before transportation overseas. The number of admissions was too small to permit any deductions as to the endemicity of the overseas areas in which they occurred.

TABLE 48.-Total cases and incidence rate of coccidioidomycosis in the U. S. Army, by area and year, 1942-45

TABLE 49.-Deaths from coccidioidomycosis, in the U. S. Army, by area and year, 1942-45

COCCIDIOIDOMYCOSIS IN THE ARMY AIR FORCES

Military attention to the problem of coccidioidomycosis in World War II converged simultaneously from two directions and almost immediately united. In 1940-41, the Army Air Forces began development of an extensive year round aviation-training program to be located at airfields in the climatically advantageous Southwest, specifically in the San Joaquin Valley. Recognizing the potential hazard of coccidioidomycosis at these proposed airfields, Dr. Walter T. Harrison, United States Public Health Service, liaison officer for the Ninth Corps Area, warned the corps area surgeon and the headquarters staff of the West Coast Training Center. Dr. Harrison brought the author, who had carried on epidemiologic investigations of the disease in the selected areas, to


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meet the commanding officer of the West Coast Training Center and the senior flight surgeon. The members of this conference, appreciating the danger of serious infection, agreed that further detailed clinical and epidemiologic studies were desirable.The problem was further considered in correspondence between the surgeon of the Ninth Corps Area and the Surgeon General's Office during February and March 1941, and a policy of minimizing use of the endemic areas was established.8 A deviation from this policy in the summer of 1942 resulted in a severe epidemic of coccidioidomycosis (p.293).

While the basic training fields in the San Joaquin Valley rapidly increased, the Commission on Epidemiological Survey of the Army Epidemiological Board, Preventive Medicine Division, Office of the Surgeon General, developed plans for a study of coccidioidomycosis, including research into its epidemiology. A Ninth Corps Area consultant group, with Dr. Edwin W. Schultz as director and Dr. Edward B. Shaw and the author as members, was established in February 1941 to help accomplish this study. Dr. Francis Blake, president of the Army Epidemiological Board, and Dr. Stanhope Bayne-Jones, chairman of the Commission on Epidemiological Survey, worked closely with the author in preparing plans for this study of coccidioidomycosis which were approved by the Army Epidemiological Board in June 1941 Rapid and direct communication between the Office

of the Surgeon General and the Commanding General, West Coast Training Center, was greatly facilitated by the interest taken by Col. (later Brig. Gen.) James S. Simmons, MC, Chief, Preventive Medicine Division, Office of the Surgeon General.

The study was centered in the Department of Public Health and Preventive Medicine, Stanford University School of Medicine, where laboratory and epidemiologic facilities were provided. Dr. Rodney R. Beard of that department was appointed to the Ninth Corps Area consultant group and participated in the initial coccidioidin testing and in the subsequent semiannual retesting Funds for the first 4 months of the study were supplied by the Rosenberg Foundation. By July 1941, the project was in active operation when all the permanent party personnel of Minter Army Air Field, Bakersfield, Calif., and Gardner Army Air Field, Taft, Calif., were coccidioidin tested.

Headquarters of Minter Field was at Bakersfield Junior College. The men lived in tents pitched at the Kern County Airport. The dispensary where coccidioidin testing was performed was a large tent equipped with an electric hotplate and an empty vegetable can for a sterilizer. The Gardner Field infirmary was an unfinished building shared by the Medical Department, post exchange, and barber shop and partitioned by cases of beer and soft drinks. Dust was ankle deep and swirled in clouds over the fields. Clinical cases of coccidioidomycosis were appearing; indeed, with dust completely uncontrolled, infections were maximal and never occurred again at such a rate. At Minter Field, one-fifth of all susceptibles were infected during the summer and fall of

8 (1) Letter, Col. H. R. Beery, Surgeon, Ninth Corps Area, to Col. C. C. Hillman, Assistant to the Surgeon General, 24 Feb. 1941. (2) Letter, Col. C. C. Hillman, Office of the Surgeon General, to Col. H. R. Beery, Ninth Corps Area, 11 Mar. 1941.


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1941. The personnel of the two fields were interested in cooperating for their own protection, and the surgeons at both fields set a pattern of collaboration which their successors emulated.

New arrivals at both fields were coccidioidin tested, and results were entered on the immunization records.9 Immediate interest focused on whether or not clinical infections occurred in personnel who were sensitive to coccidioidin on arrival at the fields. It was soon apparent that clinical infections never occurred in those people and that the skin testing with coccidioidin differentiated susceptibility from immunity. Thus, the medical officers were provided with a most sensitive method of diagnosis.10 As further aids in diagnosis and prognosis, recently discovered serologic tests and mycologic facilities were made available as a result of studies supported by the Commission.11

A death from coccidioidal meningitis at one of the fields served to emphasize the importance of careful diagnosis and medical surveillance of the disease. An enlisted man had failed to react to coccidioidin when initially tested in July 1941, but he was found to have a positive reaction when retested in October. At that time, he reported that he had experienced a "flu-like" illness associated with pleural pain in late September, but he stated that he was feeling much better. No sedimentation or serologic tests were performed, and the soldier was permitted to continue strenuous activities. Meningitis developed in this soldier in December. After this occurrence, it became a requirement that histories of all personnel previously negative to coccidioidin who converted to positive at retest be recorded on clinicoepidemiologic forms and that blood from these individuals be drawn for serologic and sedimentation tests. A number of soldiers were hospitalized as a result of this procedure. Criteria of recovery from Coccidioidomycosis were established; these emphasized that patients should not only be clinically recovered but should also have, normal sedimentation rates, receding complement fixation titers, and regressing roentgenographic densities before, being discharged from the hospital to active duty. Accurate diagnosis of the disease was also emphasized.

When the author visited the field at monthly intervals to test new personnel, he saw the patients with the medical officers. Some of the clinicoepidemiologic forms were filled out by local medical officers, some by the author. Those filled out by local medical officers were reviewed by the author in the presence of the patient to insure uniformity both at the two fields and, since turnover of medical officers was rapid, on the individual fields. A fundamental objective of these activities was the provision of maximal medical service for persons who were infected, which in turn minimized the risk of disseminated

9(1) Smith, C. E., Beard, R. R., Rosenberger, H. G., and Whiting, E. G.: Effect of Season and Dust Control on Coccidioidomycosis. J. A. M. A. 132: 833-838, 7 Dec. 1946. (2) Smith, C. E., Beard, R. R, Whiting, E. G., and Rosenberger, H. G.: Varieties of Coccidioidal Infection in Relation to the Epidemiology and Control of the Diseases. Am. J. Pub. Health 36: 1394-1402, December 1946.

10 Smith, C. E., Whiting, E. G., Baker, E. E., Rosenberger, H. G., Beard, R. R., and Saito, M. T.: The Use of Coccidioidin. Am. Rev. Tuberc. 57: 330-360, April 1948.

11 Smith, C. E., Saito, M. T., Beard, R. R., Kepp, R. M., Clark, R. W., and Eddie, B. U.: Serological Tests in the Diagnosis and Prognosis of Coccidioidomycosis. Am. J. Ilyg. 52: 1-21, July 1950.


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infection. The byproduct of these activities was increased knowledge of the pathogenesis and clinical aspects of coccidioidomycosis.12

As has been indicated, periodic retesting of personnel at the fields was necessary. The results of the testing and retesting, together with clinical observation, provided information on the proportion of clinical cases to in apparent infections and served as the bases for calculating monthly and annual infection rates.13 Annual rates were essential in evaluating control measures which, as will be presented later, focused on dust control.

Late in 1941, two more basic training fields were established in the San Joaquin Valley, one at Lemoore, Calif., and the other at Merced, Calif. With the approval of the Commission on Epidemiological Survey and the Western Flying Training Command, the study was extended to those fields. Testing of the Merced personnel began in February 1942, and testing of the Lemoore personnel began in March. The same outstanding cooperation that had been shown at Minter and Gardner was shown by the personnel at Merced and Lemoore.

The intensive studies were continued at the four fields as long as they remained under the Western Flying Training Command. On 1 March 1945, Gardner Field became inactive. On 1 May 1944, Lemoore Army Airfield was transferred to the Fourth Air Force to serve as an in processing center. The study of coccidioidomycosis continued at Lemoore until 30 September 1945 when the field became inactive and at Minter until the field was closed in February 1946. On 1 July 1945, Merced Army Airfield was transferred from the Training Command, and, because the 3 years of close study had proved it was not an area where coccidioidomycosis was endemic, the intensive field work of the Commission on Epidemiological Survey was terminated. Merced had served as an unexpected but fortunate control area and also had enabled studies of the duration of coccidioidin sensitivity in a nonendemic area.14 Furthermore, studies at Merced had proved that high "inapparent" infection rates manifested by asymptomatic "conversions" at the other three fields were valid.

Other Control Programs

The Commission on Epidemiological Survey's intensive clinical and epidemiologic investigations served as a pilot program for two more extensive control programs established by the Air Forces. The first was established by the West Coast Army Air Forces Training Center. In the summer of 1942, the Western Flying Training Command was confronted with a wave of coccidioidomycosis in its Arizona flying fields. The training command surgeon requested the surgeon of the West Coast Army Air Forces Training Center to organize a control program. Flight surgeons of Santa Ana Army Airbase,

12 Smith, C. E., Beard, R. R., and Saito, M. T.: Pathogenesis of Coccidioidomycosis With Special Reference to Pulmonary Cavitation. Ann. Int. Med. 29: 623-655, October 1948.

13 See footnote 9, p. 289.
14 See footnote 10, p. 289.


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Calif., were assigned the responsibilities of developing this program, and the author was called upon as consultant.

The ultimate coccidioidomycosis-control program of the Western Flying Training Command, expanded from the Commission on Epidemiological Survey's pilot program on the four fields, was inaugurated on 16 October 1942. This new program consisted of testing new permanent party personnel on arrival at stations and of retesting them on transfer and semiannually in January and July. Cadets were coccidioidin tested during their preflight training at Santa Ana and again when taking their final "64" examination at advanced fields. To insure a uniformly high quality of medical care, all seriously ill patients and patients whose illness lasted 3 months were transferred to the Santa Ana Army Airbase Regional Hospital.

A coccidioidomycosis-control officer for the West Coast Army Air Forces Training Center was designated, and a local coccidioidomycosis-control officer was appointed at each installation. An outstanding syllabus was prepared, bringing together the orders setting up the program and essential information regarding coccidioidomycosis.15 A second edition was issued on 15 September 1943 and a third on 15 March 1944. Excellent pulmonary roentgenograms were included. The Western Flying Training Command maintained the policy of having the Commission on Epidemiological Survey's investigative group operate the coccidioidin-testing programs in the four San Joaquin Valley airfields in order to continue the detailed epidemiologic studies. Standardized coccidioidin and containers for serum specimens were sent to the West Coast Army Air Forces Training Center at Santa Ana Army Airbase to be distributed to the various fields.The serologic tests were all performed by the group at Stanford University.

A high caliber of medical care of patients with coccidioidomycosis resulted from the program, and important epidemiologic data were assembled. The value of the latter was somewhat impaired by the fact that rapidly changing personnel and varying enthusiasms at the local fields caused the quality of records to be uneven. At some of the fields in nonendemic areas, the amount of work imposed by the repeated testing, especially in light of the frequent transfer of personnel, was open to some criticism.

The second Army Air Forces control program came into being when Lemoore Army Airfield was transferred from the Western Flying Training Command to the Fourth Air Force. In consultation with the author, the Surgeon, Fourth Air Force, established a coccidioidomycosis-control program based on local needs. The testing and retesting program of the permanent party personnel at Lemoore was continued. Since the most important problem would be the infection of personnel processed at Lemoore and then assigned to other stations while in the incubation period of coccidioidomycosis, a summary of the control program was prepared and sent to all stations of the Fourth Air Force.From a depot established by the Commission on Epidemiological

15 Coccidioidomycosis Control Program for the West Coast Army Air Forces Training Center, 16 Oct. 1942.


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Survey- at Lemoore, the coccidioidomycosis-control officer sent coccidioidin and sterile containers for blood to each installation.

Coccidioidomycosis was also of importance in two airfields outside the Western Flying Training Command: Davis-Monthan Field, Tucson, Ariz., and March Field, near Riverside, Calif. There was close liaison between the Commission on Epidemiological Survey and Davis-Monthan Field, and the medical officers at the field were provided with coccidioidin and serologic and mycologic diagnostic facilities. The extensive experiences of the field's regional hospital were summarized by Lt. Col. Charles F. Sweigert, MC, and his colleagues.16 Although March Field itself was not in an endemic area, occasional cases of coccidioidomycosis in personnel who had acquired infections in the nearby endemic areas were detected with the diagnostic facilities provided by the Commission on Epidemiological Survey. In the spring of 1943, many positive specimens were received from men who had been on bivouacs around Banning, Calif., for a. period appropriate for the incubation of coccidioidomycosis. On 8 May 1943, the chief of medicine at March Field Regional Hospital, Maj. Forrest M. Willett, MC, was advised to scrutinize the situation carefully and, if it appeared to justify the suspicion that this area was endemic, to test personnel going to Banning from March Field and to retest them on their return. The importance of the possible endemic area not only to March Field but also to the Desert Training Center of the Army Ground Forces was under consideration. Major Willett and Capt. Alvin Weiss then carried out a very extensive study. Their report reviewed the spotty endemicity of coccidioidomycosis in southeastern California and their experiences with 100 coccidioidal infections.17 This study was brought to the attention of Army Ground Forces.

COCCIDIOIDOMYCOSIS IN THE ARMY GROUND FORCES

As has been indicated, in February and March 1941, a policy was established placing the San Joaquin Valley out of bounds as a location for camps and maneuvers. Only a few months later, the wisdom of this policy was supported when a new "fringe" endemic area over the Coast Range Mountains at Camp Roberts, Calif., was authenticated. In May 1941, just as the work of the Commission on Epidemiological Survey was being instituted at Stanford, Lt. Robert M. Shelton had requested coccidioidin for testing some suspicious cases of erythema nodosum. The positive coccidioidin tests were followed by serologic and mycologic confirmation.18 apparently, the infections at Camp Roberts were acquired not at the main campsites along United States Highway 101 but on bivouacs and maneuvers in the eastern sections of the camp. As time went on, Camp Roberts provided a significant proportion

16 Sweigert, C. F., Turner, J. W., and Gillespie, J. B.: Clinical and Roentgenological Aspects of Coccidioidomycosis. Am. J. M. Sc. 212: 652-673, December 1946.

17 Willett, F. M., and Weiss, A.: Coccidioidomycosis in Southern California; Report of a New Endemic Area With a Review of 100 Cases. Ann. Int. Med. 23: 349-375, September 1945.

18 Shelton, R. M.: Survey of Coccidioidomycosis at Camp Roberts, California. J. A. M. A. 118:1186-1190, 4 Apr. 1942.


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of belatedly recognized coccidioidal residual as well as of fatal disseminating infections. Had Coccidioides been any more prevalent, the value of the camp site might have been in jeopardy. No criticism can be made of locating the camp in that region for, before Lieutenant Shelton's investigations, no one realized that the endemic area extended across the Coast Ranges.

Maneuvers in San Joaquin Valley

Ground Force personnel did experience one epidemic of coccidioidomycosis as the price for violating the "no-trespassing" warning for the San Joaquin Valley. Recognition of this epidemic came as a direct result of the close liaison between the chief of the laboratory service at Camp San Luis Obispo, Calif., and personnel of the Commission on Epidemiological Survey's coccidioidomycosis-control program. During the winter and spring of 1941 and 1942, a number of serologic specimens were sent to the Commission's facilities.Only one of these specimens was positive; it came from a soldier who had acquired an infection by travel through the San Joaquin Valley. In July 1942, a large number of specimens sent by the Camp San Luis Obispo laboratory were positive. The 7th Motorized Division had maneuvered in the northwest, corner of Kern County (Antelope Valley, an arm of the :San Joaquin Valley) during June, and July. An epidemic of severe respiratory illnesses ensued which was proved to be coccidioidal. An excellent description of the epidemic was prepared by Maj. David M. Goldstein, MC, and Capt. Stanley Louie, MC.19 Seventy-five cases of clinical coccidioidomycosis were diagnosed; on the ratio of erythema nodosum to infections, it is calculated that there were between 300 and 400 infections. On 3 August, the author reported the situation to the Surgeon General's Office, and on 5 August a memorandum was sent to the Surgeon, Army Ground Forces, informing him of the situation and reemphasizing the hazards of maneuvers in endemic areas.20 Furthermore, on 15 August 1942, The Surgeon General prepared a brief outline of the coccidioidomycosis problem which was sent to the Commanding General, Services of Supply, calling attention to the unfortunate consequences of the recent maneuvers and recommending that maneuvers in the valley be kept to a minimum.

On 18 August 1942, Army Ground Forces endorsed the July sanitary report of the 7th Motorized Division and approved the recommendation it contained: "That the Western Portion of the San Joaquin Valley south of Fresno, California, and especially that portion lying in Kern County not again be used for a maneuver or training area for Army personnel." When endorsing the sanitary report to Services of Supply, the Surgeon General's Office concurred in the recommendation and invited attention to its letter of 15 August which had discussed the problem.

19 Goldstein, D.M., and Louie, S.: Primary Pulmonary Coccidioidomycosis; Report of an Epidemic of 75 Cases. War Med. 4: 299-317, September 1943.

20 Memorandum, Col. J. S. Simmons, Office of the Surgeon General, for Col. F. A. Blesse. Army Ground Forces, 5 Aug. 1942, subject: Coccidioidomycosis (San Joaquin Valley Fever) in California.


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The constant admonitions of the Preventive Medicine Service together with the finger-burning experience of the 7th Motorized Division sufficed to keep other ground troops out of the San Joaquin Valley.

California-Arizona Maneuver Area

A serious problem developed in the California-Arizona Maneuver Area, the Desert Training Center, which was located in the desert areas of southeastern California and western Arizona. Roughly triangular in shape, it was 300 miles long and 200 miles wide at its base. It consisted of series of dry lakes, sandy valleys, and mountain ranges of rock or shale.The maneuver area was used to harden troops physically, to train them mentally for the shock of battle, and to enable them to operate under realistic battle conditions; it was also used to test and develop equipment. Coccidioidomycosis constituted the chief health hazard peculiar to the area, although this fact was not recognized during the early months of the war.

Recognition of the problem began in 1943. In January, Lt. Col. Roswell Brown of the Desert Warfare Board visited the author and discussed the possible hazard of coccidioidomycosis in the Desert Training Center. Sample skin-testing surveys were advised, and it was suggested that medical officers be alerted to the danger of this infection, particularly in the spectacular and easily recognized form of erythema nodosum. While this plan was under consideration, the Desert Training Center received the following information from the 54th Station Hospital near Yuma, Ariz.21

* * * We were out on "grand maneuvers" for three weeks, returning to our base a week ago. Very suddenly we got a number of men with influenza-like symptoms, and a bizarre lung finding, on physical and on x-ray. Today we have three positives out of five tests, as well as an outbreak of "Epidermo phytid" [doubtless erythema multiforme] and erythema nodosum in these same patients. (One of these is a man from the Royal Dutch Army, who had been in this country only one month, three weeks of which were out on the desert, and one week in the hospital.)

Subsequent serologic examinations confirmed the epidemic as coccidioidomycosis. The site of the infections was specifically located in an area near Pallen Pass, 20 miles west of Blythe, Calif. This was in the maneuver area where personnel received final polishing. The information was sent at once to the Surgeon General's Office which immediately notified the Surgeon, Army Ground Forces, that a previously undetermined area was heavily infected with Coccidioides.22

Medical officers of the California-Arizona Maneuver Area initiated a coccidioidomycosis control program by arranging for the commanding officer of the 5th Medical Laboratory to visit the Commission on Epidemiological

21 Letter, Dr. C. E. Smith, to Maj. R. K. Brown, MC, Desert Training Center, 19 Mar. 1943.

22 (1) Letter, Lt. Col. K. R. Lundeberg, Office of the Surgeon General, to Surgeon, Army Ground Forces, 26 Mar. 1943, subject: Coccidioidomycosis in the Desert Training Center. (2) Goldstein, D. M., and McDonald, J. B.: Primary Pul monary Coccidioidomycosis; Follow-up of 75 Cases, with 10 More Cases from New Endemic Area. J. A. M. A. 124: 557-561, 26 Feb. 1944.


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Survey's Stanford facilities the first week in May 1943. At this meeting, it was recognized that a testing and retesting program, such as that followed in the Air Forces Western Flying Training Command, was impractical in this area. The Commission consultants recommended a twofold program: (1) To educate the medical officers in recognition of coccidioidomycosis and provide them with diagnostic facilities, and (2) to delimit endemic areas by epidemiologic investigations including selected skin-testing surveys and a continuous search for "sentinel" erythema nodosum. It was agreed that coccidioidin and, after precipitin screening by the 5th Medical Laboratory, serologic tests would be provided by the Commission on Epidemiological Survey. However, the 5th Medical Laboratory was succeeded by the 7th before these procedures could be instituted.

Meanwhile, a greater appreciation of the problems of coccidioidomycosis was stimulated among the medical staff of the headquarters of the communications zone of the California-Arizona Maneuver Area at Banning. It was here that Major Willett was conducting an intensive investigation as a result of the epidemic described on p. 292.23 Possible procedures were discussed by the staff with Major Willett during June and July (1943). Later, the author offered to them the same suggestions as had been made to the commanding officer of the 5th Medical Laboratory. In August, the commanding officer of the 7th Medical Laboratory visited Stanford to institute the necessary diagnostic facilities. However, the work had only begun when the 7th Medical Laboratory was succeeded by the 9th.The commanding officer of the latter developed an efficient method for the distribution of skin-testing coccidioidin and for the collection and screening of serum specimens. Consequently, there was a great increase in confirmed diagnoses of coccidioidomycosis.

On 23 August 1943, the office of the surgeon of the communications zone proposed a systematic control program under an established control officer together with recognition and avoidance of highly endemic areas, but the proposal was rejected by the commanding general on 31 August because of shortage of personnel and in the belief that there seemed to be no urgent necessity for such a program.24

Although no systematic coccidioidomycosis study was made by the medical staff of the Desert Training Center Headquarters, an analysis of the area was made by one officer. His survey showed that in the Desert Training Center coccidioidomycosis was highly endemic in the Pallen Pass Maneuver Area and in the southern Arizona strip from Yuma to Camp Hyder, whereas it appeared not to be endemic in much of the northern section of Arizona and in California localities including Pomona, San Bernardino, Camp Young, and most of the area of Imperial, Riverside, and San Bernardino Counties.25

That a very significant hazard persisted is borne out by the history of

23 Seefootnote 17, p. 292
24 Letter, Lt. Col. H. A. Furlong, MC, to Surgeon, Desert Training Center, Camp Young, Calif., 23 Aug. 1943, subject: Coccidioidomycosis.

25 (1) Letter, Maj. G. A. Young, Jr., MC, to Dr. C. E. Smith, 18 Jan. 1944.(2) Letter, Capt. G. A. Young, MC, to Surgeon, Headquarters, Communications Zone Desert Training Center, 18 Aug. 1943, subject: Comprehensive Survey of Coccidioidomycosis in the Desert Training Center, with 2d endorsement.


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coccidioidomycosis in the 77th Infantry Division, which was at Camp Hyder, Ariz., from 1 April to 4 October 1943. Infections in personnel from this division were reported from Indiantown Gap Military Reservation, Pa., Camp Pickett, Va., and the 219th General Hospital on Oahu, T. H. The monthly statistical report of the division for September 1943 refers to an outbreak of 106 cases of epidemic pleurodynia, all of which occurred at Camp Hyder, while even in 1944 roentgenograms of the personnel in the Central Pacific revealed 80 suspicious cases, of which 20 were established as coccidioidal in etiology. 26

A patient who had cavitation due to coccidioidomycosis was discovered at Fort Bragg Station Hospital, N. C. The patient was one of a group of field artillery trainees from the California-Arizona Maneuver Area.27 Subsequent tests of 1,522 cavalry personnel trained at Camp Hyder revealed that 22 percent reacted positively to coccidioidin.28 However, they were sent overseas before adequate histories or roentgenograms could be taken.

An excellent memorandum reviewing the coccidioidomycosis problem was prepared for The Surgeon General by the Epidemiology Division, Preventive Medicine Service, Office of the Surgeon General.29 Capt. Philip E. Sartwell of that division visited the Surgeon, Army Ground Forces, in an attempt to improve the control measures of the California-Arizona Maneuver Area.30 Before any realistic measures could be taken, however, the maneuver area began to disband, so the problem ceased to exist.

Perhaps the policy of virtually ignoring the problem of coccidioidomycosis was wise. However, if there should be future need for reestablishing such a training program and if advantages of climate and terrain do not outweigh the hazards of coccidioidomycosis, the highly endemic southern rim and central portion of Arizona and the Pallen Pass area of California as well as the southern and western San Joaquin Valley should be avoided.

COCCIDIOIDOMYCOSIS AMONG PRISONERS OF WAR

Another Army problem due to coccidioidomycosis concerned prisoners of war. A major camp for prisoners was established at Florence, Ariz. Col. Verne R. Mason, MC, medical consultant to the Surgeon, Ninth Service Command, visited the Florence Station Hospital in September 1943. Recognizing that there were a number of probable coccidioidal infections, he alerted the medical officers, reported his findings, and also informed the Commission on Epidemiological Survey. On 7 October, a letter of inquiry was sent from

26 (1) Letter, The Surgeon General to Commanding Officer, Desert Training Center, 23 Oct. 1943, subject: Reported Epidemic of Pleurodynia, with endorsements and enclosure. (2) Letter, The Surgeon General to Commanding Officer, Indiantown Gap Military Reservation, 13 Nov. 1943, subject: Reported Cases of Coccidioidomyeosis, with 1st endorsement.

27 Letter, Dr. T. J. Abernethy to Dr. C. E. Smith, 8 Jan. 1944.

28 Letter, Dr. T. J. Abernethy to Col. Stanhope Bayne-Jones, 16 Mar. 1944.

29 Memorandum, Col. K. R. Lundeberg, MC, for The Surgeon General, 3 Jan. 1944, subject: Review of Coccidioidomycosis Problem in the Army.

30 Memorandum for file, Capt. P. E. Sartwell, Office of the Surgeon General, [23 Dec. 1943], subject: Conference With Ground Surgeon on Coccidioidomycosis.


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Florence Station Hospital to the Commission at Stanford. A detailed reply outlined a control program and offered the Commission's facilities.31 Florence, the Arizona prisoner-of-war headquarters from which a number of side camps for field work radiated, was in a known endemic area. Already, the Commission on Epidemiological Survey had provided coccidioidin, serologic facilities, and consultative advice to the Japanese Relocation Center on the Gila River not far away because of outbreaks of cases there. From that experience and from the information garnered from Williams Field, Ariz., in the Western Flying Training Command, it was realized that endemicity was high.

Despite the Commission's offer of facilities, personnel at Florence made no use. of them until December 1943, when the first serologic specimens were sent for testing. The results of these tests, together with recognition of two deaths due to coccidioidomycosis, and a return visit by Colonel Mason initiated action. An additional complication at Florence was the fact that, because of the reputation of the area for its salubrious climate, Florence Station Hospital was being used to hospitalize all tuberculous prisoners of war. On 4 February 1944, Colonel Mason transmitted to Professional Services and, in turn, to Preventive Medicine Service of the Surgeon General's Office a report on the coccidioidomycosis hazard in the prisoner-of-war area. Colonel Bayne-Jones, aware of recent German complaints that prisoners of war had been placed in unhealthy areas, decided upon an immediate investigation.32 Accordingly, the author was dispatched to Florence on 23 February. A review of hospital records using erythema nodosum as an index of infection showed a rapidly increasing problem. A sampling coccidioidin survey of hospital patients and personnel substantiated the more extended series made previously at Florence and the extensive coccidioidin-testing figures from nearby Williams Field. In that region, 50 percent of susceptibles were infected within 6 months' time. Indeed, 10 tuberculous prisoners of war were found to have been infected while they were hospitalized in the wards.

One patient who had a tuberculous effusion on admission to hospital developed a coccidioidal effusion in his other lung.The superimposed coccidioidal infections did not appear to affect the tuberculous infections adversely.

A systematic testing and retesting program for detecting coccidioidomycosis was suggested by the author, with the realization that very soon everyone in the area would be infected and, as a result, immune. Since prompt recognition of the onset of the infection was important in order that appropriate medical attention might be given and since patients hospitalized because of tuberculosis were already undergoing bed rest and apparently were not harmed by the superimposed coccidioidomycosis, the author recommended that a control program be inaugurated and that operation of the hospital be continued.33

31 Letter, Dr. C. E. Smith to Capt. T. Kendig, MC, 12 Oct. 1943.

32 Memorandum, Col. S. Bayne-Jones, MC, for General Simmons, 18-19 Feb. 1944, subject: Coccidioidomycosis in Prisoners of War at Florence, Arizona.

33 Letter, Dr. C. E. Smith to The Surgeon General through Col. S. Bayne-Jones, Preventive Medicine Service, 3 Mar. 1944, subject: Coccidioidomycosis at the Prisoner of War Camp, Florence, Arizona.


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However, when the report was reviewed in Washington, the decision was made to avoid any criticism of violation of policies governing hospitalization of prisoners of war,34 and tuberculous patients were moved to other hospitals. Florence was maintained as headquarters for Italian and later German prisoners of war working out of the side camps. Because of the small number of medical officers and the extreme rapidity with which prisoners as well as medical personnel were transferred, the suggested systematic coccidioidin-testing program could not be carried through. However, the hospital's personnel continued to make use of the Commission on Epidemiological Survey's serologic diagnostic facilities.

Another outbreak of coccidioidomycosis in prisoners of war occurred the following year (1945) in the San Joaquin Valley. From the prisoner-of-war base at Camp Cooke, Calif., several work camps were established near Minter and Lemoore Fields. The station hospitals of these fields were used for temporary hospitalization of the prisoners. In an exchange of correspondence with the surgeon of Camp Cooke Station Hospital, the author indicated the probability that coccidioidomycosis would become a serious problem in these camps after June.35 When General Bayne-Jones received copies of this correspondence, he informed the Provost Marshal General, who indicated that the endemic areas would be avoided. However, nothing was done, and the incidence of the disease rose during that summer.

On 7 August 1945, the chief of the Epidemiology Division, Preventive Medicine Service, pointed out to the commanding officer of Camp Cooke that the incidence of coccidioidomycosis in prisoners at that camp was greater than the total for all of the United States Army troops. Further information was requested.36 During 2 months and 10 days, June to August, 150 German prisoners of war with coccidioidomycosis were hospitalized at Minter Field.37 These represented approximately 10 percent of the local prisoner-of-war population. During the same period, there were only 22 clinical cases in the 3,400 Minter Field personnel. Even if one-third of the Minter personnel were immune, the rate was still less than one-tenth that of the prisoners. These data were strong testimony to the value of the dust-control program provided at Minter Field. Indeed, the rate in the prisoners of war was comparable to that which had occurred in 1941 at Minter itself. This rate attested the problems posed by coccidioidomycosis every time recommendations concerning operations in endemic areas were ignored despite the vigilance of the Preventive Medicine Service.

34 Memorandum, Brig. Gen. H. J. Morgan, Director, Medical Division, Office of the Surgeon General, for Hospital Division, Office of the Surgeon General, 24 Mar. 1944, subject: Tuberculosis Center for Prisoners of War at Florence, Arizona.

35 Letter, Dr. C. E. Smith to Col. W. C. von Kessler, Surgeon, Camp Cooke, 19 Feb. 1945.

36 Letter, The Surgeon General, to Commanding Officer, Camp Cooke, Calif., through Commanding General, Ninth Service Command, 7 Aug. 1945, subject: Coccidioidomycosis.

37 See footnote 9 (1), p. 289.


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SERVICES PROVIDED BY THE COMMISSION ON EPIDEMIOLOGICAL SURVEY

One of the objectives of the Preventive Medicine Service was provision of facilities for accurate diagnosis of coccidioidomycosis in order that patients would have the benefit of care which would minimize risk of disseminated infection. Therefore, the Commission on Epidemiological Survey at the Stanford University Medical School prepared coccidioidin, standardized it, and distributed it freely on request to all the armed services. The Commission also performed serologic tests. In 1941, it performed 500 serologic tests; in 1942, 2,000 tests; and, in the succeeding years, it performed over 3,000 tests annually.

Since it was required that brief histories accompany specimens and that interpretations be included with reports, a considerable amount of consultative service developed. The data obtained also aided greatly in determining the values and limitations of the tests. These diagnostic aids made unnecessary most of the culturing of Coccidioides, which is known to be hazardous from the point of view of laboratory infections. However, in seven military installations, coccidioidal infections are known to have occurred in laboratories.

The Commission on Epidemiological Survey's facilities were always available for examination of suspicious cultures and were used freely by installations in the West. This arrangement minimized risk of infections in the laboratories of the Armed Forces, although it probably contributed to the continuation of laboratory infections at the Stanford University School of Medicine. Moreover, one of the most valuable aspects of the provision of diagnostic materials and facilities together with consultative service was the "listening post" it provided for the Preventive Medicine Service which took immediate and appropriate action as the need arose.

COLLABORATION OF ARMED FORCES ORGANIZATIONS WITH THE PREVENTIVE MEDICINE SERVICE

The Deputy Air Surgeon had maintained a special interest in coccidioidomycosis since the inception of investigations in 1941, and close liaison with the Preventive Medicine Service, Office of the Surgeon General, provided a continuity of interest and collaboration even after the Office of the Air Surgeon was organized as a unit independent of the Office of the Surgeon General.

Special mention should also be made of the extraordinary interest and contributions of a large number of medical officers, many of whose studies have been cited in this chapter, in effecting the objectives of the Preventive Medicine Service in the prevention of complications of coccidioidomycosis, in minimizing the movement of troops in endemic areas through necessary delimiting of such areas, and in achieving dust control for installations in


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known endemic areas. Moreover, data which they assembled also added significantly to knowledge of the pathogenesis, epidemiology, and clinical aspects of coccidioidomycosis.

An interesting study initiated by an officer at the Marine Corps Air Station, Mojave, Calif., established Mojave as an endemic area.38 The endemicity of this desert region was confirmed by positive serologic specimens sent from adjacent Muroc Army Airfield.

Another outstanding instance of Navy medical interest and cooperation occurred at the United States Naval Hospital, Corona, Calif., where all officer in the Medical Service Corps of the United States Navy provided specimens and histories which showed that the endemic area in the San Joaquin Valley extended to include the Naval Air Station, Vernalis, Calif. Subsequent careful studies revealed that the Corona region itself was mildly endemic.

In the endemic area of Texas, investigations at William Beaumont General Hospital and Fort Bliss confirmed the fact that coccidioidomycosis lead been locally acquired in the El Paso area. Investigation at Peyote Regional Hospital established the Peyote area of Texas as one of high endemicity. In discussing the surgical manifestations of coccidioidomycosis, Quill and Burch reviewed endemicity of coccidioidomycosis in Texas military installations.39

A study at Regional Hospital, Fort Ord, Calif., aided in delimiting adjacent endemic areas and in identifying coexisting tuberculosis and coccidioidomycosis.40 Working closely with the Commission on Epidemiological Survey, staff members at Hammond General Hospital also carried on coccidioidin studies, sampling various personnel returned from overseas, including a considerable number from Australia. However, these investigations could locate no one who reacted positively to coccidioidin.41 Members of the staff at Letterman General Hospital, San Francisco, Calif., took an active role in the investigation of cases, aad staffs at the various service command laboratories, especially the Ninth at Monterey, Calif., the Second at New York; N. Y., and the Fourth at Fort McPherson, Ga., took a significant interest in the subject. The staffs of Roads General Hospital, N. Y., Percy Jones General Hospital, Micki., -Moore General Hospital, N. C., and Baxter General Hospital, Wash., were very much alert to their problems of coccidioidomycosis.42 Very often one could trace the location of medical officers aware of coccidioidomycosis by the reporting of specimens from patients having recognized coccidioidal

38 Pfanner, E. F.: Coccidioidomycosis at the U. S. M. C. Air Station, Mohave, California.U. S. Nav. AI. Bull. 46: 229-236, February 1946.

39 Quill, L. M., and Burch, J. C.: Surgical Manifestations of Coccidioidomycosis. Ann. Surg. 120: 670-679, October 1944.

40 Cherry, C. B., and Bartlett, A. G.: The Diagnosis of Acute Coccidioides immitis Infections. Bull. U. S. Army M. Dept. 5: 190-193, February 1946.

41 (1) Denenholz, E. J., and Cheney, G.: Diagnosis and Treatment of Chronic Coccidioidomycosis. Arch. Int. Med. 74: 311-330, November 1944. (2) Cheney, G., and Denenholz, E. J.: Observations on the Coccidioidin Skin Test. Mil. Surgeon 96: 148-156, February 1945.

42 (1) Rifkin, II., Feldman, D. J., Hawes, L. E., and Gordon, L. E.: Coexisting Tuberculosis and Coccidioidomycosis. Arch. Int. Mod. 79: 381-390, April 1947. (2) Groover, M. E., Jr., Cleve, E. A., Bornstein, S., Rice, A. G., Galloway, A. F., and Macaluso, C. P.: Sensitivity of Skin to Histoplasmin in Differential Diagnosis of Pulmonary Disease. Arch. Int. Med. 80: 496-513, October 1947.


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infections. This was evident in the assignments of Maj. Lewis T. Bullock, a pioneer worker on coccidioidomycosis at Duke Field, Ariz., in the Western Flying Training Command. as he moved back and forth across the country. Another example is in the assignments of Lt. Col. J. Murray Kinsman-first coccidioidomycosis-control officer at Lemoore Army Airfield who moved first to Florida, then to the Schick General Hospital, Clinton, Iowa, to Walter Reed General Hospital, Washington, D. C., and finally to Fort Bragg, N. C., where at each station many cases of coccidioidomycosis were recognized coincidentally with his arrival.

A number of interesting diagnostic and epidemiologic problems, some of which were reported by Maj. Dumont Clark and J. H. Gilmore, were worked out by the staff of McCloskey General Hospital, Temple, Tex.43 At LaGarde General Hospital, New Orleans, Ira., several cases of coccidioidomycosis in Negro troops from the Desert Training Center were recognized. The primary infections in these cases had not been recognized in California or in Arizona. Several cases of primary coccidioidomycosis in troops formerly in the Desert Training Center were discovered at Tayer General Hospital, Nashville, Tenn., and proved serologically.

While a complete listing of all the helpful investigations is not possible, special mention should be made of the contributions of staffs at three tuberculosis hospitals for Army personnel Fitzsimons, Bruns, and Moore General Hospitals. The histories accompanying specimens from Fitzsimons General Hospital, Denver, Colo., contributed to knowledge of distribution and pathogenesis of infection, especially of coccidioidal cavitation, as well as to laboratory methods 44 The staff of Bruns General Hospital, Santa Fe, N. Mex., also took all active part in investigations. There, Capt. H. E. Bass focused attention oil the problem of differentiation from tuberculosis,45 and Capt. S. R. Rosenthal developed a theory of contagiousness of coccidioidomycosis based upon instilling pus or sputum into tracheas of guinea pigs.46 The importance of coccidioidal residual pulmonary lesions in differentiation from tuberculosis was apparent, also at Moore General Hospital. As an outgrowth of this interest, the group at Moore wrote an extensive paper oil the results of skin testing.47

Both in the Office of the Surgeon General and in the field, there was a close liaison between clinical and preventive medicine personnel. Medical consultants for the Eighth and Ninth Service Commands were alert to problems of coccidioidomycosis and frequently stimulated the interest of medical groups unfamiliar with the infection.Col. Verne R. Mason, medical consultant to the

43 Clark, D., and Gilmore, J. H.: A Study of 100 Cases With A Positive Coccidioidin Skin Test. Ann. Int. Med.24: 40-59, January 1946: correction Ibid.24: 519, March 1946.

44 Wilhelm, S.: Isolation of Coccidioides immitis from Sputum. Bull. U. S. Army M. Dept. 5: 468-473, April 1946.

45 (l) Bass, II. E.: Coccidioidomycosis and Tuberculosis-Diagnostic Problem. Tuberculology 7: 72-75, January 1945. (2) Bass, 11. E., Schomer, A., and Berke. R.: Coccidioidomycosis: Persistence of Residual Pulmonary Lesions. Arch. Int. Med. 82: 519-528, December 1948. (3) Bass, 11. E., Schomer, A., and Berke, R.: Question of Contagion in Coccidioidomycosis, a Study of Contacts. Am. Rev. Tuberc. 59: 632-635, June 1949.

46 (1) Rosenthal, S. R., and Routien, J. B.: The Infectiousness of Coccidioidomycosis. Science 104: 479, 22 Nov. 1946. (2) Rosenthal, S. R., and Routien, J. B.: Contagiousness of Coccidioidomycosis, An Experimental Study.Arch. Int. Med. 80: 343-357, September 1947.

47 See footnote 42 (2), p. 300.


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Surgeon, Ninth Service Command, made an extensive review of the problem of coccidioidal pulmonary cavitation.48

Even from overseas, requests for consultative service and diagnostic facilities were received by the Commission. It was hoped that evidence of other endemic areas would be obtained, but this was never realized. Coccidioidin was distributed widely to Europe, North Africa, the Near East, India, Australia, China, the South Pacific, the Philippines, Hawaii, and North and South America, and, while some serum specimens were sent in from these scattered areas, the only positive specimens found were in the military personnel who had been infested in the arid Southwestern United States prior to overseas assignment. Since World War II, the continued activities of the Armed Forces Epidemiological Board have disclosed two new arid endemic areas: Lara, Venezuela, and the Paraguayan Chaco.49

While widespread collaboration continued throughout all medical branches of the services, the greatest amount of epidemiologic and practical data was assembled through the integrated studies of the Western Flying Training Command. In addition to the studies of Sweigert, Clark, and others, Maj. H. W. Jamison and Maj. J. R. Colburn were among those who made outstanding studies of roentgenograpic lesions.50 In the Commission on Epidemiological Survey studies of coccidioidomycosis at the four basic training fields of the San Joaquin Valley, everyone from the succession of surgeons to the enlisted personnel participated enthusiastically. These participants are indicated in the Commission's first published article on seasonal distribution and dust control.51

CONTROL MEASURES

The control of coccidioidomycosis by means of recognition of the primary infection and proper care of the patient has been emphasized throughout this discussion. Some of the lessons learned with respect to the significance and limitations of the skin test and serologic tests will be indicated later (p. 303). Certainly, in any evaluation of control measures, one must be certain of diagnosis, which can be achieved only by laboratory methods, including the skin test.

Control through more accurate knowledge of the geographic distribution of endemic areas aids in diagnosis by raising the level of suspicion. Mere travel through an endemic area may provide the exposure. From the military standpoint, knowledge of endemic areas is even more important in providing

48 Letter, Lt. Col. V. R. Mason, MC, to Commanding General, Army Service Forces. Attention The Surgeon General, 7 Oct. 1943, subject: Report on Patients With Pulmonary Cavities Following Coccidioidomycosis.

49 (1) Campins, H., Schary, M., and Gluck, V.: Coccidioidomicosis (Enfermedad de Posadas) Su Comprobacion en Venezuela. Arch. venezol. patol. trop. y parasit. med. 1: 1-20, October 1949.(2) Gomez, It. F.: Endemism of Coccid ioidomycosis in the Paraguayan Chaco. California Med.73: 35-38, July 1950.

50 (1) Jamison, H. W.: A Roentgen Study of Chronic Pulmonary Coccidioidomycosis. Am. J. Roentgenol. 55: 396-412, April 1946. (2) Jamison, 11. W., and Carter, R. A.: The Roentgen Findings in Early Coccidioidomycosis. Radiology 48: 323-332, April 1947. (3) Colburn, J. R.: Roentgenological Types of Pulmonary Lesions in Primary Coccidioidomycosis. Am. J. Roentgenol.51: 1-8, January 1944. (4) See footnote 16, p. 292.

51 See footnote 9 (1), p. 289.


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information on where not to establish large camps or conduct maneuvers unless climatic and topographic advantages outweigh the hazards of coccidioidomycosis. Here, however, additional special knowledge with respect to the infection spectrum, racial susceptibility, and infection rate is of importance. For instance, an installation which can be stabilized and which contains white personnel would not be a serious problem even in an area of high incidence because everyone would soon be infected and, if properly cared for, would recover without many serious complications and would subsequently be immune. However, transient personnel in such an area could present serious problems during the coccidioidomycosis season. Serious consideration should be given to bringing Negro troops into an area of high endemicity because, as it will be pointed out (p. 307), dissemination occurs in 10 percent of those clinically ill and in over 2 percent of all those infected.

The importance of dust control became increasingly apparent during the course of World War II, although application of dust-control measures was limited. Of no value during maneuvers or with ground forces in training, dust control proved very valuable in reducing rates of coccidioidomycosis at airfields. There, in permanent installations, the requisite steps could be undertaken. Dust control itself constituted a research problem because it was necessary to determine monthly infection rates in order to evaluate the effect of dust control. This control method will be discussed, therefore, in the following section on research.

RESEARCH DURING WORLD WAR II

Methods of Diagnosis

Coccidioidin.-First in importance in research accomplishments are the combined field and laboratory studies which permitted the widespread use of coccidioidin. The use of coccidioidin is the first step in diagnosis, vital to the clinical care of the patient; in epidemiologic investigations; and indirectly in control of the environment. Coccidioidin was prepared by the group at Stanford University as an activity of the Commission on Epidemiological Survey and was distributed as a service. The data accumulated from reports on its use, however, were ample reward for this effort. The active principle of coccidioidin was shown to be very stable, withstanding autoclaving and remaining potent for years even when diluted. The reaction was of the bacterial

type, not a passive transfer of sensitivity. As prepared on asparagin synthetic medium, coccidioidin was not significantly antigenic. Since it did not evoke humoral antibodies, it could be used without complicating subsequent serologic tests. It did not aggravate a quiescent infection, and, even in very sensitive patients, except for local discomfort and slight fever and malaise, the only complication encountered was occasional erythema nodosum. Sensitivity was always demonstrable in patients with uncomplicated primary infection. Although dermal sensitivity appeared earlier than diagnostic precipitins or


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complement-fixing antibodies, it was absent in one-sixth of all patients during the first week of illness. However, with the use of
1:100 dilution of coccidioidin, dermal sensitivity always appeared by the end of the third week. Sweigert and Willett found that sensitivity to 1 :1,000 coccidioidin was sometimes slightly slower.52 The degree of sensitivity was shown both by Beare and by the Commission on Epidemiological Survey to increase during the first 3 weeks of illness.53 These two studies also confirmed previously observed association of erythema nodosum with maximal sensitivity; the sensitivity to coccidioidin was found to be quite durable, even in one group tested outside the endemic area. However, Cheney and Denenholz, as a result of tests in an adjacent nonendemic area, believed that sensitivity was less tenacious.54 Certainly sensitivity was frequently lost during dissemination of the infection, and a definite association was noted between sensitivity and favorable prognosis.

When stronger coccidioidin was used, cross-reactions were observed. Indeed, care had to be taken to standardize coccidioidin both for specificity and potency. The coccidioidin did not cross-react with bacteria or viruses, but several investigators found definite positive reactions to it occurring nonendemic areas in the Middle East.55 Emmons and Ashburn called attention to apparent cross-reaction with Haplosporangium parvum.56 As the result of positive reactions seen in new arrivals at the San Joaquin Valley airfields, an association was suggested in 1943 between these cross-reactions, histoplasmosis, and pulmonary calcification in those persons negative to tuberculin. Two years later, as the result of the reports of Christie and Peterson and of Palmer, extensive studies of histoplasmin sensitivity and pulmonary calcifications were inaugurated and were continued after World War II. 57 The Commission on Epidemiological Survey summarized their experiences in the American Journal of Public Health . 58 It was found that histoplasmin produced a much higher proportion of cross-reactions in those persons who had had coccidioidomycosis than coccidioidin produced ill those with dominant sensitivity to histoplasmin. Indeed, if histoplasmin was too concentrated, it evoked larger reactions than did coccidioidin during a course of clinical coccidioidomycosis. Used in "balance," however, the tests could be interpreted without difficulty.

52 See footnotes 16 and 17, p. 292.

53 (1) Beare, W. K.: Primary Pulmonary Coccidioidomycosis. Air Surgeon's Bull. 2: 397-399, November 1945. (2) See footnote 10, p. 292.

54 See footnote 41 (2), p. 292.

55 Smith, C. E.: Coccidioidomycosis. M. Clin. North America 27: 790-807, May 1943.

56 Emmons, C. W., and Ashburn, L. L.: The Isolation of Haplosporangium parrum n. sp. and Coccidioides immitis from Wild Rodents; Their Relationship to Coccidioidomycosis. Pub. Health Rep. 57: 1715-1727, 13 Nov. 1942.

57(1) Christie, A., and Peterson, J. C.: Pulmonary Calcification in Negative Reactors to Tuberculin. Am. J. Pub. Health 35: 1131-1147, November 1945. (2) Christie, A., and Peterson, J. C.: Pulmonary Calcification and Sensitivity to Histoplasmin, Tuberculin and Hoplosporangin. J. A. M. A. 131: 658-660, 22 June 1946. (3) Christie, A., and Peterson, J. C.: Histoplasmin Sensitivity. J. Pediat. 29: 417-432, October 1946. (4) Palmer, C. E.: Nontuberculous Pulmonary Calcification and Sensitivity to Histoplasmin. Pub. Health Rep. 60: 513-520, 11 May 1945. (5) Palmer, C. E.: Geographic Differences In Sensitivity to Histoplasmin Among Student Nurses.Pub. Health Rep. 61: 475-487, 5 Apr. 1946.

58 Smith, C. E., Saito, M. T., Beard R. R., Rosenberger, H. G., and Whiting, E. G.: Histoplasmin Sensitivity and Coccidioidal Infection.1. Occurrence of Cross-Reactions. Am. J. Pub. Health 39: 722-736, June 1949.


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Serologic tests.-Simultaneous precipitin and quantitative complemeutfixation tests provided as service functions by the Commission on Epidemiological Survey were extremely important in the diagnosis and treatment of coccidioidal infections. Again, the data obtained from reports by investigators permitted an evaluation of the procedures. These tests indicated specificity with respect to viral, rickettsial, spirochetal, bacterial, and most other mycotic infections.59 There was evidence of irregular cross-reaction in histoplasmosis. The combination of the two tests detected over 90 percent of clinically manifest, nondisseminating primal infection but less than 10 perceut of asymptomatic infections. It confirmed three-fifths of coccidioidal pulmonary cavities and 99 percent of dissemitlating infections. Precipitins only were demonstrated in 44 percent, acid complement fixation alone in 22 percent of positive serums from those with uncomplicated primary infections. The tests were positive only after allergy was established unless the infection was disseminating and the patient was allergic. Thus, coccidioidan was shown to be a useful screen. Precipitin tests were more useful early in the course of infection; complement-fixation tests were more useful later. Precipitins were established within the first monthly of illness, although within the first week only one-half of them had converted from negative to positive; in most of the serums, antibody coiitei.t lead reverted from positive to Negative within 3 months. Complement-fixation tests converted for 3 months, while reversions were slower. Even after uncomplicated primary infections, positive tests sometimes persisted for years. Regarding prognosis, it was observed that the titer of complement; fixation rose with severity of infection. Less than 1 in 40 patients witll nondissemiliating coccidioidal disease had maximal complement-fixing titers in excess of 1 in 16, but more than one-half of the patients with disseminating disease exceeded that level. While patients with solitary extrapulmoliary lesions had findings comparable to those with nondisseminating disease, titers exceeded 1 in 16 in 95 percent of the patients with extensive fatal lesions. Precipitins and complement-fixing antibodies were demonstrable in ascitic and pleural fluid due to coccidioidomycosis. Complement was fixed in three-quarters of the patients with coccidioidal meningitis and, if present, it was diagnostic of coccidioidal etiology.

Recognition of Endemic Areas

Knowledge, of the endemic areas is of great importance in recognizing clinical coccidioidal infection and in planning its control. Prior to World War II, the endemic area in the United States was not clearly defined. It was believed to center in the southern San Joaquin Valley of California, while its northern limit was uncertain. On the basis of some cases reported from southern California, this area was suspect.60 just before the war, isolated

59 See footnote 11, p. 289.

60 Kessel, J. F.: Recent Observations on Coccidioides Infection. Am. J. Trop. Med.21: 447-453, May 1941.


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cases were reported from Tucson 61 and Phoenix, Ariz.,62 while the regions around El Paso and San Antonio, Tex., had been established as other endemic areas by a few reported cases.63 Northern Mexico was suspect, while the Chaco region of Argentina was the only other such area known.64

By means of extensive coccidioidin tests and from records of clinical cases (proved serologically or by recovery of the fungus) in which the known incubation period fixed the site where the infection was acquired, the endemic areas became much more accurately delimited. The studies at the San Joaquin Valley airfields showed that the incidence in that valley was maximal in the south. Further north, at Merced and Modesto, it was very spotty. Along the west side of the valley, incidence extended further north, nearly to Tracy, and over the Coast Range, as Shelton demonstrated at Camp Roberts, into Monterey and San Luis Obispo counties. Skin tests and recognized cases also implicated contiguous Santa Barbara, Ventura, and Los Angeles counties.

Spotty incidence in Riverside and San Bernardino counties was also recognized, and the region around San Diego was reconfirmed as mildly endemic. Imperial County was uncertain but "probable." The experiences of Army Air Forces Western Flying Training Command, 65 the Army Ground Forces in the California-Arizona Maneuver Area, and the prisoner-of-war camp at Florence proved that southern and central Arizona were the most highly infected of all the areas in the United States. The studies in the Western Flying Training Command also indicated that there were infected areas in the southern tip of Nevada and southwest Utah, as well as in southern New Mexico. The region of Albuquerque and Sante Fe, N. M., was free of infection. In Texas, the endemic area was not proved to extend as far north as Wichita Falls, but it did extend south along the Rio Grande to the Mission-McAllen region. No other endemic areas were found in the continental United States.

Coccidioidin tests of Italian and German prisoners of war captured in North Africa were uniformly negative, as were tests of natives in Arabia. However, shortly after the war, the work of the Commission on Epidemio logical Survey aided in discovering two other endemic areas in the arid province of Lara, Venezuela, and the Paraguayan Chaco. Thus, all known endemic areas are arid.

61 (1) Woolley, M. T.: Mycological Findings in Sputum. J. Lab. & Clin. Med. 23: 553-565, March 1938. (2) Farness, O. J., and Mills, C. W.: Coccidioides Infection: A Case of Primary Infection in the Lung with Cavity Formation and Healing. Am. Rev. Tuberc. 39: 266-273, February 1939. (3) Storts, B. P.: Coccidiodal Granuloma Simulating Brain Tumor in a Child of Four Years. J. A. M. A. 112: 1334-1335, 8 Apr. 1939.

62 (1) Phillips, E. W.: Presence of Coccidioidal Infection in Phoenix.Southwestern Med.23: 48-51, February 1939. (2) Brown, O. H.: Coccidioides Infection in Arizona-Allergic Factors in Nodules? Southwestern Med. 23: 131-132, April 1939.

63 (1) Caldwell, G. T.: Coccidioidal Granuloma, A Report of Three Cases Recognized in Texas. Texas State J. Med. 28: 327-333, September 1932. (2) Smith, L. M.: Coccidioidal Granuloma; Report of a Case Originating in Western Texas. Arch. Dermat. & Syph. 28: 175-181, August 1933. (3) Smith, L. M., and Waite, W. W.: Coccidioidal Granuloma; Report of a Fatal Case. Southwestern Med.18: 305, September 1934.(4) Lehmann, C. F., and Pipkin, J. L.: Coccidioidal Granuloma (Chronic Hypertrophic). Arch. Dermat. & Syph. 31: 586-589, April 1935. (5) Foley, M. P., Love, J. F., Broders, A. C., and Heilman, F. R.: Coccidioidal Granuloma; Report of a Case Originating in Texas. West. J. Surg.48: 738-741, December 1940.

64 See footnote 1 (1) and (2), p. 285.

65 Lee, R. V.: Coccidioidomycosis in the Western Flying Training Command. California & West. Med. 61: 113-134, September 1944.


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Pathogenesis of Coccidioidomycosis

One of the primary purposes of the intensive study of the San Joaquin Valley Army airfields was to ascertain the frequency of in apparent infection, clinical disease, and especially dissemination. All permanent party personnel were tested with coccidioidin soon after arrival at a field. Initially, there was great interest in ascertaining the number of coccidioidin reactors who might develop manifestations of the disease. None did, nor were any such cases reported in the entire Western Flying Training Command. Apparently, second attacks of primary infection are very rare. Every 6 months, those personnel previously negative to coccidioidin were retested. The proportions of various types of coccidioidomycosis were revealed.66 Of 1,351 infections, 60 percent were asymptomatic and only 25 percent were manifest clinically and had been diagnosed (table 50). Erythema nodosum occurred in 24 percent of infected white females, in 4.3 percent of infected white males, but very rarely in Negroes (table 51). This form of the disease can serve as a useful index of infection. Dissemination of the organism occurred in about 1 percent of clinically manifest infections in white males and in 0.25 percent of all their infections; whereas disseminated infections occurred over 10 times as frequently in Negroes despite the fact that Negroes had the same housing, food, and medical care as the white males.

TABLE 50.-Distribution of primary coccidioidal infections at Minter, Gardner, and Lemoore Fields

The study by Willett and Weiss (p. 292) of the infections at indicated 8 percent disseminations among Negroes with clinical illness. For the entire Western Flying Training Command, Lee and Jamison suspected an even higher risk of dissemination in the Negro.67

66 See footnote 9 (2), p. .289.

67 See footnotes 65, p. 306, and 50 (1), p. 302. 


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TABLE 51.-Distribution of primary coccidioidal infections in white personnel at Miner, Gardner, and Lemoore Fields, 1 July 1941 to 31 December 1945.


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These findings reveal a grave hazard in exposing Negroes to coccidioidal environment, a point to be borne in mind in future military planning. However, these studies also indicate that among white troops it should be possible to maintain a stabilized command in a coccidioidal endemic area without too grave a risk. The value of periodic coccidioidan testing is apparent, since a conversion constitutes the most, sensitive diagnostic procedure. Moreover, once the person is positive, the doctors need not worry that an attack of influenza or pneumonia is coccidioidomycosis.

Special mention may be made of coccidioidal pulmonary cavitation. In the Army experience, it occurred as follows: In 2 percent of 753 hospitalized cases in the San Joaquin Valley airfields, in 4 percent of Goldstein and Louie's cases and in 4 percent of Colburn's 75 cases from Camp San Luis Obispo, in 6 percent of Willett and Weiss' 100 March Field cases, and in 8 percent of Sweigert, Turner, and Gillespie's 77 cases from Davis-Monthan Field. These cavities were seen to be a complication of the primary infection and not comparable to disseminating coccidioidal disease. The relatively benign nature of these cavities was discussed in an article by Smith, Beard, and Saito who pointed out that among 153 military patients with such cavities, three-fifths were diagnosed incidentally and two-fifths had symptoms; among civilians, only one-quarter were asymptomatic.68 This study on the pathogenesis of coccidioidal cavities and Bass' studies also were evidence against the theory of contagion which Rosenthal advanced after he infected guinea pigs by instilling coccidioidal pus down their tracheas (p.301).

Three additional military papers dealt with pathogenesis of coccidioidomycosis. Kunstadter and Pendergrass, at Ashford General Hospital, White Sulphur Springs, W. Va., presented evidence of asymptomatic pulmonary lesions, including observations of an anatomical specimen from a soldier on whom an autopsy was performed for accidental death.69 Schlumberger summarized 13 cases of coccidioidal meningitis from material of the Army Institute, of Pathology.70 The most ambitious study and one supported by the Commission on Epidemiological Survey was that of Forbus and Bestebreurtje.71 It contains a comprehensive illustrated discussion of the pathogenesis based on specimens from 95 patients with disseminated coccidioidomycosis. Certain of the conclusions with respect to geographic distribution were taken from protocols which were incomplete; thus, Oregon and Missouri were listed as endemic areas. Also, based upon the continuing endogenous reinfections of immunologic defectives, these investigators deduced that disseminations would continue to develop in veterans for 10 years and would cause a number of deaths. Fortunately, these apprehensions are not being borne out.

68 See footnote 12 (1), p. 290.

69 Kunstadter, R. H., and Pendergrass, It. C.: Primary Coccidioidomycosis; A Possible Pediatric Problem. J. A. M. A. 127: 624-827. 17 Mar. 1945.

70 Schlumberger, H. G.: A Fatal Case of Cerebral Coccidioidornycosis With Cultural Studies. Am. J. M. Sc. 209: 483-495, April 1945.

71 Forbus, W. D., and Bestebreurtje, A. M.: Coccidioidomycosis: A Study of 95 Cases of the Disseminated Type With Special Reference to the Pathogenesis of the Disease. Mil. Surgeon 99: 653-719, November 1946.


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Infection Rates and Seasonal Distribution

The intensive study of the San Joaquin Valley airfields provided an opportunity for determining monthly infection rates at those stations. Clinically recognizable infections were listed according to the months in which they occurred, and in apparent infections were distributed proportionately. The susceptibles exposed each month were known, and infection rates were calculated. The sum of the monthly infection rates gave the annual infection rate.72 Throughout the study, Merced remained remarkably free of infection and virtually served as a control.

Monthly infection rates of Minter, Gardner, and Lemoore fields which were located in the endemic areas are presented in table 52. Annual rates for these three fields as well as for Merced are presented in table 53. At each of the three fields in the endemic area, the initial season was the worst. As will be noted (p. 313), the presence of excessive dust was associated with each of the new fields during the initial seasons. Tables 52 and 53 also show that

TABLE 52.- Monthly incidence of coccidioidomycosis at San Joaquin Valley Army airfields, and monthly precipitation, 1941-45

72 This method of computing the annual rate is not the usual procedure folloed by the Medical Statistics Division Office of the Surgeon General, since equal weight is given to each month regardless of the amount of variation in the number of susceptibles from month to month. The following method is generally used: Annual rate per 1100 susceptibles equals the total infections during the year multiplied by 100 divided by the average number of susceptibles during the year. In this chapter, the data are presented as they were originally calculated by the author. - E. C. H.


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TABLE 52.-Monthly incidence of coccidioidomycosis at San Joaquin Valley Army airfields, and monthly precipitation, 1941-45-Continued


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greatest incidence of the disease occurred in seasons preceded by heavy rainfall in the winter and spring. Lemoore had much lower rates than Minter and Gardner fields to its south. From the infection rates, one can readily understand why nearly all longtime residents of the San Joaquin Valley react to coccidioidal. However, the incidence, even during the initial year at Winter when one-quarter of the susceptibles were infected, was far below that in Arizona where, in the region of Florence and Williams Field, one-half of the susceptibles were infected within 6 months.

The monthly infection rates rose and declined, according to the rainfall (table 52). The peak occurred in the dusty summer and fall, and the rate continued to be high until the winter rains appeared. While the effect of heavy winter rainfall in providing abundant infection chlamydospores during the ensuing summer is hypothetic, the immediate beneficial effect of the rain in keeping the chlamydospores from blowing around in the air is obvious.

TABLE 53.-Annual coccidioidal rates at Army airfields in the San Joaquin Valley and precipitation at Bakersfield, Calif., 1941-45

Dust Control

Appreciation of the importance of dust control at, the permanent installations in the endemic areas came from all directions. At the 1944 annual meeting of the Army Epidemiological Board, the advisability of environmental (dust) control of coccidioidomycosis was discussed. Dr. Blake, as chairman, and General Bayne-Jones, representing The Surgeon General, requested the Commission on Epidemiological Survey to direct attention to the problem.73

73 (1) Letter, Brig. Gen. S. Bayne-Jones to Dr. C. E. Smith, 7 May 1944. (2) Letter, Dr. C. E. Smith to Brig. Gen. S. Bayne-Jones, 22 May 1944.


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As a matter of fact, this type of control was already being planned, but the directive from the Preventive Medicine Service, Office of the Surgeon General, greatly strengthened the Commission's efforts. Dust control was also supported by the Air Surgeon. On the individual fields, the commandants, post surgeons, post engineers, and coccidioidomycosis-control officers were well aware of its advisability. Originally considering dust control only as a procedure to protect engines from being ruined, the Pacific Division, United States Army Engineers, located at San Francisco, became very much interested in dust control in preventing coccidioidomycosis. Maj. Howard B. Sprague, Army Air Forces liaison officer to that Division, made a very complete review of the dust problem at Gardner, Lemoore, Davis-Monthan, Luke, and Marana Fields.74 Particularly striking was his comparison of coccidioidomycosis at Davis-Monthan and Marana. Both fields were located near Tucson, Ariz., and their incidence of coccidioidomycosis was parallel until Davis-Monthan organized systematic dust control. Then the incidence of coccidioidomycosis at Davis-Monthan fell sharply while that of Marana continued unchanged.

In the fall of 1941, there were vast earth scars where Minter and Gardner Fields were being built. As there was no dust control in operation, the locally generated dust billowed in clouds over the areas. The highest coccidioidal infection rates of the study occurred during this season of maximal dust at these two fields (table 53). The following year (1942-43), during which Lemoore Field was opened, was a season of relatively low incidence rates at all three fields. However, in the second year at Lemoore (1943-44), the incidence rate was only one-half that of the preceding years while it had increased at both Minter and Gardner. The improvement in local dust control at Lemoore had more than offset the more favorable conditions for Coccidioides.

The measures largely responsible for local dust control up to the 1944 season had been grassing and construction of surfaced roads. After the relatively bad year of 1943-44, the surgeons, coccidioidomycosis control officers, commanding officers, and post, engineers at Minter and Gardner Fields worked diligently to effect additional improvements. The principal areas left without turf, and those which therefore presented problems, were the areas used for calisthenics, baseball, volleyball, and other forms of physical training. Some of these areas were surfaced with asphalt which was not completely satisfactory as it is both expensive and hard on the feet in hot weather. A crushed rock or gravel surface causes injuries and was therefore not used. The decision was made to try oiling these areas. Crude oil was considered but was rejected as it forms a crust and breaks into lumps as well as stains clothing and irritates the skin. Highly refilled oils were finally selected for use in dust control because of their availability and because it was found that they are nonirritating, that they penetrate the soil, and that, even if the treated soil breaks

74 Memorandum, Maj H. B. Sprague, Army Air Forces Liaison Office, Pacific Division, United States Army Engineers, for Lt. Col. L. B. McCloud, Army Air Force Headquarters, I Oct. 1945, subject: Summary of the Relation Between Occurrence of Dust and Incidence of Coccidioidomycosis (Valley Fever) at Army Air Fields in California and Arizona.


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into dust, the oil-impregnated particles fall back to the ground instead of being blown into clouds and dispersed.

In the spring of 1944, a highly refined oil was applied to the athletic areas at both Minter and Gardner Fields. Despite two applications, the procedure was a failure at Gardner. This field had been built on the very fine silt of an old lake bottom and because of the character of the soil the oil merely formed a crust. When the crust broke, the dust was exposed. At Minter Field, however, the soil was heavier and contained more clay, so that the application of the oil was more successful. Preliminary tests conducted on volleyball courts determined optimal dosage to be one quart per square yard. When oil was applied in late May and early June, dust was fairly well controlled until the fall. In October, the effect of the oil was diminished, but fortunately late October rains put an end to the dusty season. In 1945, two applications were necessary at Minter Field. Just after the first application in May, unseasonable rains appeared and drove in the oil. By August, the areas became dusty, and, upon a sudden increase in number of cases of coccidioidomycosis, it was decided to reapply oil in September, after which there was a prompt decline in infections.

A comparison of the infection rates of Minter and Gardner Fields in the fall of 1944 indicated that Minter had benefitted by the oiling. Infection rates for the 6 months from 1 June to 30 November 1944 were 6.87 per 100 susceptibles at Minter and 7.62 at Gardner. While the difference between these rates is not great, this was the first time that the Minter rate had been less than the Gardner rate. Rates for infections for the same period during the preceding year were 12.22 at Minter and 10.13 at Gardner. In 1943, the Minter infection rate exceeded the Gardner rate in 4 of the 6 months. In 1944, the Gardner rate exceeded the Minter rate in 4 of the 6 months. Moreover, the only months when the 1944 Minter rates exceeded the Gardner rates were June and October when the effectiveness of the oiling had been diminished at the former field. Rates during July, August, and September at Gardner Field all exceeded rates for October at that field, while the October Minter rate was almost as high as any two of the preceding months combined.

Another item of evidence supports the argument that dust control is effective in reducing the incidence of coccidioidomycosis. In the summer and fall of 1943, enlisted personnel of the medical detachment at Minter Field suffered 15 coccidioidal infections during a 6-month period. The number of susceptibles was an even 100, so the infection rate was 15 per 100 men. Athletic fields were behind the station hospital, and the barracks of the enlisted personnel were directly at the edge of the athletic areas. In the summer and fall of 1944 and after initiation of dust-control procedures, in the same period of time, only two infections were acquired. The comparable 1944 infection rate was 5 per 100 men. Admittedly, the number are small, but the trend coincided with the rest of the evidence favoring dust control.

Interesting comparison in rates can be made for 1945. The Minter Field strength was three times that of a prisoner-of-war group which was performing agricultural labor in the vicinity, yet as many prisoners were being hospitalized


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for coccidioidomycosis per day, as were Minter Field personnel per month. Within 2 months and 10 days, June to August, 22 Minter Field personnel were hospitalized for coccidioidomycosis while 150 prisoners of war were hospitalized for the same disease. Dust was well controlled at Minter Field, where the airfield personnel were stationed, but the prisoners were harvesting potatoes and sugar beets in maximal dust nearby.

In summary, local dust-control measures certainly seem warranted in preventing coccidioidomycosis. Of course, definite knowledge as to where the infections have been acquired is necessary. For example, local dust control at the base area of Camp Roberts or at March Field proper was not indicated, since infections of personnel at these two installations were acquired on bivouacs. Where the installation itself is probably infected, dust control should be employed to the fullest extent possible. Whenever feasible, grassing should be used. Surfacing of roads and, to a limited degree, athletic areas is important. Many athletic areas cannot be surfaced because of excessive heat and the danger of injuries after falls. If turf cannot be maintained on such areas, a highly refined oil may be tried. However, the character of the soil should first be examined. If the soil is a fine, loose silt-like that of Gardner Field success is unlikely. If it is a heavy, adobe type of soil, the outlook is favorable. In any event, preliminary tests should be run to prove effectiveness, to decide the product to be used, and to fix the quantity to be applied. Volley ball courts are especially suitable for such tests. In carrying out these dust control procedures, a close liaison between the post engineer, the surgeon and his staff, and the commanding officer is very important. Also, the engineers responsible for dust control in the respective service commands should be consulted, and their advice should be heeded. In addition, experience has shown that in order to avoid exposure of personnel to dust in endemic areas, every effort should be made to develop an aquatic physical training program during the hot months which correspond to the season of high incidence of coccidioidomycosis.

SUMMARY

The leadership that was undertaken by The Surgeon General of the Army and his preventive medicine representatives in safeguarding the health of United States troops was well portrayed in the experience of the armed services with coccidioidomycosis in World War II. The Preventive Medicine Service of the Medical Department aided in the provision of vital diagnostic and service facilities; through the Army Epidemiological Board, it fostered both fundamental and applied research, including environmental control, and throughout the war it maintained constant vigilance in order to minimize exposures in endemic areas. The Army Air Force demonstrated a kindred interest. Thus, there resulted a fine collaboration which developed a successful control program and performed extensive and rewarding research. The Army Ground Force was not as alert or responsive; its control programs and


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research were minimal and very largely dependent upon the unsupported enthusiasm and initiative of individual medical officers. The increase in medical knowledge as the result of the influx of the physicians of the Army of the United States into endemic areas of coccidioidomycosis is especially notable. Intrigued by this "new" infection, most medical officers contributed wholeheartedly to programs of control and research.