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Part 8

Table of Contents


World War I (1914-1919)


At the end of 1916, almost the whole of the United States Regular Army and the National Guard were mobilized in the Southern Department, chiefly along the Mexican border. This had come about through a series of annual training maneuvers starting in 1910, and through the punitive expedition into Mexico in 1916 when General Pershing led about 12,000 troops against the force under General Francisco Villa. In all of these situations, the health of the troops was remarkably good, attesting to the enforcement of measures of military hygiene which had been improved constantly since the Spanish-American War. No innovations in preventive medicine practice were made, but experience was gained, capable men were developed, and the preventive medicine component of the Medical Department was strengthened by the formation and training of additional units. Without a knowledge of what was hidden in the unforseeable future, a capacity to cope with problems that arose in 1917 was acquired from the basic experiences of the preceding 7 years.

The United States was alarmed by the attack of Austria on Serbia on 28 July 1914, and emotionally aroused by Germany's invasion of Belgium on 4 August 1914, which drew England and France into alliance with Russia, Serbia, and Belgium, signalizing the beginning of World War I.

During the next period of almost 3 years of anxious watching of the progression of the great war in Europe as it went against the Allies, much was done to prepare



the United States for the possibility of eventually joining in the conflict on the side of the Allies.

National Defense Act of 1916.-Of these preparatory actions, two were of major importance for the Medical Department. The first was the passage by the Congress of the Act Reorganizing the Army, 1916, better known as the National Defense Act (174).

In addition to the indirect effects upon the organization, administration, and relations of the Medical Department, this Act contained several long sections of specifics. In referring to this Act in his Annual Report for 1916, Col. H. P. Birmingham, Acting Surgeon General in the absence of General Gorgas, who was in South America as a member of the Rockefeller Foundation's Yellow Fever Commission, wrote (p. 16): "As a result of legislation reorganizing the Army under the national defense act of 1916, the Medical Department was placed, for the first time in its history, upon a satisfactory basis." Seven medical officers were allowed for each 1,000 of the enlisted strength of the Army. The Dental Corps was reorganized and the probationary contract system was abolished, permitting immediate commissioning. The Veterinary Corps was established as an integral part of the Medical Department. Provision was made for the assignment of five medical officers for duty with the military relief department of the National Red Cross, and Col. Jefferson R. Kean, MC, "distinguished as a sanitarian and executive," was made first director general of military relief of the Red Cross, to the advantage of both the Red Cross and the Army. The details of this Act are too numerous to be mentioned here. Indeed, some of the provisions were so broad that only experience could disclose their content.

National preparedness and the Committee on Medicine.-On 29 August 1916, as one of the consequences of the National Defense Act, Congress created the Council of National Defense. It consisted of the Secretary of War, the Secretary of Navy, the Secretary of Agriculture, the Secretary of Commerce, the Secretary of Labor, with an advisory commission of seven, and with the power to estab-



lish such committees as might be needed. One of the groups established was the Committee on Medicine of which The Surgeon General, William Crawford Gorgas, was a member. This was important for military hygiene and sanitation of the Army. Among the other members, the three who were of special significance from the point of view of preventive medicine were Col. Jefferson R. Kean, Dr. William H. Welch (fig. 36), and Dr. Rupert Blue, Surgeon General of the Public Health Service. The functions of this committee are well indicated by the term "Medical Preparedness," including medical mobilization, the combating of venereal disease, and research in cooperation with the National Research Council (175).


When the United States entered World War I on 6 April 1917, military hygiene and preventive medicine in the Army, like public health and preventive medicine in civilian society, had attained competence in a variety of disciplines. Since the Spanish-American War, in addition to the general advances that had been made in knowledge and skill, and in the development of sanitarians, several special experiences had broadened the capabilities of the Medical Department to fulfill the first specified object of the sanitary service in war; namely (176), "The preservation of the strength of the Army in the field by (1) the necessary measures; * * *. The initiation of sanitary measures to insure the health of the troops."

Military preventive medicine concerned with administration of the whole Army.-During most of the preceding 7 years, maneuvers in the Southern Department had provided practical experience in field sanitation, and the "Punitive Expedition" into Mexico in 1916 furnished campaign schooling. This capacity was expanded by the attitude and enlarged view of those who were primarily responsible for supervising the health of troops. Witnessing to this, the "Introduction" to the volume on sanitation in



FIGURE 36.-William Henry Welch (1850-1934). One of the founders of the Johns Hopkins Hospital and Medical School and Professor of Pathology, he became a world-renowned authority in bacteriology, public health, preventive medicine, and in many other fields. A wise and forceful medical and educational statesman, he rendered invaluable services to Surgeons General from Sternberg to Ireland, exerting a formative influence upon military preventive medicine-a force of global dimensions. (Portrait photograph of Dr. Welch as a colonel, Medical Corps, in World War I. Courtesy of the National Library of Medicine, photograph negative No. 1674.)

the official medical history of World War I begins with this statement (177): "Military sanitation may be defined, in general, as the prevention of disease in armies. * * * [It] includes in its sphere both personal and public hygiene and in addition makes use of all the well-established procedures



which more recently have been grouped under the heading of 'preventive medicine.' " An additional guide to policy was the recognition that the activities of military preventive medicine extended beyond the limits of the command of The Surgeon General; they were concerned with the administration of the Army as a whole.

Furthermore, during the 3 years since 1914 when the great war began in Europe, there had been an opportunity for the Medical Department to study situations and make some preparations for possible eventualities. Through medical preparedness, as already outlined, the department had gained the support of the medical profession of the country and knew that in case of need, it could count on voluntary services of thousands of skilled physicians and surgeons, bacteriologists, epidemiologists, and public health experts. The National Research Council, which was to be enormously helpful, had been established by the National Academy of Sciences at the request of President Woodrow Wilson, in 1916, to mobilize the scientific resources of the country as a preparedness measure. Thus, at the outset of the American phase of World War I, the Medical Department of the Army was in better position than it had ever been at the beginning of any of its wars to render superior service. From the point of view of preventive medicine, it was capable of coping with the sanitary problems of the greatest military undertaking in the history of the United States up to that time. The health record would have been excellent if in the autumn of 1918 and subsequent winter the invincible pandemic of influenza had not deluged the world with sickness and death. Nevertheless, the death rate from disease in the total Army in World War I (178) was 14 per 1,000 average strength per annum, as compared with the rate of 25 in the Spanish-American War, and for the first time the ratio of battle deaths to death from disease was 1 to 1 (50,510 battle deaths-[37,568 killed in action; 12,942 died of wounds] -51,477 deaths from disease).

Mobilization and crowded camps.-In January 1917, practically at the start of the war, the strength of the



United States Army was approximately 200,000. Between 6 April 1917 and 15 November 1918, 3,704,630 men were mobilized in the United States. Many thousands of troops were called up rapidly, increasing each month, until during the year 1918 the numbers in camps in the United States averaged approximately 1,381,429 monthly.

Camps, hurriedly constructed, became crowded, and a series of epidemics of measles, mumps, and meningococcal meningitis passed through them. These were not too serious. The more damaging outbreaks were the epidemics of 1918-pneumonia (lobar pneumonia, and streptococcal bronchopneumonia and empyema following measles) and pandemic influenza. Influenza occurred also, but less severely among troops of the American Expeditionary Forces in France in 1918. The total number of deaths from influenza in the Army in 1918 was 23,000-a rate of 9.4 per 1,000 mean strength per annum. Nothing in the way of prevention or treatment of influenza was effective.

Pneumonia Commission established (1918).-To assist the Office of The Surgeon General in the investigation and control of these latter two groups of respiratory diseases, Surgeon General Gorgas secured the establishment by the War Department, on 20 May 1918, of a Pneumonia Commission (known also as the Pneumonia Board), composed of distinguished pathologists and bacteriologists, among whom were Drs. Rufus I. Cole, William G. MacCallum, Alphonse R. Dochez, Oswald T. Avery, Thomas M. Rivers, and Francis G. Blake. This Board not only rendered advisory service but also organized and directed the studies of groups of expert epidemiologists, bacteriologists, pathologists, and chemists who were sent into the camps to combat these infections. The Pneumonia Board functioned truly in the tradition of General Sternberg. It was the forerunner of the World War II Board for the Investigation and Control of Influenza and Other Epidemic Diseases in the Army. Established by the Secretary of War on 11 January 1941, this Board became known as the Army Epidemiological Board, and later, in 1950, as the Armed Forces Epidemiological Board. The Central Board and its



Commissions have dealt with hundreds of problems of communicable diseases among military personnel and environmental civilians, have assisted the Surgeons General of the Army, Navy, and Air Force in the formulation of sanitary policies and procedures, and they continue at this writing to render service of inestimable value.

Sanitary organizations in the Surgeon General's Office.-At the beginning of the war, Surgeon General Gorgas expanded his office to meet the wartime demands for disease prevention. The first step was to increase the responsibilities of the already conglomerate Division of Sanitation. This division had been in existence for many years and had been responsible not only for sanitation and preventive medicine but also for a variety of miscellaneous activities, such as the selection of recruits, the physical examination of officers and enlisted men, and the collection and analysis of statistics of morbidity and mortality. In April 1917, four new activities were added: (1) Hospitalization, (2) Medical Officers Training Camps, (3) Field Sanitation, and (4) Infectious Diseases and Laboratories. Later, the Division of Sanitation while becoming more complex in some parts of its anatomy, was simplified somewhat by an extirpation which created a separate Division of Infectious Diseases and Laboratories.

Thus, there were two divisions in the Surgeon General's Office which were concerned with preventive medicine; namely, (1) the Division of Sanitation, and (2) the Division of Infectious Diseases and Laboratories. It was difficult to draw a line between the responsibilities of these two divisions, and their overlapping jurisdictions were confusing. In theory, however, the relation between them was compared to the relationship which existed between a municipal board of health and its laboratories. The Division of Sanitation was the executive division so far as measures taken by the Medical Department for the prevention of disease among troops were concerned, while the Division of Infectious Diseases and Laboratories concerned itself largely with the scientific study of communicable diseases and with laboratory diagnosis. It used the



results of its studies as bases for recommendations for disease control.

It is worth noting particularly that the medical statistical operations of the Surgeon General's Office were located in the Division of Sanitation in recognition of the close relationship between the reporting of communicable diseases and their control. Telegraphic reporting of the occurrences of disease strengthened the control system (179).

Sanitary inspectors.-A century before, enlightened and ingenious Surgeon General Lovell secured the establishment of the principle that medical officers should make sanitary inspections, locally and generally. Over the years since the issuance of War Department General Orders to this effect on 18 April 1818, such inspectors functioned from time to time, appearing and disappearing from the Military Establishment according to the whims of the Congress or the War Department, fulfilling inspectorial duties according to their inclinations. After the Spanish-American War, however, sanitary inspectors became more important and influential, and conscientious.

When the United States entered the war in 1917, sanitary inspectors who had proved their worth in maneuvers in the South and in the Mexican campaigns of the preceding years were on active duty. Many more sanitarian-officers of experience were added by General Gorgas to supervise sanitation in departments, armies, corps, and divisions, and even smaller units. Their presence, abilities, and influence throughout World War I imparted a special quality and efficiency to the military sanitary activities of American organizations both in the camps in the United States and in the campaigns of the AEF (American Expeditionary Forces) in France.

To the brilliant Sanitary Inspector of the Second Army, AEF, Col. Hans Zinsser (fig. 37), the Medical Department was indebted for an unusually thoughtful, analytical, and broadly conceived article on the theme of area sanitation-an article which has sometimes been reproduced in whole or in part without attribution of authorship (180).



FIGURE 37.-Hans Zinsser (1878-1940), Professor of Bacteriology and Immunology successively at Stanford, Columbia, and Harvard Universities. As a bacteriologist, epidemiologist, sanitarian, and administrator, he directed communicable disease control and prevention activities in the American Expeditionary Forces in France in World War I. He was Sanitary Inspector of the Second Army at that time and published a general order on "Sanitation of a Field Army." Later he served as a consultant to The Surgeon General for the advancement of preventive medicine. (Portrait photograph of Dr. Zinsser, as a major, Medical Corps, in his laboratory office in France in World War I. Courtesy of the National Library of Medicine, photograph negative No. 11634.)

In this article, laboratory and epidemiological services are discussed in relation to the qualifications of the sanitary inspector. Dr. Zinsser wrote:

Just as the laboratory is of partial efficiency only in hospitals if the bacteriologist is unfamiliar with the cases in the wards, so in armies the laboratory service cannot be entirely efficient unless the



laboratory officer is trained in and in touch with the epidemiological data. For this reason, the Sanitary Inspector of the Army, who should be capable of acting as an adviser to medical officers and sanitary inspectors of the several troop units, should be a man not only trained in practical sanitation but one who at the same time is familiar with the facts of epidemiology, the methods of making epidemiological surveys, and can handle a laboratory for the control of communicable diseases as an important tool of his profession.

Sanitary Corps established (1917); reestablished (1923).-At the time when the United States entered World War I, only graduates of medical, dental, and veterinary schools were eligible for regular commissions in the Medical Department. As soon as activities and responsibilities were increased as a result of mobilization in April 1917, it became evident that the Medical Department would require the services of a considerable number of officers other than doctors of medicine, dentistry, and veterinary medicine. To meet this need, the President, moving by authority of the Act of 18 May 1917, " 'to increase temporarily the Military Establishment of the United States,' [directed that] there be organized under the Medical Department for the period of the existing emergency a sanitary corps consisting of commissioned officers." These officers would be provided by assigning officers of the Medical Reserve Corps thereto, or by the appointment of officers of the Medical Reserve Corps, or of citizens of the United States who had been found under regulations established by the Secretary of War to possess special skill in sanitation, in sanitary engineering, in bacteriology, or in other sciences related to sanitation and preventive medicine, or to possess other knowledge of special advantage to the Medical Department (181). Grades and numbers were specified in the previously cited General Orders and in an amendment issued 2 months later (182).

This authorization brought into the Medical Department sanitary engineers, psychologists, chemists, bacteriologists, epidemiologists, laboratory technicians, statisticians, adjutants, office experts, mess officers, supply and finance officers, and other categories not professionally medical.



A detailed history of the Sanitary Corps will be presented in another volume of the administrative series of the Medical Department, United States Army, and the valuable work of the Corps will be mentioned often in appropriate sections of this volume.

In World War I, the commissioned personnel grew to be upwards of 8,000 officers. After the end of the emergency, the Sanitary Corps was abolished by Section 10, Act of 4 June 1920, and it officially ceased to exist (for the time being) on 31 December 1920. It was reestablished in 1923 as a Reserve unit solely.

Gas defense and service.-Consultations relative to chemical warfare began between British, French, and American military representatives soon after the effective German chlorine gas attack upon French and Canadian troops in the Langemark sector on 22 and 24 April 1915. As a result of these conferences, on 5 November 1915, the furnishing of gas defense equipment was tentatively assigned to the Medical Department; and on 4 May 1917, the Secretary of War directed that The Surgeon General be informed that his Department would be charged with furnishing gas masks and other prophylactic (gas defense) apparatus for the Army. This responsibility was met by the Office of The Surgeon General. Overcoming many difficulties, the Medical Department carried on the work from that date until 28 June 1918, when gas defense ceased to be a function of the Department and was transferred to the newly established Chemical Warfare Service (183).

Chemical warfare policies and missions.-From the beginning of this uncongenial task, it was recognized that the two main aspects of chemical warfare-offense and defense-were inextricably interwoven. This raised a serious moral and practical problem for The Surgeon General. While the Medical Department was dedicated to defensive and therapeutic measures-prophylaxis and treatment-it could not devise equipment and procedures for either without being familiar with materials, weapons, and tactics. In addition, it was necessary for some members of the Medical Department of the Army to participate in



some of the experimental and training phases of the use of poisonous gases in warfare. This Janus-like configuration which the Office of The Surgeon General was bound to assume in World War I continued through World War II, carrying over into concern with biological warfare; and to this day, it causes a somewhat schizophrenic behavior of the Army Medical Department. While these questions were and are ethically troublesome, the Medical Department could not and cannot avoid involvement in certain stages of offensive measures of chemical warfare up to their employment on the battlefield.

Sanitation of manufacturing and gas plants.-To produce the gas masks and other protective devices required by the War Department for the Army during the period when gas defense was a responsibility of the Office of The Surgeon General, it was necessary to construct and supervise a gas defense plant at Long Island City, New York, to manufacture equipment, etc., that was not procurable in commercial markets. This plant was authorized by the Secretary of War on 20 November 1917. It was built and managed by the Field Supply Section of the Gas Defense Service, which was directly under the Office of The Surgeon General. At the time of its peak of production in January 1918, this plant had 4,691 civilian employees. From its own manufacture, plus production from other plants under contract, 1,718,632 gas masks, and much other protective material, were produced and delivered.

It was soon obvious that this and related plans required sanitary supervision, specifically geared to the hazards, for the protection and care of workers serving under conditions in which there might be acute exposure to large concentrations of gas or prolonged exposure to small concentrations. The Office of The Surgeon General in collaboration with the Bureau of Mines of the Department of the Interior instituted a Sanitary Supervision of Gas Factories, both Government owned and operated and contractor owned and operated. The first chief of these activities in the Bureau of Mines was Dr. Yandell Henderson, Direc-



tor of the Experimental Physiological Laboratory. He worked closely with Capt. H. C. Bradley, SnC, who had charge of these affairs in the Sanitation Division of the Surgeon General's Office.

It is of particular interest to those familiar with the developments in sanitary supervision of industrial and governmental plants engaged in warwork in World War II to note that the first Medical Department participation in this beneficent work arose from the Army's concern with poisonous gases and chemical warfare. Later in a volume in the preventive medicine history series, it will be shown how large a development of activities in industrial and occupational hygiene was fostered and administered by the Preventive Medicine Service, Office of The Surgeon General, during World War II.


During the 2 years and one month between the declaration of war against Germany on 6 April 1917 and the signing of the Treaty of Versailles on 28 June 1919, the United States exerted a stupendous national effort in carrying out its strong part on the side of the Allies in World War I. As Surgeon General Merritte W. Ireland wrote in his letter of 8 October 1919, transmitting to the Secretary of War his annual report for that year;

The period covered by the report of 1918 and by this one has been one of the most memorable in the history of this country. It has witnessed the inauguration, the full development, and the successful ending of the unparalleled activities of the War Department and of the Nation as a whole. Never before in the history of this country has the Government put so large an armed force into the field as during the year 1918.

This armed force was indeed formidably large, and the energy expended in assembling it, equipping it, and sending it overseas was prodigious. In the late fall of 1918, the total strength of the United States Army reached



3,704,630 men. Of these, approximately 2,000,000 were equipped for combat, preliminarily trained, and transported to France to form the American Expeditionary Forces. They served in camps, in the field, and fought great battles in 1918, from Chateau Thierry in July to St. Mihiel in September, and the Meuse-Argonne Campaign from 26 September to the armistice on 11 November. The citation of these figures and the mention of the campaigns and battles are enough to indicate the magnitude of the effort which the Medical Department was called upon to make both in the continental United States and in Europe to serve this Army in all of its situations-static and in motion, in safety and in peril, in threatened or actual sickness, and in the preservation of its health. As so much has been written (184) about the problems, exploits, and accomplishments of those days, there is no need to go over the well-known details here. Rather, an attempt will be made to present, in a sketched setting, several special developments and considerations which, while occurring in the AEF, were relevant to preventive medicine in the entire Military Establishment and contained some lessons for the future. The chief topics will be staff relationships, sanitary organizations and operations, and certain results.

Staff relationships.-(a) The Theater of Operations, AEF, and the War Department. In May 1917, an intrajurisdictional war was declared which through the involved divisions of the Medical Department had repercussions upon military preventive medicine. This conflict, inferential at first, was fought in strong disagreements later between the authorities of the AEF and the War Department, represented respectively by the Commander-in-Chief of the former, General John J. Pershing, and the Chief of the General Staff of the latter, General Peyton C. March (185).

In General Orders No. 1, Headquarters, AEF, issued in Washington on 26 May 1917, General Pershing announced that he had assumed command of the AEF "pursuant to the orders of the President." By this, he indicated that he exercised virtually independent authority, under the Presi-



dent, over the Army Forces in France. According to his Chief of Staff, Maj. Gen. James G. Harbord (186):

General Pershing commanded the American Expeditionary Forces directly under the President and Secretary of War, as the President's alter ego. No military person or power was interposed between them. The President himself recognized this relationship, and the relative importance of the two Generals in it, when he returned to the United States in July, 1919, after the termination of the Peace Conference, by recommending to the Congress that Generals Pershing and March receive the permanent grade of General, but with precedence to the former.

Opposing this position, General Peyton C. March issued "by order of the Secretary of War" General Orders No. 80, War Department, Washington, 26 August, 1918. In this, among other statements, he announced that:

The Chief of Staff by law (Act of May 12, 1917) takes rank and precedence over all officers of the Army, and by virtue of that position and by authority of and in the name of the Secretary of War, he issues such orders as will insure that the policies of the War Department are harmoniously executed by the several corps, bureaus, and other agencies of the Military Establishment, and that the Army program is carried out speedily and efficiently.

This statement was interpreted by General March to mean that the Chief of Staff was the superior of the Commander-in-Chief of the American Expeditionary Forces (187).

General Pershing assumed and practiced command. In his final report, he devotes little or no discussion to the disputed question of authority; and in his later book about the war, he pays compliments to General March (188). The question was not settled until after the war when the Army was reorganized in 1921. At that time, General Pershing was Chief of Staff as well as General of the Armies. He approved the recommendation of the Harbord Board that the Chief of the General Staff should be the commanding officer of the Army.

More than 40 years later, Edward M. Coffman reviewed the Pershing-March correspondence and many related papers. His summary and charitable conclusions were that the conflict was resolved. He wrote (189):



Stories have multiplied since World War I about the so-called feud between March and Pershing. During the war there were differences, some of which were not worked out, but the legend outstrips the facts. The cables and Pershing's letters reflect dissension, but the March-Pershing wartime correspondence, although revealing disagreements, maintains throughout a friendly tone. Here were two men, both strong personalities, installed in positions and involved in a situation which invited trouble. Add the tension, the continual crises, and the awesome responsibilities of war to the traditional conflict between the line and the staff and the lack of a General Staff tradition, and friction becomes a natural result.

Staff relationships.-(b) The Chief Surgeon, AEF, and The Surgeon General, War Department. The disagreement over command affected many aspects of the military administration of the AEF, and exerted some influences upon the technical services of the Army. Undoubtedly, the point of view of General Pershing affected the attitude of General Ireland who, after serving as a most influential assistant to Col. (later Brig. Gen.) Alfred E. Bradley, MC, became Chief Surgeon of the AEF on 1 May 1918 and continued in that position until 9 October 1918. There was encouragement in the theater to the conduct of the Medical Department therein with an unusual degree of independence of the Office of The Surgeon General. In spite of this, or rather because of the magnanimity, the mutually respected abilities, and the cordial personal relationship of the two men in the highest medical positions (Generals Gorgas and Ireland), no impeding disagreements occurred. Nevertheless in World War I, precedents were set in the first great theater of operations overseas which in World War II tended to restrict the freedom of relations and communications between theater surgeons and The Surgeon General in all categories of military-medical activities, including those of preventive medicine.

From the start, very broad powers were conferred upon the Chief Surgeon, American Expeditionary Forces. On the recommendation of The Surgeon General (General Gorgas), the Secretary of War on 28 May 1917 designated Colonel Bradley "as chief surgeon United States forces in Europe," and in further accord with The Surgeon General's



recommendation authorized the Chief Surgeon "to exercise over the forces under your control the same authority as The Surgeon General holds over the entire Medical Department." During the remainder of the year 1917, the Office of the Chief Surgeon, AEF, was organized and operated along lines quite similar to those of the Office of The Surgeon General. However, with the authorization for semiautonomy exercised by a vigorous Assistant Chief Surgeon, Col. (later Maj. Gen.) Merritte W. Ireland, who shared General Pershing's philosophy and aims, the Medical Department of the AEF was modified in both personnel and equipment, and in its activities, to such an extent that the resultant changes bore but small resemblance to the existent tables of organization and equipment manuals. Such changes had to be made on the spot to meet the manifold new requirements of both trench and mobile warfare. Among the notable achievements of the medical administration of the zestful theater was the development of vigorous services of sanitation and preventive medicine. This was but natural under the encouragement and requirements of a Chief Surgeon who, reviewing his experiences 10 years later when he was The Surgeon General, emphasized the importance of sanitation, sanitary inspectors, epidemiologists, and laboratories. He wrote (190): "Probably no activity pays in the military service such huge dividends as preventive medicine."

Another important difference was the relation between the Chief Surgeon and the Commander-in-Chief and his Staff at General Headquarters, American Expeditionary Forces. The Chief Surgeon and a small group of medical officers were members of the staff at general headquarters, members of the commander's family, as George Washington expressed it. There they dealt with policies, plans, and a broad range of military medical coordination. The Office of the Chief Surgeon, Line of Communications (later Services of Supply), handled most of the details of operations, such as supply, hospitalization, personnel, etc. Thus the Chief Surgeon, AEF, was in far more intimate association with the top American command in France than



was The Surgeon General, in relation to the General Staff and the War Department in Washington. General Ireland insisted successfully that a first necessity was the recognition of the surgeon as a staff officer and his inclusion in the councils of command. This is also an important principle for chiefs of services of preventive medicine, for as representatives of their chief surgeons they need to receive, as a basis for intelligent action, the kind of information that derives from the staff status of the surgeon of the command.

Sanitation in the AEF.-The sanitary organizations and the men in charge of them were all important. In the Office of the Chief Surgeon, there were two main divisions for operations of military hygiene-a Division of Sanitation and Inspections, and a Division of Laboratories and Infectious Diseases, with which a Section of Epidemiology was closely associated. The Division of Sanitation eventually became, in a large measure, an office of preventive medicine wherein all activities relating to that subject were centralized. The Division of Laboratories and Infectious Diseases, coupled with Epidemiology, functioned in the closest possible cooperation and support with the Sanitation Division. At the head of Sanitation was the distinguished health officer and scholar of public health, brought into the service from civil life, Dr. (Colonel, MC) Haven Emerson; and high ranking in the Division of Laboratories and Infectious Diseases was Dr. (Lieutenant Colonel, MC) Hans Zinsser, world-renowned bacteriologist, immunologist, and epidemiologist, who was also in the closing months of the war Sanitary Inspector of the Second Army.

Special features of the Division of Laboratories and Infectious Diseases were its centralized and decentralized laboratories for diagnostic services, control procedures, and research. The main Central Medical Laboratory, established at Dijon in January 1918, was under the direction of Col. Joseph F. Siler, MC, and had connections with many other laboratories in headquarters, field armies, corps,



divisions, hospitals, and certain special units such as engineer water supply battalions.

Results and the influenza pandemic (1918-1919).-Without recapitulating details which had been set forth profusely in the historical volumes cited in this section, it can be affirmed that while nothing particularly new in preventive medicine was developed in the AEF, the application of known methods and the adaptation of measures to the situations of the campaigns in France in 1917-1918 were carried out with an unusually high degree of thoroughness and intelligence. Inevitably, sanitation in some units was much better than in others, and sanitary practices broke down in a number of circumstances, as during and after a battle. On the other hand, except for the outbreaks of influenza, the insidious recurrences of diarrheas, and the extensive prevalence of lousiness due to lack of bathing facilities and scarcity of clean clothing, there were no extensive afflictions of the troops by diseases. The general health of the AEF was good.


Among the concluding engagements of the AEF, the occupation by the Third Army of a part of the German Rhineland involved two major activities pertinent to this monograph. These were (1) sanitation and preventive medicine in the Army of Occupation, and (2) public health activities of Civil Affairs-Military Government in the occupied area. In the evolution of preventive medicine in the United States Army, both of these phases of the work presented new situations and new policies and principles, for the administration of which practically no preparation had been made. As a consequence, elementary experience was gained and basic concepts developed. The lessons learned, or displayed, were potentially important guides for the future, but they received only superficial notice until about 1939, when the United States began to prepare for World War II (191).



The Third Army, Maj. Gen. Joseph T. Dickman, commanding, was activated at Ligny-en-Pavois, Meuse, France, on 7 November 1918, 4 days before the armistice was signed. Its mission, assigned soon after the armistice on 11 November 1918, was to serve as the Army of Occupation in Germany, in an American zone. In a strength of approximately 260,000, it marched from France through Luxembourg and the Treves (Trier) region to Coblenz and beyond, to occupy the Moselle area of Germany from the eastern boundary of Luxembourg to the western bank of the Rhine and the northerly half of the bridgehead of 30 kilometers radius east of the Rhine, centered at Coblenz. Upwards of 1,000,000 civilians and an unknown number of disarmed German soldiers were in this region.

Third Army sanitation, preventive medicine, and health. -The Office of the Chief Surgeon, Third Army (Col. Jay W. Grissinger, MC), at Army Headquarters at Coblenz included an enlarged Division of Sanitation presided over by the Army Sanitary Inspector (Maj. Stanhope Bayne-Jones, MC) and the Army Epidemiologist (Maj. Alan M. Chesney, MC). Higher authority had decided, correctly as events proved, that as the Army of Occupation was stationed in a fixed area with divisions and other large units in stabilized positions, there was no need to install an Army-area system of sanitation and preventive medicine. The corps, divisional, and regimental medical groups could be depended upon to carry out in their areas all the work necessary for the preservation of the health of the troops. The important sanitary matters that required some degree of centralized operation by the Army were attempts to reduce venereal diseases by control of houses of prostitution, the supply and control of drinking water, and the enforcement of safeguards against the consumption of vegetables contaminated by the German practice of fertilizing fields with emulsions of human feces sprayed from "honey carts" that had been filled from cesspools.

The office of the sanitary inspector and epidemiologist maintained from inspections and reports a ledger of cases of communicable diseases and a huge spot-map of the



Army area affixed to the walls of a room in the spacious German building in which the Chief Surgeon's office was located. Here data on the incidence of diseases were compiled and analyzed and a Weekly Health Bulletin was composed for issuance by the Office of the Chief Surgeon. There were brief outbreaks of influenza and typhoid fever among the troops in 1919, and some diphtheria. However, communicable diseases were not excessive in the Army of Occupation (192).

Civil affairs-military government public health.-The I. L. Hunt Report (191), previously cited, severely criticized the general conduct of civil affairs-military government by the Third Army in Germany in 1919-20. After reviewing events, the author of chapter IV (p. 65, vol. I) wrote:

The conclusion from these facts is incontestable; the American army of occupation lacked both training and organization to guide the destinies of nearly 1,000,000 civilians whom the fortunes of war had placed under its temporary sovereignty. * * * There can be no doubt that the belief felt in many quarters * * * that the armies could occupy enemy soil and yet divest themselves of responsibilities of government, was both prevalent and powerful.

Such strictures could not be applied to the public health activities of civil affairs-military government of German territory occupied by the Third Army from 7 December 1918 to 31 May 1919. Health conditions among the civilian population were of vital concern to the Chief Surgeon of the Army and to the Chief Sanitary Officer in Civil Affairs at Advance Headquarters, AEF, at Trier.

The Department of Sanitation and Public Health in the office of Civil Affairs-Military Government in German occupied territory was established pursuant to General Orders No. 1, Advance General Headquarters, AEF, Treves, Germany, 18 December 1918, to supervise and control civil sanitary service in the occupied area with a view to protecting the health of the troops of the American Army of Occupation and of guaranteeing to the civil population adequate medical service. This department was directed by a Chief Sanitary Officer, Lt. Col. Walter Bensel, MC, a medical Reserve officer called to active duty from the



New York City Department of Health, where he had had a long experience. He kept in close touch with the Chief Surgeon of the Army. In the official Army medical history of that period, the coordination of the civil and military sanitary service was appraised in terms of satisfaction, as follows (193):

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

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

Typhoid fever (especially at the towns of Bruck and Alternach on the Ahr River), diphtheria, and influenza were occurring in the civil population under conditions favorable to their transmission to troops. That such transmission did not occur to any appreciable extent was due in largest measure to the coordination of the civil and military sanitary services.



Discontinuance of Third Army.-After the Germans signed the peace treaty of Versailles on 28 June 1919, American troops were speedily returned to the United States. The Third Army was inactivated on 2 July 1919, and the American Forces in Germany, a force of about 8,000 men, came into being in the area of occupation. The Department of Sanitation of the original section of Civil Affairs-Military Government of the American Forces in Germany was terminated in a practical sense on 10 January 1920 when the Inter-Allied Rhineland Commission became the supreme Allied authority in the occupied territory.