(3) S. O. No. 120, W. D., May 24, 1917, paragraph 38; S. O. No. 143, W. D., June 21, 1917, paragraph 50; also, letter from Col. George E. Bushnell, M. C., to Col. Charles Lynch, M. C., May 4, 1921. On file, Historical Division, S. G. O.

(4) Biggs, H. M.: A War Tuberculosis Program for the Nation. American Review of Tuberculosis, Baltimore, 1917, i, No. 5, 257.

(5) Examination of Soldiers for Tuberculosis, June 27, 1917. On file, Record Room, S. G. O., 181927 (Old Files).

(6) Letter from the Surgeon General, U. S. Army, to The Adjutant General of the Army, June 26, 1917. Subject: Detail of officers in Medical Reserve camps for duties as specialists in Army camps. On file, Record Room, S. G. O., 089101 (Old Files).

(7) Circular, War Department, July 16, 1917. Subject: Examinations of commands at camps for tuberculosis by board of medical officers. On file, Record Room, S. G. O., 189101 (Old Files).

(8) Bushnell, G. E., Col., U. S. A.: How the United States is Meeting the Tuberculosis War Problem. The Military Surgeon, Washington, 1918, xliii, No. 2, 127.

(9) G. O. No. 90, W. D., July 12, 1917.

(10) War Department Annual Reports, 1918, Vol. I, 1103.

(11) Reports, Tuberculosis Boards. On file, Record Room, S. G. O., 730.

(12) Annual Report of the Surgeon General, U. S. Army, 1918, 343.

(13) Telegram from the Surgeon General, to all camp surgeons and other senior surgeons of commands, April 29, 1918. Subject: Single examination.

S. G. O., Correspondence File, 327.2 (Examinations).

On file, Record Room,

(14) Matson, B. C., Maj., M. C. U. S. Army: The Elimination of Tuberculosis from the Army. American Review of Tuberculosis, Baltimore, 1920, iv, No. 5, 398.

(15) Instructors of School of Tuberculosis Examiners. On file, Record Room, S. G. O., 176001-144 (Old Files).

(16) Annual Report of the Surgeon General, U. S. Army, 1918, 344.

(17) Ibid, 119.

(18) Ibid, 219.

(19) Personal communications to the author.

(20) Brewer, Isaac W.: Tuberculosis Among the Indians of Arizona and New Mexico. New York Medical Journal, 1906, lxxxiv, No. 20, 981.

(21) Cabot, Richard C.: In Conference on Tuberculosis of the Lungs. War Medicine, Paris, 1919, ii, No. 6, 978.

(22) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1070.

(23) Letter from the Surgeon General, U. S. Army, to Dr. Edouard Rist, Geneva, Switzerland, January 28, 1920. Subject: Occurrence of tuberculosis in the Army. On file, Record Room, S. G. O., 702-5.

24) Webb, Gerald B.: Some Lessons of the War in Pulmonary Tuberculosis.

Transac

tions of the American Climatological and Clinical Association, Lancaster, Pa., 1919, XXXV, 114.

(25) Glomsett, D. J., Maj.: What Can We Learn Regarding Pulmonary Tuberculosis from the Opportunity Afforded by the General Postmortem? War Medicine, Paris, 1919, ii, No. 6, 993.

(26) Borrel, A.: Pneumonie et tuberculose chez les troupes noires. Annales de l'Institut Pasteur, Paris, 1920, xxxiv, No. 3, 105.

(27) Roubier, Ch.: Sur la Tuberculose chez les troupes noires. Paris médical, 1919, xxxiii, No. 37, 207.

(28) Nägeli, Otto: Ueber Häufigkeit. Localisation und Ausheilung der Tuberkulose. Virchow's Archiv für pathologische Anatomie und Psysiologie und für klinische Medicin, Berlin, 1900, clx, No. 2, 426. (29) Opie, Eugene L.: The Focal Pulmonary Tuberculosis of Children and Adults. Journal of Experimental Medicine, New York, 1917, xxv, No. 6, 855; and xxvi, No. 2, 263; also: First Infection with Tuberculosis by Way of the Lungs. American Review of Tuberculosis, Baltimore, 1920, iv, No. 9, 629.

(30) Cummins, S. Lyle: Tuberculosis in Primitive Tribes and Its Bearing on the Tuberculosis of Civilized Communities. International Journal of Public Health, Geneva, 1920, i, No. 2, 137.

(31) Bruns, Earl H., Lieut. Col., M. C.: The Tuberculosis Situation in the American Expeditionary Forces. Unpublished Report to the Surgeon General, U. S. Army. On file, Record Room, S. G. O.

(32) Bushnell, George E., Col., M. C., U. S. Army: A Study in the Epidemiology of Tuberculosis. William Wood and Company, New York, 1920, 97.

(33) Freund, Heinrich: Ueber cutane und conjunctivale Tuberkulinreaktion bei Gesunden und Kranken. Wiener medizinische Wochenschrift, Wien, 1908, lviii, 1242; 1302. (34) Hamburger, F.: Die Ueberlegenheit der Stichreaktion über die Kutanreaktion. Münchener medizinische Wochenschrift, München, 1919, lxvi, part 1, No. 4, 100. (35) Lereboullet, P.: Les questions actuelles de tuberculose. Paris médical, 1918, xxvii, No. 1, 1. (36) Gallagher, Joseph F., First Lieut., M. C.: Statistical Résumé of the French Medical Service. The Military Surgeon, Washington, 1920, xlvi, No. 5, 579.

Mün

(37) Fraenkel, A.: Ueber Lungentuberkulose vom militäräztlichen Standpunkie aus. chener medizinische Wochenschrift, München, 1916, lxiii, part 2, No. 31, 1109. (38) Blümel: Die Fehldiagnose Lungentuberkulose bei Beurteilung der Felddienstfahigkeit. Medizinische Klinik, Berlin und Wien, 1915, xi, August 8, 884.

(39) Goldscheider: Aufgaben und Probleme der inneren Medizin im Kriege. für Tuberukulose, Leipzig, 1915-16, xxv, No. 1, 36.

Zeitschrift

(40) Piéry: Le Poumon de guerre. Revue génerale de pathologie de guerre, Paris, 1916, i, 509. (41) Goldscheider: Diagnose und Prognose der Lungentuberkulose vom Standpunkt des Praktikers. Berliner klinische Wochenschrift, Berlin, 1917, liv, No. 53, 1266.

(42) Letter from the Surgeon General to commanding officers of all base and general hospitals, April 15, 1918. Subject: Discharge of tuberculosis patients. On file, Historical Division, S. G. O.

(43) Letter from the Surgeon General, U. S. Army, to The Adjutant General of the Army, July 2, 1918. Subject: Discharge on account of pulmonary tuberculosis. On file, Record Room, S. G. O., 220.8, G. H. No. 18 (k).

(44) Matson, R. C., Maj., M. C., U. S. Army: The Value of Chest Fluoroscopy. The Journal of the American Medical Association, Chicago, 1919, lxxii, No. 26, 1887.

(45) Hospitals designated for reconstruction of disabled American soldiers and policy to be pursued outlined by the Surgeon General. Official Bulletin, published daily under order of the President of the United States, by Committee on Public Information, Washington, D. C., April 2, 1918, ii, No. 273, 8.

Transac

(46) Hoagland, H. W.: The Treatment of Tuberculosis in the Army Hospitals. tions of the American Climatological and Clinical Association, Lancaster, Pa., 1919, XXXV, 21.

(47) Annual Report of the Surgeon General U. S. Army, 1918, 344.

(48) Ibid., 1919, ii, 1072.

(49) Ibid., 1919, i, 51.

(50) Ibid., 1920, 178.

(51) Memorandum on the question of line of duty, November 7, 1914.

S. G. O., 153517 (Old Files).

On file, Record Room,

(52) War risk insurance act, with amendments prior to July 1, 1918. In special Regulations No. 72, Washington, Government Printing Office, 1919, 90, and amendments to war risk insurance act in Bulletin 7, War Department, April 17, 1923, 26.

(53) Annual Report of the Surgeon General, U. S. Army, 1918, 158.

CHAPTER IV

CEREBROSPINAL MENINGITIS "

Cerebrospinal meningitis was of serious importance in the United States Army during the World War, not because of its incidence, which was comparatively low-in fact this disease ranked seventy-sixth as a cause for admission to hospital-but because of its high case mortality. Approximately 39 per cent of the cases died, thus causing meningitis to rank sixth as a cause of death. Furthermore, its appearance in a command usually caused a definite feeling of apprehension or alarm, and as a consequence few diseases were the cause of more concern to, or were given more active attention by, medical officers.

Many sporadic outbreaks and small epidemics have been reported throughout the world since 1805, when the disease was recognized clinically by Vieusseau. However, an accurate bacteriological diagnosis was not possible before 1887 when Weichselbaum' showed the meningococcus (Diplococcus intracellularis meningitidis) to be the specific cause of cerebrospinal meningitis.

This infection has, no doubt, occurred in our Army during all previous wars. Interesting clinical reports of outbreaks are recorded in histories of the War of 1812, the Mexican War, and Civil War; while it is evident from these reports that meningitis was present, the incidence is not known since there was considerable confusion in the nomenclature and differential diagnosis and, of course, bacteriological diagnostic methods were unknown. In spite of the fact that the meningococcus had been recognized as the specific cause of cerebrospinal meningitis for 10 years previous to the Spanish-American War, very few of the cases which occurred during that period were diagnosed by accurate laboratory methods, and clinically the disease was confused to some extent with typhoid, typhus, and other fevers. It is obviously impossible, therefore, to make a comparison of the meningitis rates of our Army for the World War with the rates for any previous war. Such a comparison not only would be worthless, but also misleading.

Since the Spanish-American War the diagnosis of cerebrospinal meningitis in the Army has been more exact, and the records have included only cases in which the clinical diagnosis was confirmed by bacteriological examination. During this time, as indicated graphically in Chart XXVI, the annual admission rate per 1,000 strength has been almost negligible, except during the mobilization of unseasoned troops; for example, the rate increased noticeably in 1907 at the time of the Cuban occupation, in 1913 during the mobilization on the Mexican border, and again in 1917 when the United States entered the World War. It is noteworthy that the concentration of Regular Army troops on the Mexican border in 1911 was not attended by any remarkable increase in the meningitis admission rate.

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

Cerebrospinal meningitis has for some time been known as a disease of soldiers, or a "barracks disease," because of its tendency to become more prevalent during the mobilization of recruits. These terms were justified by the increased incidence in the Army during the World War. The rapid mobilization of enormous numbers of untrained, unseasoned men, from all sections of the country, and their subsequent, intimate contact in large camps, provided ideal conditions for the dissemination of meningococci, and as a consequence meningitis was far more prevalent than in normal peace times.

1.75

.00

1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 CHART XXVI.-Admissions and deaths for cerebrospinal meningitis, United States Army, 1900 to 1920. Ratios per

1,000 strength

STATISTICAL CONSIDERATIONS

DEATHS

The total mean annual strength of the Army for the period April 1, 1917, to December 31, 1919, was 4,128,479. As indicated in Table 28, 4,831 cases of cerebrospinal meningitis were reported as "primary admissions" during this period, giving an annual admission rate of 1.17 per 1,000 of strength, or 117 cases among every 100,000 men. Death occurred in 1,836 cases, or 38 per cent, giving an annual mortality rate of 0.44 per 1,000, or 44 deaths in 100,000 men.

TABLE 28.-Cerebrospinal meningitis.

Primary admissions and deaths shown by countries of occurrence for officers and enlisted men, United States Army, with ratios per 1,000 strength, April, 1917, to December 31, 1919

Only cases admitted to hospital primarily for cerebrospinal meningitis are considered in the figures given above or in the statistical tables used in this chapter. However, during this same period 1,008 additional cases and 443 deaths were reported as "concurrent diseases," having been admitted to hospital for other conditions. Therefore the total number of cerebrospinal meningitis cases was 5,839, an annual admission rate of 1.41 per 1,000 strength; while the total number of deaths was 2,279.