Tag: vaccination

This blog post originated in an exchange of social media posts with Alex Lyons (https://315-204-6regiments.com/). What started with some statistics has developed into something much larger in scope and in terms of questions it raises…

There were 112,315 cases of typhoid in the French Army in 1914-1915. Despite a law of 28 March 1914 imposing a requirement for vaccination, the epidemic would kill around 10,400 soldiers. This was all in a climate where, as with vaccination in other circumstances, there was vaccination scepticism and even fear.

The water supplied to the soldiers at the front was a breeding ground for many pathogenic micro-organisms that caused dysentery and typhoid. (“A pathogen, in the oldest and broadest sense, is any organism or agent that can produce disease”). Meanwhile, after the first gas attacks in early 1915, the army through the Service de Santé formally forbade drinking the water at the front because the gases poisoned stagnant water.

Problems also came from the infantry’s small capacity water bottle; the Bidon d’infanterie Mle. 1877.

At the beginning of the Great War, in 1914, two models of different capacity equipped the French army: a one-litre can for metropolitan troops (below left) and a two-litre can (right) for troops stationed in hot countries (the infanterie coloniale of l’armée d’Afrique). During 1915, due to the water supply problems of the men in the front line, the two-litre model was gradually distributed to the entire army.

However, enhancing the individual’s ability to carry more water was one thing; providing enough of it that was safe to drink was another.

Chloration de l’eau and Hypochlorite ion treatment

At the same time there was valuable work accomplished in purification of water. The methods evolved to become more efficient during the conflict. They differed depending on whether the water was available in containers or supplied directly and continuously by pipeline. From the outset of the war the method of purifying drinking water described by the pharmacist Auguste Georges and the physician Louis Vaillard in the July 1902 in the « Revue de médecine et de pharmacie militaire » was employed for water in containers.

This method of treatment was with iodine using 3 tablets: 1 blue, 1 white and 1 red:

• A blue tablet contained potassium iodide and iodate as well as methylene blue
• A white tablet contained sodium thiosulphate (or “sodium hyposulphite”)
• A red tablet which contained tannic acid.

The instructions for use were as follows: « Dissoudre 1 comprimé rouge avec 1 comprimé bleu dans ½ verre d’eau. Verser le liquide obtenu dans 10 L d’eau à traiter. Agiter. Attendre 10 min. Dissoudre 1 comprimé blanc dans un ½ verre d’eau. Verser cette solution dans les 10 L d’eau traités ».

The blue and red tablets in the water produced iodine, which is bactericidal and viricidal. After letting it act, the white tablet eliminated the excess iodine. In tablet form, it seemed that this ‘patriotic purification’ could help protect the soldiers of the nation. Cue hymn of praise for « les comprimés de la Patrie … »

The other approach was the much larger-scale process of chloration intended for use “en campagne“. The method was called Javellisation as it used l’eau de javel.

L’eau de Javel takes its name from the then-village of Javel, west of Paris (now a stop on the RER and on the Metro line 10), where it was manufactured from 1784 to 1889. It was first used for its laundry bleaching properties and then for its disinfectant properties in diluted solution. Whether L’eau de Javel or (as we may know it) bleach, it’s effective in combating the spread of diseases such as typhoid and cholera spread by contaminated water. Bleach is both bactericidal and a virucide.

The method of Javellisation saw 1 to 4 milligrams of chlorine added per litre of water, before it was treated with sodium hyposulphite to eliminate the excess chlorine and make the water drinkable. But this second treatment was considered unfeasible in war and the high command eliminated it. The poilus would have to accept the inconvenience of their drinking water tasting of the disinfectant. But, although the water was free of pathogenic microorganisms, its strong chlorine taste made it very unpleasant to drink. So, many men still continued to drink contaminated water from unreliable sources.

Meanwhile, in August 1914, Philippe Bunau-Varilla, Polytechnicien and famous for championing the construction of the Panama Canal and as a railway engineer, resumed his military service (which had ended in 1902) with the grade of Capitaine in the Engineers. He moved to the Génie de la 2e Armée in April 1915, using his engineering knowledge and expertise to supply water for the army’s horses from the Suippe river using centrifugal pumps powered by steam engines. He was then promoted to be commander of the service des eaux of Philippe Pétain’s 2e Armée for the September 1915 Champagne offensive.

The story (as told by Bunau-Varilla) of his work over 15 days to ensure 2e Armée had adequate water supplies for the attack has many similar features to those of the inventors and innovators who, from late 1914, produced new technological responses to the stalemate of trench warfare and the problems it caused. Those like Adrian (the protective helmet and barracks accommodation), Jean Baptiste Eugène Estienne (tanks) and Marie Curie (mobile x-ray machines) are examples from among the French, Ernest Swinton (tanks again), John Norton Griffiths (military mining), William H Livens (gas and the Livens Projector) from the British. Bunau-Varilla bought pumps, pipes and demi-muids (large oak barrels that hold 600 litres) in Paris; he bent regulations to get the equipment transported; water distribution devices, capable of supplying eight trucks each carrying 3 demi-muids, were installed along the front near hastily dug wells. On 25 September, 2,000,000 litres of water were ready to flow daily and follow the Army’s advance.

The extent to which these innovative entrepreneurs in the First World War could realise their aims without some form of support has been the subject of analysis (cf. Aimée Fox’s Learning to Fight as a very good example). Clearly, Bunau-Varilla was the beneficiary of patronage from Philippe Pétain and his staff with a rapid rise to a position of authority in his field.

What interests me (and connects to my broader subject interest in liaison and co-operation between the British and the French) is whether these two major combatant nations, and the most important ones in the Allied cause, did enough to share innovations that could have shortened the war, or reduced casualties, or improved medial support for their armies. From my own research, the British actively worked to keep their development of the tank secret from their ally. Was this an extension of pre-war cautiousness over giving a long-standing ancien ennemi and potential rival information that might offer them an advantage in a future conflict between the nations? It seems likely.

Whatever the reasons (and I’ll be looking for further examples and consider the factors at play as this blog goes forward), it was paralleled in a non-military context, including medicine, as in the development of an anti-typhoid vaccine – as we’ll see. In the 21st Century, campaigns against disease through bodies such as the World Health Organisation treat such things as a global problem – to eradicate the disease is for the benefit of all mankind. Other historians will have tracked how this development came about. Please feel free to use the contact form and recommend any who you feel do this particularly well.

According to Bunau-Varilla’s own account, in Champagne in September 1915 and at the start of the Battle of Verdun in February 1916, water sanitation was not a huge problem, as he stated in his book From Panama to Verdun: “I never paid attention to the purification of the water because the whole army had been vaccinated against typhoid during the first part of 1915”. (We will see the extent to which this was not, in fact, the case later). What Bunau-Varilla believed changed matters was that around July 1916 large contingents of labourers from what was then termed ‘Indochine’ arrived on the Western Front, brought from the region of modern Vietnam, Laos and Cambodia because of the growing problem of manpower shortages caused by the Army’s mounting casualty lists. Among these men were carriers of two new intestinal diseases not previously encountered on the Western Front (amoebic dysentery and bacillary dysentery). Antityphoid vaccinations had no effect on these and these diseases could be spread by contaminated water. It was necessary to find a solution to this problem.

In 1916 at Verdun, Buneau-Varilla managed to capture and transport water from the Meuse using wells, pumps and pipes to the trenches. He developed an automatic process for making this water potable by injecting diluted bleach just at the entrance to the centrifugal pumps. This process required doses of bleach ten to fifty times lower than javellisation (around 0.1 mg of active chlorine per litre). This water had a much better taste than water that had undergone javellisation.

The difference in effectiveness came from the methodology: in this process, the addition of bleach was carried out slowly with vigorous and prolonged stirring. These conditions promoted the dissolution of carbon dioxide in the air, which lowered the pH and promoted the change of the hypochlorite ion to a more bactericidal form. Bunau-Varilla gave the name « Auto-Javellisation Imperceptible » to his process and in the postwar years it became increasingly used by local governments across France and greatly improved the quality of drinking water for the citizens of these communities.

Bunau-Varilla himself lost a leg after suffering severe wounds in an air attack at Souilly in September 1917, but he survived and live until 1940. But let’s return to his contention that “the whole army had been vaccinated against typhoid during the first part of 1915”.

Vaccination: An unmitigated triumph?

A systematic campaign of inoculation by the Army authorities against typhoid on the Western Front from the spring of 1915 definitely produced results: from 118 deaths per 100,000 men in the workforce at the end of 1914, there was a near-disappearance of typhoid mortality in the French army as early as 1917 (0.3 deaths per 100,000 soldiers). Morbidity fell from 26 ‰ in early 1915 to 0.28 ‰ in 1918. Between 1915 and 1917, according to médecin général inspecteur Jean Hyacinthe Vincent*: “cases of typhoid diseases observed in the armies at the front are nearly seven times fewer and deaths eight and a half times rarer than in peacetime”. Plaudits came from academia and the press. The 1915 Osiris prize “for the work of typhoid vaccination” was shared between André Chantemesse, Georges-Fernand Widal and Vincent, its three “inventors” and chief architects in France. The popular press celebrated “Vincent, the great saviour of the Army” and « les vainqueurs de la fièvre typhoïde ». The message from all parts was clear: vaccination had triumphed over a disease that, as much as combat, put bodies at risk.

Although not specifically concerned with the anti-typhoid vaccine, which it had an important role in development and deployment, in Institut Pasteur et la Grande Guerre : le vaccin et les poilus a collection of photographs depicts the work of the Institut Pasteur during la Grande Guerre, particularly focusing on the development and administration of vaccines to soldiers. This historical visual record provides insights into the medical efforts and conditions during the war and indicates the extent to which animals were used in the development of the serum to combat diseases such as cholera, smallpox, rabies, etc.

WARNING: Some people may find some of the images here distressing.

* Jean Hyacinthe Vincent was an associate professor at Val-de-Grâce and the Collège de France, and he held the chair of epidemiology in 1912. He worked with Georges-Fernand Widal who had developed a diagnostic technique in 1896; the Widal test. Together they developed a vaccination against typhoid fever, that was first applied to humans by Vincent in 1910. It should be noted that, in England, Sir Almoth Wright had already separately developed a vaccine and applied it to humans in 1896.

In France, typhoid vaccination was permitted by the Académie Nationale de Médecine from 1911. In 1912, the vaccine was made available to the French army’s
troops, and in that year more than 62,000 men volunteered for the operation. Vincent successfully vaccinated the French contingent in North Africa against typhoid using his entero-vaccine.

Early in 1914 (as previously mentioned), the French Senate passed a bill making it compulsory in the French army. At this time, it was described as “incontestably effective,” and it was beginning to play a lead role in the struggle against typhoid fever.

There was, however, among the PCDF « Pauvres cons du front » – the ordinary soldiers – a strong and growing mistrust of vaccination and there was much reluctance and even refusal. The concern was in some part based on the at-that-time unfamiliar process (as Anne Rasmussen puts it) through which “inoculating a healthy body puts it at risk, for an uncertain benefit.” The argument was mainly based on the adverse reactions assigned to vaccination, increased by multiple injections that only increased risks and inconveniences. Complete inoculation effectively required four injections spaced 7 to 10 days apart. A repeat dose was required every year.

There was resistance to the High Command in some quarters which, in turn, led the army’s military and medical leaders to push even harder for the vaccination programme to be enacted. Doctors who did not carry out their vaccination mission with enough zeal and showed reluctance to inoculate were disciplined. Hyacinthe Vincent, during the course of the war, developed the TAB vaccination (a combined vaccine used to produce immunity against the diseases typhoid, paratyphoid A, and paratyphoid B). However, he talked of “the incredible resistance” that his TAB vaccine encountered “almost everywhere”.

Meanwhile, the phenomenon of the “falsely vaccinated” appeared. Men who, during the questionnaire preceding vaccination, either claimed they had already been vaccinated, or that they had previously developed typhoid fever. These reasons would mean they escaped inoculation: “Some vaccinations have been recorded on the simple declaration of men. Many military personnel say or claim to have been vaccinated and cannot provide any evidence of this. Their booklets do not mention this vaccination and they do answers when they are questioned. Suspicious and contradictory. There are serious reasons to think that these men claim to have been vaccinated to avoid injections […]”.

A Subjective Case Study: le 72e Régiment d’Infanterie, August 1914 – December 1916

The issue of consistently ensuring the required programme of multiple injections was followed is illustrated by a few extracts from the JMO (Journal de marches et opérations – the ‘war diary’) of the medical service of a single infantry regiment (72e RI – notionally from the Somme region) chosen solely on the basis of easily available information in a transcribed form.

In the JMO, it’s only in December 1914 that we first read of any issues with typhoid:
8 au 11 décembre 1914
Le Régiment occupe des tranchées au N.O. de Vienne-le-Château. Très peu de blessés, par contre, beaucoup de maladies pour diarrhée, dysenterie et embarras gastrique fébrile, début indéniable de fièvre typhoïde [my emphasis].
and of how
11 au 16 décembre 1914
En raison de son mauvais état sanitaire, le régiment est mis au repos. …
…
It might reasonably be assumed that at this stage of the war, because of the pressure of adaptation to the very different character of the war as encountered and the pressure of events, there’s a period in which pre-war preparation dissolves into a second phase where there’s an absence of control and resource.

There’s an inevitable attempt to re-establish control and good practice at the beginning of the new year. This would be part of the wider systematic campaign of inoculation by the Army authorities against typhoid:
14 janvier 1915
1250 vaccinations anti-typhoïdiques sont pratiquées.
Of course, the situation for any regiment depended always on whether they were in the line or not. At this stage, 72e RI as part of 3^e division d’infanterie, was under 2^e corps d’armée in the Argonne. This vaccination en masse seems to coincide with a withdrawal to rest and an imminent review by Joffre.

In February 1915, the regiment took part in offensive operations on the Champagne front. Possibly in preparation for active operations, we see a real example of the problems of delivering a full vaccination problem:
1er au 8 février 1915
…
Des vaccinations anti-typhoïdiques sont continuées sur tous les hommes n’ayant pas encore reçu dans les Dépôts au moins deux injections de vaccin.
8 au 17 février 1915
…
Les vaccinations anti-typhoïdiques ont été continuées. Depuis la mise au rafraîchissement du régiment, les opérations
de vaccinations sont ainsi réparties :
Hommes ayant reçu 3 injections = 929
2 = 473
1 = 531
Certains hommes n’ont pas reçu la 2ème ou la 3ème injection parce qu’ils étaient indisponibles lors de l’une de ces opérations ou parce que n’étaient pas arrivés au Corps qu’avec les 5 ou 6 derniers renforts.
During the next few months, we can probably assume that a vaccination programme continues as there’s no mention until July:
12 juillet 1915
La vaccination antityphoïdique est continuée pour tous les hommes non vaccinés ou incomplètement vaccinés.
while August provided a reminder of the connection of the vaccination programme to the maintenance of unit effectiveness:
25 août 1915
…
L’état sanitaire se maintient satisfaisant. Les diarrhées diverses constituent les affections prédominantes, un certain nombre d’hommes sont évacuées pour courbatures et embarras gastriques fébriles. Les vaccinations antithyphoïdiques sont continuées chez tous les hommes. Les renforts non vaccinés. En somme, le nombre des cas d’infections gastrointestinales est très peu élevé pour la saison.
The next entry concerning typhoid and vaccination suggests a reactive programme of re-vaccination in response to circumstances; but there’s an interesting qualifying remark:
21 décembre 1915
…
Les vaccinations antityphoïdiques et antiparatyphoïdiques étendues à tout le régiment ont été reprises le 16 décembre. Le besoin s’en faisait sentir, car malgré le très petit nombre des malades, le nombre des fièvres typhoïdes s’est élevé à une cinquantaine depuis un mois. Les malades ont été évacués de très bonne heure, au 1er et au second jour de la fièvre. Ils ne présentaient pas le mauvais aspect des typhoïdiques de l’hiver 1914-1915.
In January 1916, the JMO’s author is moved to speculate on whether there’s a decline in effectiveness of the vaccine or an increased vulnerability to ill-effects from the vaccine amongst men fatigued by trench warfare:
25 janvier 1916
…
La fièvre typhoïde donne toujours un certain nombre d’atteintes. Souvent, il s’agit de paratyphoïdes. Les malades sont évacués de façon très précoce et la mortalité est peu élevée. Les vaccinations antityphoïdiques et antiparatyphoïdiques sont activement poursuivies. Est-ce la qualité du vaccin, les hommes fatigués par la guerre sont-ils moins résistants ? toujours est-il que les réactions paraissent plus vives que celles que nous avons a observées l’an dernier à pareille époque, alors que nous avons vacciné tout le Régiment. Il y a lieu d’ajouter qu’il est resté au repos complet pendant un mois. – Tous les hommes qui ont eu antérieurement la fièvre typhoïde sont spécialement examinés au point de vue cœur et urines. Une assez forte proportion de ces militaires ont de l’albumine dans leurs urines et ne sont pas soumis à la vaccination. Jusqu’à ce jour, 6000 injections de vaccin environ ont été pratiquées avec du vaccin de Vincent. Grâce aux éliminations de suspects, nous n’avons pas encore eu à déplorer d’accidents.
But it’s only when the subject next appears in the diary in August that we get mention of the specifics of an adverse reaction to the vaccine:
15 août 1916
Continuation des vaccinations anti-typhoïdiques. 174 ont reçu la 1ère injection, 41 : la seconde, 4 : la troisième. Une réaction violente chez un s/officier a motivé son évacuation.
soon followed by
23 août 1916
Continuation des vaccinations antityphoïdiques.
18 ont reçu la 1ère injection, 133 la 2ème, 77 la 3ème, 4 la 4ème, total 232.
Une réaction assez intense a motivé l’entrée à l’infirmerie.
and again, even sooner after that
26 août 1916
Continuation des vaccinations antityphoïdiques.
37 ont reçu la 1ère injection, 258 la 2ème, 34 la 3ème, 5 la 4ème, total 334.
Une réaction assez intense a motivé l’entrée à l’infirmerie.
From this point forward, the recording of how many men have received what number of injections becomes the ‘standard’ format whenever the subject of typhoid vaccination is mentioned, as in this case:
5 septembre 1916
Continuation des vaccinations antityphoïdiques.
47 ont reçu la 1ère injection, 110 la 2ème, 326 la 3ème, 105 la 4ème, total 588

Conclusion

The subjective recording of episodes in one unit’s first years of war can’t be taken as the definitive experience of typhoid and anti-typhoid vaccination in the French Army in the same period, but it does enable some insight from an operational unit perspective.

One weapon in the French Army’s propaganda war to convince vaccination sceptics of the value of the vaccine was the deployment of statistics like those on this poster showing the benefits of vaccination among the civilian population in various localities in the period prior to the outbreak of war. (Credit: Quelques exemples de vaccinations antityphoïdiques dans la population civile en France en 1912 et 1913 / Laboratoire de Vaccination Antityphoïdique et de Sérothérapie de l’Armée, Val-de-Grâce, Paris. In copyright. [Source: Wellcome Collection]).

As the war progressed, in order to overcome vaccination reluctance, the army’s high command ultimately had to adjust its approach from disciplinary coercion to one that acknowledged the soldiers as citizens of the Republic who participated in a relationship with authority. This resulted in orders published on 5th April 1915 announcing and setting the limits for the rights of the individual to refuse treatment when injured or sick, but which also aimed to convince people of the advantages of medical treatment rather than to force or punish them, in an attempt to preserve collective health in the military without sacrificing individual choice. Citizens had a right over their own body, reflected in the concept of consent to any medical treatment (including preventative measures, like vaccination), but this freedom was necessarily limited given refusal of the vaccine, in the context of fighting an epidemic, was not an individual right, as it endangered the collective body of the nation.

Persuasion and education were now used in combination – beginning with the medical personnel administering the vaccine. They were required to convince the soldiers by developing trust based on their training and education, maintain confidentiality and adapt their approach to individual cases. It’s important, therefore, to acknowledge the important role played by those actually delivering medical care in the armed forces in making sure that the programme of vaccination was the success it undoubtedly was.

Note: The featured image for this post is ‘Gallic Cock’ (1916) by the sculptor and artist, Raymond Duchamp-Villon (born Pierre Maurice Raymond DUCHAMP) (5 November 1876 – 9 October 1918). This was part of the design by Duchamp-Villon for a temporary theatre on the French front.
In late 1916, Duchamp-Villon contracted typhoid fever while serving as a médecin aide-major de 2e classe in Champagne. He died on 7 October 1918 at the Cannes – Hôpital complémentaire N°75, 06 – Alpes-Maritimes, France.
André Chantemesse, whose work with Georges-Fernand Widal on the causes of typhoid and an experimental antityphoid inoculation were foundations on which Vincent and Widal’s work was developed, died in February 1919 as a result of another deadly infectious disease – the Spanish Flu influenza pandemic.

Several articles were referenced in preparing this blog post and helped me explain the science of water purification and the vaccination controversy, as well as the experience of vaccination for a single unit. On occasion, I have found no better way of explaining than through the words of these authors themselves. This is intended as an overview of the subject to encourage interest in, and inspire further reading around, aspects of the French experience of the First World War. For that reason, I encourage you to read any or all of the following:
* Traiter l’eau dans les tranchées durant la guerre de 14-18 (accessed 31 August 2024).
* Rasmussen Anne, « À corps défendant : vacciner les troupes contre la typhoïde pendant la grande guerre », Corps, 2008/2 n° 5, pp. 41-48.
* M. Mura, R. Haus-Cheymol, J.-N. Tournier, Immunization on the French Armed Forces: Impact, organization, limits and perspectives, Infectious Diseases Now, Volume 51, Issue 7,
2021, Pages 583-589.
* Smith L.V., Between Mutiny and Obedience. The Case of the French Fifth Infantry Division during World War I (Princeton University Press, 1994).
* JMO du Service de santé du 72ème Régiment d’Infanterie 5 Août 1914 au 18 Décembre 1916 (Service Historique de l’Armée de Terre (SHAT): 26 N 659/18: https://www.memoiredeshommes.sga.defense.gouv.fr/fr/ark:/40699/e00527b82eaba107/527b82eabd785 helpfully available in ts. here: https://argonne1418.com/wp-content/uploads/2012/08/service-sante-ri072.pdf
* Bunau-Varilla, Philippe, From Panama to Verdun (Dorrance and Co. [c1940]) is available here: ark:/13960/t9476bd73