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Influenza

Excerpts on the Influenza and Pneumonia Pandemic of 1918

EXTRACTS FROM REPORTS RELATIVE TO INFLUENZA, PNEUMONIA,

AND RESPIRATORY DISEASES

INFLUENZA


CONTENTS

Map of U.S. Camp Sites

A.  Camp Funston, Division Surgeon's Report

B.  Fort Riley, Kans., Base Hospital

C.  Camp Bowie, Division Surgeon Report

D.  Camp Bowie Base Hospital Report

E.  Camp Travis, Division Surgeon's Report

F.  Camp Travis Base Hospital Report

G.  Camp Sherman, Division Surgeon Report

H.  Camp Kearney, Division Surgeon's Report

I.   Camp Kearney Base Hospital Report

J.  Camp MacArthur, Division Surgeon's Report

K.  Camp Greene, Division Surgeon's Report

L.  Camp Greene Base Hospital Report

M.  Camp A. A. Humphreys, Division Surgeon's Report

N.  Camp A. A. Humphreys Base Hospital Report

O.  Camp Grant, Division Surgeon's Report

P.  Camp Grant Base Hospital Report

Q.  Camp Eustis, Division Surgeon's Report

R.   Camp Eustis Base Hospital Report

S.   Camp McClellan, Division Surgeon's Report

T.   Camp McClellan Base Hospital Report

U.Camp Wheeler, Division Surgeon's Report

V.Camp Wheeler Base Hospital Report

W.Camp Lee, Division Surgeon's Report

X. Camp Lee Base Hospital Report

Y. Camp Custer, Division Surgeon's Report

Z. Camp Custer Base Hospital Report

A1.  Camp Upton, Division Surgeon's Report

   Camp Upton Base Hospital Report

B1.Camp Meade, Division Surgeon's Report

C1.Camp Meade Base Hospital Report

D1.Camp Logan, Division Surgeon's Report

E1.Camp Logan Base Hospital Report

F1.Camp Gordon, Division Surgeon's Report

G1.  Camp Gordon Base Hospital Report

H1.  Camp Pike, Division Surgeon's Report

I1.Camp Pike Base Hospital Report

General Hospital No. 33 [Fort Logan H. Roots, AR]

J1. Camp Jackson, Division Surgeon's Report

K1.Camp Fremont, Division Surgeon's Report

L1.Camp Dix, Division Surgeon's Report

M1.Camp Beauregard, Division Surgeon's Report

N1.   Camp Joseph E. Johnston, Division Surgeon's Report

O1.Camp Dodge, Division Surgeon's Report

P1. Camp Hancock, Division Surgeon's Report

Q1.Camp Hancock Base Hospital Report

R1.Camp Sheridan Base Hospital Report

S1.Camp Wadsworth Base Hospital Report

T1.Camp Lewis Base Hospital Report

U1.Camp Sevier Base Hospital Report

V1.Camp Mills Base Hospital Report

W1.Fort Sill Base Hospital Report

X1.Camp Shelby Base Hospital Report

Y1.Camp Devens Base Hospital Report

Z1.Camp Zachary Taylor Base Hospital Report

A2.Camp Merritt Base Hospital

B2.   General Hospital No. 2 [Fort McHenry, Baltimore, MD]

C2.  General Hospital No. 3 [Colonia, NJ]

D2.  General Hospital No. 4 [Fort Porter, Buffalo, NY]

E2.General Hospital No. 6 [Fort McPherson, GA]

F2.General Hospital No. 7 [Baltimore, MD]

G2.General Hospital No. 8 [Otisville, NY]

H2.General Hospital No. 9 [Lakewood, NJ]

I2. General Hospital No. 11 [Cape May, NJ]

J2. General Hospital No. 13 [Dansville, NY]

K2.General Hospital No. 15 [Corpus Christi, TX]

L2.General Hospital No. 16 [New Haven, CN]

M2.General Hospital No. 17 [Markleton, PA]

N2.General Hospital No. 25 [Fort Benjamin Harrison, IN]

O2.General Hospital No. 27 [Fort Douglas, UT]

P2.General Hospital No. 29 [Fort Snelling, MN]

Q2.General Hospital No. 26 [Fort Des Moines, IA]

R2. Army and Navy General Hospital, Hot Springs, Ark.

S2. Fort Sam Houston Base Hospital

T2. Letterman General Hospital, San Francisco

U2. Camp Stuart Embarkation Hospital [Newport News, VA]

V2. Embarkation Hospital No 1 [Hoboken, NJ]

W2. Debarkation Hospital No. 1 [Ellis Island, NY]


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A. CAMP FUNSTON, DIVISION SURGEON'S REPORT.

The influenza epidemic

-The progress of this disease from the East toward Camp Funston was being watched with the intention of a recommendation to the commanding general that the camp be placed in quarantine as soon as the epidemic had reached Chicago or other cities at about that distance from Camp Funston. Telegrams requesting immediate report of the appearance of the disease were sent to these cities, but while awaiting these reports the epidemic began in this camp without any traceable connection with other diseased camps or communities.

On September 16, 1918, 47 cases were sent to the hospital from Battery C, 29th Field Artillery. No other cases were reported on this day. The division surgeon was notified at once and the following orders were issued:

(a) That the organization be restricted to its area when not at the training area.

(b) That all drills and training of this organization be as separate unit,

(c) That possible contacts with other organizations be limited to the minimum necessary to the conduct of military duty.

The following day only a few cases were reported from this organization but the total gradually increased until 35.9 per cent of the command had been sent to the hospital.

Two days later, on September 18, 8 cases appeared in the 28th Field Artillery and 4 cases in the 30th Field Artillery. In the 28th Field Artillery the increase to the


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maximum was rapid and in the 30th Field Artillery more gradual. Because of its location next to the 30th Field Artillery, the 10th Ammunition Train was next affected. The 10th Trench Mortar Battery, next to the 28th Field Artillery, also became affected. These organizations are all located beyond the parade ground from the rest of the camp. The nearest organization is the 70th Infantry, which is over a quarter of a mile from the Artillery groups, and this was the next to be affected. The next large group was the Quartermaster Corps. This organization belongs to the camp, but because of their work from one part of the camp to another they aided in spreading the infection. The 70th Infantry and the 69th Infantry being composed of new men were heavily affected. The 20th Infantry, having some older men, was less affected, while the 41st Infantry, being almost entirely composed of seasoned men, had a relatively small number of cases.

The sanitary train and the 210th Engineers have their barracks in the canyon at the extreme opposite corner of the camp from the Artilleries and about a half mile from the camp proper. These only became affected after all the other organizations in the camp were well in the midst of the epidemic. The infection probably reached them through some incipient case. The enlisted personnel of the sanitary train had been assisting in the emergency hospitals and the Engineers had assisted in driving emergency ambulances. The fact that these organizations were not affected earlier shows that the preventive precautions used on the men who handled the influenza patients, and the disinfecting methods were satisfactory.

The United States Army base hospital at Fort Riley was filling so rapidly from the first that it was known that considerable extra space would be needed for emergency hospitals during the epidemic. Two days before the base hospital had reached its maximum capacity the Kansas Building, a large auditorium was prepared to receive patients. This building measures 200 by 90 by 50 feet, and was arranged to accommodate patients. It was opened on September 30, at 8 p. m., and by midnight had received 229 patients. The following morning the Nebraska Building was opened. This building is of about half the capacity of the Kansas Building and is also of the auditorium style of building, i. e., having one large room with a small stage at the end. In the Kansas Building there were rooms in addition that could be used for kitchens and for offices, but in the Nebraska Building it was necessary to set up field kitchens outside to prepare the diets.

The increase in the number of cases was so rapid that it became necessary on the same day to prepare the Young Men's Christian Association auditorium for patients. This building accommodated only 225 patients and was largely used for convalescent cages sent out from the hospital at Fort Riley. Next, the barracks recently occupied by the 815th and 816th Pioneer Infantry Regiments, were prepared and, as these buildings were capable of holding 3,000 patients, ended the necessity of looking for further space.

The personnel used in these emergency hospitals was composed of men from the sanitary train and officers from the sanitary train from the medical officers̓ training camp at Fort Riley, and from the various organizations in the 10th Division. The officers were selected with a view to using those who had had special work in chest examination in order that the patients who developed pneumonia might be found early and sent to the pneumonia ward at the base hospital.

The supplies used in the emergency were collected from every available source. Some were bought in the open market, some were donated by various societies in the neighboring towns, and perhaps the largest help came from the Red Cross.

The maximum admission for influenza patients from the 10th Division for any one day came on the 2d of October, when 708 cases were admitted, This was on the 17th day from the first appearance of the disease in the camp. Thirty-four days after this peak was reached the last definite case of influenza had been sent to the hospital. The highest week's admissions ran from September 28 to October 5, during which time over 400 cases were sent each day with a total for the week of 6,036 cases. These figures are taken from the hospital records and run considerably higher than those taken from Forms 84 in which many influenza cases were listed as "undiagnosed."

The total number of deaths due to pneumonia following influenza was 430. Pneumonia cases in this division totaled 1,235, practically all of which followed influenza. Some of the pneumonia developed so quickly after the onset of the symptoms of influenza that the men were toxic by the time they reported at the regimental infirmaries. Pneumonia was responsible for practically all the deaths during the influenza epidemic. The first cases appeared in the 28th Field Artillery, when 7 cases were sent to the hospital on September 25.

The largest total number of pneumonia cases and also the largest relative number occurred in the 70th Infantry. Two hundred and sixty-one cases were sent from this organization, a daily average of 0.72 per 1,000 strength. The lowest total came from


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the 210th Field Signal Battalion, but the lowest relative number came from the old 41st Infantry. One thousand two hundred and thirty-five cases were sent from the division with pneumonia, but others developed after the patient entered the hospital.

As to the percentage of each command sent to the hospital, the following figures are arranged in order:

  Per cent.

30th Machine Gun Battalion 

61.3

28th Machine Gun Battalion 

60.9

29th Field Artillery  

35.9

70th Infantry

34.2

30th Field Artillery  

33.2

10th Ammunition Train 

32.9

10th Supply Train

29.3

210th Engineers 

28.7

69th Infantry  

28.5

10th Sanitary Train

28.2

29th Machine Gun Battalion

26.9

28th Field Artillery

26.0

210th Field Signal Battalion 

23.5

20th Infantry 

22.4

10th Headquarters Troops and Military Police

20.7

41st Infantry

17.3


B. BASE HOSPITAL, FORT RILEY, KANS.

Sick of Camp Funston were treated at base hospital, Fort Riley.

The epidemic of influenza and influenzal pneumonia began about September 15, 1918. Between September 15 and November 1, 1918, 15,170 patients with influenza out of a total population for the military reservation of 63,374 were admitted to hospitals, of whom 9,105 were admitted to the base hospital. The influenza incidence for the population of the reservation was 23.9 per cent. Twenty-six hundred and twenty-four patients developed pneumonia, of whom 941 died. The pneumonia mortality for the period of the epidemic was 35.8 per cent. The largest number of influenza and pneumonia patients admitted to the base hospital was 785, on September 30. On October 8 the hospital housed 5,666 patients, of whom 2,951 had influenza and 719 pneumonia. One week later, on October 15, there were 1,336 pneumonia patients in the medical wards. The incidence of pneumonia among influenza patients was 17.2 per cent (2,624 in 15,170). The largest number of deaths, 81, occurred on October 13, The normal capacity of the base hospital was 3,068. It was necessary during the epidemic to nearly double the number of available beds. This was done by utilizing the large corridors and porches of the convalescent sections, the porches of sections A, B, C, F, H, and L, eight double-story detachment barracks, and the Young Men's Christian Association building. The war capacities were taxed to the utmost, but every attempt was made to give each patient 100 square feet of space and 1,000 cubic feet of air space. Fortunately the weather was favorable and it was possible to secure adequate ventilation by widely opened windows and doors, and by electric fans placed throughout the wards, where it had been found necessary, because of overcrowding, to decrease the available space.

C. CAMP BOWIE DIVISION SURGEON REPORT.

The influenza epidemic began at Camp Bowie about the 24th of September, the first cases being reported to the camp surgeon's office on the 26th. It lasted until November 5, although there have been a number of sporadic cases since that time.

Duration of epidemic in days, about 41

Influenza in same period  4,439

Influenza from Nov. 5 to Dec. 31 99

Total influenza 4,538

Pneumonia over epidemic period 687

Deaths from pneumonia over epidemic period 130

There were two peaks in the epidemic curve, October 2,when 403 cases were admitted to the base hospital and observation wards and October 26, when 260 cases were admitted. The two peak loads were so excessive because of admissions of draft men to the detention camp:

Sept. 27 3,000 (approximate).

Oct. 22 to Oct. 26 3,000 (approximate).


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It was distinctive of the epidemic that three-fourths of the cases came from the detention camp even though the detention camp was quarantined while the remainder of the camp was not:

Total influenza 4,538

Detention camp influenza 3,473

Preventive measures.-Members of command forbidden to attend any mass meetings such as moving pictures, theaters, etc. Detention camp quarantined. Prevention of crowding in street cars, extra cars being put on the lines for this purpose. Tents furled, and all bedding and clothing sunned and aired daily. In the detention camp the woodwork in tents, buildings, etc., was sprayed with chloride of lime solution and the tents were sprayed with formaldehyde solution. All men throughout the camp were examined by medical officers twice daily and noses and throats were sprayed with chlorazene in Dobell's solution.

In order to provide immediate treatment for cases of influenza and to prevent delay and exposure in transporting cases to the base hospital, eight mess halls in detention camp were converted into observation wards. Special ambulance service between the different infirmaries throughout camp and the base hospital was established. Winter clothing was issued at once to all organizations which had not already received it. After men were dismissed from the base hospital they were kept under observation for a period of five days.

There was a severe pneumonia epidemic during the winter of 1917-18 which did not abate until the beginning of May, 1918. This epidemic was concurrent with measle epidemic and the greater number of pneumonia cases were complications from measles. The prevailing type of pneumonia in this epidemic was the lobar. During the fall of 1918, beginning the first few days in October there was a second pneumonia epidemic which was the direct result of the influenza epidemic. The first peak of the pneumonia curve reached its height October 7, just five days after the first peak of the influenza curve and the second peak of the pneumonia curve reached its height November 2, just seven days after the second influenza curve. The winter epidemic of 1917-18 had the predominating type lobar while the fall 1918 epidemic had the predominating type broncho.

D. CAMP BOWIE BASE HOSPITAL REPORT.

On September 27, 1918, the first case of influenza was admitted to the hospital. The number of cases coming to the hospital increased rapidly until, on October 7, 1918, a total of 1,989 patients were under treatment at the hospital, most of whom had influenza. A total of 3,907 cases were treated from date of beginning of the epidemic until the end of the year. A total of 671 pneumonia cases resulted from the epidemic in this camp. The percentage of pneumonia cases arising from influenza can not be determined at this hospital, as many cases of the latter disease were treated in infirmaries established in the camp.

During the first part of the epidemic 569 cases were treated in observation wards, 264 being sent from the wards to the base hospital. During the latter part of the epidemic a total of 674 were treated in wards, and of these 173 were sent to the base hospital.

The Negro troops showed greater susceptibility to the disease than the whites.

E. CAMP TRAVIS DIVISION SURGEON'S REPORT.

The influenza epidemic of October and December: The epidemic of influenza, which invaded this camp in common with the rest of the country, had its onset on September 30, with 51 cases, from which date it developed with great rapidity, reaching its peak with 1,072 cases admitted October 7. The decline was gradual, lasting until November 9, when the epidemic was considered over, with 14 new cases on that date. Rigid quarantine was established with the onset and every effort was made to instruct the command in preventive measures.

F. CAMP TRAVIS BASE HOSPITAL REPORT.

The appearance of influenza epidemic (October, 1918) in Camp Travis caused a rapid disorganization of the routine work of the Medical Department and changed, in a relatively few days, the entire medical service into one of post-influenza pneumonia. At the onset of the epidemic our knowledge of this type of pneumonia was very vague. The epidemic of streptococcus pneumonias last year gave us a slight working knowledge of the situation, but gave no hint of diagnosis or treatment of this


744

type of pneumonia. The typing of the pneumococcus usually showed Type IV. These pneumonias differed greatly from ordinary ones in their -method of onset, being more insidious and rarely starting precipitately.

Pfeiffer bacillus was found 344 times out of a total of 888 cases. In other words, the organisms were found in the throats of 39 per cent of the patients. It is difficult to explain why it was not recovered in larger percentage of cases.

In anticipation of the appearance of influenza at Camp Travis, on the afternoon of September 30, 1918, a group consisting of nine buildings, located between Avenues F and G, and extending north from Third Street, was selected, chiefly because opportunity was offered for further expansion, in case of necessity. The information office was located in the headquarters building, a small room being set aside for this department. This office furnished information to relatives concerning the condition and location of patients. A card system, alphabetically arranged, was prepared, a card being made out for every patient as he entered the hospital. When a patient was discharged from the hospital, his card was removed from the file of active cases, the date of discharge placed thereon, and the card placed in the third file. As a result, within a few minutes following an inquiry concerning a patient, complete information could be given to relatives. During the first seven days of the epidemic, the most urgent problem was the providing of wards for the reception of patients. A glance at the table of admissions will emphasize the difficulties encountered in thin connection, in view of the admissions of 4,563 cases on the five days of October 4 to 8, inclusive. At no time was there a lack of beds available for new cases. This was the result of a carefully planned organization, whose sole duty consisted of the preparation of buildings for the reception of patients, and provided a command of over 200-enlisted men and noncommissioned officers under the command of two medical officers. The buildings were first thoroughly cleaned by a crew of enlisted men, detailed for that purpose, another crew following immediately behind arranged the cots, allowing 100 square feet of floor space to each, at the same time a third crew of 100 or more colored enlisted men were engaged in filling bed sacks with straw and placing them on the cots; a fourth crew brought to the wards, by means of large motor trucks, sheets, pillows, pillow cases, and blankets, and prepared all the cots for patients. A fifth crew strung wires between the cots and hung the sheets thereon, in order to provide cubicles for each patient. A sixth crew completed the conversion of the barracks building into a hospital ward by bringing to the building the equipment. Altogether 76 large 2-story barracks buildings were taken over and converted into wards, each building, allowing 100 square feet floor space to a cot, permitted the housing of from 70 to 90 patients, making a total of approximately 6,500 beds available for patients. As strict a quarantine as possible was maintained about all the buildings comprising the annex, and no visitors were allowed to enter the wards. All attendants and medical officers were required to wear gowns and face masks while working in the wards. Patients, when out of cubicles or ambulatory, also wore similar face coverings. All ward floors were gone over daily with a mop dampened with a 3 per cent solution of cresol. All discharges from the mouth, nose, sputum cups, napkins, and paper bags were collected and burned. All dishes used by patients were boiled after being used. Abundant fresh air and ventilation was maintained in all the wards, and in case of cold weather, proper heating facilities were instituted. All patients were kept in bed with normal temperatures f or 72 to 96 hours, depending upon the severity of their attack of influenza, and all cases were kept in the hospital or quarters until their temperatures had been normal for 10 days. During their stay in the hospital frequent examinations of the chest were made. Temperatures were taken two or three times per day, depending upon the severity of the case. No special medicinal therapy was instituted, the chief dependence being placed upon Dovers powders and aspirin, combined with catharsis, abundant fluids, and liquid diet while in bed, and rest.

The epidemic began on October 1, 1918, one day prior to the opening of the annex, when 240 cases were admitted to the base hospital; on September 30 there had been 51 cases. On the four days, September 19 to 22, inclusive, there had been 45 cases of influenza in the camp. From September 23 to 29, inclusive, no cases were reported. With the opening of the annex on October 2, 1918, cases were admitted with unprecedented rapidity, and if the organization had not been well in hand, would have swamped. the resources provided. During the first 7 days 5,645 cases of influenza were admitted to the annex, and at the end of the first 2 weeks the figures had reached 8,539, an average of 609 cases per day. The largest day's record of admissions was October 7, when 1,006 cases were admitted, the admissions on the 2 days previous exceeding 900 each. During the 50 days that the annex was maintained 10,606 cases of influenza were admitted (this figure is lower than that shown in the table of admissions above, owing to the fact that the latter includes several hundred cases of


745

convalescent pneumonias transferred to the annex from the base hospital in order to relieve the congestion at the latter place, in addition to this number there were several hundred cases admitted to the base hospital, mostly prior to the opening of the annex, bringing the complete total of influenza cases during these fifty-odd days up to 10,942 cases. During the epidemic there were 34,127 soldiers in Camp Travis, making an incidence of influenza of 32.06 per cent. About 9 per cent of the colored troops in the camp suffered from the disease, while about 41 per cent of the white troops were attacked. From October 16 to November 4, 1918, 1,596 new draft men arrived at Camp Travis; of these 900 were admitted to the annex with a diagnosis of influenza. Up to November 10 there had been 2,459 cases of pneumonia develop among the influenza patients, 203 among the colored and 2,256 among the white soldiers, the incidence for each being, colored 27.6 and whites 21.3 per cent; 22.4 per cent of all influenza cases developed pneumonia this being 7.2 per cent of all the soldiers in the camp. Among these 2,459 pneumonia cases, up to November 10, there had been 199 deaths, this being 8.8 per cent of all the pneumonias, 1.82 per cent of all the cases of influenza, and 0.58 per cent of all the men in camp. It is remarkable that not one death occurred at the annex; this is due to the fact that all cases were given immediate medical care and during their stay in the annex were frequently and carefully examined for complications. The annex closed on November 20, at which time the epidemic had practically spent itself,

POST-INFLUENZAL PNEUMONIA.

The onset of the epidemic was around September 30, 1918, when the first cases of well-defined influenza were noted by ward surgeons and the diagnosis corroborated by the throat cultures showing the influenza bacillus as the predominating organism. On October 4, 1918, the first post-influenzal pneumonias were recognized. It was at this point that a 10,000-bed hospital down in the camp proper was organized almost over night, with expedition that was nothing short of marvelous. This took over the whole influenza population of the camp, and the medical officers stationed there soon became so expert in early physical signs that pneumonias were picked out almost in their incipiency and sent to the base hospital, where arrangements had been made to handle all the pneumonias. At the beginning of the epidemic our knowledge of this type of pneumonia was very vague. The infection differed from ordinary pneumonia markedly in type of onset. It was, as a rule, more insidious, rarely starting very precipitately with signs of pleural involvement. Many had vague indefinite sensations in the chest variously described by the patients as (1) soreness, (2) hurting, (3) tightness, (4) "chokiness," (5) congestion, (6) fever in the chest (7) burning in the chest, (8) rawness in the chest, etc., and but very few had the sharp sticking pain so common in the onset of acute lobar pneumonia. The onset was more like that of our ordinary winter "la grippe" infections, though more severe and with more marked prostration.

G. CAMP SHERMAN DIVISION SURGEON REPORT.

During the influenza epidemic, which made its appearance very suddenly, it became necessary, owing to the base hospital being filled to capacity, to turn about 50 of the ordinary barracks buildings into wards for the reception of the less serious cases. During this entire epidemic the entire camp was held under a rigid quarantine from the surrounding country. No public gatherings of any description were permitted, all amusement places, post exchanges, Y. M. C. A. community houses, etc., were closed; draftees were not sent to the camp; all transfers out of the camp were discontinued; a gargle consisting of a 5 per cent solution of bisulphate of quinine was prepared which, by order of the commanding general, each and every person in the camp were required to use twice daily. All medical officers were required to make daily inspections of all troops for the early recognition of suspects or those already suffering from the early symptoms of the disease. Those persons coming in contact with patients suffering from this disease, including ambulance drivers and patients en route to the base hospital were masked. The cubical system was used throughout the base hospital and the barracks devoted to the reception of the influenza patients. The usual precautionary measures were taken to prevent overcrowding throughout the entire camp, and men were warned not to congregate, and to remain out of doors as much as possible. Sprinkling of the main highways and parade grounds was adopted in order to allay the dust. All typhoid vaccinations and other inoculations were discontinued during the epidemic.


746

H. CAMP KEARNEY DIVISION SURGEON'S REPORTS.

The first epidemic of influenza appeared in April. This type, while prostrating, was very brief. And there were very few cases of pneumonia following. The local term "Japanese influenza" was given to the disease, as it was thought to have been started by the arrival of a squadron of Japanese warships which arrived at San Diego during the first week of April with a number of cases of influenza.

The second epidemic of influenza appeared at Camp Kearney in September. This was the local manifestation of the influenza pandemic. There were numerous cases of pneumonia and empyema, but the mortality was comparatively low. The following preventative measures were in force during the epidemic:

Companies and organizations were quarantined when the disease occurred within the units concerned.

A general quarantine was placed over the entire camp October 9, 1918, and on this date a detention camp was established, where everyone entering camp was held for five days and examined daily.

All indoor amusement halls and exchanges were closed 14 days after the first case was reported.

Gauze masks were worn by everyone in camp from November 2 to November 12, inclusive.

The cubicle system was established in the hospital and a minimum floor space of 100 square feet and 1,000 cubic feet of air space was allowed. All dishes were boiled. Paper napkins and bags were used at the base hospital and no dry sweeping allowed. All bed linen was sterilized by boiling, and blankets, pillows, and mattresses were steam sterilized.

In no instance were more than five men allowed in a large pyramidal tent, and whenever possible the limit was placed at four. In organizations in close quarantine within the camp only two or three men were allowed in a tent. Screens between cots were used. Hoods were removed at all times and tents were furled daily, except during inclement weather. Mess kits and utensils were boiled and allowed to dry. Men were inspected twice daily.

A convalescent camp was established for patients returning from the hospital where they were excused from all duties for two days, and then gradually returned to full duty. When this camp had to be abolished on account of its location and the inclement weather, all patients returning to their organizations were placed at the end of their company streets, and excused from duty as they had been while in the convalescent camp. All men were supplied with sufficient clothing.

No systematic prophylactic spraying of the nose and throat was instituted, though some organizations used this, but the result shown did not warrant its use as a routine measure. Neither was antiinfluenza vaccine used. Antipneumococcic vaccine was not used until the epidemic was practically over, and then only in a small group of cases.

I. CAMP KEARNEY BASE HOSPITAL REPORT.

This camp was subject to the epidemic of influenza which first manifested itself at Balboa Park, San Diego, in April, 1918, and was termed locally "Japanese influenza," as the disease was thought to have been established in this vicinity following the visit of a Japanese fleet to San Diego in April, 1918. The first cases admitted to hospital were on April 10, 1918, to a maximum admission on April 29, 1918, and to decline with no admissions the latter part of June. No distinctive organism could be accused as to the causative factor. No epidemic disease exhibited itself again until September 24, 1918, on which date this camp was first visited with the pandemic of influenza.

The medical service had 1,280 available beds, with medical officers, Army Nurse Corps, ward masters, and orderlies in sufficient strength to operate them. All cases developing pneumonia were immediately sent to the wards, four in number, known as pneumonia wards, where special medical officers and specially trained nurses and enlisted men wore on duty. Patients convalescent from pneumonia ,were immediately transferred to another ward and area under observation of a medical officer and not in contact with fresh infections. The treatment by drugs was restricted and, in order to comprehensibly control this restriction, all prescriptions had to be counter-signed by the chief of medical service. Through conference with the officers of the medical service, a line of treatment was established. Various symptoms and varying conditions were met by proper therapeutics and medical officers were warned that sick soldiers were not a clinical material to be subjected to experimental therapy. Serotherapy was not used except in a few cases proved by type to be pneumonia type 1, in which case type 1 serum was used. Only convalescent patients were put in tents. Ten field hospital war tents with 16 beds and 12 hospital tents with 4 beds each were used; the cubicle system with sheets being maintained.


747

J. CAMP MACARTHUR DIVISION SURGEON'S REPORT.

There were a few sporadic cases of influenza reported from January 1 to September 30, on which date a train of 500 men arrived from Camp Grant, Ill. Of this number126 were sent to the base hospital with a clinical diagnosis of influenza, the remaining 374 men were quarantined in a "wired" detention camp. Of these there were 94 subsequent admissions for influenza.

These men were infected before coming to this camp, were kept in quarantine from time of arrival and had nothing to do with the influenza epidemic experienced in this camp.

It is believed the infection was much more virulent among these troops than among those who contracted the disease locally.

The local epidemic of influenza began about October 4 when there were 12 cases reported, while on October 5 there were 391 cases. The greatest number of admissions occurred October 6, when 964 cases of influenza were reported. The number of admissions fell off daily until October 27, on which date the admissions decreased to 6.

On October 18 there were 1,929 cases in the base hospital and 1,402 in quarters. Due to the limited capacity of the base hospital it was necessary to treat these 140 cases in an improvised field hospital. These men were rationed with line organizations, consequently they were carried as quarters cases.

As a result of influenza, 930 cases of pneumonia developed, of which number 202 died. Seventeen cases of empyema have developed as a complication to date. There was only one death reported from influenza without complication.

K. CAMP GREENE DIVISION SURGEON'S REPORT.

The first cases of influenza developing in this camp were reported by the base hospital on September 22, 1918. There were five cases arising in the following organizations: 9th Company Recruit Camp No. 4, 22d Company Recruit Camp No. 4 (white), nnd Company D, 810th Pioneer Infantry, Company B, 347th Labor Battalion, and Company C, 346th Labor Battalion (colored). On September 24, two cases (white) were reported from the quarantine camp. No cases developed on September 25. On September 26, 23 cases were reported, all white, from seven different organizations. On September 27, two cases (colored) were reported from the 810th Pioneer Infantry, and one from Recruit Camp No. 1. On September 28, five white cases were reported, one from the auxiliary remount depot, being from a new organization, up to this time the cases had been sporadic, developing in widely separated organizations and there was little evidence of direct contagion in the command originating the epidemic.

On September 29, 40 cases were reported, and from this time the disease took on the definite appearance of an epidemic. The disease spread rapidly, involving all organizations in the command with daily admissions increasing rapidly, until from October 3 to October 10 the crest of the epidemic was reached. From this time the daily admissions dropped gradually until the end of October, at which time the disease had apparently run its course. With the rapid influx of patients it became early apparent that the base hospital would be overtaxed, and to relieve this congestion a supplementary field hospital and convalescent camp were opened on October 3. This consisted of two camp infirmaries with tentage added to meet the growing need. The personnel for this hospital was drawn from the various departments of the camp, approximately 15 surgeons and 125 enlisted personnel of the Medical Department, together with cooks from the school of bakers and cooks, being used. On October 5, 1918, an additional unit was put in operation, two near-by camp infirmaries being used, and this personnel, corresponding in strength to that of the first, was drawn from evacuation hospital No. 30, base hospital No. 92, base hospital No. 122, and base hospital No. 123, these organizations having been mobilized at this camp.

The convalescent camp was all under canvas, and tentage was added as necessity arose. The same personnel administered the convalescent camp and supplementary field hospital. As soon as a patient had a normal temperature for two days he was moved into a convalescent camp, where he remained for four days before his return to duty. Patients were sent back to their organizations in auto trucks accompanied by a surgeon and personally turned over to their organization. Camp orders were issued to give these men the lightest possible duty for four or five days upon their return to duty, and the surgeons of the various organizations were directed to keep careful watch on these men. Upon a patient being sent to the supplementary field hospital, his bedding and mess kit were sent with him. Owing to the excellent cooperation on the part of the school for bakers and cooks, within two hours after the


748

opening of the supplementary field hospital hot liquids were being served, and this was repeated every two hours. The patients in this hospital were carefully supervised and upon the first appearance of a rise in temperature or complication of any nature immediate removal to the base hospital was accomplished. Seventeen hundred and eleven cases were treated in the supplementary field hospital.

L. CAMP GREENE BASE HOSPITAL REPORT.

The epidemic of influenza was first manifested when, following the admission on September 20, 1918, of two cases of slight fever to a general white ward, within five days the convalescent and chronic cases, as well as the nurses and orderlies in that ward, began to come down with serious influenzal symptoms. The ward was "at once quarantined and no other ward was similarly attacked. Four days later the first noteworthy influx of influenza cases began, confined to colored troops, the epidemic among the white soldiers occurring distinctly later. Successive vacant wards" were opened and rapidly filled, until the new cases were concentrated and placed in a state of protective isolation against exposure to the influenza cases, and, except-for the ward mentioned above, none were seriously invaded. In the management of the influenza wards every effort was made to recognize complicating pneumoma promptly. On increase in respiration, rusty sputum, or physical signs cases were removed from each influenza ward to a separate part of the outside porch and screened, on one side. The weather was fortunately fair practically throughout the period of stress, but in case of rain while the porches were in use tarpaulins were hung ready to drop as protection.

M. CAMP A. A. HUMPHREYS DIVISION SURGEON'S REPORT.

The epidemic of influenza began about September 13, and it was practically over by October 18. During that period there were 4,237 cases. The height of the epidemic was during the week September 28 to October 4. During the period of the epidemic there were 413 deaths. With a few exceptions these were due to pneumonia, principally broncho-pneumonia. The incidence of influenza was lowest among the colored troops, but the incidence of penumonia was highest and the death rate from pneumonia was also high. An interesting fact brought out in the study of this epidemic was that the use of cubicles in the barracks reduced the incidence of influenza and also that the incidence of the disease varied with the floor space. In those organizations having a floor space in excess of 50 square feet per man the incidence of the disease was lowest.

N. CAMP A. A. HUMPHREYS BASE HOSPITAL REPORT.

Occupation of the new base hospital was effected by September 20, 1918, with a theoretical bed capacity of 600 beds, 300 of which were immediately available. The removal of the new hospital, which had been impending since May 1, was accomplished none too soon, for almost immediately the influenza epidemic swept through the camp and the demand for hospital care increased beyond all expectation. The crisis found the medical service with 14 medical officers, but one of these was assigned to internal medicine and two to the neuropsychoatric division. Three hundred members of the medical detachment constituted the entire nursing force, none of the Army Nurse Corps having as yet been assigned. Within the period of a week the hospital capacity was increased to 1,65,0 beds, the medical detachment to 800 men, the Nursing Corps to 96, including nurses' aids, and the commissioned personnel to 58. Such an expansion in so short a time could have been and was accomplished only through the most perfect cooperation. Any attempt at recognition of individual services at this time would be futile. Fortunately, great emergencies stimulate the spirit of unselfish service, and in this the epidemic was no exception.

The entire hospital, including the surgical wards (except for 10 beds), was turned over to the medical service, and 2,400 cases of influenza were admitted. No case was refused admittance and at no time was the limit of the hospital's capacity reached. The number of admissions was greatest on October 5, 1918, when 293 cases were admitted, and the number of deaths on October 6, 1918, was greatest, when 48 were reported. Broncho-pneumonia complicated the disease in more than 605 cases admitted to the hospital. As a general rule, the pneumonias were extremely diffuse, though the demonstrable areas of consolidation varied from the most minute to the entire lung on both sides. During the entire epidemic 450 deaths occurred, all from broncho-pneumonia, with or without other complications. No death from uncomplicated influenza was observed in this hospital. In the majority of the cases


749

the death was mechanical, resulting from interference with respiration by the massive exudates, in the bronchi, the extensive areas of consolidation, and the diffuse pleural adhesions. Circulatory failure was rare except as a terminal event. In so fulminant an infection as might be expected pleural effusions and empyemata were relatively rare, except as late complications of recovering cases. Eighteen cases of empyema and 20 pleural effusions were observed. Meningitis was rare, though meningeal symptoms were common. Lumbar puncture was performed in a large number of cases without demonstration of actual meningeal infection except in two instances, Pericarditis was a fairly common complication in the cases of longer standing, and was usually serofibrinous in type. Two cases of pyopericardium were observed and operated-one with satisfactory convalescence to date, the other terminating fatally a week later. Otitis media was very common and necessitated frequent recourse to paracentesis. Parotitis occurred 12 times, necessitating drainage twice. Phlebitis was observed in six cases. Sinusitis of varying degrees and involving most commonly the frontal sinuses was very common. Peritonitis resulting from extension by contiguity occurred once, from perforation of an acute peptic ulcer once, and, so far as could be determined by autopsy, occurred as a primary infection in one case. A singularly interesting complication in the form of a deep fascial infection of the abdominal wall in the hypogastrium occurred in four cases, necessitating drainage in three. Cholangitis was noted in a number of cases and was bad prognostic significance. The gauze mask undoubtedly has some efficacy by virtue of its partially preventing unrestricted dissemination and inhalation of forcibly expelled infectious droplets, but it also performs and immeasurable service in emphasizing to the wearer that the mouth and nose afford the entrance for the infection and, more importantly, in preventing him from getting his hands, eating utensils, etc., in contact with his mouth and nose.

O. CAMP GRANT DIVISION SURGEON'S REPORT.

In the latter part of September a severe epidemic of clinical influenza attacked the camp, resulting in 10,713 cases of this disease during the months of September and October, with 2,355 cases of pneumonia and 1,060 deaths resulting.

The rapidity with which cases developed during the height of the epidemic promptly flooded the base hospital, and it became necessary to equip the various infirmaries throughout the camp to receive patients. When the housing space in the infirmaries was filled, one or more contiguous barracks in each area were assigned for the reception of patients. All mild cases were received in these infirmary wards, and if the cases became more severe they were transferred at once to the base hospital. These wards were also used for the reception of convalescents returned from the base hospital, who were held for about a week for observation before being returned to duty. In addition to the observation and attention given the men in the infirmary wards by the surgeons of the various organizations, a medical officer of experience was detailed as visiting consultant. This officer visited each infirmary daily and gave his advice as to which cases should be transferred to the hospital.

The efficiency of the attention given in these wards is attested by the fact that although more than 2,000 cases were handled, but 1 death occurred in an infirmary, and that man was a returned convalescent. As the number of convalescents multi plied, their care became a problem which was particularly acute on account of the lack of a detention or isolation camp. It was solved by granting furloughs to selected men after ascertaining that their families were able and willing to give them proper care or supervision.

As the infirmary wards becan to fill up with convalescents rather than acute cases, it was noted that many of these men had a pronounced tachycardia. A cardio-vascular specialist was detailed to visit all these wards and report upon all cases having heart symptoms, with recommendations. This officer examined all convalescents returning from furloughs and made recommendations as to their disposition.

P. CAMP GRANT BASE HOSPITAL REPORT.

Following in the wake of Camp Devens, the Great Lakes, and other camps, Camp Grant was visited by the so-called Spanish influenza in an explosive manner Saturday, September 21, 1918. So sudden and appalling was this visitation that it required the greatest energy and cooperation of every officer, every man, and every nurse to meet the emergency, and this they did gladly-"they were weighed but not found wanting." Up to that time the storehouses and 12 of the wards in the main part of the hospital were empty. It was obvious that an epidemic was on hand and that great effort would have to be made to prepare sufficient bed space. Therefore all


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two-story ward barracks were vacated and every available office, nurse, and enlisted man called upon.

Sunday, September 22, 1918, the admission to the hospital was 194. The main portion of the hospital was made ready for occupancy, increasing the available beds to 1,318, The total patients in the hospital were 836.

Monday, September 23, 1918, the admissions to the hospital were 370; total in the hospital, 1,159. Telegrams were sent to all officers on leave to return without delay. Every effort was put forth to open all two-story war barracks and by nightfall 6 of these buildings were completely equipped for 480 beds. Property meetings were held among the various executive departments of the hospital, the camp medical supply officer and his assistants, as well as the director of the American Red Cross. Immediate steps were taken to obtain more property.

Tuesday, September 24, 1918, the admissions were 492; total in hospital, 1,593; deaths, 1. Six additional beds were added to every influenza ward, and two convalescent barracks were completely equipped.

Wednesday, September 25, 1918, the admissions were 711; total patients in hospital, 2,134; deaths, 2. Patients were placed in the corridors 2, 3, and 4. Property meeting was held, and, on account of the emergency, the camp medical supply officer sent his assistant to Chicago to expedite shipment of supplies. One thousand units of mess equipment were ordered by the mess officer, and the Red Cross placed an order in Chicago for 6,000 sheets and other supplies.

Thursday, September 26, 1918, the admissions were 670; total in hospital, 2,598; deaths, 1. The detachment medical department moved their barracks, exchange, and other corridors were made into a 500-bed hospital, the kitchen opened for hospital purposes, also.

Evacuation Hospital No. 37 turned over their entire personnel; the depot brigade furnished 250 men as laborers; beds were set up and bedding sacks stuffed with straw, and quartermaster property was used entirely to enlarge the hospital over 1,800 beds. Officers, nurses, and enlisted men rendered excellent service, but showed marked fatigue. Five officers, 35 nurses, and approximately 50 enlisted men were sick in the hospital. Four carloads of medical supplies were received by express and about 20 motor vehicles were put into use, handling heavy supplies, The receiving office was overtaxed, but this date found them handling the patients very satisfactorily. The Red Cross took over the handling of the patients' money. The depot brigade handled patients also. Approximately 300 patients were sick in the infirmaries.

Tent floors, Sibley stoves, and electric lights were supplied to the tents occupied by the base hospital men. The clothing room becoming overtaxed, the patients' clothing was checked, bundled, and placed under the head of the patients̓ bed. Mules of the mule ambulances were becoming exhausted. Quartermaster's trucks and private motor vehicles were attached to the base hospital. The depot brigade handled approximately 200 patients. The registrar's office was moved to the ward room (officers' ward) and the entire receiving ward turned over to the receiving officer. Patients were discharged with a request to their commanding officer that they be relieved from duty for one week.

Because of the weakened condition of the patients, they were not allowed to walk to their barracks.

The number of nurses was inadequate and the Red Cross transferred 25 from Chicago and surrounding points. Notice was given that the hot water plant was being taxed to the limit and all persons should conserve hot water as much as possible.

Friday, September 27, 1918, the admissions were 671; total patients in hospital, 2,936; deaths 3. In view of the cool nights and threatening weather, it was considered a risk to place patients on the various verandas without inclosures. The constructing quartermaster was called upon for assistance. They furnished 50 carpenters and the utilities department furnished a like number. During this day 39 verandas were inclosed with roofing paper and muslin and 800 beds were placed and made ready for occupancy. The war relief committee was called upon to make sputum cups, etc., and thus relieve nurses. The school for cooks and bakers was called upon to furnish 14 cooks.

Sunday, September 29, 1918, the admissions to the hospital were 788; total patients in hospital, 3,346; deaths, 6. Nine barracks buildings of the sanitary train area have been turned over to the hospital for hospital purposes. During this day barracks 827-N was fully equipped for 126 patients and all mumps cases transferred from the main part of the hospital. Two hundred and sixty additional enlisted men were attached to the hospital force from the depot brigade, as officers, nurses, and enlisted men were showing marked fatigue.

There were four medical officers, 45 nurses and 63 enlisted men of the base hospital sick at this time, principally with influenza.


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By extreme effort on the part of all concerned and using all sources for property, this hospital was increased (as concerns capacity) from 10 occupied beds to a capacity of 4,102 beds in six days.

The American Red Cross opened an emergency canteen service in the Red Cross house to serve officers, nurses, and enlisted men of the base hospital with light lunches and hot coffee.

Monday, September 20, 1918, there were 688 admissions to the hospital; total patients, 3,546; discharged from hospital, 490; deaths, 8. During the day 160 beds were added to the various verandas of the influenza wards, increasing the capacity of the base hospital to 4,381 beds, from 610 occupied beds, in 7 days. Two additional barracks of the sanitary train were fully equipped as wards, making three barracks in that area available for patients.

Patients in the hospital together with persons on duty and those attached, brought the total number of persons at the base hospital to approximately 11 per cent of the entire camp. The main kitchen served the larger portion of these diets, and during the day served 2,780 liquid diets and between 1,500 and 2,000 regular diets.

All persons on duty at the base hospital were advised to take advantage of every opportunity when off duty to take light exercise in the open air, or to rest or relax, as the number of persons becoming sick were increasing. At this date there were 5 officers, 51 nurses and about 100 enlisted men on the sick report. In the event that ward men were left on duty for more than 12 hours a day, they were instructed to call the detachment commanding officer and inform him accordingly, as occasionally this matter had been overlooked during the rapid expansion of the hospital.

The nursing force of the ward was vastly inadequate. However, every nurse and available man was assigned. In order to help this situation, a service corps was organized and divided into eight sections. A pupil nurse was placed in charge of each section, with six men as her assistants. The hospital was divided into eight areas and a service section assigned to each area. Their principal duties were to assist the ward personnel by policing the ward and doing the heavy work. Their hours were from 7.30 a. m. to 5.30 p. m.

Tuesday, October 1, 1918, there were 561 admissions to the hospital; discharges 496; total patients in hospital, 3,601; deaths, 14, All deaths were due to pneumonia following influenza (clinical). The admissions to the hospital decreased approximately 100 daily for the preceding three days. In order that relatives of the patients ill in the hospital may be kept informed, danger telegrams were sent out at regular intervals.

Wednesday, October 2, 1918, the admissions were 412; discharges 426; total patients in hospital, 3,587; deaths, 30-all due to pneumonia following clinical influenza. The number of admissions was smaller than the preceding day, but the patients admitted were more seriously ill, and a greater number of litter cases were among them. The number of pneumonia complications rapidly increased, Nine wards were filled with this type of disease.

Local undertakers, Murphy & Fitzgerald, were unable to cope with the situation, The capacity was estimated at 12 to 15 bodies a day. Inspection of their establishment revealed 25 untouched bodies at 5 p. m. and 47 left in the morgue at the base hospital. Their establishment was in confusion and not systematically arranged. Two soldiers, embalmers, were sent to Murphy & Fitzgerald at 7 p. m, to work under Sergt. Reid of the base hospital, experienced embalmer. Five more soldiers and one clerk were asked for.

Great confusion in the records of the information bureau resulted from many transfers of patients about the hospital without notifying the information bureau. Consultation was held and it was decided that generally speaking pneumonia patients would be as well cared for in influenza wards as if transferred to pneumonia wards. One ambulance and three wheel litters and the motor truck, with many men had been used the entire day in transferring pneumonia patients to pneumonia wards.

Thursday, October 3, 1918, there were 525 patients admitted to the hospital; discharges, 482; total patients in hospital, 3,659; deaths, 46, all due to pneumonia following the so-called influenza, There was a light increase in the number of cases admitted, and a large increase in the death rate. Patients admitted to the hospital, generally speaking, were of a sicker nature than heretofore. There were more litter cases admitted and more cases developing pneumonia over the hospital than usual which greatly increased the difficulty in transportation of patients. Approximately 40 nurses arrived for the emergency, and telegraphic notice was received that a like number would arrive in the near future. The ladies of Rockford offered their service in large numbers, and were used in filling capsules and at the information bureau. They also prepared paper cups and did clerical work in the wards, transferring temperatures from memoranda to clinical records; also supervised the Red Cross emer-


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gency canteen. The Red Cross furnished 75 electrical flash lights to be used by night nurses in the wards and on verandas.

The number of visitors greatly increased; they having been summoned by danger or death telegrams. The ward personnel was instructed to show these persons every consideration during their deep moments of distress. There were 438 telegrams sent and received by the hospital on this date. Authority was received to employ civilian nurses, and as they were sadly needed, a great many were employed.

The undertakers of Rockford were in conference, and plans were made to consolidate their efforts to handle the present situation. An additional line officer reported for duty to handle patients' clothing and effects. The telephone lines were swamped. A letter was written to the commanding officer, Camp Grant, recommending additional lines. From 400 to 500 telegrams were sent and received daily. An emergency telegraph office was recommended to be established here, All the undertakers of Rockford were called in conference, and each agreed to take his share of the base hospital work at $50, the contract price. This, however, was decided upon after a certain amount of argument on the part of some of the undertakers, especially Marsh, who wanted to raise the price. There were at that time 49 bodies in the morgue, and about 30 in Rockford, untouched. Each undertaker took his capacity, which was from 3 to 10 bodies, and after all had had their establishments filled, there were about 30 in the morgue. It was obvious that something had to be done in the way of organization and increased capacity. Maj. Baum called the president of the Western Casket Co., Chicago, and requested him to come to Camp Grant for consultation and assistance.

Friday, October 4, 1918, the admissions to the hospital were 437; discharged, 520; deaths, 76, all due to pneumonia. Total number of patients in hospital was approximately 3,396. There was a decrease of approximately 100 patients in the hospital; however, those admitted, generally speaking, were of̓ a more serious nature. The exact hour of death to the minute had to be given on the clinical record, and ward surgeons were instructed to see that this data were placed on all clinical histories before they were sent to the office.

The handling of the effects of the deceased grew into an enormous task. To meet this emergency, - Infantry was attached to the base hospital this date, and handled all patients' clothing, trinkets, and other valuables. His office was in the clothing room, receiving ward, and the company commanders had to report to this officer to obtain and receipt for the effects of the deceased. The procuring of transportation for remains, too, developed into a large and important proposition. Q. M. Sergt. Starket, Quartermaster Corps, was placed in charge of the transportation for remains, as well as the clearing of same from the hospital morgue. His office was located in the administration building, base hospital, and all inquiries relative to the shipment or location of a body were referred to him.

Saturday, October 5, 1918, there were 439 admissions; discharges; 328; deaths, 103; all due to pneumonia. Total patients in hospital, 3,579. The admission rate remained practically the same for several days. The mortality rate increased steadily from the end of the first week of the epidemic and it was thought probable that the apex had not been reached. There being no specific treatment for this disease, and no known absolute preventive, the following memorandum was issued: "The wearing of masks and gowns, frequent washing of the hands, and the avoiding of putting hands in mouth or nose are very important. Persons must avoid crowding, whether on duty or not, and all officers, nurses, and enlisted men should use every effort to avoid this. Fatigue plays a very important part in rendering one susceptible to sickness and should be avoided as much as possible." A sufficient number of nurses arrived under orders and an adequate number of enlisted men also. There being a division of responsibility between the service corps and the ward men, the wards were not sufficiently well policed. The service corps was abandoned. Mr. Statler and Sergt. Reid got the embalming problem solved through untiring effort.

Sunday, October 6, 1918, the admissions were 370; discharged, 430; deaths, 99; all due to pneumonia. Total number of patients in hospital, 3,420. During the day Head House was equipped and opened as nurses' quarters. The eye department was moved to the former electrotherapeutic room, and the ear, nose, and throat department was moved into operating room No. 3. The recruiting office was moved into the hallway of the dental department. There were approximately 370 nurses (including pupil nurses), and these nurses were quartered in the Red Cross house and barracks 1029-N, as well as the Head House and regular nurses' quarters.

The death rate reached the highest point October 6, when there were 117 deaths recorded. The city morgue was overtaxed, leaving 20 bodies at the base hospital at 8 p.m.


753

The number of visitors increased until thousands of persons called upon the information bureau daily for various kinds of information. During a day, several thousand telephone calls were answered and sent out. The space was inadequate, and in order to meet the demand a hospital ward tent was erected, floored, wired with drop-lights, three telephones installed-two on the hospital switchboard and one on the Camp Grant exchange-desks conveniently arranged, seats provided for the visitors, beds placed for persons who required to lie down, cloak and suit hooks provided, and stoves installed. The floor extended to the end of the road and the new information bureau is conspicuously marked by signs, electric lights, and Red Cross flag. The tent communicated with the near-by corridor and visitors were shown to the various wards by Red Cross representatives; masks and gowns were provided at the information bureau.

The index was transferred and only direct information to visitors given; the clerical side of the information bureau being retained in the old quarters. An arc light was installed in the parking area and the vicinity of the information bureau brilliantly illuminated.

Monday, October 7, 1918, the admissions were 235; discharges, 301; deaths, 117; total patients in hospital, approximately 3,238. There was a decrease in the admissions to the hospital during the previous 24 hours. The number of pneumonias increased until there were about 1,250 patients in the hospital suffering from this disease. Following the conference held among the medical men of the institution and Prof. Kyes, of Chicago, it was decided to group the pneumonia patients so that those acutely ill, coughing and running high temperatures, would be in one group, the convalescents in another group, and the intermediate cases still in another group. Transfers were made accordingly. The idea of the plan was to prevent reinfection of the convalescent patients. It was decided that cubicle sheets extended to the foot of the bed both interfered with ventilation and prevented the ward attendants from keeping a close watch on the patients. Therefore, cubicle sheets were arranged to extend from the wall to a point not beyond the patients' waistlines.

Tuesday, October 8, 1918. the admissions were 195; discharges, 358; total patients in hospital, 2,957; deaths, 98, all due to pneumonia following so-called influenza. There was a reduction in the number of deaths during the previous 24 hours. The general improvement in the appearance of the hospital during the preceding 48 hours was very gratifying, thus showing the getting of things under better control, and more nearly approaching the previous efficiency of the hospital. The extra beds were removed for the 30 rows of wards. It would appear that the epidemic had passed its crest.

Wednesday, October 9, 1918, there were 133 admissions; discharges, 268; total patients in hospital, 2,782; deaths, 110, all due to pneumonia. There were approximately 1,500 cases of pneumonia in the hospital and this death rate was not surprisingly high. It would appear that the acme of admissions had also been reached.

During the early days of the epidemic the increasing morbidity rate was alarming among the personnel. The emergency civilian nurses showed the highest percentage and of those three died. There was a great difficulty in getting these nurses to wear masks and gowns or to carry out many other orders. The graduate nurses came next on the sick-rate list and three of the Army nurses died. The detachment medical department had a very high sick rate during the first week largely due to being overtaken with the immense amount of work that had to be done. About 10 per cent were sick in the hospital, with 12 deaths. The nurses, Army School of Nursing, had the lowest sick rate, with one death. This nurse was not in good health and appeared below normal on admission to the school, but it was hoped that she would improve, as she was a very fine young woman, These pupil nurses worked in the wards on long hours, and it is believed that the reasons f or their low sick rate was due to strict obedience in carrying out orders pertaining to masks and gowns, their outdoor training before the epidemic, and physical condition in general. Eleven medical officers contracted influenza, but there were no deaths. Many of the emergency nurses did not render satisfactory service and caused considerable work and worry by expressing their desire to resign and go home. It was believed that the service would be better off without this class, and they were allowed to return, although some of them rendered less than one day's service. The sick rate for the nurses continued high, and on October 8 there were 71 excused on account of sickness. To this date, 4 nurses died and about 12 enlisted men; no officers. It would seem that the Kyes serum was of benefit when the patients were gotten under treatment early.

Thursday, October 10, 1918, there were 118 admitted to the hospital; discharges, 214; total patients in hospital, 2,579; deaths, 77, all due to pneumonia. There was a noticeable improvement in the general condition of the epidemic during the previous 24 hours. There were fewer deaths, fewer admissions, and the patients as a whole were in a better condition.


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Friday, October 11, 1918, there were 86 admissions; discharges, 175; deaths, 37, all due to pneumonia following the so-called influenza; total patients in hospital, 2,476. There were 1,500 pneumonia patients still remaining in the hospital. Every effort was made to furnish as much fresh air to patients during this epidemic as possible, as rest in bed and fresh air, with ample water to drink, were believed to be the most important forms of treatment known at that time.

Saturday, October 12, 1918, the admissions were 99; discharges, 112; deaths, 54, all due to pneumonia. Total patients in hospital were 2,391. The smaller number of patients than heretofore discharged was due to the ,fact that convalescents were being held longer in the hospital for the good of the patients. Up to this time it had been necessary to discharge patients as soon as possible to infirmaries, on account of the pressing need of beds.

Sunday, October 13, 1918, there were 85 admissions; discharges, 128; deaths, 36, all due to pneumonia; total patients in hospital, 2,331. There were 1,540 cases of pneumonia in the hospital, 24 less than on the preceding day. The general appearance of patients in hospital was greatly improved, and the number of convalescents seen in the wards rapidly increased. On account of the emergency in the city of Rockford, 3 medical officers, 12 nurses, 50 beds, mattresses, mattress covers, and 100 blankets were temporarily loaned to the city. The people of Rockford rendered valuable service to the base hospital during the epidemic and especially when there was a great shortage in the personnel.

Monday, October 14, 1918, there were 40 admissions; discharges, 124; deaths, 29, all due to pneumonia following influenza.

Tuesday, October 15, 1918, there were 65 admitted to the hospital; discharges, 123; deaths, 20, all due to pneumonia; total patients in hospital, 2,139. Two-story barrack wards were standardized at 80 beds each. All quartermaster property was removed and medical department property only used.

Wednesday, October 16, 1918, there were 95 admissions; discharges, 175; deaths, 22, one of these due to scarlet fever; we see the end of what had been the most severe epidemic, if not a scourge.

Thursday, October 17, 1918, there were 67 admissions; discharges, 146; deaths, 10, all due to pneumonia following the so-called influenza. Total patients in hospital, 1,946.

The excellent work rendered, the devotion to duty and the untiing effort made by the nurses and enlisted men of this hospital during the epidemic was highly commendable. Nothing could be said that would too highly praise the work done. There were instances where nurses and men remained on continuous duty twice as long as their duty hours ordinarily required, and there was not a single instance

on record where anyone filed a complaint on account of overwork. Too high praise can not be given to the work done at this hospital during the epidemic by each and every Red Cross worker. Though at times under great stress and long hours of continuous labor, ofttimes extending away into the night, they were ever courteous and willing to serve to the best of their ability, for the relief and amelioration of the physical suffering of the patients and the mental suffering of the patients and the mental suffering of their relatives and friends. "More luster will be added to their already shining star."

The epidemic started September 21, 1918, and on that date there were 52 patients admitted to the hospital and 608 patients in the hospital.

At the outbreak of the so-called Spanish influenza epidemic, this hospital had a capacity of 610 beds, and within a week's time this number was increased to 4,500 available beds. In order to make this large increase in bed capacity it was necessary to use every bit of available space and a great deal of additional property. We did not have sufficient medical property in the camp at the time of the epidemic, so quartermaster property was used to a very large extent. The main articles being used were those of iron cots, bedsacks which were filled with fresh straw, and blankets. On account of the large increase of patients admitted to the hospital, we began to inclose the porches of the wards by using tar paper and muslin. The porches of all wards occupied by influenza patients were inclosed in this manner, and the windows leading into the wards were opened so as to equalize the heat in the wards and on the porches. Each porch was made to accommodate 24 patients in this way. The barracks of the enlisted men were also used as wards, the enlisted men having been moved out into tents which had been erected by the quartermaster for their use. The corridors of the barracks and of the hospital were converted into wards, thus accommodating a great many more patients. Every precaution was taken to avoid

the spread of the disease, one method being used was that of the installation of a cubical system in every ward and emergency ward in the hospital. During the epidemic a tremendous amount of supplies were necessary involving a large amount of work by the Quartermaster Department.


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Q. CAMP EUSTIS, DIVISION SURGEON'S REPORT.

No epidemics of infectious disease have occurred except that of influenza, which began in this camp about September 26, 1918, and of which special report has been made. From the date of its appearance to December 31, there were 2,243 cases of influenza admitted to hospital; during the same period there were 110 deaths from influenza and 26 from pneumonia. When influenza appeared in this camp the entire camp was placed under quarantine and no passes were allowed; the congregating of men except for drill and necessary fatigue duty was forbidden; increased attention was given to ventilation of barracks, to arranging of beds alternately head and foot, to the proper washing of mess kits, and to instructions relative to "covering the cough," etc. Attendants on the sick were required to wear face masks.

R. CAMP EUSTIS BASE HOSPITAL REPORT.

On September 22, the first case of influenza was admitted. From this date, the epidemic progressed rapidly, so within 10 days practically every ward in the hospital was equipped and running. Equipment for the wards was on hand, and construction was at a point where all wards practically were sufficiently finished to be occupied. Whenever there was a deficiency in construction, rush work in the wards enabled the medical service to keep even with the urgent demand for bed space. The months of October, November, and December were months of influenza. There were 2,288 cases of influenza admitted to the hospital. Maximum admissions were during October and the beginning of November. Of this number 412 were definitely diagnosed as having a complication of broncho-pneumonia. Death (138) occurred associated with this complication of broncho-pneumonia. Only 12 cases of empyema developed. The remaining broncho-pneumonia made a satisfactory recovery. Deaths were principally of two types. One in which there was an overwhelming infection, the patient dying in one to three days with marked dyspnea, cyanosis, and a lung picture showing a massive edematous broncho-pneumonia excluding all aeration to the lungs. The other type, less fulminating, showed an increasing toxemia, in which a terminal toxic nephritis was present associated with a bronchopneumonia, which frequently progressed to a lobular pneumonia, seldom to a lobar pneumonia. The jaundice frequently seen in cases where the streptococcus hemolytica is present, was terminal in many of these cases.

S. CAMP MCCLELLAN, DIVISION SURGEON'S REPORT.

Influenza furnished the most important epidemic disease in the camp. On the date of its outbreak, September 20, the camp was composed for the most part of men newly inducted into the service, their average length of service being somewhat less than two months.

Both the morbidity and mortality rates were higher in the colored troops than in the white.

On October 2 the camp was quarantined and remained till October 14. Five Y. M. C. A. and K. of C. buildings were converted into temporary wards to care for mild cases, while a tent convalescent camp was established near the base hospital. All cases in hospital with a normal temperature for 48 hours were sent to the convalescent camp and there remained for 10 days after having a normal temperature. Medical officers inspected the entire command daily, and isolated suspicious cases in the end of company streets. All cases with a temperature above 99 were sent to the base hospital. Every effort was made to isolate cases early. The entire command wore masks and overcrowding in tents was not allowed. There were five men to a tent except temporarily with some new colored troops. Tents were furled and bedding aired every day. Tent flaps were kept open at night. Roads were oiled. Cubicles were used in the hospital but not in the tents. During the early part of the epidemic the majority of the colored troops were not supplied with sufficient clothing. About one-half of the command arrived in camp during the two weeks preceding the epidemic, and during this time and the early part of the epidemic there was temporary overcrowding and unavoidable exposure due to movement of troops. Many troops arrived during a cold rain; had to make camp, and sometimes without an immediate change of clothing available, as their baggage was not unloaded. Many of the Negroes were not adequately supplied with clothing until the latter part of the month (October). During this time there were a few cases of meningitis, mumps, and measles-not in excess of an average normal. All of these cases and their immediate contacts were isolated and the meningitis cases cultured.


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The general measures of prophylaxis included the following: Oiled roads, and floors of mess halls and other buildings where crowds collect; keeping all men in fresh air and sunshine as far as their duties permitted; daily airing and sunning of bedding and clothing; tents furled daily; tent flaps open at night except in exceptionally stormy windy weather. All tent mates of measles cases isolated and inspected daily. Those contacts not having had measles sent to detention wards of base hospital for 14 days' observation. All meningitis contacts examined daily. Nose and throat cultures taken; those proving positive, isolated until there were obtained three negative cultures. An organization where pneumonia, influenza, measles, and meningitis seemed to be a menace-these units were sprayed twice every 24 hours with Di-chloramine T.

T. CAMP MCCLELLAN BASE HOSPITAL REPORT.

During the latter part of September an epidemic of influenza rapidly increased the morbidity far beyond the hospital capacity. At one time over 4,900 cases were being treated. All cases were masked before being brought to hospital and all patients and hospital personnel were masked, and given nasopharyngeal sprays at frequent intervals, beds were cubicled, and quarantine measures established for the protection of the uninfected. All roads, walks, etc., in hospital and camp were oiled, a detention camp was established, and all patients were discharged to this camp for a period of 10 days quarantine before final discharge to duty. At the height of the epidemic wards and ward porches being filled, all available buildings including Red Cross warehouse and enlisted men's barracks, were used as wards; even these did not suffice and with canvas obtained from the Quartermaster Department covered board walks were converted into wards, while wards were maintained in many buildings of the various civic organizations in camps such as Red Cross, Y. M. C. A., Knights of Columbus, etc. The height of the epidemic was between October 10 and 20, but few cases being admitted after November 1.

U. CAMP WHEELER, DIVISION SURGEON'S REPORT.

An epidemic of influenza started at Camp Wheeler the very last of September and extended through October and November. The officer making this report has no personal knowledge of the epidemic, as he did not arrive at Camp Wheeler until some time in December. It is impossible from the records to make a statement as to the exact number of cases of influenza. There were according to the records a large number of admissions of medical cases for the months of October and November and over 1,200 cases of pneumonia during this period. It is understood that the diagnosis of influenza was made only on a laboratory finding of Pffeifer's bacillus,

V. CAMP WHEELER BASE HOSPITAL REPORT.

An influenza epidemic started at Camp Wheeler about September 28, 1918. Prior to that time the number of admissions with influenza were averaging 8 to 10 a day. Beginning the 28th of September the number increased daily reaching a maximum of 69 on October 4, gradually subsiding until the 15th of October then rapidly increasing reaching the highest point of the epidemic on the 21st of October when 118 cases were admitted to the hospital. Since this date the admissions have gradually diminished to the normal figure. A large percentage of these patients had been vaccinated with influenza bacillus prior to admission to the hospital. There was practically no mortality from influenza. All the fatal cases dying of a complicating pneumonia.

W. CAMP LEE, DIVISION SURGEON'S REPORT.

1. The first recognized cases of influenza were discovered in the 3d Company, 8th battalion, 155th depot brigade, on the night of September 13, 1918, although a few cases had been admitted to the hospital as early as September 9, 1918, but were not diagnosed as influenza. These cases were immediately sent to the base hospital and the 8th battalion placed in strict quarantine; however, the disease soon spread throughout the depot brigade, which was placed in quarantine against the rest of the camp. As the number of cases was soon more than the base hospital could take care of in the early part of the epidemic, one down stairs squad room in each barrack was set aside for the accommodation of mild cases. This plan, however, was soon abandoned; whole buildings in each battalion being set aside as required for the treatment of mild cases. These were dubbed "Battalion hospitals," they being not under the administration of the base hospital, but were under the supervision and control of the battalion surgeon. In al1 about 80 barrack buildings were so used.


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These so-called hospitals were run as follows: Battalions furnished cooks and kitchen police and also a certain number of attendants and the necessary diets, principally fruit and milk. The necessary medical attendance was, of course, rendered by the battalion surgeons and other medical officers. Nearly all the new cases as they occurred were placed in the battalion hospitals and if the case was a mild one, it remained there during the whole course of the disease, but as they developed into severe cases or were suspected of being pneumonic or of having any other complication, they were immediately transferred to the base hospital annex, no serious cases being kept in these battalion hospitals. Of course this required constant supervision to see that no serious cases were so kept and on the other hand, that mild cases were not sent to the base hospital or its annex later. Two consulting medical officers of mature judgment, with motor cycles, were detailed to supervise this separation of mild and severe cases.

2. At the same time blocks of barrack buildings about one-half mile from the base hospital were vacated and equipped with quartermaster beds, bedding, and medical department equipment as far as available. Two cooks were obtained from the school for cooks and bakers, and 40 enlisted men as kitchen police and orderlies were obtained from the line for each building, which accommodated about 90 patients, allowing fully 100 feet of floor space for each bed. Four line officers as detachment commanders were also detailed. These buildings as they were equipped and manned were turned over to the commanding officer, base hospital, as an annex and administered as wards of that institution. In all 24 buildings were so used.

3. This plan of establishing so-called battalion hospitals for mild cases and not under the administration of the base hospital is believed to be better than to take over as much larger number of barracks as a part of the base hospital and to send all cases there; as under the plan employed only the more serious cases were sent to the base hospital where better facilities were to be had; such as female nurses and a greater number of trained attendants. The best medical attendance was thus concentrated on the more serious cases, without their trained personnel and efforts being dissipated on the great number of mild cases. As the patients at the base hospital became convalescent they were transferred back to the battalion hospital where they were kept at least 10 days after their temperature became normal, thus freeing the base hospital for the reception of more serious cases.

4. At the outbreak of the epidemic local intracamp quarantine was established, theaters, public meetings, etc., were closed. As the disease became prevalent in the surrounding country, all passes and leaves from camp were stopped, no one being allowed to come into the camp except on very important business or to see relatives who were very seriously ill. A bulletin explaining the methods of transmission of the disease from man to man, with a few "don'ts," was published and read to the whole command weekly.

5. The cubicle system using shelter halves, sheets or ponchos was established at once for the whole camp for barracks as well as for patients sick in hospital. This order was strictly observed by all organizations in camp except the Central Officers' Training School, in which some delay in obeying this provision was observed. Readjustment of men in barracks was made so that each occupant had at least 50 feet of floor space, and in the majority of instances over 60 feet. Where necessary to accomplish this, tents were used, five (5) men to a tent.

6. During the first half of the epidemic, there being no floor oil on hand at the camp, dust in the barracks and in buildings used for the accommodation of the sick was considered a menace. As soon as a supply was received, the floors in all these buildings were kept oiled and well mopped.

7. It is very doubtful, as far as the influenza itself was concerned, whether any measures taken ultimately reduced the incidence of the disease. The quarantine seemed to have no ultimate effect, but did delay the appearance of the disease in the organizations so isolated. For instance the Veterinary Training School of about 3,800 men, established a most rigid quarantine and all members of the command had their nose and throat sprayed daily with argyrol, consequently they had very few cases until October 5 when the epidemic reached the sudden peak-and then rapidly declined, they being practically free from the disease in one week thereafter. Therefore, it would seem that the only benefit from the measures taken was that this camp was not overwhelmed at any one time by a great number of sick; the greatest number of admissions in any one day being 650 and usually much below these figures. Thus the disease was spread over five or six weeks allowing better care of the sick, as fewer cases were under treatment at any one time as would have been the case had the admissions been one to two thousand daily, as it is understood occurred in some camps.


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8. Cubicles were used in camp and in hospitals. For the former the shelter half was used for about three-fourths of the command. Those for whom no shelter halves were available were supplied either with ponches or quartermaster sheets for this purpose, these being strung on wires, strings, and sticks. Estimate for sufficient wire to install the cubical system permanently for the whole camp has been made and requisition submitted, as it is believed this will lessen the incidence of other communicable diseases communicated through the upper respiratory tract during the winter, In the base hospital and its annex, sheets were used for cubicles. In the battalion hospitals either shelter halves or sheets were employed.

9. Soon after the outbreak of the epidemic each man was supplied with two suits of woolen underwear and an overcoat, woolen outer clothing not being available for the whole command. It is believed, however, that clothing was sufficient as the weather was not severe at any time.

10. A fresh outbreak of this disease began on December 2 and has continued, though in lessened numbers each week. The type has been mild, and of 692 cases reported, only 38 have been complicated by pneumonia, and but 4 have died. The disease has been mostly confined to the 15th Brigade which reached camp the very end of November. All cases diagnosed have been removed at once to the base hospital, and the methods used to restrain the progress of the disease have been enforced. Cubicles in squad rooms, plenty of air, head and foot methods of sleeping, and oiling of floors of barracks has been followed out. At the end of the month the daily average of new cases was greatly reduced.

X. CAMP LEE BASE HOSPITAL REPORT.

Influenza: On Friday, the 13th of September the first cases of influenza were admitted to this hospital starting the epidemic of the most extensive character that has ever visited Camp Lee. It began abruptly and in a few days reached tremendous proportions subsiding after about six weeks, during which time it had affected 12,000 men and killed about 700. A system of rapid expansion and the avoidance of overcrowding were perhaps the most important factors in successfully treating the situation. This was accomplished by cooperation with the camp surgeon, who early directed that mild cases should be treated in barracks set aside by the camp infirmaries, only the severer and complicated cases being sent to the hospital. This gave the hospital the time necessary to expand decently and in order, after having exhausted its own resources, to take over, equip, man, and operate 18 barracks of the Depot Brigade. Relief afforded by the arrival of, extra ward surgeons ordered here from Camp Greenleaf by the Surgeon General, and enlisted men from the camp supplied by the commanding general made this possible. It meant tremendous work under high pressure by the whole institution, but no patients were turned away, there was no overcrowding, and 8,000 were accommodated.

The pneumonias which developed in 2,000 of the cases were of the type made familiar by many descriptions: Marked cyanosis and respiratory distress, leukopenia, high mortality resulting from early suffocation or later exhaustion.

Y. CAMP CUSTER DIVISION SURGEON'S REPORT.

The third epidemic of pneumonia occurred in the period from September 24, 1918, to November 1, 1918, and followed the epidemic of influenza occurring during this period. There were during this period 2,437 cases, with 669 deaths, a mortality rate of 27.8 per cent. All cases of pneumonia were kept at the base hospital for at least two weeks after apparent recovery. They were organized into pneumonia convalescent companies and were given from 20 to 40 walks of gradually increasing duration. The heart was carefully examined after each walk, Upon discharge of the soldier from the hospital and his return to his company, the surgeon of the organization and the company commander were notified by letter of the soldiers' condition and required to use further care and observation to prevent undue exertion and exposure until the soldiers' condition had become normal.

The outbreak of influenza in this camp started in the last Week of September and extended through the month of October. During this period 11,626 cases occurred, or about 29 per cent of the strength of the camp. The percentage of influenza cases complicated by pneumonia during this period was 21.5 per cent, or 2,437 cases, with a mortality of 27.8 per cent, or 669 deaths.

All influenza cases were immediately hospitalized and retained in the hospital until their temperature had been normal for 3 days. They were then transferred to convalescent wards for 7 days before being sent to their companies for duty. After discharge to the company they were kept under strict observation by the surgeon and


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the company commander was cautioned to use extreme care to prevent overexertion and unnecessary exposure of the men.

During the epidemic the entire camp and each organization within the camp were quarantined, all intercourse between the organizations reduced to the minimum required to carry on the work of caring for the sick, policing, and transportation of supplies. All beds were cubicled and frequent inspection made day and night to see that the squad rooms were sufficiently ventilated and that the men were sleeping alternately head and feet as required.

Extra woolen blankets and comforters were issued and the men were supplied with wool uniforms and heavy underwear.

Z. CAMP CUSTER BASE HOSPITAL REPORT.

An epidemic of influenza and acute respiratory diseases which began in the latter part of September, 1918, and continued until about the 1st of November, was the cause of approximately 10,000 admissions to hospital and to regimental hospitals. From this number there developed 2,374 cases of pneumonia of whom 674 died-a mortality of 28.4 per cent. In all the fatal cases, pneumonia, was clinically present, without exception, and in all but one case were broncho-pneumonias, both clinically and at necropsy. There were no deaths from influenza without pneumonia as a complication. Empyema was encountered as a complication, but was in all instances secondary to a pneumonia and occurred in only 3.1 per cent of pneumonia cases, whereas in February, 1918, as high as 50 per cent of pneumonia cases developed empyema. The mortality from this complication was only 6.1 per cent, as compared with 40.5 per cent early in the year. Carefully controlled bacterial studies of sputum, throat cultures, blood cultures, and post-mortem cultures failed to demonstrate Pfeiffer's bacillus in more than a very small proportion of cases.

Al. CAMP UPTON DIVISION SURGEON'S REPORT.

The epidemic of influenza began on Friday the 13th of September and was practically ended by October 22. It began in a group of men shipped into the second battalion from eastern Massachusetts where the disease was epidemic. The disease spread rapidly through the battalion to the rest of the camp.

Quarantine measures were instituted at once. The camp was quarantined against the outside world and at first battalions were quarantined against each other. Later, single companies were quarantined when a single case was discovered in the company. Two isolated units, the 3d Development Battalion and the remount station furnished an excellent example of the benefits to be derived from quarantine. The 3d Development Battalion was lax in its quarantine allowing men and officers to mingle with the rest of the camp. Influenza was soon raging there. The remount under the direction of an efficient medical officer maintained a rigid quarantine against the camp. Not a single case developed there until toward the end of the epidemic. Even then there was a question as to whether the disease was not brought into the remount from New York City.

The base hospital being unable to care for all of the cases of influenza, camp hospitals were established in barracks to care for the milder cases of the disease. Two of these hospitals cared for new cases, while the other three cared for convalescent patients from the base hospital and the first two hospitals. The administration of the camp hospitals was very satisfactory. All patients had a hundred square feet of floor space, all beds were separated by sheets, all patients were well fed and all patients had the benefit of female nursing. Each patient had a daily physical examination, A clinical record was kept of each case.

Masks were used at first on the sick and on the attendants. Later the whole camp was masked when inside buildings or when any number were gathered together outside. The general impression among the medical men was that masking was of benefit, for when masking became general, the epidemic subsided rapidly.

CAMP UPTON BASE HOSPITAL REPORT.

The second half of the year was signalized by the outbreak of the universal pandemic of influenza. This scourge began abruptly on September 13, 1918, reached its peak on October 4, 1918, with the admission of 483 cases, then declined rapidly until October 22, 1918, with the admission of only 11 cases when the primary epidemic may he regarded as having run its course. Thereafter its course was irregular, new cases being contributed largely from new arrivals in camp. During the primary epidemic 6,131


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cases of influenza were admitted to the hospital (base and emergency hospitals) resulting in 1,295 cases of secondary pneumonia and 404 deaths ultimately (calculated up to January 1, 1919). All deaths were caused by secondary pneumonia and its sequellae. In the primary epidemic the per cent of mortality calculated for the number of cases of secondary pneumonia was 31.19 and the per cent of mortality calculated, for the admissions of influenza was 6.58. Of the 1,295 cases of secondary pneumonia 18 resulted in empyema, 7 ended fatally. There was no change from beginning to the end of the epidemic in the method of treating pneumonia. All cases were given large doses of tincture of digitalis (350-500, average 400-450 minims) and the total amount of digitalis was given in four or five divided doses during the first 36 hours after the diagnosis of pneumonia was positive or probable, often when even only suspected. These large doses of digitalis were never observed to result iu any harmful effects and it is our firm conviction that they accomplished good and saved lives. The type 1 pneumonias were treated according to the Rockefeller method.

B1. CAMP MEADE DIVISION SURGEON'S REPORT.

Owing to reports published in newspapers that a very severe influenza epidemic had been felt in Camp Dix and Camp Devens, it was expected that the same epidemic would reach Camp Meade. A telephone conversation with the camp surgeon at Camp Dix confirmed the seriousness of the prospect. It was not expected, however, that there would be such a large fatality, nor that the spread of the disease through the camp would be as rapid as it proved to be. The base hospital was immediately notified and after consultation, the commanding officer of the base hospital was directed to clear out his hospital of every man he could and make arrangements for the sick upon the porches and at all the convalescent barracks. Venereal cases, convalescent surgical cases, and the medical department were moved under canvas. The various regimental infirmaries were prepared for the reception of influenza cases there, and the regimental detachments were accommodated in tents. A survey of the camp war made to determine whether or not there was overcrowding in barracks or tents. A sanitary order was published providing for the disinfection of sputum and inviting the attention of company commanders to ventilation and to the oiling of barracks floors. All medical officers were instructed in the nature of the disease and the tactics to be employed in the handling of it. On September 17 a few cases appeared in the 71st Infantry, probably of men returning from the Jewish holidays. The epidemic broke with 286 cases in the 71st Infantry, September 22, following which this regiment was placed under quarantine, but unfortunately the disease almost immediately appeared throughout the entire camp. On the 23d a sanitary order was published prohibiting massed singing as it was observed that men singing in large groups frequently held their heads close together. The Liberty Theater and the main Y.

M. C. A. were closed. Attendance was permitted in Y. M. C. A. huts, K. of C. halls, the Jewish Welfare House, and the Hostess House, but was limited to the seating capacity of the buildings and frequent inspection was made by members of the sanitary squads to make certain that standing orders were complied with. These buildings, which were maintained for the use of separate regiments, were kept open in order to maintain the morale of the men. On the following day the epidemic was rapidly spreading and admissions increased to 800. The camp was then placed in quarantine to be effective September 26. The purpose of the quarantine was to protect Washington and Baltimore from acquiring the disease. On this date six companies of the 71st Infantry were removed to the target range 4 miles away in order that they might be placed under canvas, as it was believed that this procedure would limit the spread of the disease in this regiment. It is a matter of congratulation that the commanding general authorized this transfer which was bitterly opposed within the regiment as it was feared that their men would acquire influenza at such a distance from the camp that the sick could not be brought from the target range to the hospital but would become ill and would suffer from lack of medical care. Six companies thus removed from barracks and placed in tents escaped further infection and were singularly free from the disease.

As hospital accommodations were exceedingly crowded, Field Hospital 244 was established in the barracks vacated by the 71st Infantry, and a few empty barracks joining. The function of this hospital was to take the load from the base hospital, which was becoming crowded. From the beginning of the epidemic every sick man was removed at once from his barracks and placed in the hospital. Field Hospital 244 was located in twelve 150-men barracks with a capacity of 1,500 patients. On September 26, as the new cases were continuing at the rate of about 800 a day and as the discharge from the hospital did not balance admissions, Field Hospital 241 was established in 10 barrack buildings in one corner of the camp. To this hospital were


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assigned details from 100 to 200 men, and two officers of the line, The capacity of this hospital was 1,500. On the 27th, 28th and 29th the epidemic continued to rage, admissions averaging from 800 to 1,000 daily. The strain upon the Medical Department was great. Every officer and every man in it was working the limit of his ability with the exception of some 40 medical officers purposely held back and in fit condition for further intensive work. These officers, while constantly on duty, were not required to do more work than a physician is normally called upon to do. On the 30th, admissions started to decline in all organizations with the exception of the 72d Infantry, where they began to increase. At this time the 72d Infantry was ordered under canvas with the intent to stopping the epidemic in the regiment, as well as liberating barrack space to accommodate more sick. At this time it had become evident that troops quartered in tents did not acquire the disease as rapidly as troops in barracks. Both on the Camp Meade target range, 4 miles away, and at the Glenburnie range, 15 miles away, the soldiers were very lightly affected with influenza. On October 1, for a few hours, new cases appeared more rapidly than hospital accommodations could be arranged for them. The base hospital was full, both Field Hospitals 244 and 241 had over 1,500 sick apiece. Every available building was filled to its capacity. Accordingly the sick were moved into Y. M. C. A. huts, the Hostess House, and K. of C. buildings and Evacuation Hospital No. 38, and overseas organization under training at the base hospital. It was augmented from the medical officers in reserve and by detail of 200 soldiers and 4 officers of the line. Its capacity was 1,670. October 2 was the peak day of the noneffective rate, and from then on the substance of the epidemic was broken, new cases falling off rapidly up to the 15th and then apparently disappeared. It was about this time, however, that the great influx of pneumonia began. At this time additional medical officers were sent from the camp to the base hospital for temporary duty. The pneumonia situation was truly a terrible one. All the ambulance transportation in the hands of the Medical Department was turned over to the carriage of this class of cases and it was kept constantly day and night, literally hundreds of fresh pneumonia cases appearing every day. The heart-breaking feature of this complication was the ghastly constancy of the incidence of pneumonia. The numbers of new cases of this complication was so great that the curve of incidence became constant, and it was possible to predict, day after day, almost the exact number of pneumonia cases that would be sent to the base hospital for treatment there. Twenty-five per cent of men acquiring influenza developed pneumonia in each of the field institutions located in camp. It was soon seen that a man developed pneumonia within 48 hours after acquiring influenza. On October 8, despite the efforts of the camp quartermaster to secure additional embalmers, the number of deaths were so great (60 to 65) that the dead were accumulating at the base hospital. In the emergency, four morgue buildings were erected by the Camp Utilities between daybreak and midnight. Two days later the arrival of several more embalmers relieved the situation. At one time the number of caskets that could be secured ran short, but owing to the foresight of the camp quartermaster other caskets which had been ordered weeks before, arrived in time to prevent the situation becoming acute. Later it was necessary to purchase caskets in Washington and haul them to the camp by truck train. Following the influenza epidemic there was a brief flurry of meningitis, 17 cases occurring among those men who were recovering from influenza. As the soldiers regained their strength and their resistance to disease, meningitis ceased to be a factor.

Cl. CAMP MEADE BASE HOSPITAL REPORT.

The influenza epidemic was the only epidemic of any consequence throughout the year. During this epidemic, which raged at its highest severity from September 20 to October 20, nearly 10,000 cases were admitted to the base hospital, of which number the greater majority were influenza and pneumonia following influenza. The hospital which was accustomed to admitting between 50 and 70 new cases daily, was suddenly admitting hundreds, as many as 875 being admitted in a single day (Sept. 28, 1918). Instead of 900 to 1,000 patients to care for, the wards of the hospital were suddenly filled with 3,000, the maximum reaching 3,375 October 1, 1918. All the wards of the hospital, with the exception of three, were turned over to the Medical Service. Lack of sufficient personnel during the height of the epidemic was augmented by the illness of many members of the staff and of more than half of the nursing force. An additional disadvantageous circumstance was the sudden death from influenza and pneumonia of the chief of the laboratory service.

During the early days of the epidemic five medical officers were appointed assistants, who acted as consultants on the various wards, and who reported to the chief of service several times a day. Maj. John Howland, Medical Corps, was sent from the


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Surgeon General's Office at the request of the Chief of Medical Service, and was of great assistance. He was instrumental in bringing 25 medical students from Johns Hopkins University to this hospital as assistants in the wards.

All wards used for contagious diseases were cubicled by means of sheets suspended from wires between each bed. Face masks were used during the entire epidemic of influenza by the entire personnel of officers, nurses, and ward attendants. (Statistical figures are given under "Registrar.")

Influenza epidemic: The nursing service worked under unusual difficulties during this epidemic, which raged during September, October, and a part of November. On September 20 but 6 nurses were reported sick, but two weeks later this number had been increased to 61. Every effort was made to relieve the situation by the employment of civilian nurses, but it was necessary, notwithstanding for the nurses to work on long shifts. At this crisis more than a scome of Sisters of Mercy from various Catholic institutions of Baltimore volunteered for the emergency and rendered excellent assistance to the physicians in the care of the sick. The high caliber of the nursing force was very evident at this time, each nurse performing the duties to which she was assigned, working in many instances 14 or more hours daily, work of the most willing and helpful character. The high efficiency of this service during the epidemic of influenza was to the greatest degree helpful in successfully combating this disease.

Dl. CAMP LOGAN DIVISION SURGEON'S REPORT.

September 9, 1918, an epidemic of influenza manifested itself by 10 admissions, from which it increased until September 23 when the peak was reached with a total of 223 admissions to base hospital and 15 quarters from which decline was rapid until November 1 only 4 cases in all are recorded for the day, and with few cases such as usually are found (endemic) within a military camp, no further manifestatiqns were witnessed. Pneumonia secondary to above, first manifested itself September 16 with 1 case, from which it increased until October 2, with 650 cases for the day.

El. CAMP LOGAN BASE HOSPITAL REPORT.

On April 1, 1918, a sharp and extremely sudden epidemic of influenza appeared, due to the influenza bacillus with other organisms. Eight of the first 14 cases showed Pfeiffer's bacillus. The cases were in hospital only from three to five days on an average, and the absence of pneumonia and other complications was conspicuous. By the middle of May the epidemic had subsided. During the summer of 1918, the admission rate was very low. On September 13, 1918, the first cases of the great influenza epidemic were admitted, and during the next 10 weeks over 4,100 patients were admitted. In the first 200 cases examined, the bacillus influenza was found upon smears in 104 cases and in 78 cases by culture. Within two or three days the pneumonia epidemic was initiated and 567 cases were admitted. The disease differed from that in most Army hospitals in that it was of lobar variety in nearly 90 per cent of the cases, broncho-pneumonia in less than 10 per cent, mixed abortive and undetermined in the remainder. The type 4 pneumococcus was the predominating organism found in the sputum. Clinically the feature of the epidemic were the almost universal incidence in the lower lobes, the extremely dense texture of the invaded lung as shown by the flatness to percussion and often by the absence of respiratory sounds and proned by post-mortem examination, The comparative infrequency of plural effusion and the occurrence of eight cases of interstitial emphysema and one of pneumothorax were noted.

Fl. CAMP GORDON DIVISION SURGEON'S REPORT.

The camp participated in the pandemic of influenza and a special report covering the time when it was epidemic in this camp was furnished your office, In my opinion, the infection was checked by the use of a gargle and nose douche of chlorinated water by the entire command twice daily, since the number of new cases reached highest point four days after the order was published, which was about two days after the treatment went into actual use. A solution of two tubes calcium hypochloride of lime to 40 gallons of water freshly prepared in Lyster water bags was used, later this was increased to five tubes to 40 gallons.

The number of new pneumonia cases correspondingly decreased, which was further accelerated by causing the entire camp to bivouac during pleasant weather. The other usual quarantine measures were carried out and everyone in camp was required to wear masks continuously. A review of 20,000 men wearing gauze masks was a novel feature at this camp in October.


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It may be added that our arrangements for handling the epidemic were of such a nature that the intensive training of recruits was not interrupted, and our October shipment of trained men was delayed but nine days.

It may be of interest to refer to a sanitary order from this office in reference to shipment of recruits to port of debarkation, the last sentence of the first paragraph being the important one. The results attained by this order were most satisfactory. No cases of influenza or pneumonia occurred en route, and troops were delivered at port of debarkation free of infection at a time when reports from other camps showed deplorable conditions on troop trains and transports from these diseases.

Gl. CAMP GORDON BASE HOSPITAL REPORT.

About September 15, 1918, the increase in influenza assumed epidemic proportions and steadily increased to its height during the early part of October. Camp Gordon seems to have been particularly fortunate in the relatively low mortality which attended this epidemic, only 138 fatal cases of pneumonia resulting from the respiratory complications of influenza. It is believed that the general principles of influenza management as outlined and insisted upon in this hospital were instrumental in holding down the incidence of respiratory diseases and keeping down the mortality in these cases where respiratory complications developed. It was recognized that every case of influenza was at least a potential pneumonia. Every effort was made to find hospital accommodations for every case developing in the camp and to expedite the reception of these cases into hospital in every way possible. All cases of suspected influenza were immediately rushed to hospital, put at absolute rest in bed, separated from adjoining cases by the sheet-cubiculum method and so kept throughout the course of the disease. Cases of pneumonia developing in the influenza wards were immediately removed to isolation pneumonia wards. In this way there was but little opportunity for men to go for two or three days with an unrecognized pneumonia and then be subjected to the physical strain and discomfort involved in the transfer by ambulance from barracks to the hospital, and the early recognition of pneumonia made it possible to institute appropriate treatment with a minimum of delay. During the period October 1 to October 23, 1918, when the capacity of the hospital was not sufficient for the large number of influenza cases for treatment, the barracks building in Block N was used as an isolation hospital for the reception and treatment of primary influenza cases. Every soldier in camp who had a temperature was a potential influenza case, was immediately transferred to this isolation hospital for observation and treatment and a competent medical officer from this hospital was assigned to duty as chief of the medical service and was responsible for the proper diagnosis of respiratory complications, upon the first signs of which, the patient was transferred to an appropriate ward in this hospital where ample facilities existed for their proper treatment.

A secondary temporary hospital was opened for the period October 5 to October 14 for the reception and insolation of influenza convalescents for a period of 10 days prior to their being returned to their respective organizations. It is believed that this prompt isolation and treatment of all cases, including suspects, had much to do with the relative mild epidemic in this camp. It is believed that in many instances associated with severe coughing, that the lung infection was a secondary insuffiation pneumonia due to the drawing into the bronchial tract, after violent paroxysms of coughing of infectious material from the upper air passage; consequently as a part of the routine of treatment a persistent attempt was made to keep the nasal pharynx as clean as possible by irrigation and gargling and to allay excessive coughing when present by the rather liberal administration of opiates. Cases were given large doses of tincture of digitalis (350-500, average, 400-450 minims) and the total amount of digitalis was given in four or five divided doses during the first 36 hours after the diagnosis of pneumonia was positive or probable, often when even only suspected. These large doses of digitalis were never observed to result in any harmful effects and it is our firm conviction that they accomplished good and saved lives. The type 1 pneumonias were treated according to the Rockefeller method.

H1. CAMP PIKE DIVISION SURGEON'S REPORT.

The beginning of the influenza epidemic appeared on the daily report of base hospital on September 22, 1918. On September 26, 525 cases were reported. On September 23, however, with only one case reported from base hospital inquiry was made at the several infirmaries, which revealed the fact that a number of cases diagnosed as influenza at the infirmaries had been sent to base hospital and the presence of the epidemic was at once recognized. Orders were issued by the camp surgeon on this date to the infirmary surgeons to submit daily report of the number of cases developing in


764

the commands served by them. An order was also issued to provide each infirmary area barracks to hold in quarters the milder and uncomplicated cases of influenza and sending to the base hospital only the more severe and complicated cases.

In attempting to arrive at a picture of the actual onset and progress of the epidemic the admission slips of base hospital from September 1 were gone over and the cases which had been admitted with an infirmary diagnosis of "Bronchitis acute" had undergone almost decided increase during the month of September.

I1. CAMP PIKE BASE HOSPITAL REPORT.

On September 23 the influenza epidemic arrived, some 450 patients being admitted on that date. Conditions of overcrowding with increase in the pneumonia rate immediately occurred and the necessary steps to avert a catastrophe were undertaken. An annex hospital of barracks adjacent to the hospital were opened where uncomplicated influenza was treated; the hospital proper was turned into a pneumonia hospital with approximately 1,200 cubic feet of air space per patient. All beds in the whole hospital were cubicled. Every case was cultured for H. strep and suitable wards set aside for the so-called clean and streptococcus pneumonia, all cases first being observed and cultured in pneumonia observation wards. In all there were 13,500 cases of influenza with 1,475 cases of pneumonia and 466 deaths. In the streptococcus pneumonia wards a surgical technique obtained with individual quarantine. These conditions were also enforced in the pneumonia receiving wards.

GENERAL HOSPITAL No. 33.

During the latter part of September, 1918, an epidemic of influenza developed at Camp Pike, Ark., situated about 3 miles from this hospital. At that time there were no cases of this disease at this post and immediately upon receipt of information that the epidemic had broken out at Camp Pike, precautions were taken to prevent the entrance or rather development of influenza among the enlisted force, as well as among the nurses and medical officers stationed here. All meeting or the assembling of men were prohibited. The post exchange and the Y. M. C. A. were closed and a thorough system of prophylactic treatment was inaugurated in the detachment, consisting of spraying of the throat and naso-pharynx several times a day with Dobell's solution. All patients were immediately placed in cubicles, paper bags containing a layer of sand were used by them to expectorate into. These bags were burned in an incinerator, and it was found that these bags containing sand were more satisfactory than sputum cups, being fully as accessible and sanitary and more easily and completely disposed of by burning. Masks were worn by all the nurses, ward surgeons and ward masters, while on duty in the wards, but it was found impracticable to have the patients wear masks, as these soon became soiled and rendered unsanitary, by frequent expectoration, and the retention of particles of expectorated mucous, the patients for the most part being colored and could not be made to carry out sanitary rules. Though ventilation of all barracks and sleeping quarters and a vigorous system of sanitary inspection of the entire post together with the enforcement of strict quarantine regulations, were, at all times maintained, with the result that from September 23, the date of the beginning of the epidemic at Camp Pike, Ark., up to and including October 2, when the first case was received at this hospital (a period of 10 days) not a single case of influenza had developed here. On October 2, 1918, at 5 p. m., the first of a number of cases began to arrive, being transferred from Camp Pike, and thereafter followed in rapid succession the admission of a great number of cases, a total of 767 having been admitted during the month of October. On October 5, two days subsequent to the arrival of the first contingent from Camp Pike, and as a result of direct contact with these cases, the officer of the day and a member of the medical detachment on duty in the receiving ward became the victims of influenza and were obliged to enter the hospital themselves as patients. During the period of influx of patients from Camp Pike the total number of cases admitted to the hospital from this command was 52. These were mostly among ward men and members of the Quartermaster Corps. Seven nurses and five medical officers were also among this number. Several of these cases were very mild in character, but were admitted to the hospital as a precautionary measure, both for the individual and the command. The total of cases of influenza, or influenza with pneumonia that were admitted to the hospital during the month of October, was 819, of this number 13.5 were pneumonia, 38 having been so diagnosed upon admission and 97 cases having subsequently developed as a complication of influenza. Of the pneumonia, 50 cases were bronchopneumonia and 85 lobar pneumonia. On December 1 there was a second outbreak of influenza, this time chiefly confined to the enlisted personnel of the hospital, the officers and the nurse


765

corps. Frequent throat cultures had been made from those of the command sick during the previous epidemic and they were not allowed to remain in their barracks until the negative cultures were secured, so that the source of the second epidemic is therefore undiscovered. Contrary to the usual habits of second epidemics this one was worse than the first. The cases were all very sick from the first. There were 89 admissions for this disease at this time. One nurse died of the cerebral type of influenza. Thirty cases developed pneumonia in which the prevailing organism was the streptococcihaemolyticus. Of this number 10 died. Twenty-four cases were lobar pneumonia and six were bronchopneumonia.

J1. CAMP JACKSON DIVISION SURGEON'S REPORT.

During the month of March there was a very large number of cases of influenza, particularly in the newly inducted men and colored troops, which was complicated in a vast number of cases by pneumonia. Exact statistics were not kept on this epidemic of influenza, but between 3,000 and 4,000 cases were evident during the month of March, April, and May. Epidemiological reports forwarded about this time show the epidemic to have been of a serious nature.

The epidemic of influenza followed immediately upon induction of 21,500 men, 8,500 of which were from Boston and New York City, and most of the remainder principally from Illinois, Ohio, Michigan, and other northern States. The epidemic began September 17, and made its appearance first in men from Boston and New York City, and abruptly spreading over a large area of the camp, 8,255 cases appearing during the epidemic, lasting through September, October, and November. Since that time we have had a few cases, with a gradual increase the very last few days of the year. The depot brigade moved to Camp Sevier in the early part of September before the appearance of the epidemic. During the period of the influenza epidemic the Fifty-sixth Artillery Brigade, consisting of more than 4,800 men, had only 59 cases of influenza, their protections being fresh air, sunshine, area quarantine, and purgatives given to each man twice a week. The pneumonias following influenza were broncho 729; lobar, 433. Deaths due to influenza epidemic, 412.

K1. CAMP FREMONT DIVISION SURGEON'S REPORT.

On or about September 28, 1918, an epidemic of the disease which has prevailed at camps throughout the United States, and which has been classed under various names, such as Spanish influenza, clinical epidemic influenza, influenza vera, etc., appeared at this camp. Previous reports leaving this camp have stated that the epidemic started October 8. This is probably in error, and may account for certain discrepancies which have been noted as present. For at least a week prior to this there had been pronounced daily increase in admissions to the base hospital of acute cases of respiratory disease, with active temperature. During the next seven weeks approximately 2,418 cases of acute respiratory disease with temperatures were admitted to the base hospital. A number of mild cases were cared for elsewhere, notably at the various infirmaries, to prevent overcrowding. Practically all the cases were taken in as influenza suspects, but were not carried as influenza on the records until so proven by throat cultures with implantation and growth. On account of the overcrowded condition of the hospital and the large number of daily admissions it was found possible to culture only 537 cases out of the total cases admitted. Of the 537 cases selected, all were severe cases of the epidemic type.

Running coincident with the influenza epidemic was the associated epidemic of influenza pneumonia. It is probable that nearly all pneumonias handled during that period were influenza pneumonias and developed during the course of the influenza epidemic. Some of the cases were admitted as frank pneumonias supposed to have been the result of a previous influenza, but with sufficient history to prove a preexisting influenza. Pneumonia was diagnosed in 408 cases, or 14 per cent. It is probable that the total number of pneumonias was higher than this, as we are assuming that in the early days of the epidemic many pneumonias were classed as bronchitis or entirely overlooked. Of the 408 pneumonias, 147 died, showing a mortality rate of 36 per cent for the pneumonia series, or 6 per cent for the epidemic. No deaths occurred from influenza alone, as there were no deaths without either a complicating pneumonia or broncho-pneumonia.

L1. CAMP DIX DIVISION SURGEON'S REPORT.

The second epidemic began about the 16th of September. This time the disease was influenza (so-called "Spanish influenza"), which continued until the latter part of October as an epidemic. At first the disease spread rather rapidly and the death


766

rate was rather high. Those afflicted rapidly succumbed to the toxema and complications of the disease. The complication most frequently seen was pneumonia, which for the most part was a progressive, lobular pneumonia. There were many deaths due directly to the intense toxemia of the mixed infection with the influenza bacillus, but the majority were due to the complicating pneumonia. After about the third week there was a steady decline, so that by the 1st of November there was a normal admission rate for influenza,

M1. CAMP BEAUREGARD DIVISION SURGEON'S REPORT.

One epidemic occurred during the year 1918, that of influenza, beginning September 28, and for the most part expending its force during the next two weeks. The experience at this camp as to morbidity and mortality is in line with the other camps affected by the disease, particularly the tent camps; 7,181 cases of influenza were reported mainly during the period covered from September 28 to October 10, although a few cases occurred after this date. One thousand three hundred and seventy cases of pneumonia developed from the influenza outbreak, or a morbidity incidence of about 20 per cent. Four hundred and ten deaths occurred from pneumonia, a mortality percentage of about 30 per cent.

N1. CAMP JOSEPH E. JOHNSTON DIVISION SURGEON'S REPORT.

The accuracy of the figures can not be vouched for, by reason of the wide discrepancy in totals between the records of the camp epidemiologist and those furnished by the register of the base hospital. As early as September 15, 1918, the attention of the camp surgeon was attracted to the increase in number of coryzas and mild bronchitis reported from the different camp infirmaries and transferred to the base hospital for treatment. These were probably influenza, but the base hospital reported such cases at first of minor importance, recovering within 48 hours and sent back for duty. The commanding officer of the base hospital was directed over phone to be alert on the subject and to have nasal and thoracic discharges of all such patients examined by the camp laboratory. In his statement, noted later on in this paper, he says: "Bacteriological examination demonstrated the presence of several cases of epidemic influenza September 21, 1918," although no report was made to the camp surgeon of this fact on that date. The disease had not made much progress in Camp Johnson until September 23, 1918, at which date 41 cases were reported by the base hospital as coming from the main camp and two from the remount station. On September 23, 1918, the total strength of Camp Johnston was 20,644. During the period of the continuance of the epidemic from September 23, 1918, to November 1, 1918, inclusive a period of 40 days, the average total strength of the camp was 17,343, of which 14,246 were white and 3,097 were colored. In the main camp the soldiers were quartered in barracks where each soldier had 50 square feet of floor space and 500 cubic feet of air space. The barracks at all times were kept in an excellent sanitary condition. The average daily strength of the main camp during the epidemic was 9,223. At the remount station and the receiving group the soldiers were quartered in tents. During the epidenaic five men were assigned to a tent. The total average strength in the receiving group during this period was 6,198; white, 3,320; colored, 2,878. Beginning September 23, 1918, by the direction of the camp surgeon, the infirmaries of the main camp, receiving group, and remount were directed to send all cases of influenza to the base hospital. They were further directed to report surname, first and middle name, rank, organization, location, date and hour, and disposition in each individual case immediately by telephone to the epidemiologist. From- September 23, 1918, to November 1, 1918, inclusive, 1,365 cases of influenza were reported from the main camp, 370 from the white receiving group, 314 from the colored receiving group, and 536 from the remount station, making a total of 2,575. Out of the 314 cases from the colored troops, 223, or over 70 per cent, developed pneumonia; 25 died. Out of the 2,261 white cases, 562, or about 25 per cent, developed pneumonia; 140 died. Beginning October 8, 1918, all white and colored troops in the receiving group were treated to nasopharyngeal applications of l per cent protargol solution. Glass medicine droppers were used in the administration. The following figures showed such a marked reduction in the number of cases in this group during the succeeding six days that, beginning October 14, 1918, this treatment was adopted throughout the entire camp and installations of 1 per cent protargol solutions were made on all of the men twice daily.


767

O1. CAMP DODGE DIVISION SURGEON'S REPORT.

The influenza epidemic covered a period of four weeks, from September 20, to October 20, 1918. On September 14, 120 men from Fort Riley, Kans., were transferred to this camp. The medical officer in charge of these men stated that a few cases of influenza existed in that post at that time. None of these men became sick until after the epidemic had reached its height at this camp. These men were not considered a source of infection, except that they might have been carriers through having mild unrecognized cases. Two men arrived in this camp September 12, both complaining of feeling ill with symptoms not unlike those of influenza. "A" was admitted to the base hospital with a diagnosis of influenza on September 28. No information was obtained from the other man except that from his chart which stated he had been feeling ill since his arrival in camp. He died with pneumonia following influenza September 29, 1918. September 14, 10 enlisted men arrived in this camp from Fort Logan. None of these developed influenza for at least a week after their arrival. September 14, one man arrived in this camp from Northampton, Mass., where influenza was raging at that time. He had symptoms like those of influenza, but was never admitted to the hospital. However, he may have acted as a carrier in Company 64, to which he was assigned, this company being one of the first to become affected. September 16, 27 men arrived from Chicago and were assigned to the motor convoy. Two of these men became sick upon arrival in camp and were sent to the hospital with a diagnosis of "bronchitis." The remaining men were assigned to duties bringing them in contact with men in all parts of the camp. Various other instances of this kind show that the source of influenza was from other camps and communities, carried here by patients or carriers and spread throughout the camp. The following statistics will explain briefly the course of the epidemic:

Average strength of command 

33,070

Total number of influenza cases 

10,008

Total deaths 

702

Per cent of command developing influenza 

30. 2

Per cent of command developing pneumonia 

5.8

Per cent of command dead from pneumonia 

2.1

Per cent of influenza developing pneumonia 

19.2

Per cent of mortality of pneumonia 

36. 6

Per cent of colored troops developing pneumonia 

20. 0

Per cent of colored troops developing influenza 

29. 3

Per cent of mortality of colored pneumonia 

39.0

Per cent of white troops developing influenza 

30.4

Per cent of white influenza developing pneumonia 

19. 1

Per cent white mortality pneumonia

36. 3

P1. CAMP HANCOCK DIVISION SURGEON'S REPORT.

The influenza epidemic at Camp Hancock, Ga., covered a period of five weeks- September 28 to November 4, 1918. The first case of influenza was reported on September 28. The next cases reported were on September 30, when 3,106 men arrived from Camp Grant, Ill. Seven hundred of these went directly from the train to the base hospital. These were followed by 200 admissions on October 1, and approximately 500 admissions on October 2 from the same group of men. Cases then appeared throughout camp, groups 5 and 6, main training depot, machine-gun training center, being particularly involved. The presence of influenza at camp was made known by the camp surgeon at that camp who informed this office by wire to the effect that influenza existed there, that infected barracks were quarantined, and that men were carefully inspected before departure for this camp. In order, however, to control the disease should all contacts not eliminated, one group area was cleared of all except its permanent training cadre to receive these men and quarantine was established before their arrival. Besides the men from Camp Grant, two other groups of men were heavily infected. These were groups 5 and 6, main training depot, machine-gun training center, which were composed of men from Louisiana, Alabama, and North Carolina. The machine-gun school, composed largely of officers and noncommissioned officers under special training, and the ordnance training camp, composed largely of men with special educational qualifications had very few cases. The epidemic was characterized by an extremely rapid onset and quick spread throughout the command. So rapid were the admissions that in some organizations sick call was held almost constantly. The ambulance at the base hospital was unable to admit cases at times as rapidly as they came. Tents, cots, and blankets


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could hardly be secured and set in place sufficiently rapid to care promptly for new cases. In two of the groups this was particularly the case. In these organizations it required nearly all of those not affected to care for the sick. The number of patients in the base hospital (normal capacity a little less than 1,500 beds) at one time exceeded 3,760 while the patients in improvised field hospitals at the same time exceeded 1,600, and the total on sick report numbered 5,805. In other words, the camp which on September 29 had little or no indication of an epidemic, was in the course of a few days almost overwhelmed with this condition. Various protective measures were put into effect to limit the spread of the infection so far as possible. Y. M. C. A.s and theaters were closed. Jitney and street car traffic was stopped. Post exchanges were closed except to officers who were allowed to make bulk purchases for their organizations. All members of the command were prohibited from entering movies, theaters, dance, and other amusement halls, churches, soft drink places, hotels, and private homes in the extracantonment zone. It will be seen that, though nearly one-fourth of the whole command became infected and 6.5 per cent of those infected died, certain organizations suffered much more severely than others. Group 2, which consisted of 338 permanent cadre pius 3,108 men from Camp Grant, Ill., had 1,355 recorded cases. There were probably 200 or more milder cases which owing to the avalanche-like rapidity with which they became ill and flooded the medical organization were unrecorded. Considering only the recorded cases, over 39 per cent of the group was infected and there was a death rate of 11.7 per cent for those having the disease. The men from Camp Grant were largely from Wisconsin, Minnesota, and the Dakotas. They were largely men of excellent stature and muscular development. Their high death rate was undoubtedly due to the massive infection acquired during the 48-hour trip from Camp Grant, Ill., to Camp Hancock, Ga. Groups 5 and 6 were composed largely of a July draft from North Carolina, Louisiana, and Alabama. These men were of poor physique, mentality somewhat below average, and over 50 per cent infected with hookworm when inducted. The admissions were 52.7 per cent and 42 per cent and the mortality rates for those having the disease were 5.7 per cent and 8.5 per cent, respectively, for these two organizations. Their lack of fighting spirit was a conspicuous feature. As soon as one became ill he usually gave up hope of recovery. The men of these two groups were crowded so far as tent space was concerned, many tents quartering eight men each, and, considering all the improvised field hospitals, the least satisfactory conditions prevailed in that of group 6. Group 7 is a negro organization. It will be observed that while the morbidity rate was high the mortality was low. Nothing other than possibly a racial characteristic has been found to account for this. Although nearly half of this command was admitted, only 3.5 per cent of the cases had a fatal termination. In the headquarters group, consisting of the headquarters company, personnel detachment, ambulance company, military police, motor truck and motor cycle companies, and stockade, the morbidity rate was low while the mortality rate was high. It is believed that this was not really the case, however. It is believed that, owing to the heterogeneous character of this group and to a less efficient medical organization therein, the tent inspections and sick records were less accurate and that a considerable number of cases were unrecorded. The care of the dead presented a very serious problem. The local contract undertaker, whose service had up to this time been thoroughly satisfactory, was soon crowded beyond capacity. His place was soon literally filled with dead bodies and even after bodies were no longer taken there his organization was so demoralized by the magnitude of the task that in order to keep the work going it was necessary to take over his shop and run it with experienced embalmers found in camp. In order to facilitate the work, all the undertaking establishments in the city were utilized and an embalming establishment erected at the base hospital. This was done by building a 14-foot "lean-to" on three sides of the existing morgue and equipping same with plumbing, electric lights, and zinc-covered tables, the entire work being complete in one night. An officer experienced in embalming was placed in charge and enlisted men qualified in the work were detailed. So long as it was required, three shifts of embalmers, dressers, and trimmers, working eight hours each, were on duty. Some difficulty was experienced in obtaining caskets promptly. Even more difficulty was experienced in obtaining embalming instruments, and in order to obtain them promptly it was necessary to send a messenger to Philadelphia to purchase same.

Q1. CAMP HANCOCK BASE HOSPITAL REPORT.

During the year there have been approximately 21,413 admissions to the hospital, With the exception of the influenza which swept over the country in the fall, there have been no very serious epidemics encountered at this camp. During January and February, 1918, there was a considerable epidemic of upper respiratory infec-


769

tions which are probably best classified as a mild acute bronchitis. This epidemic presented no features of particular interest, except that most of these men were confined to the hospital for a period of 10 days to 2 weeks and comparatively few of them developed pneumonia. During the last 10 days of September there had been a number of cases admitted to the hospital which were classified as acute infections of the upper respiratory tract and which were not regarded at the time as influenza, owing to the fact that they were comparatively mild. In the light of later experience it is probable that these cases were the forerunners of an influenza epidemic which afflicted both the city of Augusta, adjacent to the camp, and the camp itself. On Sunday, September 29, 1918, about noon, the hospital was notified that several troop trains were en route to Camp Hancock and that one train had 50 sick and another train 90 sick. These trains were expected to arrive the latter part of the afternoon, and hospital accommodations were requested. The hospital was nearly full at the time, and the early part of the afternoon was spent in returning convalescent patients and those awaiting discharge for disability, but not actually needing hospital care, back to the infirmaries of their organizations. About 4 o'clock in the afternoon cases from these troop trains began to arrive at the hospital, and during the next 30 hours approximately 1,500 sick were admitted. These troops came from Camp Grant, Ill., and had been from 48 to 60 hours en route. Soon after the beginning of their journey, influenza broke out among them, and on their arrival here practically 75 per cent were afflicted with the disease, and some of them were in very serious condition. Those admitted to the hospital were immediately quarantined separately, and those from among these troops which were not afflicted and sent to camp were placed in a detention camp. In spite of these precautions, the disease ultimately spread through the entire camp, and before the epidemic was finished approximately 8,000 soldiers were afflicted. Between five and six hundred died from the disease or its complications. At one time there were in the hospital nearly 3,900 patients. The staff of the hospital received splendid cooperation from the commanding general and from the heads of various departments throughout the camp, in meeting this emergency. A very large number of pyramidal tents were put up throughout the hospital grounds and the remainder of patients acre cared for in these tents. An attempt was made to put no more than four patients to a tent, but during the height of the emergency this was impossible of accomplishment, and many tents contained six patients.

Rl. CAMP SHERIDAN BASE HOSPITAL REPORT.

Three important epidemics have risen above the average morbidity: Measles in February, influenza in May, and the virulent pandemic type of influenza and pneumonia in October. The first was not remarkable, and was checked by ordinary methods of control. The influenza in May was of a mild type, being in most cases a sharp-peaked, three-day fever, very contagious, with a very short incubation but without sequela. In all cases of contagious disease the precautions were observed, and in addition epidemiological surveys were made of contacts or of the whole organization in which every disease originated, these being undertaken by the laboratory in cooperation with the camp sanitary inspector with a view to the isolation of carriers.

The recent pandemic of influenza and pneumonia has been the most important event of the year. The total number of cases of influenza reaching 4,450, constituting 23.8 per cent of the whole year's admissions; and the 161 deaths caused by the complication pneumonia are more by 86 than the total of other deaths during 1918. Only foresight and an intelligent and hearty cooperation on the part of every officer on the staff enabled the hospital to cope with the emergency on favorable terms. It was the policy of the administration to keep ready for immediate use a bed capacity, fully equipped, at least 50 per cent beyond the greatest estimated daily need, and although the admissions leaped from day to day by numbers in the hundreds, there was no time, day or night, when every patient was not provided with the normal hospital facilities amid care. The following measures were rigidly enforced to hold the morbidity and mortality to the lowest possible levels.

(1) Face masks were worn by all on duty in the wards of the hospital.

(2) Every influenza and pneumonia ward was cubicled before patients were admitted thereto, even in converted buildings.

(3) Ventilation was enforced and porches used to their utmost capacity. At least 100 square feet of floor space was allotted to every patient, regardless of his type of disease. Every member of the working personnel was allotted at least 50 square feet.

(4) No case was discharged without negative bacteriological reports as to pharyngeal culture,

(5) Every case of pneumonia was tested bacteriologically for type pneumococcus, the laboratory being run on a 24-hour daily basis for this purpose. A graphic chart


770

of the morbidity and mortality of this epidemic, showing the daily incidence of influenza, pneumonia, total daily admissions, daily death rates, the daily meteorological data, etc., was prepared and is now on file in the Surgeon General's Office. A simplified graphic chart covering the main features by days is attached to this report as Appendix A. A report giving many clinical data of medical and epidemiological interest is also attached hereto as Appendix B.

(6) The housing problem was paramount during the acute epidemic period, and was most successfully met. No patient was unprovided for immediately upon admission, and a general rule was laid down at the commencement of the epidemic that all cases should be admitted to and cared for in the wooden hospital buildings proper and that no patient should he transferred therefrom to the tent areas until he should have been clinically well for 48 hours. This was carried out in every case without exception. No case admitted for influenza was transferred from the wooden buildings to the tents until such patient had been clinically well for a minimum of 48 hours. To carry out this plan all of the officers' quarters, and the barracks of the hospital corps were vacated at once and converted into fully equipped wards for the reception of new cases, their former occupants being moved into tents. This was also done with the genito-urinary wards, their occupants being for the most part chronic cases of localized disease, whose treatment was not interfered with by such change.

S1. CAMP WADSWORTH BASE HOSPITAL REPORT.

By far the most prominent incident of the year, medically speaking, was the epidemic of acute respiratory disease which may he said to have begun September 29 and ended December 11. This disease, popularly called influenza, came in three distinct waves. During the first wave, the streptococcus hemolysans was the microorganism usually isolated; during the last two, the pneumococcus, usually type IV, was the most commonly found. The first wave maybe said to have extended from September 29 to October 25; the second from October 26 to November 9; the third from November 10 to December 11. The most prominent feature of the third wave was the high incidence of pneumonia as compared with the admission rate. The clinical picture was very varied, so much so, that of the 4,590 patients admitted to the hospital during the epidemic, rhinitis acute, was made as a preliminary diagnosis in 166 instances; pharyngitis, acute, in 345; tonsillitis, acute, in 41; laryngitis, acute, in 24; bronchitis, acute, in 1,215; and influenza in 1,841. Of these, pneumonia was a sequela in 3 of the cases of rhinitis; in 12 of pharyngitis; in 3 of tonsillitis; in 1 of laryngitis; in 55 of bronchitis; and 39 of those in which the preliminary diagnosis was influenza. The total number of pneumonia was 783, of whom 167 died, of either the pneumonia or a complicating empyema. Of 165 cases coming to necropsy, in practically every case the lung lesion was broncho-pneumonia rather than the lobar type. Considering the fact that out of 8,062 cultures of these cases, the bacillus influenza of Pfeiffer was recovered in only 12 instances, it is difficult not to conclude that this organism was not the primary etiological agent. During the year, a total of 1,037 pneumonias were treated, of whom 202, or approximately 19.5 per cent, died, either of the pneumonia or a complicating empyema. Stool examination for parasites had been done on the majority of these patients. Only rarely was the finding positive.

T1. CAMP LEWIS BASE HOSPITAL REPORT.

From March through July, 1918, a small epidemic of so-called influenza was experienced in this camp. The epidemic started with the arrival of the First Infantry Regiment from the Hawaiian Islands. This epidemic prevailed for a period of but six weeks and was practically limited to members of this organization and the Forty-fourth Infantry. Sputum cultures in these cases showed in most instances the presence of pneumococcus, group IV, and a nonhemolvtic streptococcus. The bacillus influenzae was present with the pneumococcus group IV in but four cases. In only rare instances were there serious complications, such as lobar or broncho-pneumonia. The recent epidemic of influenza made its initial appearance at this camp on September 23, 1918. The number of cases increased rapidly and the hospital load rose in a few days from 1,490 to a maximum of 3,024 cases. The number of surgical wards were reduced to a minimum, and the ward surgeons thus made available were temporarily assigned to the medical service for duty. Also several officers from the camp were detailed to the hospital for special duty. The hospital bed capacity was exceeded and barracks in camp were vacated for use of the hospital. The maximum cases handled at this hospital annex for one day was 698. This annex was opened on October 12, and closed on November 20. As far as was possible only mild cases and convalescents were handled at the annex owing to lack of facilities. All cases develop-


771

ing pneumonia were immediately transferred to the base hospital for care. The diagnosis of influenza has been based on the more or less classic syndrome of fever, general body pains, headache, chilliness, and backache. In the recent epidemic it has been possible to isolate the bacillus influenza from the sputum of but a very few cases, 239 being the exact number. The pneumococcus type IV and a nonhemolytic streptococcus, however, have been isolated in a large percentage of the cases. The total number of cases of acute respiratory disease during the epidemic (including cases admitted during September, October, November, and December, 1918), was 7,758. The diagnosis of influenza was made in 4,058 cases, acute bronchitis in 2,374, influenza and bronchitis in 356, and broncho-pneumonia is the admission diagnosis, in 1,126 cases. Broncho-pneumonia followed an admission diagnosis of influenza in 690 cases, bronchitis 265 cases, and the combined diagnosis of in6uenza and bronchitis in 168 cases. The diagnosis of broncho-pneumonia was therefore made in 2,249 cases during the period of the epidemic, or in 29 per cent of the 7,758 admissions for acute respiratory diseases. Of the 2,249 cases of broncho-pneumonia 157 ended fatally, or a mortality of 7 per cent. This mortality for pneumonia is low when compared to other camps. The reasons for this low mortality we feel are: (1) The rather low virulency of the infection at this camp; (2) a large percentage of diagnoses being made because of a well-trained consulting staff and extensive use of the X-ray and postmortem findings as check in the work: (3) the care exercised in sending cases to the hospital early and their retention in bed until several days after the febrile period; (4) the ample facilities provided by the camp authorities and excellent cooperation throughout the epidemic.

U1. CAMP SEVIER BASE HOSPITAL REPORT.

In the epidemic of influenza during the latter part of September and October 6,000 cases were treated. Beginning about the first of April and continuing for two or three weeks there was a flareup of influenza which, while ii was not in sufficient numbers to be characterized as an epidemic, yet displayed such remarkable characteristics that it deserves some especial mention.

The outstanding medical feature of the year was the influenza epidemic. This started about September 20, 1918, with a few scattered cases which showed no distinctive characteristics and gave no clinical indication that they were the forerunners of the very severe epidemic which followed. The cases rapidly increased in numbers until within 10 days we were receiving several hundreds daily and the clinical picture was one of a very severe intoxication. The hospital proper was soon filled to its capacity. The Red Cross and Y. M. C. A. buildings were offered and gladly accepted; the schoolhouse, Liberty Theater, and mess halls were next filled, and finally the tents of the engineers̓ camp were appropriated and several hundred patients were sent there. The wards of the surgical, head, and G. U. sections were all surrendered by the heads of these departments to meet the crisis and the officers assigned to these departments cheerfully lent every professional and other assistance in their power to aid the medical service. Medical officers were furnished by the field and camp organizations; civilian, professional, and practical nurses offered their assistance which was accepted during a period of the greatest stress. Pneumonias rapidly developed, as soon as the disease became epidemic, and these early cases were most desperate, the toxemia manifesting itself in the deep cyonosis, marked dyspnoea and tendency to hemorrhage from the lungs and mucous membranes. The influenza bacillus was demonstrated in the sputum almost invariably. Early in the epidemic every effort was made to prevent cross infections. Patients were isolated by the cubicle system as far as possible, and with sheets hung between the beds where cubicles could not be procured. As fast as they could be made bed screens were substituted for sheets, as the blowing sheets seemed to be a menace in themselves. All officers, nurses, and ward attendants wore masks and gowns at all times while in the ward. As fast as pneumonia developed the patients were removed to pneumonia wards where extra precautions were taken against infection. An officer especially trained in the treatment of pneumonias was put in charge of these cases. As far as was possible wood en and paper drinking cups and plates were used so that they could be burned after using. When this was impossible, the cups were sterilized at least once daily and not taken off the table in the meantime, The early cases were apparently much more virulent than the later ones. Almost 6,000 cases were treated during the epidemic. So far as is known no one died of uncomplicated influenza. Pneumonia developed in approximately 1,000 cases, practically all of the cases being broncho-pneumonia. Many of these were massive consolidations and gave the clinical signs of lobar pneumonia, for which they were sometimes mistaken. This mistake and the natural high mortality of these cases led to the mistaken idea that the lobars were more fatal than the broncho-pneumonias


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following influenza. In all about 340 deaths occurred. It is believed that many mild cases of pneumonia were left in the influenza wards, overlooked in the stress of work during the height of the epidemic, and that if these could have been taken into account the mortality percentage would have been lessened materially. The epidemic subsided almost as rapidly as it made its appearance, the entire affair, aside from the pneumonia, lasting no more than four weeks.

V1. CAMP MILLS BASE HOSPITAL REPORT.

Forty-two hundred and seventy-eight cases of influenza were admitted from September 14, 1918, to December 31, 1918. During the epidemic it was found necessary to erect about 50 tent wards in order to accommodate influx of influenza cases. The first cases of influenza entered this hospital September 14, 1918. Of these one developed pneumonia of the typical influenza variety, but made an excellent recovery. On September 14, 1918, we received 5 cases of influenza; on September 15, 6 cases. From then on the cases rapidly increased, reaching the maximum of 257 entries October 5, 1918. During the last 16 days of September this hospital treated 719 cases, of whom 116 developed pneumonia and of whom 51 died. During the period October 1-15, inclusive, 2,154 cases of influenza were received, of whom 711 developed pneumonia and 287 died. During the period October 16-31, inclusive, the epidemic rapidly subsided, only 739 cases of influenza being received, 177 developing pneumonia and 44 dying. In November the epidemic still further subsided, relatively fewer patients developed pneumonia, and still fewer dying. The incidence of morbidity and mortality in this epidemic was greatly enhanced at Camp Mills by the long railroad trips of most of the men affected, troops from Georgia, Mississippi, and California furnishing all of our cases. One patient from California, sick on the train, entered the hospital at 10 a. m. and died at 4.25 p. m. the same date. Many patients were in the hospital only 36 to 48 hours before their deaths.

W1. FORT SILL BASE HOSPITAL REPORT.

The epidemic reached this post September 26, 1918. The cases rose rapidly, reaching the apex on October 11, 1918, when 131 cases were admitted. The total number treated thus far is 2,145 cases. In the receiving ward the cases were cultured for influenza and meningitis; the blood was counted, and then the patient was brought to a receiving ward for influenza. Here he obtained his hospital clothes, his bath, a thorough physical examination, and disposed of according to whether he had an uncomplicated or a complicated case. Owing to the large number of patients, it was necessary to evacuate skillfully as well as quickly. An arrangement was therefore made to wit: All cases who had a normal temperature for 48 hours were sent to a convalescent camp established in each regiment where they were kept in quarantine and at rest for seven more days. Before they were discharged from the hospital, however, they were thoroughly examined and their fitness for discharge was again determined. The method worked excellently. Approximately 10 per cent of the command developed influenza; of these 10 per cent developed pneumonia, and of all pneumonia cases about 33 per cent died. The mortality therefore is about 3.15 per cent, a very gratifying result. The average incapacity for uncomplicated cases was found to be about 21 days. During this period the country was scoured for nurses and 10 additional doctors were sent from Fort Riley.

X1. CAMP SHELBY BASE HOSPITAL REPORT.

This disease first made its appearance in this particular camp on April 8, 1918, at which time the first case definitely known to belong to this syndrome entered the base hospital. From April 8 to April 23, 643 cases were admitted. The epidemic reached its height on April 15, when 112 cases entered. The total number of cases in the camp at this time was difficult to determine, for the reason that the admissions at the base hospital represent simply the overflow from the various regimental infirmaries throughout the camp. It would seem as though a conservative estimate would probably place the total number of cases in the camp at about 1,200. The epidemic very promptly disappeared and did not again make its appearance until the latter part of August of the same year. The next appearance of influenza in this camp was noted on August 29, 1918, at which time an epidemic occurred while the 38th Division was still in the camp. With this, there were 543 cases, followed by 35 cases of pneumonia, 4 deaths. This epidemic was probably due to the fact that many relatives and friends entered the camp about this time to bid farewell to the members of the 38th Division, who began entraining September 9. The epidemic gradually receded until


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from September 11 to 18 there were from 1 to 5 cases admitted to the base hospital daily. From September 18 to 21, inclusive, no cases were admitted. September 22 there began another epidemic which occurred among the enlisted personnel of the medical detachment and the nurses of the base hospital who were in contact with the previous patients with this disease; this continued and was augmented by patients coming from the development battalion. On October 10 there were received 200 enlisted men, Medical Department, transferred from Camp Dodge, for duty with an attached hospital unit. Many of these soldiers were taken sick with influenza en route, and were carried from the station directly to the base hospital; the infection which these men had was apparently more virulent than the infection with which had previously been dealt. On October 23 troops began to arrive from Wisconsin, and with them came a new and more virulent infection, so that from October 23 the daily admissions began to rise very rapidly, until on the 27th there were admitted 262 patients, making a total for the month of October of 1,689 admissions for this one infection. During November the daily admissions for influenza began to decrease, so that for this month there were only 388 cases admitted to the base hospital. During the month of December 111 cases were admitted. Complications were rather frequent. Out of the total number of influenzas admitted to the base hospital from the latter part of August to and including the last of December, there were 326 cases of either lobar or broncho pneumonia. Of this number 69 died.

Y1. CAMP DEVENS BASE HOSPITAL REPORT.

For the year 1918 the great outstanding condition met with at the base was, of course, the epidemic of so-called Spanish influenza, there being in all 14,784 cases throughout the year. These all occurred during the months of September, October, November, and December; 14,000 cases occurred in September. Next in importance and in number of cases came the various types of pneumonia, 3,743 cases in all. Of these cases, 2,838 followed the influenza epidemic in September and October. Measles, with 928 cases, ranks next in importance and frequency, while scarlet fever, meningitis, and diphtheria bring up the van with 69, 46, and 25, respectively. An accurate account of the mumps is not at hand, but the hospital took care of at least 400 cases, the majority of them occurring during October, November, and December. Camp Devens was the first of the large Army cantonments in which the influenza appeared and was the one hardest hit. The first cases were noted-about a dozen of them- on September 8. The hospital admissions of the disease increased with great rapidity, until one week later, the 15th, there were 1,200 admitted in one day. This high number continued for about three days, then rapidly diminished, until three weeks later the number of admissions were back to normal. There were in all admitted in 30 days, 11,000 cases, of which 7 per cent died. These deaths were practically all due to influenza-pneumonia. The fatal cases of pneumonia had an average duration of seven days to nine days, and there were as high as 90 deaths in a single day. After the terrific strain of handling these patients had somewhat lessened, some of the cases which ran a rather prolonged course were quite carefully studied, as was also the pathology of the more acute types. These studies will be later reported. Among other things, a very unusual condition of subcutaneous emphysema was noted. There were about 20 of these cases studied, and they were found simply to be one manifestation of the condition found commonly in the acute disease of the lung, namely, vesicular emphysema. This in some instances would become so extensive as to break into the interstitial tissues of the lungs and from there work its way through the root of the lung into the mediastinum and from there into the tissues of the neck, and occasionally it would spread all over the body. The amount of air in the subcutaneous tissues in some instances was enormous. Some of these cases were followed for several months and the physical signs noted and X-ray pictures were taken. The staff and nursing organization during the epidemic were entirely inadequate, though the individual members showed unfailing devotion. The pneumonia of the influenza or broncho type showed a fairly high mortality of about 25 per cent. This may be accounted for by the rush of the epidemic of influenza, the insufficient number of doctors and nurses, and the vast amount of work necessary that could not be done for them physically. With the straight lobar type, especially type L, our results were better and were most gratifying. These cases were incident in March and April, with a large increase after the epidemic in September, October, and November.

Z1. CAMP ZACHARY TAYLOR BASE HOSPITAL REPORT.

With sanitary inspectors and the camp epidemiologist constantly on the alert, the possibility of epidemics has been reduced to a minimum. With the advent of the influenza in other camps, extra precautionary measures were adopted. For two


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weeks before this camp was attacked two sick inspections were made daily of all troops by the regimental surgeons. When the epidemic arrived preparations had been duly made, in so far as human ingenuity could devise. Later, about one-third of the camp came under the administration of the hospital. The patient, upon admission, was at once masked and a shipping tag placed about his neck by a line officer detailed for this purpose, showing name, rank, age, organization, etc. An elaborate follow-up system was carried out to make assurance of identification doubly sure. In no single instance was a mistake made in the shipping of a dead soldier to relatives, nor unnecessary delay in embalming or shipping. Every man was promptly placed in bed, even though in one period of 10 days a thousand beds with necessary ward equipment were added daily. Hundreds of soldiers were placed under canvas, to make room, and the barracks made into very effective hospital wards. Not a single death took place in the emergency area. The uses of the cubicle, mask, and gown have been extended to all wards on the service of whatever class and their value has been fully proven. The use of the cubicle has been even extended to the quarters of the soldiers in the barracks, and records at present seem to point to its great value in preventing the transmission of disease in the early stages. The early hospitalization (segregation) has been pushed as far as practicable and has seemed to be of extreme value in the lessening of the extent and severity of the initial disease.

A2. BASE HOSPITAL, CAMP MERRITT.

About September 16, 1918, a few cases were admitted to the hospital diagnosed as "influenza." This diagnosis had been a frequent one all the summer and implied a short febrile disease of moderate severity for which no cause could be found. On September 16 these new "influenza" cases presented a picture of far greater severity than the old variety; attention was attracted to them and there was considerable discussion about them among the medical officers. It was not until three days later that it was realized that a real epidemic was at hand and that a new and entirely different problem was to be dealt with. On September 19, 1918, the epidemic started at Camp Merritt, with the admission of 58 cases to the hospital. At that time there were about 1,300 patients in the hospital, including some 500 venereal cases. The medical service then comprised 22 wards, one an influenza ward, with 18 ward surgeons in all. In less than three weeks 51 wards were used for treating influenza and influenza-pneumonia alone and 81 officers were on the medical service. This meant rapid evacuation of ward after ward. All cases acted upon by the S. C. D. board were sent to barracks near the hospital. Medical and surgical convalescents and venereals were sent to barracks or evacuated. All patients not actually requiring hospital treatment were discharged to regimental infirmary. Surgical wards were evacuated and all operating except on emergency cases was discontinued so that in a short time almost the entire hospital was filled with influenza patients.

Practically the entire surgical staff was turned over to the chief of medical service. All the specialists on the hospital staff were acting as ward surgeons or were in other ways concerned in the care of the influenza patients. Extra beds were placed on all the porches; the cross corridors had to be used to provide bed space, but no extra beds were at any time placed in the wards. Wires were put up not only in all wards but on porches and corridors so that sheets could be hung between all beds. In spite of the sudden influx of patients we were able to provide bed space so that proper ventilation was maintained and patients were not crowded. In these early days of the epidemic the appearance of the wards was very striding. Row after row of sick men lay motionless, quite prostrated by the disease. The wards recently filled seemed like a morgue; those filled a day or two previously looked a little more cheerful with now and then a patient lifting his head or talking, while those filled three and four days before seemed more like the ordinary hospital ward. Needless to say the opportunity for observing not one patient through the various stages of the disease but an entire ward full of patients, all passing through together and always presenting a homogeneous picture, was unusual. An order was issued at the outset requiring all cases suspicious of pneumonia to be isolated at once. Instructions were given that the diagnosis of pneumonia was to be made not so much on chest findings as on temperature continued after the third day, rising pulse and respiration, and on cyanosis. The ward surgeons in every case, as soon as the diagnosis was confirmed, completed the chart, placed the case on the serious list, and personally superintended the transfer of the patient. These cases were ordered transferred very promptly by the chief of sections to pneumonia wards.

Three officers were on duty in the medical wards each night in addition to the officer of the day, the medical staff all serving in rotation. These officers saw and prescribed for all cases needing attention; and were on the, constant lookout for early


775

pneumonias. Similarly two officers were on duty on the pneumonia service each night. A room in the officers' ward was reserved for their use so that they were constantly within easy reach of all the pneumonia wards.

The pneumonia wards were made available by transferring their former patients to other wards. On one day it was necessary to provide 2 new wards for pneumonia patients when 66 new cases developed. Finally 16 wards, including the nurses' infirmary and officers' ward, were used for pneumonia. The wards selected were at the south end of the group, easily available for the east, middle, and west sections of influenza wards and at the same time grouped close enough together f or ease of administration. In the pneumonia group 2 officers were assigned to each ward and the most experienced officer was then placed in charge of the group of 4 wards. To promote more effective work, a duly conference of all officers on the pneumonia service was held in the officers' ward mess hall from 3 to 4 o'clock. At these conferences, presided over by the chief of medical service, a free discussion was encouraged. Questions of diagnosis and treatment in all its phases were thoroughly and informally discussed, suggestions were offered with a view to securing better efficiency in the enlisted personnel by instruction, by definite plan of ward work, and by encouragement under the trying conditions. At this time deaths were so frequent that autopsies were held daily and a definite hour for these (1.30 p. m.) was arranged so that all might plan to be present. With such a wealth of material, the opportunity for consultation was naturally great.

Several large transfers of sick soldiers were made by hospital train from Hoboken and often formed a complicating problem. The commanding officer or his assistants were present at the detraining of these patients and their transfer to the hospital. Over 600 of these patients transferred from ships were admitted in one day.

Personnel increase .-The rapid expansion of the hospital made necessary a much larger personnel. Every effort was made to have this new personnel work in with the permanent staff in all departments.

Ten officers and 50 enlisted men from Debarkation Hospital No. 2, Fox Hills, Staten Island, 21 officers and 120 men from Base Hospital No. 98, and 5 officers from the camp surgeon's office were detailed to this hospital during the epidemic. These officers and men rendered very effective aid. With the arrival of the new personnel several cases of influenza and pneumonia developed among them almost immediately, especially among the nurses. it was very noticeable that the incidence of disease was greater in tire temporary than in the permanent personnel. This is partly explained by the new environment and the long hours under high nervous strain, and that probably the permanent staff acquired a certain immunity gradually by prolonged contact with the malady. The overwork, the care of the critically ill, especially in pneumonia wards, where the death rate was high amid the rather large number of nurses and ward attendants who succumbed to the disease had a depressing effect, and yet at no time was there evident any indication of panic. The constant supervision and care of the sick personnel was in great measure responsible for the fine esprit de corps which was maintained. The enlisted personnel was supplemented by a day and night detail of 120 men, each from the overseas casuals. These men were taken from Infantry, Engineers, and Artillery organizations, etc., and had no experience in caring for the sick. Their training devolved upon the ward surgeons and nurses and added to the difficulties of attaining efficient organization. With the advent of influenza, the officers' ward soon became overcrowded, though the capacity was increased from 34 to 49 beds by placing 15 extra beds on the porches. The number of nurses taken ill with influenza increased so rapidly that it was necessary to devote ward 37 as well as the nurses' infirmary to them. Later ward 47, a double-decker convalescent ward, was opened for nurses. Pneumonias were treated on the porch. As soon as convalescence was established the nurses were given sick leave, many of them going to their homes. The convalescent officers were transferred as early as was practicable to Oakdene, the domiciliary hospital at Bernardsville. The epidemic character of the disease was early apparent and prompt measures were taken to deal with it as such.

Many features of the disease very strikingly simulated measles.

Clinical aspects-During the prevalence of the epidemic there was a great similarity in the symptoms manifested; sudden onset, marked prostration, fever, headache, general muscular pains, epistaxis, moderately high temperature but pulse rate rather low, respirations not high, and pulmonary symptoms not prominent.

It was evident on the fifth day of the epidemic that a larger number of complicating pneumonias would have to be dealt with, 13 cases being reported on that date. The number of new cases increased daily until on September 29 the apex was reached with 66 cases,10 days after the beginning of the epidemic. A total of 188 cases of influenza-pneumonia with 23 deaths was the summary at this time. This date, September 29,


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corresponded with the maximum incidence of influenza. The summit of the death curve came 10 days later with 24 deaths on October 9. In 643 cases of influenza-pneumonias there had occurred 160 deaths, a death percentage of 24.8 per cent. During the whole period, September 19 to November 1, 1918, there were 999 influenza-pneumonias with 265 deaths, a mortality of 26.5 per cent.

The decline in virulence of successive groups of pneumonia cases was striking. The average duration of influenza to onset of pneumonia in 726 recovered cases was 4.03 days. This period was longer, 5.7 days in 47 fatal cases. In 39 fatal cases the average duration of the disease was 4.7 days.

Clinical signs.-The signs of pneumonia were usually indefinite; temperature persisting after the third day, pulse and respiratory rate rising, often cyanosis, a few rales at the base, more often on right side, diminished breath sounds or broncho vesicular breathing, later on dullness and bronchial breathing and increased voice sounds were noted.

Autopsy findings.-The pathological findings on autopsy were very interesting and different from any other pneumonias we had seen. The pleural cavities were free from pathological fluid. The lung surfaces were a characteristic dry slate blue color with here and there hemorrhages. Pinkish patches of emphysema surrounded the consolidated areas. The cut surface was bluish red, smooth, showed no fibrin, and exuded quantities of frothy, bloody serum, the lung tissue easily lacerated. The whole lobe was frequently involved, especially the lower lobes. The emphysema surrounding the consolidated areas was very striking, especially in the upper lobes; no pus was seen in the bronchi as a rule, in contrast to the interstitial bronchopneumonia with the small reddish nodules firm on section. the larger areas grayish, the bronchi exuding pus, the tendency to abscess formation and the common occurrence of empyema, the influenza-pneumonias brought to post mortem were very striking.

B2. GENERAL HOSPITAL NO. 2.

The only epidemic of note began during the week of September 15. About that time the prevailing influenza and pneumonia made its appearance in Camp Holabird and at Curtis Bay, and this hospital was soon called upon to take care of many cases from those commands and elsewhere. In all, approximately 345 cases of pneumonia were treated in this hospital during the next five weeks, with a total of about 140 deaths. Practically all of these showed the streptococcus hemolyticus as the causative organism; because of this and of the facts that. the progress of the disease was so extremely rapid and that many of the cases were received when the disease was well established, serum was not used. Every case of influenza and of pneumonia was isolated in a cubicle of sheets immediately upon admission. Pneumonia cases received 2 drams of fresh tincture of digitalis every four hours until contraindicated, fluids were forced up to at least 4,000 c. c. a day, and morphine and stimulants were given as indicated. Every patient was treated in the open air as far as porch space allowed, and thoracentesis was done at the first indication of fluid. All medical officers, nurses, and attendants wore gowns and masks, and to this may be attributed the extremely low incidence of infection among the personnel of the command. Two deaths only of enlisted men occurred, with none among the officers and nurses.

C2. GENERAL HOSPITAL NO. 3.

The influenza epidemic was very mild here and there were less than 100 cases, very few being serious. Of interest from an epidemiological standpoint was the unusually small number of cases of influenza, this no doubt being due to the strict quarantine maintained from the beginning and enforced after the State quarantine was lifted. The bacteriological findings in these cases were practically identical with the findings elsewhere. In a few cases the influenza bacillus was obtained in almost pure culture from the nasopharynx, but usually accompanied with staphlococci and streptococci. Several hemolytic streptococci were isolated. No positive blood cultures were obtained. Of the pneumonias complicating there were three cases of type 3 and one of subgroup type 2, all of which proved fatal,

D2. GENERAL HOSPITAL NO. 4.

There were two epidemics during the year, one of influenza in April, 1918, with about 20 cases and 1 death, and the other influenza in October, 1918, which was a local manifestation of the great epidemic which swept the country; about 250 cases were


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treated, with 14 deaths. Upon the outbreak of the epidemic, the command was quarantined and all unauthorized persons kept off the post. The throat and nose of members of the command were sprayed daily and inoculations given.

E2. GENERAL HOSPITAL NO. 6.

About 500 cases of this disease were treated at this hospital during the pandemic which occurred from the latter part of September, 1918, to the middle of December of the same year. Cultures were taken from the nasopharynx and sputum and the pleural effusions, the latter during life and at autopsy and also from the lungs and other viscera at autopsy. In only 13 cases were the Pfeiffer bacillus of influenza found, the organism uniformly appearing being the streptococcus hemolyticus, together with pneumococcus. In view of the above pathological findings, systematic protective inoculation with stock vaccine of streptococcus hemolyticus prepared in our laboratory (since organized as a department laboratory), was administered to the medical personnel, the nurses, Hospital Corps, Quartermaster Corps, and the men in the neighboring camp, Camp Jessup, making a total of about 4,000. In these Organizations such cases as did occur were of milder type, none with the complication of pneumonia.

F2. GENERAL HOSPITAL NO. 7.

There have been two epidemics of influenza; the first in October, 1918, 5 cases. The second in December, 1918, 18 cases, due to streptococcus hemolyticus. In the later epidemic there were 3 cases of pneumonia and pleurisy, with 1 death.

G2. GENERAL HOSPITAL NO. 8.

Two small epidemics of influenza developed, one in November, 1918, and a brief epidemic beginning at the end of December, 1918, and ending during the early part of January, 1919. A strict quarantine was promptly established and all suspicious cases were immediately transferred to an isolation ward, where appropriate treatment was administered. The cubicle system of bed arrangements, wearing of caps, masks, and gowns by attendants were maintained. Six deaths from pneumonia, complicating influenza, occurred during both epidemics.

H2. GENERAL HOSPITAL NO. 9.

Early in October the epidemic of so-called influenza began among patients, commissioned and enlisted personnel, nurses and civilians. Since that date there have been admitted 332 cases. Among this number 41 cases of lobular pneumonia developed. About 50 per cent of these were typed and showed type 4. Eight of the pneumonias died and 1 case of influenza died without demonstrable pneumonia. Five of these deaths occurred among the members of the New Jersey Militia and United States guards, who had been on duty at Morgan, N. J., following the explosion, and were admitted to the hospital with pneumonia and in a more or less desperate condition.

I2. GENERAL HOSPITAL NO. 11.

Ninety-four cases of epidemic influenza, of which 7 were complicated with pneumonia, with 1 death. The only other epidemic diseases were noted above in the reports of the special departments.

J2. GENERAL HOSPITAL NO. 13.

During September and October the influenza epidemic raged in the town of Dansville, 25 per cent of the population being affected. At the same time there was no spread of influenza in the personnel of General Hospital No. 13, only two cases occurring, both contracted elsewhere before the men reported for duty at this post. There has been no occurrence of epidemic disease, and practically no acute sickness among either patients or enlisted men. Methods of handling the cases of epidemic disease: Isolation of cases. All soldiers forbidden to visit Dansville during prevalence of influenza. Prompt examination and treatment of any "cold" or suspected respiratory infection.


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K2. GENERAL HOSPITAL NO. 15.

An epidemic of "Spanish influenza" began October 3, terminating November 13, 1918. There was a total of 47 cases, 6 of which were complicated with broncho- pneumonia; deaths, 1, Autopsy showed complications of broncho-pneumonia, nephritis, and pulmonary tuberculosis.

L2. GENERAL HOSPITAL NO. 16.

During the latter part of September and October the hospital became suddenly taxed by the epidemic of influenza which occurred among patients, corpsmen, and medical and nursing personnel. All beds in the hospital, reconstruction wards, and barracks for corpsmen were at once separated from each other by means of cubicles and all persons coming into contact with influenza cases wore masks. The reservation was placed under quarantine. An effort was made to stop the admission of all new tuberculous cases. The receiving ward and one entire general ward, together with two long protected corridors were used exclusively for influenza patients. Barracks "A," a building used for the housing of corpsmen, was used for all suspicious cases that needed to be kept under observation. Here they were held in isolation and if a diagnosis could be made or if the patient did not quickly recover, he was transferred to a bed in the hospital. As the epidemic grew it was found necessary to take over the two Red Cross houses and equip them with beds and other ward requirements, They made the most excellent hospital wards, they were light, well ventilated, and cheerful. In spite of the fact that the hospital was carrying its

full quota of tuberculous cases, we were able to make room for 267 cases of influenza and to provide them with the very best of care. Of these cases, 72 developed bronchopneumonia and 14 died. The last week of September, as before stated, the influenza epidemic, then raging throughout the country, broke out here. During that period 11 of our nurses were off duty on account of illness. Aside from 2 incapacitated by diseases absolutely dissimilar to influenza, 9 cases were diagnosed as bronchitis, acute or subacute; 1, influenza; and 1, under observation for influenza; the first cases developing acute bronchitis shortly after reporting here from New York City. On September 27, 20 nurses were ordered to Camp Devens to assist in cases for the victims of the epidemic at that post. This left us with a nursing force of 36, only 27 of whom were fit for duty. The largest number of nurses off duty on any one day was 11, which number reported sick on October 5. This situation was met by withdrawing the nurses from all ambulatory wards. On September 28, the day after the 20 nurses were transferred from this hospital, our roster was as follows: 36 nurses at the post, 5 sick, 27 present for duty; of these, 1 was the chief nurse; 7, head nurses on wards in the main building; 12, ward nurses; 1 nurse in the operating room; 1, doing social service work at the Red Cross convalescent home; and 4, night nurses. On one ward there was only 1 nurse; on another ward having only moderately ill patients there were but 2 nurses, 1 of whom was the head nurse; and on another ward, having critically ill patients, there were but 3 nurses besides the head nurse. By October 11, 3 emergency wards had been organized, the two Red Cross houses and a room in the administration building, for officers, being used for this purpose, on which, of course, it was necessary that nurses be detailed for duty. Nothing was neglected, however, and the patients, though greatly increased in number, were well cared for, as the nurses worked 10 and 12 hours a days.

M2. GENERAL HOSPITAL NO. 17.

On October 13 a virulent case of influenza with pneumonia was brought to the hospital. The influenza epidemic was late in arriving at Markleton owing to the secluded position of the hospital and the precautions taken by those in command. However, the middle of October saw the number of workers much diminished and it was necessary to put a large number of patients at work to replace the detachment men who were sick in the influenza ward. Men from the typewriting classes went into the office and helped there. Men from the accounting class took over the individual purchasing, for the men could no longer go to the store. The agriculture classes were employed in fatigue work, doing the outside policing. Men from other classes were put on guard. All of this work was supervised by the reconstruction department. Three of our instructors were among those in the "flue" ward. Our classes necessarily suffered, both through the withdrawal of pupils to other activities and the necessity of giving up some classes due to loss of teachers. In October three of our nurses and the chief nurse fell ill with influenza, leaving six on the wards and


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diet kitchen, the remainder being detailed to the care of the influenza cases. At this time a request was sent to the Surgeon General's Office for nurses and four reported on the 28th.

N2. GENERAL HOSPITAL NO. 25.

During the month of October, 1918, the influenza-pneumonia epidemic reached its height, and a brief history of this epidemic as experienced in the hospital is appended. The influenza epidemic reached its acme during this month; the first case of influenza was received on September 24, the total number of all cases in the hospital on this date being 203, with a hospital capacity of 400 beds. On October 9, there were 1,701 patients on the hospital, improvised barracks wards and 25 tents erected in the emergency, of which approximately 1,550 were influenza cases and their secondary complications. On October 9, there were 264 cases of secondary pneumonia, and on October 21 there were 350 cases of secondary pneumonia under treatment. The total number of influenza and complications in this epidemic were as follows:

Influenza, 3,116,

Pneumonia, 521.

Empyema, 16.

Otitis-mastoiditis, 32.

Nephritis, 40 per cent approximately (short duration).

Emphysema, 5 (generalized of subcutaneous tissues),

Cardiac, Most of fatal cases were due to final cardiac complications. At autopsy (32 cases), 3 cases of pericarditis and 1 of aortitis were found.

Jaundice, 30 (severe type).

Meningitis, 2 (pneumococcus).

Panophthalmitis, I (with secondary pneumococcus meningitis).

Epistaxis, 15 per cent approximately of all cases.

The influenza was characterized by rapid and severe onset, high temperature, dry mucous membranes, general cyanosis most marked on the face, neck, and extremities and severe toxic symptoms involving the respiratory and circulatory centers, in the latter resulting in a relative bradycardia and vaso-motor dilatation. The most striking symptoms noted in our cases being the general depression. One very characteristic and almost constant finding among our severe cases was a foul and almost gangrenous odor of the breath, most marked during exhalation. The pneumonia was characterized by its striking regular involvement primarily of the lower lobes posteriorly. The first finding being numerous subcrepitant rales in this location. Rapid extensions upward was the rule with a resulting general lobular pneumonia of a malignant type, terminating usually in early death or a subsidence by lysis. In about 5 per cent of cases a massive consolidation resembling the lobar type resulted in resolution by crisis. The sputum in all cases was scant during the first days. Blood streaked early, later viscid and mucopurulent. At autopsy in most instances a general involvement of all lobes was noted, however, irregular in its distribution. There was a marked leucapenia in most cases. Empyema was diagnosed in 18 cases. It is worthy of notation that the empyema following the influenza pneumonia was very benign as compared with the epidemic of streptococcus empyema in the spring of 1918. Following aspirations of from two to four weeks duration 14 cases required thoracotomy. In these cases one-half inch of rib was resected, in most cases the ninth rib in the post-axillary line being the seat of choice for the operation. A Brewer tube was used and negative pressure was obtained by attaching a collapsed Ewald bulb. Whenever the patient complained of too great a negative pressure, as evidence by pain, the tube was clamped and time bulb removed and allowed to expand, before being attached, The Ewald bulb was removed and emptied every two hours by a nurse who is in charge of this work. The cavities were irrigated from two to six times daily with a neutral Carrol-Dakin solution. Four cases made a complete recovery under repeated aspiration without operation. The above statistics do not include 10 cases of empyema which have been referred to this hospital for operation from other institutions in this part of the country, making a total of 28 cases, of which 20 have been treated surgically, and 4 are still being aspirated, with apparent recovery. In this series of 28 cases only 2 have died, both of these post-operative. One from a direct extension to the peritoneum through spontaneous perforation in the right side of diaphragm, the second developed a generalized sepsis and purulent pericarditis. Otitis and mastoiditis have been infrequent, 30 cases being referred to the otologist.

Pharyngeal and laryngeal complications, although comparatively infrequent, have been interesting, especially the severe cases of laryngitis which were very persistent.

Nephritis was present in approximately 40 per cent of all pneumonia. Rapid disappearance of urinary findings during convalescense has been the rule. So far no


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tendency toward chronicity has been observed. Acute cardiac complications have been frequent, resulting in sudden death in not less than 15 cases, which appeared to be convalescing. At autopsy of those cases the right heart is dilated, more especially the right auricle, and the venous system engorged. Relative bradycardia has been one of the most striking of this disease. General emphysema of the face, neck, and trunk has been noted in five cases. Three of these cases have gone to autopsy and two have recovered. These eases as well as numerous others have shown a marked emphysema of the lungs and blistering of the pleura. In all three fatal cases the right lung and the side first involved by the subcutaneous emphysema, the upper lobe was bound down by old adhesions and the mediastinum was markedly infiltrated by air. Percussion of the chest was of little value because of the marked emphysema in the subcutaneous tissues. Subcutaneous cultures taken during life by deep punctures and those taken at autopsy have been uniformly negative. Other clinics have reported gram positive bacilli with aerobic and anaerobic growth, but we have been unable to corrobate these findings. Of especial interest in this epidemic was a group of new recruits. Thirteen cases of severe influenza in recently enlisted recruits were brought into the hospital. They were en route from Minnesota when detrained. All received from 1 to 3 mils of autolyzed pneumococcus antigen (Rosenow), 1 mil upon admission and in severe cases repeated daily. None of these recruits had received prophylactic triple typhoid vaccinations. In these cases the blood counts ranged between 3,280 and 21,000 and in the severe cases showing moderate reaction from the antigen. The influenza in the recruits was of the severer type with toxic and vaso-motor symptoms as seen in the local epidemic at its height. Four of the 13 developed extensive pneumonia. All but 1 recovered. This last case developed a lung abscess, pneumothorax, empyema and died November 18, 1918. During December a fresh outbreak of influenza and secondary pneumonia was experienced. This group of cases while not as virulent as the October group was associated with a comparatively high mortality and far more virulent than the more or less sporadic November cases. One hundred and forty-one influenza cases were admitted, of which number 35 developed pneumonia with 9 deaths, a mortality of 25.7 per cent; 30 were given antigen with 7 deaths, mortality 23 per cent; and 5 did not receive antigen with 2 deaths, 40 per cent.

Due to the fact that the troops at this post were undergoing demobilization during December, many of the cases refused to answer sick call during the first days of their illness and three of the fatal cases of pneumonia did not enter the hospital until the third, fourth, and fifth day of their illness, respectively. One other fatal case was under treatment for syphilis. In October epidemic this latter class of cases showed a high mortality. One of the fatal cases during December was a nurse in charge of an influenza case, the only death among the nurses during both epidemics. She developed a generalized broncho-pneumonia.

O2. GENERAL HOSPITAL NO. 27.

The medical service has been limited practically to the treatment of influenza, which has been pandemic, and to its most common complications, pneumonia and empyema. This disease began early in October and gradually developed into a malignant type, followed frequently by pneumonia. The height of it lasted four or five weeks and then gradually subsided with only an occasional case, due to new arrivals at the post, until November 18, when an acute recrudescence occurred and filled the hospital to its capacity. This was the result of the return to duty of those members of the Students' Army Training Corps, University of Utah, who had been furloughed home at the outbreak of the disease. The disease gradually subsided, and on December 31, 1918, there remained in the hospital but three influenza cases and eight pneumonia cases. In the treatment of all infectious diseases the cubicle system was used; all attendants gowned and masked; linen disinfected in 2 per cent cresol, in the absence of a steam sterilizer; dishes boiled; floors scrubbed with cresol solution; in general the instructions contained in War Department orders relating to infectious and contagious diseases were followed in their entirety as far as circumstances would permit.

P2. GENERAL HOSPITAL NO. 29.

An epidemic of influenza visited the command in March. Many of the cases were followed by infection of streptococcus hemolyticus, pneumonia, and pleurisy with effusion. The mortality was necessarily high, but the medical and surgical service did excellent work in caring for these cases and much valuable information was obtained from careful study of the clinical records and of pathological findings. In the last days of September, 1918, while the officials of the hospital were busy perfect-


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ing the organization which was to be designated by War Department order as General Hospital No. 29, the medical service contained 20 patients. On September 27, the first case of influenza was admitted. In less than 10 days the medical service was caring for 850 patients, nearly all influenza cases. Altogether during the epidemic about 1,800 cases were admitted, of whom 200 developed broncho-pneumonia, with 61 deaths, a total mortality of 3.38 per cent. The most of these men were members of the Students' Army Training Corps, having been in the military service but a few days. They were for the most part men under twenty years of age, and unfortunately had not had time to become adjusted to the conditions of military life before contracting the disease. Their close proximity in barracks and classrooms favored the rapid spread of infection. Like most contagious infections the epidemic gathered momentum as it progressed, reached its height about October 15, after which it began to decline both in incidence and severity.

Q2. GENERAL HOSPITAL NO. 26.

On October 1, 1918, orders were issued placing general hospital No. 26 under quarantine indefinitely, on account of the epidemic of Spanish influenza.

In April, 1918, about 50 per cent of the medical detachment of this hospital became affected with influenza, which was characterized by sudden onset of severe symptoms, high temperature, gastrointestinal symptoms predominating. Marked prostration accompanied the above and the febrile state, terminating in about 48 hours in recovery with a couple of days of convalescence, Seventy-five men were thus affected, with one fatality.

Observations in this hospital of the epidemics of influenza with their complications of pneumonia are not materially different from those reported at other military and civil hospitals. In the first week of October, 1918, when the epidemic ranged all around us, we had not one case develop in this hospital, neither from patients nor personnel. Fifty-two cases of influenza were brought here from an outside military institution in Des Moines, and shortly afterward cases began to develop among the patients, orderlies, nurses, and officers, and hospital detachment men, in spite of all precautions that were taken to prevent its spread.

Total number of influenza cases, 376.

The report from the laboratory is to the effect that cases diagnosed as lobar pneumonia did not differ from those diagnosed as broncho-pneumonia.

R2. ARMY AND NAVY GENERAL HOSPITAL, HOT SPRINGS, ARK.

An epidemic of influenza prevailed in the hospital during the months of October, November and December, 1918. A total of 63 cases developed in the hospital during these months, 8 of which developed pneumonia, and 5 cases died. Methods pursued in handling epidemic were as follows: immediate isolation of all cases and suspects; subisolation of pneumonias; isolation for at least 5 days after temperature was normal; disinfection of nose and throat with dichloramine-T before liberation from isolation; gowns and masks for all attendants in wards.

S2. BASE HOSPITAL, FORT SAM HOUSTON.

About the 1st of October the influenza epidemic struck Fort Sam Houston. This taxed the personnel to the utmost, and it was not long before it was attacked by the influenza as well, placing doctors, nurses, and detachment on the sick list. The number of patients in the hospital rose from 800 to 2,475 in one week. This necessitated the placing of corps men in tents and using their barracks, the Red Cross, Young Men's Christian Association, recreation hall, nurses' dormitory of 200 rooms, every available space in all the wards, and finally putting the 15th Cavalry in the field and using 11 of their two-story barracks. It was ultimately necessary to utilize the personnel of Field Hospital 24, as fatigue and influenza were overpowering those combating this disease. The large number of cases soon dwindled to about 80 cases in all, when a second rise occurred, soon after the general quarantine was lifted, during the celebration of the armistice. There were still quite a number remaining at the close of the year. The pneumonias, following influenza, were not so severe after the second rise. Statistics show that this hospital was credited with a favorable record during this epidemic.


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T2. LETTERMAN GENERAL HOSPITAL, SAN FRANCISCO.

There has been no epidemic affecting this hospital except the one of influenza which started in October, 1918, and continued with unabated virulence until the last part of January, 1919. The disease was characterized by an onset with chill, chilliness, marked prostration, slight coryza and general soreness and pain, the latter most marked in the lumbar region. The incidence of pneumonia as a complication was the same as that experienced throughout the country generally. Empyema was a serious and fatal complication. Middle ear involvement was not frequent. Neurocirculatory asthenia was observed in a large number of cases. The lung pathology, as disclosed by X-ray, following the pneumonia complication, is slow in clearing up, requiring from three to six months. This condition presents very great diagnostic difficulties in differentiation from tuberculosis.

U2. EMBARKATION HOSPITAL, CAMP STUART.

Influenza became epidemic at this port about the middle of September. During the height of the epidemic, September 20 to October 20, 2,523 cases were treated, which, together with those cared for before and after these dates, brought the total up to over 3,000. These cases, of course, represented the more severe infections, as temporary hospitals maintained at the various camps cared for less serious cases. Between the dates above noted, 623 cases of pneumonia came under the care of the medical service. The mortality rate was 25.8 per cent, Of the many complications to be expected, empyema was noticeable for its small incidence, only three cases appearing. The Pfeifer bacillus was found in only 1.6 per cent of 1,148 examinations. Of the secondary infections, the streptococcus hemolyticus showed only 0.6 per cent incidence and to its absence the low empyema rate can probably be attributed.

V2. EMBARKATION HOSPITAL NO. 1.

During the year 1918 the most prevalent disease was influenza, beginning in January, 1918, with 40 cases, rising to 150 in March, and declining to average of 10 during May, June, and July, then sudden drop to 75 cases in November. The total number of cases for the year was 2,124 cases.

The only epidemic experienced among the corps men and nurses here was that of influenza and this came on while this hospital was receiving a great number of influenza cases. The majority of deaths among medical cases were due to pneumonia, the principle reason for this was type staphlococci as seen in the influenza epidemic and the late arrival of cases to this hospital coming from ships.

W2. DEBARKATION HOSPITAL NO. 1.

This disease made its first appearance about September 20 and lasted for a period of six weeks. Every precaution was taken for early diagnosis and isolation of suspected cases, Both patients and personnel were inspected twice daily and those presenting the slightest symptoms were isolated. This resulted in having 232 isolations made. Of these 24 developed pneumonia, 6 of whom died. The disturbing organism was in all cases the streptococcus hemolyticus. The diseases treated at this hospital have been the usual type and no unusual clinical forms have been presented.