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Extracts

The U.S. Army Medical Department and the Influenza Pandemic of 1918

Extracts on

"Acute Infectious Diseases and Their Control"

(Including Influenza)

in

 "Medical Department Promulgations"

Volume 1: The Surgeon General's Office

The Medical Department of the United States Army in the World War

Washington, D.C.: Government Printing Office, 1923


CONTENTS

Circular Memorandum, from the Surgeon General, January 1, 1918.   Care of Infectious Diseases in Hospitals.

Circular Memorandum, from the Surgeon General, January 8, 1918.   Camp Epidemiologist.

Circular Letter, Surgeon General's Office, March 22, 1918.  Prophylactic Treatment of the Respiratory Tract.

Circular No. 1, Surgeon General's Office, March 25, 1918.  The Control of Respiratory Infections and Communicable Diseases in Hospitals.

Circular Letter, Surgeon General's Office, August 16, 1918.  Experience of Medical Officers in the Diagnosis of Communicable Diseases, Especially the Exanthemata.

Circular Letter, Surgeon General's Office, August 29,1918.  Care of Communicable Diseases.

Circular Memorandum, Surgeon General's Office, for camp and division surgeons, etc., September 6, 1918.  Control of Acute Respiratory and Other Diseases.

Circular Memorandum, Surgeon General's Office, for Camp and Division Surgeons, etc., September 24, 1918.  Control of Epidemic Influenza.

Memorandum, Surgeon General's Office, for camp and division surgeons, September 27, 1918.  Personal Defense Against Spanish Influenza.

Circular Memorandum, Surgeon General's Office, September 28, 1918.  Control of Communicable Diseases.

Circular Memorandum from the Surgeon General, September 30, 1918.   Method of Handling Influenza Epidemic at a Camp.

Circular Memorandum, Surgeon General's Office, October 2, 1918.  Precautions Against Transfer of Influenza Contacts.

Circular Letter from the Surgeon General, October 13, 1918.  Assignment of Epidemiologist to Camp.

Circular Letter, Surgeon General's Office, October 30, 1918.  Report on the Influenza and Pneumonia Epidemic.


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ACUTE INFECTIOUS DISEASES AND THEIR CONTROL

(INCLUDING INFLUENZA)

Circular Memorandum, from the Surgeon General, January 1, 1918.

Care of Infectious Diseases in Hospitals.

Report of inspectors indicate lack of uniformity in the care and isolation of infectious disease in hospitals, and in many instances the steps taken are reported to be insufficient to prevent possible spread of infection and development of complications. The following procedure should be followed whenever local conditions permit. When any or all of the necessary medical department material is lacking, requisition should be made by telegraph to this office for the needed articles, attention Colonel Howard, and referring to this memorandum as authority. Such additional precautions should be taken as are deemed advisable by the commanding officer of the hospital.

1. Meningitis.- Strict isolation should be instituted. Male attendants should be segregated and not allowed to eat or sleep with the sanitary detachment. The same steps should be carried out with female nurses as far as possible. When on duty in the wards all female nurses, male attendants, and medical officers should wear operating gowns, caps, and gauze masks over nose and mouth. The hands should be thoroughly washed and disinfected after coming off duty and before leaving the ward. Cultures should be taken every fourth day from medical officers, nurses,


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and male attendants on duty in meningitis wards, and no such nurse or attendant should be assigned to other duty until a negative culture is obtained. Bedding, clothing, etc., of patients, and gowns and caps of attendants should be thoroughly disinfected by steam or chemicals before going to the laundry. Nasal and oral discharges of patients should be disinfected or burned. Dishes, etc., for bringing food should be sterilized before being returned to the general kitchen. Meningitis convalescents and carriers will not be returned to duty until after three consecutive negative cultures taken at intervals of from three to six days. Meningitis carriers should not be segregated in the same room with men sick with meningitis, but in a suitable segregation ward, camp, or barrack.

2. Diphtheria.-The same precautions should be taken as prescribed for meningitis. In addition, the Schick test should be applied to nurses and male attendants, and those not immune should be immunized.

3. Measles.-An allowance of at least 1,000 cubic feet per patient should be provided in wards or barracks used for treating measles patients. Wires should be arranged across measles wards and sheets, or newspapers, hung over these in such a way as to form a screen between each two patients; or some other suitable screening arrangement should be provided. This is with a view to preventing spread of pneumonia by droplet infection during coughing. Patients convalescent from measles should be retained in hospital, or in a well-warmed convalescent barrack, for at least 10 days after the temperature has permanently returned to normal Medical officers, nurses, and male attendants in measles wards will wear gowns, caps, and face masks. Nasal discharges and sputum of patients will be disinfected. Oral cleanliness should receive special attention. Attendants who have had measles should be selected, if possible, for duty in measles wards. Floors of wards should be gone over daily with a cloth wet in disinfectant. Dishes and eating utensils should be disinfected. Individual drinking cups should be used. Particular care should be taken to disinfect thermometers and other utensils as they pass from patient to patient. Wards should be kept warm. A urinary examination should be made before discharge from hospital.

Patients developing pneumonia should immediately be removed from the measles wards. They should not be placed in the same wards with primary lobar pneumonia.

4. Pneumonia.-Pneumonia patients should be treated in wards used exclusively for pneumonia. Ordinary lobar pneumonias and post-measles and post-scarlet-fever pneumonia should not be treated in the same wards. At least 1,000 cubic feet of air space per patient should be provided, and all of the precautions referred to in the section on measles should be carried out, viz, gowns, caps, masks, screens between beds, disinfection of utensils, thermometers, excretions, and floors. Convalescent pneumonia patients should use a mild antiseptic mouth wash as long as they remain in hospital, and should pay special attention to oral hygiene. Special attention should be given to the early detection of empyema.

5. Scarlet fever.-All of the precautions prescribed in measles should be carried out in the treatment of this disease. Attendants who have had scarlet fever should be selected when possible.

Patients should not be released from quarantine until nasal, aural, glandular, or other abnormal discharges have ceased, and all open sores have healed, nor earlier than six weeks after the onset of the disease under any circumstances. A urinary examination should be made before discharge from hospital.

6. Smallpox-Patients should be handled with the same precautions as meningitis, and in addition all attendants and others in the vicinity and all contacts should be revaccinated. Smallpox may safely be treated in a room in the isolation ward if these precautions are observed.

7. Where the hospital facilities are insufficient to provide treatment for measles and scarlet-fever patients for the periods above prescribed, request should be made to the commanding general for the setting aside of the necessary barracks or tentage for use as convalescent hospitals. Special attention should be given to keeping such convalescent quarters well warmed, and additional stoves should be installed if necessary. Warm and conveniently located lavatories are essential. Patients in the acute stage of measles and scarlet fever should use commodes.

8. Enlisted attendants in wards for infectious diseases should wear white cotton coats and trousers, which should be changed twice a week. These garments are on hand in depots and should be requisitioned for at once by the local quartermaster.

9. No nurse or attendant should have charge of two different classes of the above-mentioned infectious diseases. Medical officers in charge of different classes of infectious diseases will carefully disinfect the hands before passing from one class to the other.


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10. No blanket or mattress cover used for any of the above-mentioned diseases should be used for another patient until it has been disinfected by steam or chemicals or laundered at a steam laundry. Preferably they should be laundered. The underclothes of patients admitted for the above-mentioned diseases should be disinfected by steam or chemicals at once, or laundered, preferably the latter. Other clothing, except in the case of measles, should be disinfected by formaldehyde in a closed box, and then aired and sunned for three consecutive days.

11. In wards used for the above-mentioned infectious diseases, paper napkins are recommended for receiving nasal secretions. At the head of each bed will be kept a paper bag, fastened to the bed by adhesive plaster. These bags will be used for napkins, gauze, swabs, and other infected refuse, and will be burned when full. Napkins and paper bags may be purchased locally, quoting this memorandum as authority.

12. The above precautions in regard to measles are prescribed primarily to diminish the incidence of the very fatal post-measles pneumonia, which has reached alarming proportions in some camps. There has been widespread failure to appreciate the seriousness of measles under existing camp conditions.

13. Immediately on receipt of this memorandum, the commanding officer of a hospital will hold a conference with such of his assistants as are concerned with the handling of infectious diseases, and will arrange for the carrying out of the details as far as local conditions will permit. Report of action taken will be made to this office, attention Colonel Howard.

Circular Memorandum, from the Surgeon General, January 8, 1918.

Camp Epidemiologist.

1. It is contemplated that an officer of the Medical Department with special training as an epidemiologist will be assigned to each camp and cantonment where serious epidemic disease exists. While not an officer of the division, he will be under your jurisdiction in your capacity as camp surgeon, acting under the immediate control of the sanitary inspector as his assistant. Where the amount of sickness warrants such action, it is desired that in each brigade a suitable medical officer be selected who will be assigned as whole or part time assistant to the epidemiologist. One of these should be trained as an understudy with a view to having him serve as an assistant to the sanitary inspector in communicable-disease problems when the division leaves camp. The epidemiologist should make such reports to you as you deem necessary.

2. It is expected that the epidemiologist will be given free access to the wards of the base hospital and that the commanding officer and staff of the hospital will cooperate with him in every way. The facilities of the laboratory should be at his disposal in so far as the study of epidemics may render this desirable. In the event of serious epidemics, prompt request by wire should be made to this office for additional bacteriologists if needed.

3. The epidemiologist should personally, or through one of his assistants, visit the tent or barrack in which each case of infectious disease originates, and observe, as far as possible, everything pertaining to that case from an epidemiological standpoint. He should assure himself that the necessary quarantine measures and the daily inspections for incipient cases are promptly inaugurated and carefully carried out, and that proper disinfection of contaminated articles is practiced. In all these steps he should act through and in cooperation with the regimental commander and regimental surgeon.

4. He should trace the connection, if any, between cases, and observe where the sick man came from, how long he has been in the camp and in the service, where he has been, and what associates he has had, if any, outside his present company.

5. He should investigate the air space per man, the arrangement of beds, the ventilation and the heating in infected barracks, and also the clothing of the soldiers concerned, in so far as these factors pertain to the prevalence of disease.

6. He should give special attention to the adequacy of the prescribed examinations of outgoing and incoming troops for the detection of incipient communicable disease.

7. He should keep spot maps of infectious diseases in the camp. In this connection special attention must be given to the frequent movement of whole organizations from one barrack to another, to the change in personnel within organizations and from one organization to another, and to the constant arrival of new men from outside the camp.

8. Under your supervision, he should give to the medical officers of the camp special instructions, by lectures and practical demonstrations, regarding the most approved methods of handling communicable diseases.


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9. The attached extracts indicate the character of detention camps and quarantine camps which will probably be constructed at each cantonment and camp. The epidemiologist should supervise the management of both camps. At the detention camps the following points should especially be emphasized: The camps will consist of huts holding eight men, or tents holding five, These huts or tent units must be kept separate. Drills must be by these units only. In the vaccination, the physical examination, and the issuing of clothing, great care should be taken to prevent one squad of eight, or group of five, from being in a room at the same time as another

squad or group. Messing should be outdoors or, during inclement weather, in the huts or tents.

10. The following points should receive special attention in view of the prevalence in our camps at present of the diseases named. The particular details to be emphasized in caring for these diseases while in hospital are covered by memorandum, S. G. O., dated January 1, 1918, and sent to all division surgeons and base hospitals.

(a) Measles.-This disease should be regarded as one having a high mortality, not directly, but through its complications and sequelae. Experience has shown that patients sick with measles often carry most virulent pneumococci, streptococci, influenza bacilli, meningococci, and possibly other dangerous organisms. Patients with measles should be treated with every possible provision for the protection of one patient from another, and of the physicians, nurses, and male attendants from the patients. Convalescent cases should be carefully guarded for a long period in well-warmed quarters.

The period of infectivity probably lasts as long as the abnormal discharges from the mucous membranes persist. Allsuch discharges should be disinfected.

Contacts should be quarantined in barracks, or preferably in a quarantine camp, and be inspected twice daily by a medical officer. Special attention should be given to detecting Koplik spots and early rises of temperature as determined by the thermometer. Men showing a rise of temperature up to 100o should be isolated. Daily airing of barracks and sunning of bedding should be practiced in "contact" barracks for measles, and also for all of the below-mentioned infectious diseases.

Closure of assembly halls, exchanges, etc., may be necessary in severe epidemics of measles and other serious infectious diseases.

(b) German measles-The same precautions should be taken as for measles. Every effort should be made to correctly diagnose German measles with a view to preventing cross infection with measles.

(c) Pneumonia.-This disease is to be regarded as communicable. It should be determined in every case whether the disease is primary or secondary to measles or scarlet fever, and records should be classified accordingly. Careful cleansing of the floors should be practiced in a barrack where pneumonia has developed. Special attention should be given to sunning the patients' bedding and clothing. Ample ventilation and the widest separation of the heads of adjacent sleepers: should be insisted on.

(d) Diphtheria.-Early culture of suspicious throat conditions seen by regimental surgeons should be insisted on Contacts with a case of diphtheria should be quarantined until it is shown by both nose and throat cultures that they are not carriers All close contacts shown by the Schick test to be nonimmune should be promptly immunized by means of antitoxin Articles which have been in contact with the patient and articles soiled by discharges should be disinfected.

(e) Mumps -Cases should be isolated and special care taken to detect incipient cases No quarantine is recommended, but immediate contacts may be segregated if deemed necessary.

(f) Scarlet fever -Contacts should be quarantined for seven days and examined twice daily by a medical officer, particular attention being directed to the throat All articles which have been in contact with the patient in barracks or tent or with his discharges should be disinfected.

(g) Smallpox.-The virus is believed to be present in all body discharges, including the feces and urine. It may be carried by flies, It probably persists till all crusts have disappeared. Prompt and widespread revaccination of contacts, including at least the entire company, should be practiced. Quarantine of contacts in unnecessary, except in case of new troops, when there is doubt as regards successful original vaccination, but all contacts should be inspected twice daily for a period of two weeks, special attention being given to the mouth and to rises of temperature.

(h) Cerebrospinal meningitis.-For purposes of carrier examinations to be made after the occurrence of a case of epidemic cerebrospinal meningitis, the word "group" should he taken to mean-

First. Other members of the same squad or tent.

Second. All other men in the same room.


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Third. All other men in the same building or company.

In other words, the examination should be extended in increasing circles about a case as rapidly as time and laboratory facilities permit. While such examinations are being made on the smaller group, the largest group should be treated as potential carriers. All men in the largest group should be quarantined and prevented from mingling, as individuals, with others within or without the camp; they may, however, be permitted to attend drills and other formations as a unit. In the meantime, sprays and gargles may be used. Whenever it is impractical to culture the larger units at once, the inauguration of spraying need not be delayed. If spraying is employed, it should be timed so that it falls as closely as possible to the hour of retiring, thereby diminishing

the chances for droplet infection during the night. When practicable, a second culturing of the largest group is advisable; this to be carried out after the removal of any contacts found at the primary culture.

All carriers, as rapidly as detected, are to be removed from the building and isolated in a quarantine camp until free from meningococci on three consecutive examinations, with intervals of from three to six days between examinations. On completion of the examinations and removal of the carriers the quarantine may be raised.

11. From time to time the epidemiologist may report to this office, through the division surgeon, attention Major Vaughan, such observations as are of interest in regard to the prevention and spread of communicable diseases. Among the points of particular interest to this office may be mentioned the following:

(a) Relationship between bronchitis and pneumonia, measles and pneumonia, and septic sore throat and pneumonia.

(b) Influence of exposure to cold on incidence of pneumonia, especially during convalescence from measles.

(c) Influence of length of convalescence in measles on subsequent incidence of pneumonia.

(d) The best methods of limiting the spread of pneumonia in camps.

(e) Is the raw recruit specially susceptible to meningitis and pneumonia; and if so, why?

(f) Influence, if any, of gas masks on spread of infectious diseases.

(g) Influence of housing conditions on incidence of measles, pneumonia, and meningitis.

(h) The influence of rural and urban residence on development of measles, pneumonia, and meningitis.

(i) To what extent is epidemic disease due to transfer of troops from one camp to another.

(j) Recommendations which may be of use in preventing the development and spread of communicable diseases among men in future assemblies of troops.

12. The above instructions in no wise relieve the division surgeon from the responsibility of prescribing such other measures as in his opinion are necessary to limit the development and spread of communicable diseases.

[Extract No. 1.]

2. A detention camp should be established for each camp and cantonment, where all fresh contingents of men will be held under observation for at least two weeks, or longer if considered necessary by the division surgeon, before being assigned to organizations in general camp. The purpose of the detention camp is the observation of new men for a certain period to prevent the introduction of communicable diseases into the nonaffected camp or cantonment from without. No new men should be placed in the general camp until in the judgment of the division surgeon it is safe to do so. The capacity of the detention camp should be such that it will accommodate the full quota of each contingent expected to complete the organization of the division, The period of detention should be utilized for physical reexamination of the men, the vaccination and immunization against typhoid and paratyphoid fevers, and such equipment and training as may be prescribed by the camp and cantonment commanders without bringing the men in detention camp into contact with other men of the division.

3. A quarantine camp should be established in each camp or cantonment by the camp or cantonment commander when a command is already infected with a communicable disease, This camp is to serve the purpose of segregation of contacts or carriers of these diseases and permit of intensive search for and treatment of carriers during the period of infectivity. The required capacity of the quarantine camp will depend upon the degree of infection of the command, and will be determined by the camp or cantonment commander after consultation with the camp or cantonment surgeon.


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[Extract No. 2.]

1. National Army cantonments.-It is recommended that detention and quarantine camps be composed of wooden huts, each 20 feet by 20 feet, having a capacity of eight men. Kitchens should be provided, but no mess halls are necessary, as it is contemplated that the men eat either out of doors or in inclement weather in their individual huts. Lavatory, bath, and toilet buildings for each 250 men would be required. Near each kitchen should be constructed an open shed with water and sewer connections, where mess kits can be washed. Quarters for officers, storehouses, administrative offices, and a regimental infirmary building at the rate of 1 for each 2,000 men will be required for each detention camp. These accessory buildings will not be required for the quarantine camp. The required capacity for the detention camp will depend on War Department plans as to the number of men to be ordered into cantonments within each two weeks' period. This information is not available in this office, and the required capacity for the detention camp can not be estimated. For the quarantine camp, a minimum capacity of 1,000 should be provided for each National Army cantonment, with available space for expansion if required.

2. National Guard and other camps.-It is recommended that detention and quarantine camps for National Guard and other camps be made up of huts the same size and capacity as recommended for National Army cantonments or framed and floored tents. The hut construction is considered preferable. Latrine buildings, kitchens, and dish-washing sheds will be required. In the detention camp, the required capacity will depend on the maximum number of men expected at the camp in a single contingent. For the quarantine camp, a minimum capacity of 1,000 men should be provided with space available for expansion of this nucleus required by epidemic conditions,

3. There should be a wire fence about each detention and quarantine camp.

Circular Letter, Surgeon General's Office, March 22, 1918.

Prophylactic Treatment of the Respiratory Tract.

1. Reports from abroad and from this country indicate that great good has been accomplished in infectious diseases and in catarrhal conditions of the respiratory tract by so-called toilet of the mouth, nose, and throat. Treatment has been directed against inflammatory conditions of all kinds, with focal infections in the tonsils and sinuses. Sprays, gargles, and steam-room inhalations have been effective in cleaning up carriers and curing inflammatory conditions which have predisposed to more serious types of infection and transmission of disease to others. The cases to be given prophylactic treatment are cases suffering from infectious disease with the inflammatory condition of the air passages, chronic inflammatory condition of the nose, throat, and sinuses, severe grippes, and colds. The solution of the question as to how much can be accomplished by systematic prophylactic treatment in diminishing infections of the nose, throat, and bronchii is one of the most pressing now confronting the medical officers of the various cantonments.

2. It is directed that all patients ill with an infectious disease be required to wear a gauze mask during the active stage of the disease and for two weeks of the convalescence. This applies especially to measles. The problem of checking the spread of infectious diseases is considered of paramount importance. A report bearing on this problem will be issued shortly.

Circular No. 1, Surgeon General's Office, March 25, 1918.

The Control of Respiratory Infections and Communicable Diseases in Hospitals.

(a) Many communicable diseases such as pneumonia, meningitis, pertussis, diphtheria, tonsillitis, measles, scarlet fever, German measles, are transmitted from one person to another by means of secretions of the nose and mouth. Coughing, sneezing; or talking conveys the bacteria-laden droplets of mucus or the virus through the air. By this means the infection may be directly transmitted from one individual to another; or should this contaminated material from the nose or throat soil the floor or articles of furniture through drying, the infection may be spread indirectly by dust.

(b) If proper methods are devised to control the direct or indirect dissemination of infection it would be possible to prevent the spread of respiratory infections and the cross infections that may occur in highly communicable diseases.

With this object in view, attention is directed to the following recommendations:

The most efficient method to prevent dissemination of nasal and oral secretions is to cover the nose and mouth with two layers of thin gauze. The mask can be considered as a form of individual isolation.


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The mask is a simple square of two layers of gauze, with a tape sewed to each of the four corners. The masks should not be worn after they have become wet. They should then either be boiled or soaked in some disinfecting solution, washed, and sterilized, like surgical dressings in the autoclave.

Under the following conditions all patients should be masked-

(1) In the ambulance.-Since patients suffering from different communicable diseases may be transported, under necessity, in the same ambulance at the same time or at different times, the danger of primary and of crossed infections is always present. Consequently, at the time he designates the patient to be removed by the ambulance, the regimental surgeon should also indicate whether or not that particular patient should be masked for the protection of others in the same ambulance.

(2) In the receiving ward patients should remain masked or be remasked until it is determined that they have no infection of the respiratory tract or communicable disease. All suspicious cases should remain masked until they are placed in bed in cubicles.

(3) In the ward bed patients suffering from respiratory infections and communicable diseases in cubicles need not be masked. When for any purpose they leave their bed and its cubicle, a mask should be worn.

The following rules should be observed for the conduct of patients in wards for respiratory and communicable diseases:

1. A face mask must be worn continuously by all patients when out of cubicle.

2. In the latrine the mask may be removed only by permission and under the direct supervision of ward nurses.

3. Washbasins and bathtub are not to be used. For washing face and brushing teeth use running water over sink. Shower may be used under supervision. Use only liquid soap from container.

4. Only one patient will be allowed in the wash room at one time. Remove mask on entering and replace before leaving wash room.

5. Masks may be removed when patients are in bed.

6. Sheets between beds are not to be drawn back.

7. Corps men, nurses, and surgeons should wear masks and gowns when on duty in the ward. A guard should be on duty continually near the wash room.

8. All eating utensils should be sterilized after each meal.

9. It will be of advantage also to instruct ward surgeons and ward masters to explain clearly and frequently to the men the purpose of the masks.


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Circular Letter, Surgeon General's Office, August 16, 1918.

Experience of Medical Officers in the Diagnosis of Communicable Diseases, Especially the Exanthemata.

1. It has been demonstrated that only a small proportion of the medical officers in the base hospitals have had experience in the diagnosis of the communicable diseases, especially the exanthemata, before entering the service. A considerable number have acquired the experience since being in the service. Others either have not had the opportunity in the service or have not been capable of availing themselves of it.

2. In choosing the personnel of base hospitals for this country and for overseas duty, and also for evacuation hospitals, it is desirable that there should be assigned to each one a certain number of medical officers who are expert in the diagnosis and treatment of the exanthemata.

3. You are, therefore, requested to send to this office the names of those medical officers who have had especial training in these diseases before or after entering the service, with a statement as to what this training has been. So far as it is possible, it is requested that this information be furnished also regarding those who have had service in your base hospital, but have been ordered elsewhere.

Circular Letter, Surgeon General's Office, August 29,1918.

Care of Communicable Diseases.

1. The attached copy of a memorandum for the Hospital Division of this office, made by an officer after an inspection of certain base hospitals relative to the care of communicable diseases, is submitted for your information and guidance.

MEMORANDUM FOR HOSPITAL DIVISION.

1. The incidence of the communicable diseases (measles, mumps, meningitis, pneumonia, etc.) is very high among the troops freshly inducted in the service. From ignorance or other motives they frequently do not report sick at sick call and as a result of this there may arise serious delay in the entrance of a sick man into the hospital. To obviate this, it would be advisable, wherever it is possible, that a rapid examination of these troops should be made at a roll call held twice a day, as it is frequently possible to recognize evidences of sickness by superficial examination.

This examination could be held in the depot brigade or in whatever barracks was set apart for lodging the incoming troops.

2. Owing to the fact that isolation in the regimental infirmaries is impossible and that continuous observation and particular therapy very difficult, it is advisable to arrange that, with the consent of the division surgeon, cases be kept as short a time as possible in the regimental infirmaries and that all patients obviously seriously ill be sent at once to the base hospital.

3. Patients in whom there is a suspicion of infectious disease should wear face masks and should be sent to the base hospital in separate ambulances unless there be several suffering from the same disease, when they may be sent together.

4. No patient with a suspicion of infectious disease should be sent at once to a ward, All should go through the examining system for communicable diseases in the receiving ward.

5. The medical officer assigned to the reception ward should at all times be one who is expert in the diagnosis of the communicable diseases. He should examine all patients stripped.

6. Those patients in whom an accurate diagnosis is possible should be sent at once to the building assigned for that disease, Those patients in whom the diagnosis is still uncertain are to be sent to the wards fitted with observation booths or to one of the rooms in the isolation buildings. These patients are to remain thus isolated or are to be transferred to the proper building if the diagnosis becomes plain.

7. Patients are to be kept masked until placed in bed in the observation booth or the isolation building.

8. Physicians, nurses, and attendants engaged in the treatment of patients with communicable disease, or suspected of having communicable disease, should wear large masks of cheese cloth, covering the mouth and nose, as well as caps and gowns.

9. All utensils should be sterilized by heat, after washing, if this is possible; if not, by some appropriate method.

Thermometers should be wiped off with cotton, washed with soap in running water and after this placed for several minutes on cotton in a flat dish covered by bichloride solution 1-1000, or cresol solution.


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10.  The latrines n the observation ward should be used by only one patient at a time.

Patients should not be allowed out of the observation booths unless allowed to go to the latrine.

11. No visitors should be allowed in the observation wards except with the special permission of the ward surgeon.

12. If the wards provided for the observation of doubtful cases should be insufficient for the purpose, a similar form of isolation may be secured by the use of sheets strung upon wires.

Circular Memorandum, Surgeon General's Office, for camp and division surgeons, etc., September 6, 1918.

Control of Acute Respiratory and Other Diseases.

1. The following suggestions regarding control of the acute respiratory and other diseases usually conveyed by discharges from the respiratory tract are submitted for the information and guidance of responsible medical officers. These suggestions are not to be interpreted as supplanting existing regulations.

2. The acute respiratory and other diseases usually conveyed by discharges from the respiratory tract were responsible for the majority of the deaths from disease in camps and cantonments during the winter of 1917-18, and the probabilities are that this will hold for the coming winter. Under this heading are included pneumonia, meningitis, measles, mumps, diphtheria, tuberculosis, bronchitis, tonsillitis, and scarlet fever.

3. A careful study of these diseases during the past winter has given certain definite information regarding their relevance and the causes therefor, and it is desired that the information thus gained be intelligently applied in attempts to limit their spread in the future. This is the purpose of this memorandum.

4. The diseases of this group are disseminated for the most part by direct transference from the respiratory organs of one individual to the corresponding organs of another, The distributor may be well or sick. The transfer is usually made in the spray thrown from the mouth or nose of the "carrier" in talking, coughing, sneezing, or spitting. Less frequently the transfer is more indirect, such as from the use of the common drinking cups and in dust. With these facts in mind, the importance of instructing officers and men as to the danger of talking, coughing, or sneezing directly into the faces of comrades will be greatly appreciated. Further, men should be instructed as to the danger of indiscriminate spitting and as to the sanitary importance of keeping their bodies and personal belongings from too close contact with others, well or sick.

5. Pneumonia caused more deaths last winter than all other diseases combined, and in all probability it will be our most potent enemy in the camps during the coming winter, Every effort must be made to reduce both the morbidity and mortality. The most patent failure of medical officers during the past winter was in the early recognition of this disease. In one camp out of 485 cases only 55 per cent were diagnosed within the first three days, 27 per cent from the fourth to the sixth day, and 18 per cent were not recognized until the seventh day or later. When the disease is not recognized until the later stages have been reached, treatment is not likely to be efficient. Special instruction should be given to medical officers in the early recognition of this disease, and every suspicious case should be sent to hospital promptly. The fact that rural and southern men are especially susceptible to pneumonia, and measles as well, stands out plainly. The colored race is particularly susceptible.

6. During the past winter pneumonia was caused by the pneumococcus of the different types and by the streptococcus hemolyticus. Both of these organisms have caused both lobar and broncho pneumonia, the former being the most prevalent in most camps-not in all-and the latter more fatal. Empyema has been a serious complication in both forms of pneumonia. The bacteriological study of pneumonia should be continued with the greatest diligence and care during the coming winter. While the pneumonia curve has fallen during the summer months, the disease continues not only to persist in every camp but remains on the whole the cause of the greatest number of deaths, and with the approach of winter the curve of this disease may be expected to rise.

7. Recent, but limited, experience offers promise of aid in the restriction of pneumonia by means of direct vaccination. The purpose is to cautiously extend this experience during the coming months.

8. There is reason for grave apprehension concerning meningitis during the coming winter. This disease prevailed at every camp last winter, but became epidemic only in Camps Jackson, Beauregard, and Funston, the men in general coming from areas in which this disease was endemic. During the present summer, while there has been no alarming outbreak, meningitis is widely distributed, being reported in every section of the country. Next winter many of the camps


997

will be recruited, not especially from certain States, but with the men from widely separate localities. This will make the control of meningitis in camps more difficult.

9. When measles appears in an organization the sick man should be masked and sent directly to hospital without delay; all "contacts" should be carefully inspected twice daily during the incubation period of the disease. At these inspections the men should be stripped to the waist and the inspection should include the skin, eyes, mouth, nose, and throat. The detection of a suspicious eruption, conjunctival congestion, or coryza demands that the man be sent at once to hospital or to a suitable place for proper isolation and observation.

10. The following facts have been determined with reference to the prevalence of scarlet fever in all camps during the past winter:

(a) Camp Pike had by far the most cases. This was followed in order by Camps Lewis, Kearny, Sherman, Dodge, and Grant. Then follow camps in which the incidence of this disease was low, ending in Camps Beauregard and Wheeler without a case.

(b) Camps made up largely of southern men had but little scarlet fever. (About one-third of the troops at Camp Pike were northern men.)

(c) There was three times as much scarlet fever in National Army as in National Guard camps It is believed that this was due to the more frequent accessions from civil life in the former.

(d) It is possible-indeed, highly probable-that differential diagnoses were not always correctly made and that cases of this disease and of measles were sometimes mixed in wards and crossed infections occurred. There should he in every camp medical officers especially skilled in the recognition of exanthemata. All new arrivals should be carefully watched, and, on account of the relatively short period of incubation, most cases should be detected before assignment to organizations.

11. During the past winter deaths from diphtheria occurred in 7 out of the 29 camps studied. Camp Pike heads the list with the following order: Camps Funston, Dodge, Cody, Custer, Doniphan, and Logan. Present instruction covers the proper handling of cases of this disease, which include sending the case to hospital, the culturing Of "contacts," and quarantine of "carriers." The "contacts" should be "Schicked" and positive and suggestive "Schicks" carefully observed and promptly given proper doses of antitoxin (if symptoms of the disease develop).

12. The information gained concerning the relation between pneumonia and previous respiratory diseases, such as measles, bronchitis, tonsillitis, etc., is not yet satisfactory, and it is to be hoped that these matters will receive more attention in the future. There is also great need of exact knowledge concerning the relation between the weather and pneumonia. As has been stated, the curve of this disease has fallen to an annual admission rate of about 10 per thousand during the summer, but it remains the most serious disease in the camps, and from time to time exacerbations occur.

13. The inadequacy of sick call in the early recognition of communicable diseases is evident, When an organization is infected, medical officers should inspect every man in the organization at least once a day and should be on the alert for the recognition of each communicable disease in its earliest stages. Each case of communicable disease should he sent to hospital as soon as detected, and medical officers should be graded on their skill and success in the early detection of these diseases. During the past winter the death rate in the different camps was in inverse ratio to hospital admissions.

14. The retention and treatment of sick of organizations in regimental infirmaries or in quarters should not be encouraged. A soldier with a temperature above 100o should be considered as sick, and as such sent to the hospital unless there is an easily explainable cause for the temperature which is known to be temporary and not connected with the onset of one of the communicable diseases. Regimental medical officers should be instructed to send suspicious cases to hospital without waiting to make a definite diagnosis. It is far better to have a high admission rate than a high death rate. Medical officers should be instructed that the occurrence of a chill or sudden fever and malaise may often be the only sign of a beginning pneumonia, and that such symptoms, if unexplained, demand the prompt transfer of the patient to hospital.

15. The cubicle has proven of value in the restriction of the acute respiratory diseases, and its use should be extended to every bed in the hospital where coughing patients are being treated, and when possible to beds in barracks in which the halves of shelter tents might be used. The employment of masks in hospitals has apparently been of protective value, and their use should be extended to known "carriers." Great care should be taken to prevent cross infections, especially in admitting wards of hospitals. It is desirable that the admitting officer should be expert in exanthemata or have such a specialist always available.

16. State health officials have been requested to keep camp and division surgeons informed of the existence of communicable diseases within their respective jurisdictions. This information should be utilized in receiving men from infected places and in granting men furloughs to their homes. Responsible medical officers should use every endeavor to protect the men of their command from infection not only from within but without the camp.

17. Recent arrivals in camp should be inspected twice daily. Most alert medical officers should be charged with this duty. The mouth, nose, and throat in new arrivals should be carefully inspected. In suspicious cases cultures should be made, Instruction in the hygiene of the mouth should be given and treatment by a specialist, including dental service, should be provided when needed.

18. It is the experience of last winter that the importation of southern troops into northern camps was followed by increased morbidity in both the arrivals and the troops already at the camp. In several instances the type of the dominant pneumonia was changed after the arrival, Accessions from civilian life quite invariably introduced and intensified infections. These facts emphasize the necessity for a detention camp and its proper functioning. Most competent and alert medical officers should be in medical charge of detention camps where such have been established.

19. Further information is desired concerning the relation between pneumonia and intestinal parasites, if there be such relation. Studies should be made in each camp along these lines.

20. In 13 out of 29 camps studied last winter, the death rate was below that of the same age group at home, and in 6 out of 13 it was not more than half of the home rate, It is to be hoped that with the aid of past experience the death rate in our camps and cantonments may still further decrease during the coming winter, and with this purpose in view the aid and cooperation of every medical officer on duty with troops and in hospitals is necessary.

Circular Memorandum, Surgeon General's Office, for Camp and Division Surgeons, etc., September 24, 1918.

Control of Epidemic Influenza.

1. Inasmuch as an epidemic wave of influenza is sweeping over certain parts of the United States, and threatens to involve many of the camps and cantonments, it is important that the essential facts in regard to the nature and prevention of the disease be more generally understood.

2. The disease now epidemic is believed to have been imported from Europe, where it has been prevalent in various countries. Popularly called "Spanish influenza," there is nothing about it to indicate any departure from the influenza which has been prevalent in the United States from time to time for many years and was last seen here in Army camps and cantonments in the spring of 1918.

3. No disease which the Army surgeon is likely to see in this war will tax more severely his judgment and initiative. It will be wrong, on the one hand, to propose such measures of prevention and treatment as will interfere unduly with the rapid training of the men, and, on the other hand, make so light of the disease as to increase the sick rate from the more serious diseases with

which the influenza is associated.

4. It is important that influenza be kept out of the camps as far as practicable. To this end it must be recognized as a disease which is distinct and separate from the so-called "Cold, bronchitis, laryngitis, coryza, or rhinitis, and fever, type undetermined," which are continually with us and from time to time become prevalent. The influenza which is now epidemic is not a part of, or cause of, or the consequence of these diseases. It is a specific infection with a characteristic symptom-complex.

5. The leading symptoms are Severe headache; chills; or chilliness; pains in the back and legs; temperature sometimes as high as 104; great prostration; drowsiness. Occasionally there are nervous symptoms; sometimes, but not always, the eyes and the air passages of the nose and throat are affected; there may be gastrointestinal disturbances. The onset is sudden. The bacteriology is not definitely established. Often the Pfeiffer bacillus can be isolated. The most fatal complication is pneumonia. In most instances the patient recovers in three or four days, but is entirely incapacitated for duty while the attack is at its height. In a certain proportion of cases convalescence is slow, asthenia being a prominent symptom. Relapses may occur.

6. Upon the appearance of influenza in camp, special provision should be made for ample hospital accommodations for these patients. Owing to the great infectivity of the disease, sole reliance should not be placed upon cubicles and masks for isolation. It is needless to say that


1000

surgeons, nurses, and attendants should use every precaution against becoming infected themselves and from carrying virus to others.

7. There are few diseases so infectious as influenza. The virus is contained in the discharges of the nose and mouth and is given off in the acts of sneezing, coughing, speaking. The hands and whatever else may become contaminated by the discharges can carry the virus and produce new cases. It is probable that patients become foci of infection before the active symptoms deyelop and remain so after the active symptoms subside. Influenza is a disease which is often produced by carriers.

8. Coughing, sneezing, and coryza should not be regarded as infallible signs of influenza. Their significance lies in a means which they produce for the contamination of the air and of objects in the vicinity with whatever virus the mouth, nose, and throat contain. Coughing and sneezing play an important part in spreading meningitis, tuberculosis, and probably all the exanthematous and respiratory diseases. Some restriction should be placed on these acts. Where coughing and sneezing can not be avoided, it is usually possible to cover the face with a handkerchief or cloth, or withdraw from the immediate company of others until the paroxysm is over. The handkerchief or cloth should be burned or frequently washed, and kept closely rolled meanwhile.

9. As in all contagious diseases, the measures to be followed for the prevention of influenza depend upon the early detection and isolation of the sources of infection. Epidemics of the disease can often be prevented, but once established, they can not well be stopped. They can be mitigated by segregating the most active sources of infection, and by keeping the well away from the sick.

10. When epidemic influenza is believed to be in the neighborhood of a camp, restriction should be placed upon the intermingling of the men with the civilian population; they should be kept from frequenting crowded places of assembly; all places of amusement and post exchanges should be closed; the use of crowded vehicles for transportation should not be permitted. If the disease appears in camp, intercommunication between different parts of the camp should de prevented.

11. Reliance should not be placed upon sick call as a means of discovering the early cases. As in all epidemic infections, the surgeons should seek the disease and not wait for the disease to seek them. Inspection should be had twice a day and visits should be made to the barracks at unexpected hours to detect sick men who otherwise would not be reported. Mild attacks frequently lead to severe ones.

12. During an epidemic every case of fever which is not otherwise satisfactorily explained should be regarded as probably influenza. After a little practice, influenza patients can very often be detected by the peculiar, expressionless aspect of the face.

13. Epidemics of influenza are characterized by sudden onset, large number of cases, and short duration. In any place they sometimes run no longer than two weeks; they rarely continue for longer than two months. Some mild and unusual cases make their appearance toward the end.

Memorandum, Surgeon General's Office, for camp and division surgeons, September 27, 1918.

Personal Defense Against Spanish Influenza.

1. It is desired that the following 12 suggestions for avoiding influenza be given all possible publicity in your camp, by placarding and other proper means of bringing it to the attention of the command.

HOW TO STRENGTHEN OUR PERSONAL DEFENSE AGAINST SPANISH INFLUENZA.

1. Avoid needless crowding; influenza is a crowd disease.

2. Smother your coughs and sneezes; others do not want the germs which you would throw away.

3. Your nose, not your mouth, was made to breathe through; get the habit.

4. Remember the three C's-a clean mouth, clean skin, and clean clothes.

5. Try to keep cool when you walk and warm when you ride and sleep.

6. Open the windows-always at home at night; at the office when practicable.

7. Food will win the war if you give it a chance; help by choosing and chewing your food well.

8. Your fate may be in your own hands; wash your hands before eating.

9. Don't let the waste products of digestion accumulate; drink a glass or two of water on getting up.

10. Don't use a napkin, towel, spoon, fork, glass, or cup which has been used by another person and not washed.

11. Avoid tight clothes, tight shoes, tight gloves; seek to make nature your ally not your prisoner.

12. When the air is pure, breathe all of it you can; breathe deeply.


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Circular Memorandum, Surgeon General's Office, September 28, 1918.

Control of Communicable Diseases.

1. Attention is invited to memorandum from this office, dated January 1, 1918, relating to procedures for the control of communicable diseases in camps and hospitals. If this memorandum is not on file and available, application will be made to this office without delay and a copy will be furnished.

2. The memorandum referred to will be strictly observed, and its requirements as to the care of measles patients will be applied to influenza as well. The greatest danger in influenza epidemics lies in overcrowding hospital wards and barracks with influenza patients, which increases the incidence of pneumonic complications.

3. Any apparent contradictions or modifications in its provisions appearing in subsequent circulars from this office are hereby revoked. Responsible medical officers will be held strictly accountable that its provisions are carried out so far as possible with facilities at hand and procurable.

Circular Memorandum from the Surgeon General, September 30, 1918.

Method of Handling Influenza Epidemic at a Camp.

1. The attached report of a sanitary inspector from this office is furnished for your information, first, as showing the steps taken at one camp to handle a serious situation in a very satisfactory manner, and secondly, the recommendations for further improvement made by an inspector.

2. In epidemics of influenza every effort should be made to avoid overcrowding of the uncomplicated cases with a view to forestalling complications. At least 100 square feet of floor space per man should be provided, and all the precautions used which are prescribed for measles in memorandum this office January 1, 1918.

3. Prior to the development of epidemics of influenza, camp surgeons should consult with the camp commander with a view to laying out an extensive scheme for evacuating barracks and using them for hospital purposes.

4. The camp surgeon should take steps to keep himself informed as to the sanitary situation at the base hospital, and should endeavor to prevent overcrowding of that institution if other buildings or tentage can be obtained to shelter the sick.

REPORT OF INSPECTION IN RELATION TO EPIDEMIC OF INFLUENZA AND PNEUMONIA AT . . . . MADE SEPTEMBER 28, 1918.

1. The strength of the command is 51,177, of which number 5,934 are colored. There is no overcrowding, and for some time there has been none, except possibly in isolated instances temporarily. Barracks are marked on basis of 45 square feet floor space per man, and the number of occupants is in practically every instance much below the allowance, so that over 50 square feet is provided each man. In the depot brigade from 12,000 to 15,000 men are kept under canvas, five men to a tent. In the division men have been put under canvas when necessary to reduce overcrowding in barracks. Men sleep with head and feet alternating, and in many barracks the "cubicle system" is in use by means of shelter tents suspended between the beds.

2. Fires have been started in all buildings and the freest possible ventilation is enforced. Beds, bedding, and clothing are put outdoors all day, weather permitting. Tents are furled daily. All floors have been reoiled once and in some instances twice since epidemic started. Overcoats and woolen underwear have been issued. There is ample bedding. Men are kept outdoors practically all day. An officer is on duty in each barrack day and night.

3. Police of camp and barracks is excellent. Messes very clean. Ample steps have been taken for fly eradication, and flies are rarely seen in messes. Dishes are boiled after each meal. Where individual mess kits are used, they are washed in boiling water after each meal, and are actually boiled at intervals. There are no common drinking cups in use.

4. There is still much dust in the camp, and during the afternoon of my visit the air was filled with it. Part of the camp has been treated with "Dustex Gluteen," which appears in every way superior to oil in allaying the dust nuisance. Enough of the material can not be obtained to finish the work. The epidemic of influenza is said to have started promptly after a severe dust storm.

5. Absolute quarantine of camp against adjacent territory, and vice versa, has been in force some days, except that relatives of severely ill are admitted and visit the hospital, wearing masks. Interorganization quarantine was in force until the epidemic became so general that it was deemed useless. All large assemblies have been prevented, but the regimental Y. M. C. A. entertainments have been allowed to go on with a man in every other seat. The sale of food in post exchange has been suspended and this has greatly reduced crowding therein. It was felt that absolute suspension of entertainments and of exchange privileges would be so detrimental to morale, already somewhat shaken, that the disadvantages would more than counterbalance the advantages.

6. There is ample cooperation on the part of the line officers. Men experienced in nursing have been drawn from all organizations in camp. Line officers in barracks are constantly on watch


1001

for new cases and see that men are properly cared for. Medical officers visit all barracks at least twice a day.

7. Throughout the camp a part of each barrack, generally one room, has been set aside for the care of suspected cases of influenza and the mild cases. The men are cubicled in many instances, and masked in many others. The keeping of these cases in barracks, where more or less contact with the well is inevitable, is believed to be a serious mistake. These men were carried as "sick in quarters."

8. In the barracks frequent temperatures were being taken by medical and line officers and by enlisted men. The methods for disinfecting the thermometers in some instances appeared inadequate.

9. In all barracks and tents containing sick men, paper receptacles, usually pasteboard ice cream plates, had been bought to use as bedside sputum cups. These were collected and burned at intervals. It had been ordered that a piece of newspaper be kept on the floor under each plate, but this was not done in all cases.

10. In the tent area of the depot brigade 36 pyramidal and store tents had been set aside as an infirmary, and all suspected and mild cases were removed thereto, There were enough medical officers and attendants,- and an ample supply of spit cups and commodes. The sick were neither cubicled nor masked. All were given food six times a day. The sanitary conditions of the entire tented area in the depot brigade were exceptionally good.

11. Two thousand negroes who arrived at the camp from civil life between two to five days ago were put in an area by themselves and absolutely quarantined. The guard was most efficient and no officer or enlisted man could pass through without proper credentials. No influenza has occurred among these men.

12. All but three motor ambulances had been sent away from the camp at the time the epidemic began. The mule ambulances were entirely inadequate. Efforts to obtain ambulances and delivery wagons from an adjacent city have thus far been unavailing. Fifteen motor busses, which had been put out of business when the camp quarantine went into effect, were commandeered, and this action has fairly well solved the transportation proposition.

13. Owing to the pressure of work the statistics of the epidemic have not been entirely satisfactory. Until the last two or three days the "quarters cases," referred to in paragraph 7 above, were not reported to the Surgeon General, ho the actual number of influenza cases was in excess of the figures reported to the Surgeon General. On September 16 the reports of the base hospital show no cases of influenza, 51 cases of pneumonia, and no deaths. On September 27 there were 536 cases of pneumonia in the base hospital and the following numbers of influenza cases in the entire command

In base hospital proper 383

In base hospital annex 977

In 34 division field hospitals (isolation hospital) 663

In quarters 3, 728

Total 5, 751

During this period there had been 253 deaths almost exclusively from pneumonia.

The daily admissions for influenza and pneumonia since September 16 are as follows: The 970 cases on September 18 represent an accumulation of three days. The first known case was on the 16th.

 

Pneumonia

Influenza

Sept. 16

5

0

17

2

0

18

0

970

19

0

325

20

22

274

21

16

149

22

33

179

23

40

288

24

41

803

25

122

1,007

26

90

1,049

27

113

1,047

28

89

899

14. To supplement the base hospital, a group of 18 company barracks, fortunately empty, were set aside and fitted up as an "annex" base hospital, being administered by the base hospital. This group of buildings was three-fourths mile from the base hospital proper. The annex had been in operation three days at date of my arrival and, considering the suddenness of the organization, it was in excellent condition. Quartermaster cots were used and the rooms supplied on the basis of a bed for each 100 square feet of floor space. In some rooms the beds were too close together around the walls and the central space was empty. This will be corrected at once. The capacity of the annex was 1,040 beds. On day of my visit another adjacent group of barracks, with a capacity of 1,000 beds (on basis of 100 square feet per bed), was being vacated and the occupants placed under canvas.

The annex was equipped with straw mattresses and the soldiers' own blankets. Medical Department sheets, some pillows, pillowcases, and pajamas were provided. There was one female


1002

nurse on duty, and more were to come on arrival of nurses now en route. Messes were run in some of the buildings and were shortly to be started in more. "Ambulant cases "-that is, influenza patients whose temperatures had been normal 24 to 48 hours-went out of their particular building to the nearest mess for meals. No men with temperatures were allowed to go out to the lavatories. No cubicles had been installed. All attendants were masked. Part of the medical personnel was drawn from the camp physical examining board, A portion of the 186 enlisted men on duty were soldiers from the line who had some previous experience in hospital work, There were 977 patients in this annex, of which 18 were pneumonia. The order and system were most commendable. Adjacent officers' quarters had been set aside for a part of the 100 additional female nurses now under orders for the camp.

15. Near the annex a group of company barracks had been set aside for hospital purposes and was run by the four field hospitals of the division. This hospital had accommodations for 700 patients, The conditions here were not quite as good as in the annex. No sheets, pillowcases, or pajamas were provided, Coughing cases were neither masked nor screened. There was no overcrowding. Female nurses are to be sent here as soon as available.

16. The base hospital was in excellent condition and appeared to be meeting the situation in a most creditable manner. At time of visit there were 2,800 cases at the base hospital proper, but 300 of these were venereal cases which had been placed in tents, and 400 others were to be transferred to the new part of the annex that afternoon. There was only slight crowding at date of visit and that should be entirely obviated when the 400 are moved out, The corridors were not used for sick at all. The porches were occupied by beds and are provided with rolling canvas curtains to keep out rain, All pneumonia cases in wards were cubicled, but not those on porches, though the beds were too close together. Patients were arranged heads and feet alternating. Masking of attendants throughout the hospital was most thoroughly enforced. Ventilation of entire hospital was ample. Straw mattresses and quartermaster beds were used to a considerable extent. All influenza patients are fed in their own wards. They are not cubicled because of lack of sheets.

17. There was one ward full of sick female nurses, of whom 30 were said to have pneumonia. There were 51 on sick report. One nurse and one dietitian have died. One medical officer and one dental officer also have died.

18. There were over 100 bodies in the morgue and adjacent building used as an extemporized morgue. Relays of men were embalming, washing, and dressing the dead. The supply of coffins was adequate. The order and cleanliness of the morgue buildings was not entirely satisfactory. Only three autopsies have been done, as commanding general disapproves. The commanding officer did not know that the authority for doing autopsies had been placed in his hands. The three autopsies showed broncho-pneumonia.

19. There is no serious shortage of supplies. At the outset the camp surgeon directed the camp supply office to purchase anything necessary.

20. Thirty medical officers are en route or arriving at the camp, and it is thought this number will be sufficient, except that two additional laboratory men are needed at once, there being only two on duty, one of whom is a chemist. Ninety-four nurses are ordered to the hospital, of whom 30 have arrived. This number is not sufficient. One hundred additional enlisted men Medical Department, arrived last night and the number appears sufficient at present, in view of the men detailed from the camp.

21. The type of pneumonia was reported to be about half pneumococcus and one-half streptococcus (not hemolytic), in both instances usually associated with influenza bacillus. Six cases of empyema have developed thus far, The colored men appear to be suffering less from the influenza and pneumonia epidemic than are the whites. Influenza cases are being kept seven to eight days in hospital. The rule is to keep them in until temperature has been normal four days.

22. Numerous circulars relative to prevention of influenza and its complications have been issued by the camp authorities. These are very complete and satisfactory. The whole situation has been well handled. The only serious defect has been the retention of mild cases in quarters, but this will shortly be changed and perhaps was necessary at the outset, owing to the suddenness of the onset.

23. Report and recommendations made to commanding general:

SEPTEMBER 28, 1918.

From: ...., M. C.

To: The commanding general, Camp .

Subject: Sanitary inspection.

1. With reference to the epidemic of influenza and pneumonia at this camp, it is my opinion that the situation is being handled in a generally satisfactory manner in so far as conditions will permit. The following recommendations are made with a view to improving certain details of the work, and it is understood that, in some respects, the procedure recommended is already contemplated by the camp authorities or under way, but not yet completed, on account of lack of time or lack of material. Such recommendations as follow are probably not arranged in the most logical manner because of limited time in which to prepare this letter.

2. It is recommended:

(a) That no soldiers who have been afflicted with influenza be returned to duty until at least 10 days after the temperature has become normal.

(b) That, in caring for influenza patients, all the provisions in regard to the care of measles which were prescribed in memorandum S. G. O., January 1, 1918, to be carried out. At least 100 square feet of floor space should be provided for all uncomplicated influenza cases with a view to


1003

preventing the onset of pneumonia. This is considered even more important than providing the same space for cases which have already acquired pneumonia. All cases of influenza should be screened from each other as rapidly as possible, using cheesecloth if sheets are not available.

(c) That, as far as possible, no cases of mild influenza be treated in barracks which are in part occupied by healthy soldiers. To accomplish this purpose it is recommended that additional barracks, if possible, be set apart exclusively for the care of such cases and be administered as an annex to the hospital in the same way as the present annex is administered.

(d) That, both in barracks and in tents, the cubicle system be adopted for all healthy men by the use of the shelter tent, supported at one corner of the bed by a stick, or hung from the ceiling by a wire. This was being done in some barracks visited.

(e) That mess tables be so arranged that the men shall sit either on one side of the table alone or else the occupants of the two sides of the table be separated by a screen of cheesecloth suspended above the middle of the table.

(f) That the present quarantine of the camp against the surrounding country and of the surrounding country against the camp be continued except as regards the entry and exit of the friends and relatives of the seriously ill.

(g) That, as soon as the epidemic disappears, the population of the camp be reduced to the number for which quarters have been provided on the basis of 50 square feet of floor space per man or else that the quarters be sufficiently amplified to provide accommodations for the number here.

(h) That female nurses be provided for the barracks used as a hospital annex and in the barracks used as a hospital by the field hospital companies as soon as they are available.

(i) That, if possible, improvised corridors covered with canvas be provided to connect the lavatories with the barracks which are being used for hospital purposes.

(j) That steps be taken to prevent men from crowding together in post exchanges and also about the stoves when they are in barracks.

(h) That the laying of the dust in the camp be expedited as much as possible.

(1) That the greatest care be taken in the disinfecting of thermometers used for taking temperatures in the barracks.

(m) That all the patients in the infirmary annex to the tent area in the depot brigade be masked or cubicled.

(n) That the providing of pieces of newspapers under the spit cups in the barracks used as wards be enforced.

(o) That messes be started as soon as possible in all the barracks used as wards in order to save convalescents from the necessity of going outdoors.

(p) That sheets and pillow slips be provided for the sick in the barracks run as a hospital by the sanitary train.

(q) That greater care be taken to maintain order and cleanliness in the buildings which are now being used for the temporary shelter of the dead at the base hospital.

(r) That cases of pneumonia and influenza on porches at the hospital be cubicled as well as those in the wards.

24. Recommendations to Surgeon General:

(a) That 30 additional nurses be sent at once.

(b) That two additional officers for the laboratory service be sent at once.

Both these matters have been taken up personally with the proper divisions and are being adjusted.

Circular Memorandum, Surgeon General's Office, October 2, 1918.

Precautions Against Transfer of Influenza Contacts.

The following is furnished for your information and guidance:

[Night letter.]

AGO 220.33 (Miscl. Div.) CHA/IM.

SEPTEMBER 20, 1918.

COMMANDING GENERAL, NORTHEASTERN DEPARTMENT.

Boston, Mass.:

Reference all movements of men to and from your camp at this time all possible precautions will be taken against transfer of any influenza contacts, but movements of officers and men not contacts will be effected promptly as ordered.

Details of all movements from your camp to other camps will be arranged with commanding officers thereat. Make no movements until commanding officers of camps to which men are to be sent advise you their camps not quarantined and they are ready to receive men. All movements which may be suspended due to quarantine will be effected as soon as conditions will permit.

You will inform all under your control.

HARRIS.

[1st ind.]

On copy of-

220.33 (Miscl. Div.). CHA/HDH

War Dept., A. G. O., September 30, 1918.

To the Surgeon General, who will inform all under his control.


1004

Circular Letter from the Surgeon General, October 13, 1918.

Assignment of Epidemiologist to Camp.

1. The prevention of communicable diseases and the proper management of epidemic outbreaks is of paramount importance, and in the larger camps require the full time and services of the most competent medical officer qualified in epidemiology for this work.

2. A report is desired if you have within the camp a medical officer thoroughly qualified to undertake the duties of epidemiologist under your direction. If no officer is available, report will be made to this effect, and recommendation will be made by this office for the assignment of a qualified epidemiologist for duty at your camp.

Circular Letter, Surgeon General's Office, October 30, 1918.

Report on the Influenza and Pneumonia Epidemic.

1. It is desired that a brief report of the recent epidemic of influenza and pneumonia at all camps and stations be forwarded to this office, attention Division of Sanitation, as soon as practicable. The following should be included in the report:

(a) Composition and strength of the command.

(b) The history and general management of the epidemic.

(c) Amount of floor space provided in camp for each man, and the floor space provided in camp hospitals.

(d) Were cubicles used in camp and in hospitals?

(e) Sufficiency and suitability of clothing.

(f) Were mess kits and dishes boiled by organizations and hospitals?

(g) The relative number of white and colored men in camp, with morbidity and mortality rates for each.

(h) Any other important observations, data, or charts concerning the epidemic.

(i) Tables showing the daily admissions for influenza and pneumonia and the deaths resulting in the following form:

[Reporting form]

(j) Where reports have already been submitted by the camp surgeon or epidemiologist, information to that effect by letter will be sufficient.