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THE SURGEONS GENERAL

ANNUAL REPORTS OF THE SURGEON GENERAL

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THE AMEDD HISTORIAN NEWSLETTER

Circular No. 1, 1917

Contents

CIRCULARS PROMULGATED BY THE CHIEF SURGEON, A. E. F.

Circular No. 1, 1917

  HEADQUARTERS AMERICAN EXPEDITIONARY FORCES,
  CHIEF SURGEON'S OFFICE

It is planned that the medical laboratory work for the American Expeditionary Forces shall be done by the following organizations:

1. Field laboratories, located in each division camp hospital, will do all work that it is possible to do for the division and for the camp hospital, and will send other work to an army laboratory.

2. Army laboratories will do the bulk of the work for the troops in the field including water analyses, Wassermann reactions, detection of carriers, cultural and serological work in general. These laboratories may be specialized later. Laboratory No. 1 is already established, address P. O. No. 709.

3. Laboratories of base hospitals will do principally routine and special work for cases in hospital.

Specimens from each division should be sent to the field laboratory at the camp hospital of the division for examination or transmittal to the army laboratory. As soon as containers for specimens are available they will be kept on hand at the field laboratories for distribution.

Pneumonia.-Type determination of pneumococci should be carried out whenever possible in cases of lobar pneumonia. Sputum should be sent to the army laboratory direct, with as little delay as possible.

Syphilis.-Specimens for Wassermann reactions will be sent to United States Army Laboratory No. 1, through division laboratories.

DIPHTHERIA AND MENINGITIS

Sporadic cases of diphtheria and meningitis are to be expected and do not call for medical preventive measures. But if secondary cases occur in the same group of men, such radical measures will be undertaken as the limitations of field conditions permit.

Diphtheria.-1. Any clinically suspicious case will be cultured on Loeffler's media, and the culture will be sent to the division laboratory as soon as possible. The case should be treated with serum if sufficiently suspicious and sent to the camp or base hospital for isolation.

2. If the culture is reported positive, immediate contacts will be examined clinically each day for one week and cultures made in any suspicious cases. Isolation, the prophylactic use of antitoxin, and examination for carriers among contacts are not indicated after sporadic cases. Inquiry should be made as to the existence of diphtheria in the civil population, especially among the children of the neighborhood.

3. If secondary cases occur in the same group of men, contacts will be isolated and examination for carriers will be requested through the division laboratory.

4. If cultures on contacts are negative they will be released from isolation. Carriers will be sent to the camp or base hospital. If virulence tests can be made on carriers and are negative, the carriers will be released; otherwise, two negative cultures at intervals of three days will be required before release.

Meningitis.-1. Any clinically suspicious cases will be given a spinal puncture as soon as possible and the fluid sent to the laboratory. The case will be given serum treatment if sufficiently suspicious and sent to the camp or base hospital for isolation.

2. If meningococci are found in the fluid by smear or culture, contacts will be kept under clinical observation for three weeks and spinal punctures will be made in all suspicious cases.

3. If secondary cases occur in the same group of men, contacts will be isolated and examination for carriers will be requested through the division surgeon.

4. If cultures on contacts are negative they will be released from isolation. Carriers will be sent to a base hospital for isolation and treatment. Two negative cultures with intervals of one week will be required before convalescents or carriers are discharged from hospital.

A. E. BRADLEY,
Brigadier General, N. A., Chief Surgeon.


904

Circular No. 2.

(This circular will be superseded by Circular No. 25 which will soon be issued.)


Circular No. 2.

HEADQUARTERS AMERICAN EXPEDITIONARY FORCES,
OFFICE OF THE CHIEF SURGEON,
France, November 9, 1917. 

1. The War Department has approved the plan of the Surgeon General's Office, creating professional divisions in his office with a director at the head of each division in the United States, and a director for each division with the American Expeditionary Forces. These divisions are:

(1) Division of general medicine.
(2) Division of general surgery.
(3) Division of orthopedic surgery.
(4) Division of surgery of the head.
(5) Division of venereal, skin and G. U. (urology).
(6) Division of laboratories.
(7) Division of psychiatry.
(8) Division of Roentgenology.

2. For the expeditionary forces, Maj. John M. T. Finney, M. R. C., has been designated as director of general surgery; Maj. Joel E. Goldthwait, M. R. C., as director of orthopedic surgery; Maj. Hugh H. Young, M. R. C., as director of urology; and Lieut. Col. Joseph F. Siler, M. C., as director of laboratories. The names of officers designated for the remaining divisions will be announced later.

Additional officers will be named from time to time as assistant directors and consultants for corps, sections of the lines of communication, large hospital centers, and other areas.

3. The professional authority of directors, assistant directors, and consultants, within their respective divisions, will be recognized by all concerned and duly respected and observed, it being fully understood that this authority does not in any way include administrative control.

4. The directors, each for his particular division, will be immediately responsible to the chief surgeon, A. E. F., for the work performed in these various divisions. In general, they will direct and coordinate the professional service of all sanitary formations and hospitals so that there will be a continuity of treatment along lines of recognized approved practice, from the front to the rear, in each professional division.

They will also act as consultants and advisors, and, when necessary in the interest of the service, they will change professional procedure or inaugurate new methods.

5. In order to carry out these plans, the professional service of base hospitals and general hospitals, and other hospitals as far as practicable, will hereafter be subdivided into eight sections, as follows:

(1) Section of general medicine.
(2) Section of general surgery.
(3) Section of orthopedic surgery.
(4) Section of surgery of the head.
(5) Section of venereal, skin, and genitourinary (urology).
(6) Section of laboratories.
(7) Section of psychiatry.
(8) Section of Roentgenology.

The commanding officer of each hospital will organize his hospital as indicated, assigning a suitable officer to duty in charge of each section. He will assign an adequate number of assistants to each section as far as it may be practicable. In making these assignments the professional qualifications of an individual in a particular specialty will receive due consideration. The chiefs of sections will report direct to the commanding officer, to whom they will be responsible, each for the satisfactory operation of his particular section.

By command of General Pershing:

A. E. BRADLEY,
  Brigadier General, N. A., Chief Surgeon.
Approved:

J. G. HARBORD, Chief of Staff.


905

Circular No. 3.

HEADQUARTERS AMERICAN EXPEDITIONARY FORCES,
  OFFICE OF THE CHIEF SURGEON,
  November 24, 1917.

The following instructions are issued for the guidance of all medical officers:

1. Cases of slight illness which apparently will require but a few days on sick report, and cases of uncomplicated venereal diseases which can not receive proper care on a duty status, will be treated in camp infirmaries as far as the capacity of the camp infirmary will permit.

2. Cases of a more serious nature will be sent to camp hospitals of the divisional training areas. These will include the overflow of the mild cases from the camp infirmaries and those who will require retention on sick report for more than one week.

3. Cases of a severe nature that will require hospital treatment for a period of more than two weeks or cases for which there is inadequate equipment at camp hospitals and those that require experienced nursing will be promptly evacuated to base hospitals. It is not intended that all mild cases which will require hospital treatment for a period longer than two weeks must be evacuated to base hospitals, but two weeks is placed as a reasonable time limit for their retention in camp hospitals and is intended to serve as a guide.

4. In this connection attention is called to paragraph 4, General Orders, No. 34, Headquarters A. E. F. No uncomplicated cases of venereal disease will be sent to base hospitals.

By command of General Pershing:

   A. E. BRADLEY,
Brigadier General, N. A., Chief Surgeon.

Approved:

J. G. HARBORD, Chief of Staff.


Circular No. 4.

  HEADQUARTERS, AMERICAN EXPEDITIONARY FORCES,
OFFICE OF THE CHIEF SURGEON,
France, December 22, 1917.

The following instructions relative to charges for certain classes of dental work requiring precious metals and other expensive materials not furnished by the Government are issued for the guidance of all concerned.

1. It is contemplated that dental officers on duty at general headquarters, headquarters line of communications, division headquarters, separate brigade headquarters, army sanitary school, the several base hospitals, A. E. F., and general hospitals, B. E. F. (where there are complete laboratory equipments) will carry these materials.

2. The following list of fixed charges to reimburse dental officers using these supplies is announced, same being based upon the actual cost (in France) of materials necessary for the designated class of work, plus a small per cent to cover construction losses.

3. List of charges:

Gold fillings:

 

Simple

$2.00

Compound

$2.50-3.50

Gold inlays:

 

Simple

$3.00-3.50

Compound

$4.00-5.00

Gold shell crowns (gold bridge dummies):

 

Bicuspids-

 

Swaged cusps

$5.00

Solid cast cusps

$6.00

Molars-

 

Swaged cusps

$6.00-7.00

Solid cast cusps

$7.00-8.00

Gold-porcelain crowns

$5.00

(Richmond, Goslee, Steele, or Ash facings, and bridge dummies)

Porcelain crowns, with cast gold base

$3.00

Bridges: Charges to be based upon foregoing figures covering components, i. e., abutment crowns, inlay anchorages, and dummies, plus a charge for consolidation not to exceed $1 for each interproximal space soldered.

 By command of General Pershing:

   A. E. BRADLEY,
  Brigadier General, N. A., Chief Surgeon.
 

Approved:

J. G. HARBORD, Chief of Staff.


906

Circular No. 5.

  HEADQUARTERS, AMERICAN EXPEDITIONARY FORCES,
  OFFICE OF THE CHIEF SURGEON,
France, January 15, 1918.

DUTIES OF MEDICAL OFFICERS DETAILED AS PSYCHIATRISTS IN ARMY DIVISIONS IN THE FIELD

1. The following outline naturally does not indicate all the means by which medical officers detailed as psychiatrists in Army divisions in the field can be of service in dealing with the difficult problems arising in the diagnosis and management of mental and nervous diseases among troops. These officers are under the direction of the chief surgeons of the divisions to which they are attached, and they must be prepared at all times to render such services as he may require. These officers are not members of division headquarters staff. They are attached to the sanitary train.

2. It is essential for such officers to bear in mind the prime military necessity of preserving or restoring for military duty as many as possible of the officers and enlisted men who may be brought to their attention. On the other hand, they should recommend the evacuation, with the least practicable delay, of all persons likely to continue ineffective or to endanger the morale of the organizations of which they are a part. This is particularly true in the case of the functional nervous disorders loosely grouped under the term "shell shock," but more properly designated as war neuroses. Psychiatrists detailed to this duty have an unique opportunity of limiting the amount of ineffectiveness from this cause and of returning to the line many men who would become chronic nervous invalids if sent to the base. At the same time they can bring to the attention of other medical officers and company commanders individuals who possess constitutional mental defects of a type which make it certain that they will break down under stress.

3. Specific duties which may be performed by psychiatrists in Army divisions are as follows:

(a) Examine all officers and men under observation or treatment for mental or nervous diseases in regimental infirmaries, field hospitals, camp infirmaries, and other places, and to advise regarding their diagnosis, management, and disposition.

(b) Examine all mental or nervous cases in the divisional areas when directed to by the chief surgeons or requested to by other medical officers or company commanders.

(c) Examine and give testimony regarding officers and men brought before court-martial or under disciplinary restraint, when directed or requested by competent authority.

(d) Give informal clinical talks to groups of medical officers in the divisions to which they are attached upon the nature, diagnosis, and management of the mental and nervous disorders peculiar to troops.

(e) Keep careful records of all cases examined.

(f) Make such reports to the chief surgeons of divisions as they require and to make monthly reports of their operations to the director of psychiatry, bringing especially to his attention any matters likely to increase the efficiency of this part of the medical work of the American Expeditionary Forces.

By command of General Pershing:

A. E. BRADLEY,
Brigadier General, N. A., Chief Surgeon.

Approved:

J. G. HARBORD, Chief of Staff.


Circular No. 6.

    GENERAL HEADQUARTERS, AMERICAN EXPEDITIONARY FORCES,
    OFFICE OF THE CHIEF SURGEON,
    France, January 28, 1918.

    1. The attention of medical officers, A. E. F., is directed to the absolute necessity for the prophylactic administration of antitetanic serum (A. T. S.) under the following conditions:

    (a) Immediately after the receipt of a wound of whatever character, if a battle casualty, preferably at the regimental aid station.


    907

    (b) Upon the recognition of so-called "trench foot" with or without skin abrasions.

    (c) During operations performed under conditions of unsatisfactory asepsis, e. g., emergency operations, operations for hemorrhoids, or when there has been contamination from the contents of the large intestine.

    (d) During secondary operations necessary in the course of the treatment of wounds received 10 or more days previously.

    (e) Following manipulations incident to the reduction of compound fractures or dislocations, after the removal of adherent drains, or any other procedure resulting in a serious disturbance to the healing tissues consequent upon a wound 10 or more days old.

    2. One dose of 1,500 units is sufficient, and should always be administered under any of the above conditions. It should be injected subcutaneously, preferably over the lower abdomen.

    3. The serum should be administered by or under the immediate supervision of a medical officer. If for any reason this is impossible, it should be given by some responsible member of the Medical Department.

    4. A record of the administration is to be made upon the individual's diagnosis tag and clinical record by the letters A. T. S., followed by the date and hour; in the case of the freshly wounded, the letter T should be plainly marked upon the forehead with an indelible pencil.

    5. Absence of any records on the patient's card or face as indicated in the preceding paragraph is to be accepted as evidence that the A. T. S. has not been given. The first medical officer to assume subsequent control of a patient thus neglected should administer the serum immediately.

    6. Medical officers, who are thus compelled to administer A. T. S. because of the failure of any medical officer or officers previously responsible for this administration to carry out the above instructions, must make an immediate report of such omissions to the chief surgeon, A. E. F., through the director of general surgery, with sufficient data to establish the time and circumstances of the omission.

      A. E. BRADLEY,
       Brigadier General, N. A., Chief Surgeon.


    Circular  No. 7.

    GENERAL HEADQUARTERS, AMERICAN EXPEDITIONARY FORCES,
       OFFICE OF THE CHIEF SURGEON,
    France, January 28, 1918.

    1. The following detailed instructions supplementing and amplifying General Order No. 43, headquarters, A. E. F., September 30, 1917, and General Order No. 74, December 13, 1917, and relative to requisitions and finance papers, are published for the information and guidance of all concerned.

    2. Accountable officers of base hospitals and sanitary schools will not be affected by the provisions of the paragraphs of this circular, in so far as they apply to property responsibility and accountability.

    3. All accountable officers of Medical Department units coming under chief surgeons of divisions will at once invoice upon Form 28, M. D., all property of whatever nature for which they are accountable, to their respective divisional medical supply officers. Under the supervision of the chief surgeons of divisions this property will be issued and held upon memorandum receipt, Form 28, M. D., so modified as to meet this need.

    4. The medical supply officer of each division will prepare, after this transfer has been completed, accurate final returns upon Forms 17, 17a, 17b, and 17c, in duplicate, of all equipment, property, and supplies for which he may then be accountable. The upper certificate upon Form 17c will be used by the officer completing the final return, the lower form, as modified, by the officer making final inventory. One copy will be retained and one copy forwarded to the chief surgeon, line of communications.

    5. There will be detailed by the chief surgeon of each division a disinterested officer of the Medical Department and senior to the Divisional medical supply officer, if practi-


    908

    cable, to make personally a complete physical inventory of balance of supplies, property, and equipment on hand at time of final return. The officer making this count will certify to the facts on the final return.

    6. Accountable officers of Medical Department units, not under chief surgeons of divisions, will proceed as per instructions contained in paragraph 4 above, and subparagraphs 1 and 2, paragraph 1, General Order No. 74, above quoted. These final returns will be made in duplicate and one copy retained by the accountable officer and one forwarded to the chief surgeon, line of communications.

    7. For the method of the invoicing of and receipting for equipment, property, and supplies from depots to units, divisional or otherwise, attention is invited to paragraph 10, General Order No. 43, headquarters A. E. F., September 30, 1917.

    8. Requisitions for all property listed upon tables of supply will be made for divisional units in quadruplicate, and in all other cases in triplicate upon Forms 33, 35, or 36, M. D. In each case one copy will be retained and the others forwarded for action. Requisitions for blank forms will be made as in the past upon Form 37 and for all organizations but one copy forwarded for action.

    9. All equipment, property, and supplies needed for use of divisional units will be requisitioned for by the divisional medical supply officer, and his requisitions will be forwarded to the chief surgeon of that division for his action. The chief surgeons of divisions will forward all approved requisitions, or those approved as modified, except for transportation as noted in paragraph 11, direct to the officer in charge of the issuing depot. The same disposition will be made of requisitions from organizations other than divisional, and with the same exception. The chief surgeon, line of communications, will publish from time to time detailed instructions relative to the exact depot to which requisitions from the various units should be sent. These instructions will also contain a statement of policy as regards "articles due."

    10. Requisitions or requests for transportation of any kind whatever will be forwarded in every instance to the chief surgeon, line of communications, through divisional chief surgeons in the case of such units and direct in all other cases. These instructions will also govern where special or unusual equipment, supplies, or property are required.

    11. All unserviceable property of whatever class will be disposed of ultimately through the salvage service. Such property will, however, for the present be held awaiting further instructions from the office of the chief of the salvage service.

    12. Where purchases and payments are made necessitating the use of public voucher forms, great care will be exercised to see that the signature of individuals to whom payments are to be made are in accordance with the name of the party or company to whom the United States is declared debtor. The vouchers will show clearly upon their faces the authority for the purchase and the rate of exchange used in figuring totals. These totals will, in all cases, be made in terms of United States currency.

    13. The public vouchers referred to above will be made in duplicate and accompanied by the proper forms. In cases where the purchase has been made under the supervision or authority of a divisional chief surgeon, the vouchers will be sent to that office for visa and approval after which they will be sent direct to the proper disbursing officer for payment. The papers referring to transactions not falling normally within the province of divisional chief surgeons will be forwarded to the chief surgeon, line of communications, for final action.

    14. The chief surgeons of divisions may authorize ordinary and emergency expenditures of public funds for their own department in amounts not to exceed $100. All such expenditures so authorized will be reported to this office monthly upon a consolidated list showing the larger groups and not each individual item.

    A. E. BRADLEY,
      Brigadier General, N. A., Chief Surgeon.


    909

    MODIFIED FORM C, MEDICAL DEPARTMENT

    I certify that the foregoing return, slips Nos. ----- to -----, inclusive, is a true and correct statement of all medical property for which I am accountable for the period ending ----------, 191--; that the expenditures for which credit is claimed therein were made in strict accordance with regulations.

      --------------------------------------
    -----------------------------------------
    Accountable Officer.

       Final return of medical property, ----- Division, A. E. F., per G. O. 74, H. A. E. F. December 13, 1917.

    I certify that I have this ----------------- day of -------------------, 191--, made a complete personal physical inventory of all property enumerated upon slips Nos. ---- to ----, for which the above officer is accountable and find the total balance on hand to be as stated in the above certificate with additions and subtractions as indicated upon my list here attached.

      ---------------------------------------------
    -------------------------------------------
       Inventory Officer.

       Final return of medical property, ----- Division, A. E. F., per G. O. 74, H. A. E. F. December 13, 1917.


    Circular No. 8.

    GENERAL HEADQUARTERS, AMERICAN EXPEDITIONARY FORCES,
    OFFICE OF THE CHIEF SURGEON,
      France, February 4, 1918.

    The following information is published for the guidance of all concerned:
     

     * * * * * * *

    1. There arrived at ____, 7.25 p. m., January ____, 61 enlisted men of this division. These men were in charge of Sergeant ____, Headquarters Company, _____ Infantry. They were all being returned to duty from Base Hospital No. _____. Copy of order and written instructions to Sergeant _____ hereto attached. (See Exhibits A and B.)

    2. These men were not furnished with rations when they left the hospital; and as very few of them had any money, the large majority went without anything to eat from 6.10 a. m. to about 8 p. m. No notification was sent to the authorities at _____ from Hospital No. ____ to expect these men, and when they arrived, about 8 p. m., there was therefore no provision for taking care of them until they could be forwarded to their respective organizations.

    3. Many of the men were without sufficient warm clothing, according to the sworn statement of Sergeant _____, as well as my own observation.

    4. Sixteen of the men were admitted to the camp hospital here immediately on arrival. Thirteen of them were returned to duty next day, but three were found to require hospital treatment. (See Exhibit C.)

    5. It is recommended that steps be taken to require the hospital authorities to see that men discharged from a hospital are warmly clothed on leaving, and to provide for rationing such men for the trip back to their organizations. Also that they notify by telegram the authorities of any intermediate station where such men must be taken care of on their journey back to their organizations.
      * * * * * * *

    The recommendations set forth in paragraph 5 above will be strictly observed. The general staff at these headquarters is now engaged on the preparation of an order that will cover an automatic method of returning men from hospital to duty.

    A. E. BRADLEY,
       Brigadier General, N. A., Chief Surgeon.


    910

    Circular No. 9.

    GENERAL HEADQUARTERS, AMERICAN EXPEDITIONARY FORCES,
    OFFICE OF THE CHIEF SURGEON,
      France, February 7, 1918.

    The following memorandum has been issued by the Surgeon General, and as far as it is applicable will be observed by all concerned in the American Expeditionary Forces:

    Memorandum for all division surgeons, and surgeons at ports of embarkation, and for commanding officers of general, base, embarkation, and other hospitals:

    Reports 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 for the needed articles, 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 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, 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 3 to 6 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 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 pneumonias 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 hospitals, 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 revacci-


    911

    nated. 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 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 required 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.

    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. Outer 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.

     * * * * * * *

      A. E. BRADLEY,
      Brigadier General, N. A., Chief Surgeon.


    Circular No. 10.

       AMERICAN EXPEDITIONARY FORCES,
    OFFICE OF THE CHIEF SURGEON,
       France, March 4, 1918.

    1. Allowance for soldiers sick in hospital.-Paragraph 1212, Army Regulations, has been amended so as to provide for commutation of rations for soldiers sick in hospital and members of the Army Nurse Corps at the rate of 60 cents a day at all stations where purchases of subsistence supplies from Quartermaster Department are possible, and at the rate of 75 cents a day at stations where purchases must be made in open market-effective February 16, 1918.

    From and including February 16, the claim upon the Red Cross for 35 cents a day for additional rations will be discontinued.

    Red Cross allowance for soldiers of the allied armies in American hospitals.-The Red Cross has agreed to continue an allowance for members of the allied armies in American hospitals. Vouchers therefor will be submitted through this office, accompanied by the certificate that these funds have been or will be actually expended in providing additional rations in accordance with the purpose for which the money has been appropriated by the American Red Cross. The amount allowed is 20 cents a day for patients.

    2. Misuse of adhesive tape and surgical bandages.-It has been reported to this office by a collector of internal revenue in the United States that large numbers of packages are being received from the American Expeditionary Forces secured with adhesive tape and surgical bandages. Such waste of material is reprehensible under present conditions. All commanding officers will immediately take steps to prevent any such misuse of these supplies.


    912

    3. Reports on civilians.-Hereafter, report called for by General Order No. 13, headquarters, A. E. F., in the case of civilians employed, will be made out on the following form (letter size):

      ------------------------------------------------------------ 191---
    From ----------------------------------------------------------
    To Chief, Intelligence Section, A. E. F.
    Subject: Investigation of employee.

       It is requested that ---------------------------------------- whose description follows, be investigated by your office, with a view to ----------- employment as ------------------------------------------ at a salary of --------------------------------------------------------

      (Signature) -------------------------------------------------------------

       Name and all surnames ----------------------------------------------------------------------------------------------------------------------------
       Nationality --------------------------------------------------------------------------------------------------------------------------------------------
       Place of birth -----------------------------------------------------------------------------------------------------------------------------------------
       Date of birth ------------------------------------------------------------------------------------------------------------------------------------------
       Address (actual lodging; not business address) -------------------------------------------------------------------------------------------
       Last employment -----------------------------------------------------------------------------------------------------------------------------------
       Name and nationality of father -----------------------------------------------------------------------------------------------------------------
    Name and nationality of mother ----------------------------------------------------------------------------------------------------------------
       References (3) ---------------------------------------------------------------------------------------------------------------------------------------

    4. Use of medical supplies.-Medical officers are urged to effect every possible economy in medical supplies of all kinds, and to give careful consideration to every requisition, bearing in mind the problems which confront the supply division. Every item should be considered from the standpoint of its relation to the success of our Army and not alone from its convenience and desirability under peace conditions.

    The tonnage situation necessitates the utmost economy, and does not permit the furnishing of our hospitals with as elaborate an equipment as would otherwise be possible.

    The elimination of all supplies that are not directly beneficial to the health of the soldier or to the success of our Army will permit larger shipments of the essential and vital articles and will help to avoid a possible shortage later.

    While price is not yet an important factor, a diversion of labor from the manufacture of essential articles is and such diversion results from the purchase of nonessential articles however desirable they may be. The careful cooperation of all medical officers in this matter of economy will be of very great value. Economy should be practiced both at the time requisitions are made and in the use of the articles when received.

    It is not desired that medical officers economize in any way that will interfere with the recovery or comfort of the patients. There is no need therefor. Tonnage for all such essentials for the medical department will be forthcoming.

    But the needs of the medical department are only a part of the great needs of our Army, and the fact that the requirements for the sick are given precedence over a great many other supplies should make us insistent that the privilege is not abused. Every item saved will not insure the only future supply of the essential articles, but will aid materially in the success of the Army, whose interests we serve.

    5. Supply of nonperishable subsistence stores.-Base hospitals are authorized and directed to carry in stock a 15 days' supply of nonperishable subsistence stores based on the maximum strength of patients and personnel. Requisitions will be submitted at such times as to maintain this stock and meet the current needs. Should the hospitals be located in hospital centers where quartermaster depots are established, this stock need not be carried at each hospital if the facilities of the depot are sufficient to maintain that stock for the entire area.

    6. Empty Prest-o-Lite tanks.-Empty Prest-o-Lite tanks should be sent direct to the purchasing officer, medical department, Paris, for transmission to the Societe des Appareils, Magondeaux, No. 6 Rue Denis-Poissons, Paris, advising him by mail of all shipments and of the number of tanks shipped.

    7. Ordre de transport.-The following, from Circular No. 9, office of the chief quartermaster, general headquarters, A. E. F., is repeated:


    913

    1. The proper disposition of the pink and yellow folds of the ordre de transport does not seem to be clearly understood by many shipping and receiving officers, and, pending issuance of new forms, which are designed especially for use by the American Expeditionary Forces, officers should strictly observe the following instructions in the use of the French forms.

    2. When a passenger is given his ordre de transport he should be told to present it to the chef de gare (railroad agent) at point of departure, that the chef de gare will retain the pink fold, but will stamp and return to him the yellow fold, which is his ticket for the trip; that he must preserve and turn over this yellow fold on arriving at destination to his commanding officer.

    3. When the commanding officer receives the yellow fold of the ordre de transport from a soldier, or detachment of soldiers, arriving at destination, he will note the number of persons actually transported thereon, if there is a discrepancy, and forward it to the chief quartermaster, A. E. F.

    4. When a shipment of freight reaches the point of delivery the receiving officer will take the yellow fold of the ordre de transport (which has been forwarded to him by the shipping officer) and present it to the chef de gare who will deliver the shipment to him. He will carefully check the shipment with the ordre de transport, noting on the reverse side, in the space provided therefor, any shortage or damage, and will see, before signing it, that the chef de gare makes similar notations on the pink fold held by him. The yellow fold, after the necessary notations have been made and signature of the receiving officer affirmed, will be forwarded at once to the chief quartermaster, A. E. F., accounting division.

    5. Many copies of the pink fold of the ordre de transport (A-2 and B-2) are being forwarded to this office, which is a mistake. This part of the ordre de transport is property of the carrier, on which the transportation charges are based, and has no place in the records of this office.

    6. A careful observation of these rules will greatly facilitate the settlement of transportation accounts with the French Government.

    8. Report of supplies received not properly marked.-The commanding general, S. O. R., directs all officers receiving shipments not properly marked, as provided in General Order 17, general headquarters, A. E. F., 1918, paragraph 2, subparagraph 4, to make report, in detail to headquarters, S. O. R.

    9. Report on civilians.-The commanding officer of each Medical Department organization will submit to this office at once a report showing the present status and number of civilian laborers employed, giving location of labor, nature of work at which employed, and terms under which employed, including copy of any written contracts made in connection with same.

    10. Transfer of patients with self-inflicted gunshot wounds.-In compliance with section D, paragraph 162½, Army Regulations, the report of the board of officers which investigated the case will hereafter invariably accompany the patient upon his transfer, that whether his injury occurred in line of duty may be determined.

    A. E. BRADLEY,
      Brigadier General, N. A., Chief Surgeon.


    Circular No. 11.

       HEADQUARTERS, AMERICAN EXPEDITIONARY FORCES,
    OFFICE OF THE CHIEF SURGEON,
       France, March 4, 1918.
    The following instructions are issued for the guidance of all medical officers:

    1. Injuries to the bones and joints, as well as of the muscles and tendons adjacent to these structures, represent a large percentage of the casualties of both the training the combat periods of an army.

    2. To restore useful function to these injured structures is one of the purposes of the medical organization of the Army. The problems involved in this have to do not only with the cleansing and healing of the wounds, but also with the restoration of motion in the joint or strength to the part. This latter part naturally follows the first, but it is essential that the first part be carried out with reference to that which is to follow. Unless this second part of the treatment, the restoration of strength and motion, is carried out, much of the first part is purposeless.

    3. To insure to the man not only the proper treatment for this type of injury, but the proper supervision until he is as fully restored as possible, necessitates some form of radial control that makes it impossible for a man to be overlooked in inevitable transfers, from service to service, or hospital to hospital.


    914

    4. Since so much of the ultimate result in these conditions depends upon orthopedic measures after the first treatment of the wounds has been carried out, the following will govern:

    The director of orthopedic surgery is responsible for the treatment of the injuries or diseases of the bones or joints, exclusive of the head and face.

    He will be held responsible for the treatment of injuries or diseases of the ligaments, tendons, or muscles that are involved in the joint function of the extremities.

    Officers attached to other divisions may operate upon and treat such conditions, but the division of orthopedic surgery, through its director, will be held responsible for the character of the treatment and for the final results.

    It is expected that the direction and supervision of the treatment here indicated will be carried out, in so far as is possible, in cooperation with the director of the division of general surgery.

    5. To carry out the instructions of this circular, the director of the division of orthopedic surgery will arrange so that representatives of his division will see all cases of the nature described, to determine whether or not their management is proceeding satisfactorily so as to obtain the best possible results. These representatives will report to the commanding officers of the hospitals in which such patients are being treated and their services as consultants will be freely utilized; any recommendation made by them as to change of treatment, transfer to some other professional service, or hospital, will ordinarily, if the military situation permits, receive favorable consideration.

    6. It is not the intention of this order to interfere with the routine work of hospitals, but to insure to the soldier proper supervision during the time of his treatment and the period of his convalescence.

    By command of General Pershing:

      A. E. BRADLEY,
    Brigadier General, N. A., Chief Surgeon.

    Approved:
    J. G. HARBORD, Chief of Staff.


    Circular No. 12.

    AMERICAN EXPEDITIONARY FORCES,
      HEADQUARTERS, SERVICES OF SUPPLY,
      OFFICE OF THE CHIEF SURGEON,
       France, March 6, 1918.

    1. Hereafter all requisitions from Medical Department organizations, American Expeditionary Forces, will be made in quadruplicate, one copy being retained and three copies being forwarded directly to the supply depot.

    2. Of the three copies received at the depot, one will be retained for file, one will be returned to the organization with marks as set forth below (indicating the action taken on each item), and the other copy will be similarly marked and forwarded to the chief of the division of accounting and finance, Medical Department, headquarters, Services of Supply.

    3. The copy returned to the organization will serve both as an invoice and as a packing list, and those two forms heretofore furnished organizations will no longer be prepared. Upon receipt of the marked copy from the depot, the organization making the requisition will erase all articles on the corresponding retained copy except those shown on the copy from the depot as having been shipped (showing the amounts shipped in any article cut) and will then forward the copy so marked to the chief of the division of accounting and finance, Medical Department, headquarters, Services of Supply, direct, acknowledging receipt across its face.

    4. The depot copies may indicate certain articles as having been placed upon the due list. Such due lists will be made in triplicate. When shipments are made of these articles previously due listed, one copy of the due list will be sent to the consignee, one copy to the chief of the division of accounting and finance, and one copy retained, all copies being marked as shown in paragraph 5. Upon the receipt of such marked due lists by the consignee, he will change his retained copy of the corresponding requisition to include the articles received,


    915

    will sign the due list and forward it to the chief of the division of accounting and finance, Medical Department. When partial shipments are made upon the due lists, the articles not shipped will again be due listed and the same procedure carried out.

    5. The marks shown will be as follows:
      Check mark (requisition filled in full).
      Number replacing the original number (requisition cut to that amount).
      Erasure (requisition disapproved).
      D. L., followed by number (amount placed on due list; shipment to be made when stock is received).

    6. Articles not in stock or not expected within a reasonable time will not be due listed and should therefore be again requisitioned for, but not until the lapse of a sufficient interval to warrant expectation of their receipt from the States. Articles not on hand, but expected within a reasonable time, will be due listed and will be furnished upon receipt without further requisition.

    7. Telegraphic requisition will be made in actual emergencies only and must be followed by a requisition made out in proper form in quadruplicate, triplicate copies being forwarded, marked "Confirmation of telegraphic requisition." When requisitions are made in letter form they also will be forwarded in triplicate.

    8. In order that the receiving officer may be able to check several shipments arriving at the same time, resulting from two requisitions, or a requisition and a previous due list, the following methods of marking shipments at depots will be established:

    All boxes will be marked with the number given the requisition at the depot, followed by the number of packages in the shipment, thus: 25-48 would mean that the shipment was made on requisition No. 25 and that 48 packages were shipped. The copy of the requisition or due list returned by the depot to the consignee would carry the number 25.

    9. Attention is again called to the very great importance of conserving medical supplies in every possible way. It must be remembered that supplies are obtainable only with the very greatest difficulty, and every unnecessary expenditure is both hurtful to the country and to the individual soldiers, who by such unnecessary expenditure are deprived of their legitimate due. Frequent inspection of storerooms and the closest scrutiny of all expenditures is enjoined upon all commanding officers and surgeons.

    Hospital fund statements.-These statements for the month of April and thereafter, for all organizations of the American Expeditionary Forces in France, will be rendered upon the basis of the amount received, expended, etc., in francs-the rate of exchange employed being set forth if conversion from dollars and cents to francs has been necessary. Any loss resultant from this conversion will be shown as an expenditure by expenditure vouchers.

    Typewriter repair.-Hereafter all typewriters requiring repair will be shipped to the Medical Department repair shop No. 1, 11ter Ave. de la Revolte, Neuilly, Department of Seine.

    A. E. BRADLEY,
      Brigadier General, Chief Surgeon.


    Circular No. 13.

    GENERAL HEADQUARTERS, AMERICAN EXPEDITIONARY FORCES,
    OFFICE OF THE CHIEF SURGEON,
      France, March 11, 1918.

    1. A daily report of all new cases or suspected cases of any one of the diseases named below will be made from all hospitals by telegraph, telephone, or messenger to this office:

    Chicken pox.
    Cholera, Asiatic.
    Diphtheria.
    Dysentery.
    Meningitis (meningococcus).
    Paratyphoid fever.
    Plague.
    Scarlet fever.
    Smallpox.
    Typhoid fever.
    Tyhus fever.

    2. The report will include name and organization of the patient and the diagnosis.

      A. E. BRADLEY,
    Brigadier General, N. A., Chief Surgeon.



    916

    Circular No. 14.

      FRANCE, March 13, 1918.

    1. In view of the great importance of scabies as a cause of prolonged disability unless prompt diagnosis is made and early treatment instituted, each division surgeon is directed to select a suitable field hospital to which all cases of scabies of the division will be sent.

    2. A medical officer of the division, with an adequate knowledge of dermatology, should be used to instruct regimental medical officers in early diagnosis and treatment of this disease if necessary.

    3. The urgent necessity of close inspection frequently repeated for skin parasites of all kinds is in this connection again brought to the attention of all medical officers.


    Office circular No. 15.

      OFFICE OF THE CHIEF SURGEON,
    AMERICAN EXPEDITIONARY FORCES,
    HEADQUARTERS, SERVICES OF SUPPLY,
      France, March 25, 1918.

      OFFICE REGULATIONS, CORRESPONDENCE PRACTICE, ETC.

    1. The office hours will be 8 a. m. to 12; 1.30 p. m. to 5.30 p. m.

    2. Orderlies will regularly distribute the incoming mail to the several offices and collect the outgoing mail. The regular distributing and collecting system will be placed on an hourly basis. Within a few days a buzz system communicating with the orderlies will be installed.

    3. Incoming and outgoing baskets (so labeled) will be maintained in each office.

    4. Central correspondence files will be maintained in room No. 1. Consolidation of the American Expeditionary Forces and Services of Supply files is under way, as a result of which a single system of numbering will be provided.

    5. A central mailing section (receiving and dispatching) will be maintained in room No. 6. Both incoming and outgoing mail will be cleared through the office of Major Dickson.

    When action takes the form of an indorsement to original papers which leave the office, necessary copies of the indorsement for file purposes will be prepared. In addition, the office making the indorsement will prepare an abstract of the original papers wherever the indorsement does not fully explain the nature and basis of the action taken. This abstract will be detached in the file room. Such abstracts should be very brief and prepared only for important papers.

    7. Half sheets should be used for correspondence or memorandum purposes whenever possible; but nothing smaller than half sheets. The use of smaller pieces of paper causes confusion in the filing.

    8. Telegrams will proceed through the regular correspondence channels of the office except that an identifying number will be assigned and a brief record made in the mail room as prescribed by Services of Supply circular.

    9. The typing of envelopes in the office where correspondence originates will be discontinued beginning Thursday morning, March 28, 1918. Envelopes will be addressed in the central mailing room, where an official list of stations and addresses will be kept. As prescribed by regulations, each communication will contain the official address of the station to which it is sent.

    10. A central stenographic section will be maintained (rooms 20 and 21). Any officer desiring additional stenographic service will make informal request upon the clerk in charge of this section. This section will furnish the mimeograph and multigraph service for the chief surgeon's office.

    11. Cablegrams to the United States will be dictated direct to the official cable clerk. This clerk can be reached at any time in room No. 20.

    12. Office supplies will be issued from the property room between the hours 8 a. m. and 10 a. m. each day. An issuing clerk will be on duty during those hours. The orderlies


    917

    will replenish the supply of ink in the several offices as the need arises. Informal requests, verbally or in writing, for other office supplies should be made upon the issuing clerk during the hours mentioned.

    13. Commander in chief, G-1, to commanding general, First Corps, under date of March 22, 1918, states:

    It has been decided to designate the senior staff officer of each division as "division adjutant," "division inspector," "division ordnance officer" "division signal officer," "division veterinarian," instead of "inspector general," "judge advocate," "chief quartermaster," "chief surgeon," "chief ordnance officer."

    The title "division surgeon" will be used instead of "chief surgeon" in all official designations of the senior medical officer of Infantry divisions.

       A. E. BRADLEY,
      Brigadier General, N. A., Chief Surgeon.


    Circular No. 16.

       AMERICAN EXPEDITIONARY FORCES,
    HEADQUARTERS, SERVICES OF SUPPLY,
    OFFICE OF THE CHIEF SURGEON,
    France, March 28, 1918.
     
     
    I

    The following extract from a letter, Surgeon General's office, dated February 25, 1918, is published for the information and guidance of medical officers of the American Expeditionary Forces:

    1. * * * It is requested that whatever steps are necessary be taken to carry out the plans laid down in the Manual of the Medical Department, which provide that pathological specimens of military interest be forwarded through regular channels to the Army Medical Museum accompanied by complete histories.

    2. In turn, the Army Medical Museum will distribute all duplicate specimens and parts of specimens, together with the clinical histories, to teaching institutions throughout the United States, both in and out of the service. Since all medical students above those in the first year are now in the Enlisted Men's Reserve Corps, every teaching medical institution becomes for all practical purposes a part of the service, and it is desirable to secure an equitable distribution of material for teaching purposes.
     II

    To Medical Department personnel: 1. The Assistant Auditor for the War Department has stated that he sees no objection to quartermasters paying civilian employees of the Medical Department from quartermaster funds, provided the civilian employees payable from Medical Department funds are vouchered on separate rolls, and the Medical Department appropriation to which chargeable is clearly shown thereon, and that such rolls are entered on the abstract of disbursements under the same medical appropriation as is shown on the voucher. Under this decision, it is possible for quartermasters at all base hospitals to make the necessary payments to all civilian employees of the Medical Department on the approval of the pay roll by the commanding officer of the hospital, which action the commanding officer is authorized to take.

    Another method of ready payment to civilian employees of the Medical Department lies in making the payment from the hospital fund, if there be enough on hand. A notation to the effect that the payment was made from the hospital fund should be made upon the voucher by the paying officer, and the voucher subsequently forwarded to medical disbursing officer, who will draw one check for the whole amount payable to the hospital fund, noting on the check the object for which drawn and on the pay voucher the number and other data of the check.

    2. Recent arrangements with the French central authority provide that notifications of property shortages occurring in official shipments should be made immediately upon the discovery of the shortage of the local chef de gare of the railroad company concerned. It is, of course, necessary that immediate action should be taken upon the receipt of a shipment


    918

    to determine whether shortages are existant, in order that no allegation may be lodged that the property was received in good condition, and the abstractions subsequently made at the point of receipt. The fact that the report has been made to the chef de gare should be reported to the chief surgeon, American Expeditionary Forces, along with the report of shortages.

    3. Commutation for allied patients in hospital.-The commutation for patients of this class has now been determined to be 60 cents a day, where commissary privileges are available and 75 cents a day, where such is not the case. Under these conditions, it will not be necessary to draw the additional 20 cents from the Red Cross, as heretofore authorized. This change becomes effective from April 1, 1918, and after that date the 60 cents allowed will be drawn as the entire compensation to the hospital fund for both officer and soldier patients of the allied armies.

    III

    1. The attention of all medical officers commanding hospitals and Medical Department detachments is called to the importance of carrying out closely all the details of military administration required by existing regulations, orders, and customs of the service, to the end that their commands may at all times be ready to pass with credit the inspection of superior officers.

    2. Cases of neglect or slackness in carrying out ordinary measures of discipline, administration, and sanitation having been brought to the notice of the chief surgeon special emphasis is here given to the following points: Discipline and administration-the reveille and check roll calls are to be invariably observed in every hospital and detachment; the weekly formation and inspection of the detachment must never be omitted and military drill for all available men of the Medical Department will be held as often and to as great an extent as circumstances permit, with the object that every soldier may present a well-poised, alert, and soldierly appearance.

    A correct military bearing of officers, nurses, and soldiers must be insisted upon and the personnel should be instructed in forms of military address, manner of saluting, standing at attention, and all the fine points of military etiquette. Correct uniform properly worn and neatness of person and clothing should be required of all members of the command.

    3. Sanitation.-Details of sanitation for the maintenance of a clean hospital are only to be carried out properly by frequent and patient instruction to subordinates, by officers and noncommissioned officers responsible for the care of the wards, mess rooms, kitchens, and other parts of the hospital.

    Attention to the personal cleanliness of the convalescent patients as well as those in bed should be given.

    Garbage unless entirely removed from vicinity of the hospital should be destroyed by incineration, and excreta, in the absence of a sewer system, should be burned if possible.

    Cleanliness and order will render even a primitive and extemporized hospital attractive, but slovenliness and disorder will spoil the efficiency of the best-equipped institution. To utilize to the utmost advantage the often imperfect buildings and equipment which war conditions impose, is the ideal to be striven for and this ideal is only to be approached by unremitting attention to the small details of discipline, management, and sanitation.

      A. E. BRADLEY,
    Brigadier General, N. A., Chief Surgeon.


    Circular No. 17.

    AMERICAN EXPEDITIONARY FORCES,
       HEADQUARTERS, SERVICES OF SUPPLY,
    OFFICE OF THE CHIEF SURGEON,
      France, April 2, 1918.

    INSTRUCTION CONCERNING AUTOPSIES

    In order to secure proper records of causes of death of American troops in France, and specimens of scientific value for the Army Medical Museum, the following procedures concerning autopsies will be followed:


    919

    1. Autopsies are authorized in all cases of officers and soldiers, and should be performed whenever possible. These autopsies shall be performed only by medical officers or authorized assistants. At the conclusion of the autopsy the body must be restored, as far as possible, to its original form.

    2. The blank form supplied for the autopsy protocol indicates in general the order and extent of the examination as well as the order to be observed in completing the final record. The protocol is also to be used for recording preliminary notes when complete dictation at the post-mortem is not possible. It is not to be used for the final record.

    3. The headings on the protocol are to be filled out in every case and transferred in the same order to the final record.

    4. Clinical data should include only such essential facts as date and nature of wound or first symptoms, length of stay in hospital, operative procedures, clinical course and diagnosis.

    5. Weights and measurements should be indicated by the metric system.

    6. In performing the post-mortem attention should be directed when possible, not only to the condition primarily responsible for death but also to evidence of previous disease (tuberculosis, syphilis, etc.) and to all anomalies of development.

    7. Bacteriological examinations, when indicated, should be undertaken and the results appended to the final record.

    8. When necessary to perfect the diagnosis, tissues for microscopic examination should be removed and preserved in 10 per cent formal or other suitable fixative.

    9. Gross specimens suitable for museum purposes are to be removed and preserved in 10 per cent formal. Such specimens are to be sent to the central Medical Department laboratory, A. E. F., as soon as possible, for eventual transference to the Army Medical Museum. Each specimen must have attached an identification tag with name and organization of patient, date, diagnosis of specimen, and name of sender. In case special tags for this purpose are not available, an ordinary label protected by dipping in melted paraffin may be used. For further details as to handling gross specimens, see supplement to section 135, Manual of the Medical Department.

    10. At the earliest possible moment following the examination, a complete record should be made. In addition to the required copies, one copy is to be sent to the central Medical Department laboratory, A. E. F. If additional bacteriologic, microscopic, or other data are obtained, additional reports will be made in the same manner, in each report repeating the name, rank, and organization of the case.

    A. E. BRADLEY,
    Brigadier General, Chief Surgeon.


    Circular No. 18.

       AMERICAN EXPEDITIONARY FORCES,
    HEADQUARTERS, SERVICES OF SUPPLY,
      OFFICE OF THE CHIEF SURGEON,
       France, April 3, 1918.

    1. In order that patients and Medical Department personnel in mobile sanitary formation and evacuations hospitals located in the one of the advance may be prepared for gas defense in emergencies, the following instructions are issued to responsible medical officers concerned:

    (a) The gas mask of each incoming patient should be separated from his other equipment, and kept at the head of his bed.

    (b) To supply such patients as are admitted without proper gas defense equipment, requisitions should be made on the proper officers for a reserve supply of masks, based on 20 per cent of the maximum bed capacity.

    (c) The personnel of these units should be equipped with masks and instructed in the necessary routine gas defense measures.

    (d) The commanding officer of each unit should so organize and drill the personnel as to insure the quick adjustment of gas masks to patients, especially to those patients who are more or less helpless, in the event of an alarm being given.


    920

    (e) The plan to be prescribed for announcing the gas alarms is left to be determined by the commanding officer concerned.

    (f) Paragraph 3, General Orders, No. 25, A. E. F., chief surgeon, prescribes that all military equipment of a soldier be forwarded with him when he is transferred to a hospital. This equipment includes gas masks. Should patients be received at hospitals in appreciable numbers without this equipment, report of same, particularly giving the soldier's organization, will be made to this office for the action of the commander in chief.

    A. E. BRADLEY,
      Brigadier General, Chief Surgeon.


    Circular No. 19.

    AMERICAN EXPEDITIONARY FORCES,
    OFFICE OF THE CHIEF SURGEON, SERVICES OF SUPPLY,
    France, April 4, 1918.

    1. Accountable office for Medical Department transportation.-There seems to be some misunderstanding by organizations in the different sections regarding the accountable office for Medical Department transportation in France.

    M. S. D. No. 3 is the only accountable office for Medical Department motor transportation.

    Motor ambulances and motor cycles with and without side car are Medical Department transportation; touring cars and trucks are Quartermaster Department property, and memorandum receipts for the latter should not be sent to M. S. D. No. 3.

    2. Charging excess leave against nurses under General Order No. 6.-The commanding officers of base hospitals where nurses are stationed will take care that no excess leave is charged against nurses who are granted leave under General Order No. 6, general headquarters, A. E. F., c. s. Several instances have occurred where nurses have been charged on efficiency reports and returns of Nurse Corps with the time taken going to and returning from the places where leave was spent. Attention is invited to the provisions of paragraph 7, General Order No. 6.

    3. Shoes for distribution to Medical Department personnel.-The quartermaster has in storage a certain number of shoes without hobnails, for distribution to Medical Department personnel serving in base and camp hospitals. Requisition therefor should be made asking specifically for special shoes for base hospitals.

    4. Care of unwounded cases of gas poisoning.-The dangerous results of poisoning by irritant gases are essentially limited to their effects on the respiratory tracts, and all such cases should be under careful medical supervision in view of the danger of pulmonary edema and pneumonia. It is directed therefore that all unwounded cases of gas poisoning be placed in the medical wards of the hospitals to which they are admitted. Such burns as occur from mustard gas poisoning may be readily treated in medical wards.

    A. E. BRADLEY,
    Brigadier General, N. A., Chief Surgeon.


    Circular No. 20.

    AMERICAN EXPEDITIONARY FORCES,
      OFFICE OF THE CHIEF SURGEON, SERVICES OF SUPPLY,
    France, April 12, 1918.

    1. White clothing for hospital attendants.-So much of paragraph 8, Circular No. 9, office chief surgeon, A. E. F., February 7, 1918, as provides for the wearing of white cotton coats and trousers by enlisted attendants in wards is changed to provide for the wearing of blue dungarees under the conditions named. Requisitions on the Quartermaster Department for clothing to be worn on ward duty will specify the blue dungaree, instead of white clothing.  The Quartermaster Corps has made provision for the supply of white clothing for cooks; and requisitions may specify this class of clothing for this class of personnel.

    2. Red Cross allowance for soldiers of allied armies in United States hospitals.-So much of paragraph 1, Circular 10, office chief surgeon, A. E. F., March 4, 1918, as provides for the


    921

    payment of 20 cents per diem by the Red Cross is rescinded. Quartermasters are paying 60 cents per diem for subsistence of allied patients, or 75 cents as the situation may demand, dependent upon the presence or absence of commissary facilities. No voucher for Red Cross subsistence, therefore, will be rendered in the future, the cost of allied patients being collected from the quartermaster in the same way that it is collected for patients of our own Army.

    3. Manual, sick and wounded reports.-A manual dealing with the sick and wounded reports and returns for the American Expeditionary Forces, and with the methods of preparing the same, will be issued shortly from the office of the chief surgeon, A. E. F., Services of Supply.

    It is desired that every medical officer of the American Expeditionary Forces and all medical officers arriving hereafter in France and England be furnished a copy of this manual.

    Copies will be sent to division surgeons, section surgeons, and commanding officers of camp, evacuation, and base hospitals, who will immediately distribute them to each officer of their command.

    Sufficient copies to supply all incoming medical officers will be sent to surgeons of ports of debarkation, who will be responsible for their distribution.

    Instructions for obtaining the blank forms prescribed for the new system will be issued later.

    4. Splint repair shop at Dijon.-The Red Cross has installed a splint repair shop at Dijon for the purpose of repairing the ironwork of splints and re-covering the splints.

    All organizations having broken splints in sufficient quantities to make a case will ship to the Croix Rouge Americaine entrepôt, gare Dijon Ville (Cote d'Or), cases to be plainly marked "For splint repair shop."

    A. E. BRADLEY,
    Brigadier General, N. A., Chief Surgeon.


    Circular No. 21.

    APRIL 13, 1918
     
     
    SUPPLY AND DISTRIBUTION OF BIOLOGICAL PRODUCTS (HUMAN)
    1. The following standard biological products are available for issue to Medical Department units of the American Expeditionary Forces:

    (a) Bacterial vaccines.-Triple typhoid vaccine-typhoid, para "A," and para "B" (1 c. c., 5 c. c., 10 c. c., and 25 c. c. ampules).

    (b) Serological products.-(l) Sera, agglutinating for diagnosis:

    Typhoid.
    Paratyphoid A.
    Paratyphoid B.
    Dysentery, Flexner.
    Dysentery, Shiga.
    Dysentery, Y.
    Cholera.
    Malta fever.
    Gas gangrene (B. welchi).
    Pneumococcus Type I.
    Pneumococcus Type II.
    Pneumococcus Type III.
    Meningococcus, polyvalent.
    Meningococcus, normal.
    Meningococcus, intermediate A.
    Meningococcus, intermediate B.
    Parameningococcus.

    The diphtheria toxin unit for applying the Schick test will be issued to meet special indications. 

    (2) Sera, therapeutic and prophylactic:

    Antimeningococcus serum, polyvalent (15 c.c. bottles).
    Antistreptococcus serum (50 and 100 c. c. bottles).
    Antipneumococcus serum, polyvalent (50 and 100 c. c. bottles).
    Antipneumococcus serum, Type I (50 and 100 c. c. bottles).
    Diphtheria antitoxin (bottles containing 1,000 and 10,000 units).
    Tetanus antitoxin (bottles containing 1,000, 1,500, 3,000, and 5,000 units).
    Normal horse serum.

    2. In view of the well-known instability of these products unless kept under very special conditions, to avoid wastage, and to insure prompt distribution, reserve supplies of


    922

    these products will be kept on hand only at the laboratories mentioned below. It is not contemplated that a supply greater than a reasonable amount to meet actual emergencies be kept on hand in other Medical Department units.

    Central medical department laboratory, advance section, Services of Supply, A. P. O. No. 721.

    Army laboratory No. 1, advance section, Services of Supply, A. P. O. No. 731.

    Base laboratory, base section No. 1, headquarters base section No. 1, Services of Supply, A. P. O. No. 701.

    Base laboratory, base section No. 2 (Base Hospital No. 6), headquarters base section No. 2, Services of Supply, A. P. O. No. 705.

    Base laboratory, base section No. 5, headquarters base section No. 5, Services of Supply, A. P. O. No. 716.

    Base laboratory, intermediate section, Services of Supply, headquarters Services of Supply, A. P. O. No. 717.

    Laboratory, American Red Cross Military Hospital No. 2, Services of Supply, A. P. O. No. 702.

    3. Hereafter, biological products will be obtained from the commanding officer of the nearest designated distributing center by telephonic or telegraphic request. In emergency, deliveries will be made by motor-cycle courier whenever necessary and feasible. In instances where travel by train would be in the interest of economy and would not result in delay in delivery, the commanding officers of the laboratories designated above are authorized to dispatch couriers by train to make the deliveries.

    4. The designated distributing centers are so located that deliveries, as a rule, can be made to any Medical Department unit of the American Expeditionary Forces within a few hours. The geographical location of these laboratories can be ascertained by application to the headquarters in which the medical unit is located.

    5. It is not deemed advisable to furnish therapeutic antipneumococcus serum except to hospitals that are prepared to make pneumococcus type determinations. Whenever the disease assumes epidemic proportions, special laboratory personnel and equipment will be detailed to handle the situation.

    6. Requests for special biological products will be made directly to the director of laboratories, A. E. F., A. P. O. No. 721, indicating the necessity for their use. The director of laboratories and the commanding officers of laboratories designated as distributing centers are authorized to modify requisitions whenever the demands are manifestly in excess of actual requirements or when the biological products requisitioned for are of such a nature as to require careful laboratory control in their administration and it is definitely known that such laboratory facilities are not available.

    7. Additional distributing centers will be designated as necessity for their establishment arises. 

      A. E. BRADLEY,
      Brigadier General, N. A., Chief Surgeon.


    Circular No. 22.

    AMERICAN EXPEDITIONARY FORCES,
      OFFICE OF THE CHIEF SURGEON, SERVICES OF SUPPLY,
    France, April 17, 1918.

    1. The attention of all medical officers is again called to the extreme importance of bodily cleanliness and freedom from vermin throughout the troops of the American Expeditionary Forces. The following notes are furnished for the information and guidance of all concerned:

    Scabies and lousiness, with their resulting inflammations and scratch infections of the skin; also trench fever, due to lice, bid fair to cause more ineffectiveness than any other disease or disease group in the American Expeditionary Forces.

    The experience of the British is well summarized in the lectures of Major McNee and Captain Parkinson:

    Trench fever, scabies, inflammatory processes in the skin such as boils and furuncles (the pyodermias), etc., caused 90 per cent of all diseases in the British armies in France in the summer of 1917. (Major McNee.)


    923

    At the head of the diseases which actually cause loss of efficiency is scabies, and its frequent sequelæ, impetigo, and ecthyma. Impetigo means a loss of 10 to 12 days at the base, and scabies means a loss of 50 per cent of a man's efficiency from loss of sleep by itching and scratching. Nearly all cases of fever of unknown origin (F. U. O.) are accompanied by lice. This F. U. O. is a serious cause of sick wastage among the English. (Captain Parkinson.)

    Sanitary reports from our own divisions, and from numerous scattered organizations in France, indicate that infestation with lice and scabies is widespread, in some large commands as many as 75 per cent of the men being infested.

    The steady and heavy demand at dispensaries and regimental infirmaries for ointment to relieve itching indicates that there is a great mass of infestation which is not recorded on sick report.

    Sanitary reports should show the incidence of scabies and the extent of the louse infestation. The causes of infestation should be indicated and measures necessary to correct the condition recommended. The remedial action taken must be invariably recorded.

    Advantage should be taken of the opportunity to inspect the person and clothing of the command at the semimonthly inspection for venereal diseases, as specified in M. M. D. 1917 (par. 198-c, p. 75). General bodily cleanliness and cleanliness of underclothing are quite as much an evidence of good military discipline and adequate medical service as is a low rate for venereal infection.
     

     * * * * * * *

    HINTS FOR DIAGNOSIS AND TREATMENT
     All scratch marks, complaints, or evidence of itching, or "pyodermias" should be considered as due to scabies or lice until proved to the contrary.

    Although in civil life the characteristic distribution of scabies is between the fingers and and on the anterior surface of the wrists, the site of infestation among our troops, even when severe, may be exclusively beneath the clothing, and must be sought by thorough inspection of the genitals, the buttocks, the belt line, the arm pits, and behind the knees.

    The characteristics lesions of scabies, in addition to the burrow in the skin, are papules, superficial crusted ulcerations  (often called impetigo and ecthyma), and in severe cases extensive areas of dermatitis resembling eczema and furunculosis. These secondary lesions may predominate and conceal all burrows. The Acarus scabiei, or itch mite, can not usually be found. The scratching in scabies usually does not tear the skin deeply nor form linear welts, in spite of the intensity of the itching.

    Body lice, on the contrary, are more generally distributed over the body and are to be found commonly on the hairy parts and in the body creases and where the clothing is tight, and it is in these regions that the long deep linear scratches are found. Lice and nits are to be sought for and can be readily seen in the seams of the clothing.

    Prevention of general infestation of men and their clothing can be assured by the discovery of early cases, through careful inspection and accurate diagnosis, and the instant removal of the patients and their possessions from barracks or billets, to avoid the general infestation of quarters. All men should be questioned as to itching of the skin, and no complaint considered too trivial to investigate.

    The treatment of scabies requires prolonged scrubbing of the entire body with hot water and a generous soap lather, followed by thorough inunction with sulphur ointment. Clean underclothing must be put on after each such treatment to avoid reinfestation.

    A complicating eczema or furunculosis may prevent the above radical treatment of scabies until the secondary lesions are controlled, but then the scabies must be treated as above.

    Thorough hot water and soap bathing will free the body from lice, but the lice and nits in the clothing and blankets must be destroyed, preferably by dry heat, at the same time in order to prevent immediate reinfestation.

    Every medical officer in the American Expeditionary Forces will be expected to give his personal attention to the prevention and treatment of scabies and louse infestation in the command for which he is responsible.

      A. E. BRADLEY,
      Brigadier General, N. A., Chief Surgeon.


    924

    Circular No. 23.

      FRANCE, April 22, 1918.

    1. Payment of civilian employees by quartermaster.-Whenever payment of civilian employees is made by the quartermaster under the method laid down in paragraph 1, section 2, Circular No. 16, this office, a true copy of the roll as paid will be sent to this office, through the section surgeon, by the commanding officer of the hospital concerned.

    2. Repair of surgical instruments and typewriters.-The surgical instrument repair shop is now ready to repair surgical instruments and typewriters at U. S. A. P. O. No. 702. When articles need repair they should be sent to the repair shop or turned into the nearest supply depot, dependent upon the relative distance of the depot and repair shop from the point where the instruments or typewriters are held. It will often be advisable to send instruments of precision and of delicate makeup by special messengers, and authority should be obtained for their transportation from the nearest headquarters authorized to order the travel.

    3. Ordre de transport for movements made by hospital trains.-Copies of those orders which are furnished to train commanders for each trip made by their trains should be retained until the end of the month, at which time they should be forwarded to this office, where they are checked against the journey reports and forwarded to the chief quartermaster, Services of Supply.

    4. Return of blankets to hospital trains.-Hospital trains have been unnecessarily delayed at base hospital awaiting the return of blankets delivered by them with patients. These blankets are to be returned with expedition in order to avoid delaying the trains.

    5. Report of French patients in American military hospitals.-Hereafter when French military patients are admitted to or discharged from American military hospitals, notification of the fact will be sent immediately to the Service de Sante, No. 1, Rue Lacretelle, Paris, on Form 52, Medical Department. The data on the report card will show the name, number, rank, and organization of the patient, the diagnosis, whether or not the disability was incurred in line of duty, and the designation of the hospital to which he was admitted or from which discharged. Information in this form is strictly for the use of the French, and no duplicates of these cards shall be sent to the chief surgeon's office, A. E. F. The monthly list of French patients in American Expeditionary Forces hospitals, giving the above data, will be continued.

    6. Discontinued medical forms.-Forms 83 and 85, Medical Department, and so much of Form 84, Medical Department, as applies to daily field report of patients, are discontinued.



    Circular No. 24.
    AMERICAN EXPEDITIONARY FORCES,
       France, April 23, 1918.

    Disability boards passing upon mental and nervous cases under section I, General Order No. 41, general headquarters, A. E. F., March 14, 1918, will, as far as practicable, be governed by the following considerations.
     

    GENERAL
     In dealing with these cases, there should be borne in mind their chronicity, the probability of recurrences or acute episodes in constitutional disorders, and the bearing which abnormal mental states have upon questions of responsibility. The special mental stresses of modern warfare and the fact that the safety of many soldiers often depends upon the conduct of one of their number should be given due weight in considering the fitness of men with mental or nervous diseases for service at the front. At the same time the importance of utilizing, in any safe and suitable way, the services of men partially incapacitated should not be overlooked. The essential question for boards to decide is usually whether, taking all the facts into consideration, the individual before them will be an asset or a liability to the Expeditionary Forces. Whenever possible a psychiatrist or a neurologist should act as one member of a board passing upon mental cases.


    925


     

    PSYCHOSES (INSANITY, MENTAL ALIENATION, MENTAL DISEASES)

    All officers and enlisted men in whom frank psychoses exist should be marked "D" and returned to the United States as soon as this can be done without injury or endangering their chances of recovery. It will often be advantageous to hold these cases in the psychiatric departments of base hospitals at base ports until acute and severe manifestations have passed or, in cases of an especially favorable type, until recovery has taken place, but it should not be made the practice to provide extended treatment in hospitals of the American Expeditionary Forces.

    In exceptional cases where it seems desirable to depart from the rule of returning to the United States soldiers who have or who have had psychoses, the patients may be classified "B," and the special considerations which make a departure from the rule desirable must be noted on the report card.

    MENTAL DEFICIENCY (FEEBLE-MINDEDNESS, DEFECTIVE MENTAL DEVELOPMENT)
     The existence of a readily demonstrable degree of mental deficiency should almost invariably be sufficient reason for not classifying soldiers as "A," but it should by no means be regarded as sufficient reason in itself for placing them in class "D." In recommending mentally defective soldiers for duty in labor organization at the rear, especial weight should be given to good physique, emotional stability, and freedom from such delinquent traits as alcoholism, dishonesty, nomadism, and the like. Military delinquents, of whom the mentally defective constitute a large proportion, are a source of almost as much noneffectiveness as illness, and it is important that the Expeditionary Forces should not be burdened with their care and supervision. Defective delinquents should always be classified "D."

    CONSTITUTIONAL PSYCHOPATHIC STATES
    In making recommendations as to the disposition of soldiers found to have constitutional psychopathic states, the considerations mentioned under the preceding heading should govern. It should be remembered that many individuals with volitional defects are amenable to military control. Conditions which should usually indicate the wisdom of returning these cases to the United States are marked emotional instability, sexual psychopathies (homo-sexuality, etc.), paranoid trends, and specific criminalistic traits. These cases should be classed "D." Excessive fear or timorousness should prevent return to duty at the front. For military reasons it is especially undesirable, however, to return such cases to the United States. They should be recommended for duty in labor organizations and marked "C."
     
     EPILEPSY
    Epileptics should be classed as "D," the only possible exceptions to this rule being individuals in robust physical health who have attacks of moderate severity at long intervals and those in whom treatment has had this result.

    In making the diagnosis of epilepsy the fact should be borne in mind that attacks are likely to be less frequent in the favorable environment of the hospital while observation is being carried on than in the organizations from which patients are received. Great weight should be given to a well-authenticated history of epileptic seizures, especially when witnessed by medical officers or other persons who can give a clear account of their character. While the possibility of malingering should not be overlooked, it should be remembered that attacks similar to those in epilepsy are much more frequently psychoneurotic in their nature than feigned. The high prevalence of epilepsy among soldiers should be remembered.

    DRUG ADDICTION AND ALCHOLISM
    These conditions are essentially curable. Inebriates and drug addicts should not be recommended for return to the United States with a view to their discharge until they have failed to respond to adequate treatment. Then, their disposition should depend upon the type of personality presented, the effects of alcohol or drugs in physical deterioration or damage to the central nervous system, and the conditions to which they will be exposed when they are returned to duty. It will often be found that these cases do better at the front than in duty at the rear.



    926


      

    PSYCHONEUROSES (HYSTERIA, NEURASTHENIA, PSYCHASTHENIA)


    These conditions must be dealt with as disorders amenable to treatment under proper conditions. Individuals who fail to benefit from such treatment in the special hospital which has been provided, either because of severe defects in make-up or on account of previous mismanagement, should be returned to the United States for continued treatment unless it seems likely that good results can be obtained from their assignment to duty at the rear. A very large proportion of the severe neuroses seen in war are of the "situation type," rather than psychoneurotic manifestations in persons who have had many previous episodes of the same kind in civil life.

    A. E. BRADLEY,
      Brigadier General, N. A., Chief Surgeon.


    Circular No. 25.
      AMERICAN EXPEDITIONARY FORCES,
    France, May 5, 1918.
     
     ORGANIZATION OF PROFESSIONAL SERVICES, MEDICAL DEPARTMENT, A. E. F.

    There has been appointed, by General Order No. 88, general headquarters, A. E. F. June 6, 1918, for the Medical Department:
     

    A director of professional services, A. E. F.;
    A chief consultant, surgical service, A. E. F.;
    A chief consultant, medical service, A. E. F.;
    Senior consultants in special subdivisions of surgery and medicine;
    Division specialists; and
    Consultants for base hospital centers and other formations.

    In order to utilize the professional services of the specialists of the Medical Department, A. E. F., in a manner which will best facilitate complete coordination between forces from front to rear, the following instructions are issued:

    Director of professional services.-The director of professional services, under the hospitalization division of the office of the chief surgeon, will supervise the professional activities of the Medical Department, A. E. F., and coordinate the work of the consultants and specialists of the Medical Department.

    Chief consultants.-The chief consultant, surgical service, will supervise the professional surgical subdivisions in the American Expeditionary Forces. He will organize and coordinate these divisions in a manner which will permit him to anticipate, as far as possible, necessary changes in personnel so that timely requests for such changes may be made. He is responsible for the proper formations of the surgical teams in the American Expeditionary Forces, and those attached to the units of the Allies, and he will keep lists and records of the teams whereby the amount and the efficiency of their work may be checked. For this purpose he will require from each surgical team suitable monthly reports of the number of operations performed and the results obtained. He will make such recommendations as he may deem necessary for inspections as to technical procedure and instruction, details of operating surgeons, details to surgical teams, and appointment of surgical consultants in the American Expeditionary Forces.

    The chief consultant, medical service, will supervise all medical subdivisions in the American Expeditionary Forces, and will make such recommendations as may be necessary to insure a high professional standard and complete harmony among his assistants functioning in all formations.

    Senior consultants.-Under supervision of the director of professional services and the chief consultants in surgery and in medicine, senior consultants of the special subdivisions of medicine and surgery will coordinate professional activities relating to their specialties.

    They will make such recommendations to the chief consultant as are deemed necessary for the instruction of consultants and specialists in divisional and other army formations, in order that prompt execution of directions relative to professional subjects may be assured.

    Senior division consultants.-One senior medical and one senior surgical consultant will be assigned to all tactical organizations which are the equivalent of one army corps, and



    927

    consultants wlll be appointed in such numbers as may be necessary to assist the senior division consultants. Senior division consultants will hereafter be responsible for the duties now being performed by the division consultants.

    The senior division surgical consultant, under the chief surgical consultant, A. E. F., will be expected to make at frequent intervals a complete survey of the professional instruction, surgical technique, and the methods of treatment in use in the division, and he will render from time to time such reports and recommendations to the chief surgical consultant, A. E. F., as will promote a free interchange of suggestions and the most effective coordination with the other professional services.

    He will supervise the professional activities of all consultants, operating teams, and operating surgeons attached to his division, in a manner which will permit him to familiarize himself with the individual capabilities of the men, with a view to selection, based on observation, of those likely to adapt themselves to modern military surgical teams formations, rather than individual work.

    He will be responsible for the organization, effeciency and distribution of surgical teams, and he will make such recommendations to the chief surgical consultant, A. E. F., as will facilitate the formation of sufficient teams to meet the constantly increasing demands incident to the arrival in France of new formations.

    The senior divisional consultant will also coordinate the activities of the professional personnel in his divisions in a manner that will be conducive to high surgical standards, and elimination or reassignment to other duties of those who fall below the requirements. He will spare no effort to promote professional harmony and unity of treatment in the divisional formations.

    Senior divisional medical consultants.-The senior divisional medical consultant will, by frequent inspections, satisfy himself that the various classes of patients suffering from medical disabilities are receiving the best and most advanced treatment possible. He will report from time to time to the chief medical consultant, A. E. F., the results of his inspections, and make suggestions looking toward the perfection of the medical services of the American Expeditionary Forces.

    Divisional surgical consultants.-The divisional surgical consultant will, under the senior divisional surgical consultant, supervise the immediate surgical activities of operating teams within his division. During mobile or semimobile warfare, when established evacuation hospitals are absent, the operative work, in formations for nontransportable cases, will be handled, when practicable, by surgical teams functioning under the supervision of the senior divisional surgical consultant, or his assistant.

    Divisional medical consultants.-Divisional medical consultants will supervise the immediate medical activities in the division to which they may be assigned.

    Relation of the division surgeon to senior division surgical consultants and consultants functioning with divisions.-The many details of organization and administration which will devolve upon the division surgeon, in the care of sick and wounded and their evacuation, will so tax his time and ability that it is not believed that the supervision of the technical surgical work, which at times must be done in divisional formations, should be added to his already serious responsibilities; therefore, the direction and supervision of the purely operative side of the work done in divisional formations is placed upon the senior divisional surgical consultant, or his assistants.

    The division surgeon will supply the necessary hospital facilities, supplies, and personnel other than those forming teams. He will spare no effort in technical cooperation which may promote harmony of action between the professional services with the fighting forces, from the front to the rear.

    Division specialists.-One orthopedic surgeon, one urologist, and one neuropsychiatrist will be appointed from the division sanitary personnel, and, under the direction of the divisional chief surgeon, they will perform the duties pertaining to their several specialties, in addition to the other duties of medical officers which may be required of them by the exigencies of the service.



    928

    Consultants for base hospital centers.-Upon the recommendation of the chief surgical and medical consultants, A. E. F., there will be appointed for base hospital groups such consultants as may be necessary from time to time. These consultants will at all times be within reach of the base hospital group to which they are attached.

    The organization of base and general hospitals and other hospitals, as far as practicable will be made on the basis of three services-surgical, medical, and laboratory-each composed of sections coordinated through a chief of service designated by the commanding officer, who may be selected from any section, ability and experience being the determining factors. In detail, the professional services of hospitals are divided according to the following:
      

    ORGANIZATION OF BASE AND GENERAL HOSPITALS 


       Surgical services.
    Chief of service.
    First section. General surgery (general, chest, abdomen fractures).
    Second section. Orthopedic surgery.
    Third section. Urology.
    Fourth section. Head surgery (brain (also neurological); ear, nose, and throat: eye; oral, face and mouth).
    Fifth section. Roentgenology.
    Sixth section. Dentistry.
       Medical services.
    Chief of service.
    First section. General medicine.
    Second section. Neurology.
    Third section. Psychiatry.
       Laboratory services.
    Chief of service.
    First section. Pathology.
    Second section. Bacteriology and serology.
       Circular No. 2 of this office, November 9, 1917, is hereby revoked.

    M. W. IRELAND,
      Brigadier General, U. S. A., Chief Surgeon.
     AMERICAN EXPEDITIONARY FORCES

    Director Professional Services
    Chief Consultant, Surgical Service
    Chief Consultant, Medical Service


    ARMY
     

    Senior consultant, surgery, A. E. F.:

    Senior consultant, medicine, A. E. F.:

    1 general surgery.

    1 general medicine.

    1 orthopedic surgery.

    1 neuropsychiatry.

    1 urology and dermatology.

    1 formations, equivalent to an army corps.

    1 eye.

    2 consultants (assistants to division senior consultants).

    1 ear, nose, and throat.

    (Others as required.)

    1 neurological surgery.

    1 maxillofacial surgery.

    1 Roentgenology.

    1 research.

    1 formations, equivalent to an army corps 

    4 consultants (assistants to division senior consultants).


     

     

    929


     

    (Army corps)
      
     

    DIVISION

    Specialists: Each tactical division

    (A part of division sanitary personnel, Tables of Organization)

    Surgery:

    Medicine:

    1 orthopedic surgery.

    1 neuropsychiatrist.

    1 urology.

    HOSPITAL CENTERS

    Consultants, medicine (each hospital center, Services of Supply):

    Consultants, surgery (each hospital center, Services of Supply):

    1 general medicine.

    1 general surgery.

    1 neuropsychiatry.

    1 orthopedic surgery.

    (Others as required)

    1 urology and dermatology.

    1 eye.

    1 neurological surgery.

    1 ear, nose, and throat.

    1 maxillo-facial surgery.

    1 Roentgenology.

    SERVICES OF SUPPLY

    Specialists: Each base hospital

    (Part of unit personnel)

    Surgery (as needed):

    Medicine (as needed):

    General surgery.

    General medicine.

    Orthopedic surgery.

    Psychiatry.

    Urology and dermatology.

    (Others as required.)

    Neurological surgery.

    Eye.

    Ear, nose, and throat.

    Roentgenology.

    Maxillo-facial surgery.

    Circular No. 26.

      AMERICAN EXPEDITIONARY FORCES,
      France, May 4, 1918.

    1. Requisitions for medical supplies for army troops.-So much of Circular No. 12, office chief surgeon, A. E. F., March 6, 1918, as conflicts with the procedure prescribed in paragraphs No. 27 and No. 29, General Order No. 44, general headquarters, A. E. F., March 23, 1918, is rescinded. Organizations of the Medical Department serving with a division, corps, or army will hereafter obtain medical supplies in the manner prescribed by the general order and paragraphs cited. A combined packer 's list and invoice will be furnished the receiving officer.

    2. Shipments to Medical Department repair shop No. 1.-In connection with paragraph 2, Circular No. 23, this office, April 22, 1918, it is directed that when typewriters or surgical instruments are sent to Medical Department repair shop No. 1, an order for transport or the number of the order be mailed to the officer in charge to facilitate the receipt of such articles from railroad station. When organizations have sufficient typewriters needing minor repairs to warrant the sending of a typewriter repair man with a portable outfit to make these repairs, a request will be made directly to the officer in charge of the shop.

    3. Manner of washing mess kits.-The Surgeon General of the Army has called attention to the fact that complaints have come from many civilian sources about the manner of dish washing or mess-kit washing in vogue in many camps, viz, that large numbers of men



    930

    rinse their kits in the same small bucket or can of water, so that late comers really use a cold or cool slop mixture. While this office is without evidence that disease has been spread by the practice complained of, it must be admitted that the practice is dirty and not in accord with the teachings of good housekeeping or good hygiene. In only exceptional circumstances will it be impossible, by the exercise of a little ingenuity, to obtain water decently clean and scalding hot for the use of each man. Surgeons with all commands are directed to do everything in their power to bring about proper practices in this matter. Should they be unable to do so, report will be made to this office.

    4. Requisitions for laboratory and X-ray supplies.-It has become apparent that the director of laboratories and the director of Roentgenology, in order to maintain proper supervision over the technical services, must visa all requisitions for those services. Hereafter all requisitions for laboratory supplies and for X-ray supplies, including both articles listed on the supply table and articles not so listed, will be made separately and forwarded as follows:

    Requisitions for laboratory supplies: To the director of laboratories, American Expeditionary Forces, U. S. A. P. O. 721.

    Requisitions for X-ray supplies: To the director of Roentgenology, American Expeditionary Forces, U. S. A. P. O. 731.

    It is desired that so far as possible these requisitions be so timed as to permit shipments thereupon to be included in the larger shipments made on ordinary requisitions. These special requisitions should therefore be sent approximately 10 days prior to larger requisitions contemplated and should bear notation that shipments should be held pending receipt of the requisition for general supplies.

    5. Forwarding of purchase vouchers.-All vouchers covering purchases made under the provisions of paragraph 4, Circular No. 15, chief surgeon's office, line of communications, and all vouchers, for purchase made under the provisions of paragraph 1, Circular No. 19, chief surgeon's office, line of communications, will be sent through the section surgeon to this office, for payment by the disbursing officer attached hereto.

    6. Requisitions upon the Red Cross.-Hereafter requisitions upon the Red Cross will be honored at the Red Cross depots after approval by the following officers:

    For all troops within a division, by the division surgeon.
    For all hospital and troops in the services of supply, by the section surgeons.

    Attention is again invited to the fact that the Red Cross should not be asked for articles on the supply table or properly chargeable against Medical Department funds, except in emergencies, and to the undesirability of submitting to the Red Cross requisitions for articles erased from the medical supply tables by reason of their unimportance.

    7. Purchase of food supplies locally to be charged against hospital fund.-Due to the fact that local French authorities are not authorized to receive payment for supplies purchased from them the United States Government is receiving bills from the French Government for food supplies purchased by United States Army hospitals. Commanding officers should bear in mind that there will be ultimately a charge against the hospital fund and should keep accurate track of all such purchases and the cost thereof and should consider the same an outstanding charge against the hospital fund, reserving a sufficient balance to enable prompt reimbursement to the fund from which these bills are paid.

    8. Purchase of technical apparatus locally.-It is believed that many small purchases, particularly of surgical instruments and minor technical apparatus, are being made in the local markets. This is no doubt due to the fact that there was great difficulty in securing these articles from the supply department in the early days. A well-balanced and well-maintained shipment of such equipment is now being received from the United States, and it is desired that all requests for this material should pass first through the medical supply depot; the officer in charge of which will, if necessary, make request upon the purchasing officer.

      M. W. IRELAND,
    Brigadier General, N. A., Chief Surgeon.

    NOTE.-Circular No. 25 has been delayed and will be issued later.



    931

    Circular No. 27.

       AMERICAN EXPEDITIONARY FORCES,
      France, May 13, 1918.

    1. Administration of messes-Function of dietitian.-The reports of medical inspectors and officers of the food and nutrition section show that the administration of messes is, as a rule, the least efficient and satisfactory part of hospital administration. The defects noted are a monotonous and ill-balanced dietary, poor service, and lack of cleanliness in the kitchen and the kitchen personnel. These inspections show that commanding officers have not made proper use of the agency which is especially intended to correct these defects, that is to make proper use of the dietitians who have been assigned to the base hospitals, to use their expert knowledge for the correction of these defects, and to exercise the constant vigilance and attention to detail which is necessary for successful mess administration.

    Dietitians are trained experts in nutrition and food preparation. If not trained nurses, they are civilian employees having a status analogous to that of a trained nurse. The function of the dietitian is to supervise the preparation not only of the special diets, but to make out the bills of fare and supervise the preparation of all food furnished by the Government. The dietitian has expert knowledge of which the commanding officer should make the fullest use for the benefit of his command. She should be able to relieve the mess officer from the burden of details required to secure a well balanced ration, proper variety and preparation, and a good service. The mess officer should make a daily inspection, accompanied by the dietitian and the mess sergeant, to see that the details of a good service are carried out fully and completely.

    Like all other women of the personnel of a base hospital, the dietitian is under the disciplinary authority of the chief nurse.

    2. Instructions for the use of the Lyster water sterilizing bag.-(a) The following instructions for the use of the water sterilizing bag (Lyster) are published for the information of all concerned:

    (1) Clean the inside of the bag thoroughly.

    (2) Fill it to the white band, with best water available.

    (3) Place a tube of hypochlorite in an ordnance cup and break the tube with the butt of an ordnance knife. Mix the powder into a smooth paste with a little cold water, using the blade of the knife to break up the lumps. (Hypochlorite tends to lump when added to water and, therefore, special care must be taken to obtain a smooth paste.) Fill the ordnance cup about half full of cold water, stir and pour the nearly clean solution into the water in the bag, keeping the glass in the cup. Stir the treated water thoroughly.

    (4) Fasten the cover on the bag and allow the water to stand 30 minutes before use.

    (5) Never refill a partially emptied bag. Always empty the water from the bag before filling with fresh water.

    (6) Use one tube of powder for every bag full of water. Tubes of hypochlorite are to be obtained from the quartermaster.

    (7) Report any difficulties to the medical officer.

    (8) Keep a record of the treatment attached to the card.

    (b) Cards containing these directions on waterproof paper are in source of printing and will soon be available for issue.

    3. Bandaging of mustard gas cases.-The direction du Service de Sante of the first French Army has sent to this office the following "Note de service":

    It has been called to my attention that men suffering from mustard gas conjunctivitis are evacuated with cotton tightly bandaged over their eyes. This is an improper dressing. The lids should be compressed as little as possible. A small compress of dry gauze, and a loose bandage should be applied.

    4. Nurses' service chevrons.-The War Department has informed general headquarters that under date of January 12, 1918, authority was given for members of the Army Nurse Corps to wear war service chevrons under the same conditions heretofore prescribed for officers and enlisted men.

    5. Vouchers to be forwarded to this office.-Attention is invited to Paragraph 2, Circular 5, chief surgeon, line of communications, September 21, 1917. All vouchers pertaining to money or property accountability, which formerly have been forwarded to the Surgeon General, United States Army, will, in future, be forwarded to this office.



    932

    6. Visiting places for convalescent officers.-Commanding officers of hospitals are notified that the persons whose names and addresses are given below have expressed a willingness to receive in their homes as guests, free of all expenses, convalescent officers to the limit of the accommodations. Commanding officers should exercise judgment in the selection of cases which will be received on their recommendation, and should not send any who are not fully able to look after themselves or require hospital treatment. There is, however, a Red Cross physician in the town of Cannes who can give treatment in the case of emergency. Before sending an officer to either place the commanding officer should ascertain by telegraph whether it is convenient for the host to receive him. The chief surgeon's office should be notified by mail of each case in which an officer has availed himself of this hospitality, and given the name and organization of the officer, and the date.

    Capt. Clement Brown, Villa-les-Lotus, Cannes (A. M.).

    Mr. Samuel Goldenberg, Nellecote, Villefrance-sur-Mer (A. M.).

    7. Disposition of psychiatric, pulmonary tuberculosis, and war neuroses cases.-(a) Psychiatric cases, including those of insanity and feeble-mindedness, should not be held for prolonged observation, but should be sent to Base Hospital No. 8, provided the cases are in fit condition to make the journey. Upon request, special trained attendants will be sent from Base Hospital No. 8 to care for the cases en route. Such request should state the character and condition of the cases. On account of the local restrictions as regards transportation of the insane, a diagnosis will not be made, nor will the patient be declared insane or classified as of class D. Carefully prepared histories will be forwarded to the commanding officer of Base Hospital No. 8.

    (b) For the present, cases of pulmonary tuberculosis should be sent to Base Hospital No. 8. Such cases should not be classified as of class D before transfer.

    (c) Cases of war neuroses should be transferred to Base Hospital No. 117.

    M. W. IRELAND,
    Colonel, M. C., Chief Surgeon.



    Circular No. 28.

       AMERICAN EXPEDITIONARY FORCES,
    France, May 15, 1918.

    Subject: Sick and wounded reports for the American Expeditionary Forces.

     

    * * * * * *

    (ADDITIONAL INSTRUCTIONS FOR FORM 22, A. G. O., S. D., A. E. F. (SEC. V)

    1. When giving admissions on "Daily report of casualties and changes of patients in hospital," Form No. 22, A. G. O., S. D., A. E. F., "Line of duty" or "Not in line of duty" may be specified by "L" or "N" in quotation marks.

    2. On that form, diagnosis, in addition to including nature of disease, injury, or wound, will specify regional location of wounds, slight or severe ("O" or "S"), in action or accidentally incurred ("I. A." or "Acdt.").
     

    (AMENDMENT TO SECTION XVI (ALLIED PATIENTS IN A. E. F. HOSPITALS)

    FRENCH PATIENTS

    1. Paragraphs 3 and 4 of this section are revoked.

    2. When French military patients are admitted to, discharged from, or die in American military hospitals in the French zone of the armies, notification of the fact will be sent within 24 hours to the Chief of the Bureau de Compatibilite of the Service de Sante des Armees, No. 1 Rue Lacretelle, Paris, on Form 52, Medical Department.

    3. When French military patients are admitted to, discharged from, or die in American military hospitals in the French zone of the interior, notification of the fact will be sent within 24 hours to the Franco-American section of the region (Service de Sante) on Form 52, Medical Department.

    4. The data on this card will show the name, number, rank, and organization of the patient, the diagnosis, whether or not the disability was incurred in line of duty, and the designation of the hospital sending the report.


    933

    5. Information in this form is strictly for the use of the French. No duplicates of these cards will be sent to the chief surgeon's office, A. E. F. The monthly list, required in paragraph "1-b" of this section, is sufficient.
     BRITISH PATIENTS

    6. For all British patients admitted to A. E. F. sanitary formations, A. E. F. medical cards, envelopes, etc., will be made out except where British forms have previously been used.

    7. A separate daily list of casualties and changes of patients in hospitals, Form 22, A. G. O., S. D., A. E. F., will be made out for all British patients; one copy will be forwarded to the deputy adjutant general's office, Third Echelon, British Expeditionary Force, France, and another to medical communications, British Expeditionary Force, France. No copy will be sent to the chief surgeon, A. E. F.-the monthly report called for in "1-b" being sufficient.

    8. When cases of British patients have been completed by death, return to duty, or otherwise than by transfer, field medical card, envelope, and contents will be sent at the end of the month to the deputy adjutant general's office, Third Echelon, British Expeditionary Force, France, together with a list of the names of the cases so completed. No report, Form 52, need be made out.

    9. If patient is transferred to a British medical unit, field medical card, envelope, etc., will be forwarded attached to the patient.
     CHANGE OF SYSTEM

    1. All surgeons with troops will, upon arrival in France or England, complete the records of all cases actively on the register either as "Returned to duty" or "Transferred to____________ Hospital," as the case may be. Thereafter the system set forth in this pamphlet will prevail. If cases completed as "Returned to duty" are subsequently transferred to hospital, they will be considered new cases.

    2. Cases transferred to convalescent camps will be considered completed as far as sick and wounded records are concerned.

    3. For the purposes of reporting sick and wounded under the new system, all medical organizations which do not habitually hold patients for more than three days will be considered as without hospitalization facilities.
     COMPLETENESS OF DATA

    1. Whenever a patient is received by a base hospital without field medical card or data sufficient to completely fill one in, steps will be taken to obtain the necessary data, and the patient will be held a reasonable time in the hospital until the lacking information is received and the card and envelope made out. Whenever this is done, statement of the fact will be made on the back of the card, reference being made to it by an asterisk (*).

    2. In stating causes of death, care will be exercised to report in terms which describe the true cause rather than the symptoms. Reference should be made to the "Nomenclature of diseases," Manual of the Medical Department, 1916, page 144-156, and the terminology therein will invariably be used.

    PROCURING OF FORMS

    1. Units arriving in France or England after June 15, 1918, will requisition immediately for forms. Form No. 4, A. G. O., S. D., A. E. F., will be procured from the adjutant general's office statistical officer, the others through the usual channels.

    2. Troops serving with the British will not make requisition for these forms, but will use the British system. This will not apply to Form 22, A. G. O., S. D., A. E. F. or Form 52 M. D. as used by the A. E. F. base hospitals with the British in France.
     IMPORTANT
     1. Weekly telegraphic report, Form 211, M. D., will be continued to and including the last week in July.

    2. All previous instructions at variance with this circular are revoked.


    934

    3. It is essential that all medical officers in the A. E. F. have a full understanding of the new system. Questions should be addressed to the chief surgeon, A. E. F., Services of Supply.

    4. If the supply of this circular and pamphlet describing the new system is not sufficient to furnish each medical officer in your command with a copy, request should be made for a further supply. Care must be exercised, however, to avoid waste.

    5. Every organization will send weekly venereal report to division or section surgeon, even though no new cases have appeared since last report. It is essential that the strength of divisions and sections be obtained through this report.

    6. Attention is called to the fact that Forms No. 4 and No. 22, A. G. O., S. D., A. E. F., are used by both the adjutant general's office and the Medical Department. Instructions issued by either agency relative to methods of sending reports on these forms apply only to the copies sent to that agency. Two copies of Form No. 22, A. G. O., are required to be sent direct to the chief surgeon's office; Form No. 4, A. G. O., is not to be sent to that office.
     

    M. W. IRELAND,
       Brigadier General, N. A., Chief Surgeon.


    Circular No. 29:
    AMERICAN EXPEDITIONARY FORCES,
    France, May 21, 1918.

    The following instructions are issued for the guidance of all medical officers, superseding Circular No. 11, chief surgeon's office, March 6, 1918:

    1. Injuries to the bones and joints, as well as of the muscles and tendons adjacent to these structures, represent a large percentage of the casualties of both the training and the combat periods of an army.

    2. To restore useful function to these injured structures is one of the purposes of the medical organization of the army. The problems involved in this have to do not only with the cleansing and healing of the wounds, but also with the restoration of motion in the joint or strength to the part. This latter part naturally follows the first, but it is essential that the first part be carried out with reference to that which is to follow. Unless this second part of the treatment, the restoration of strength and motion, is carried out, much of the first part is purposeless.

    3. To insure the man not only the proper treatment for this type of injury, but the proper supervision until he is as fully restored as possible, necessitates some form of radial control that makes it impossible for a man to be overlooked in inevitable transfers, from service to service, or hospital to hospital.

    4. Since so much of the ultimate result in these conditions depends upon orthopedic measures after the first treatment of the wounds has been carried out, the following will govern:

    The senior consultant, orthopedic surgery, will, under the chief consultant, surgical services, make such recommendations relative to treatment of "injuries and diseases of the bones and joints, other than those of the head, as well as the injuries or diseases (other than nerve lesions) of the structures involved in joint functions," as will insure early restoration of functions, shorten convalescence, and hasten return to active military duty.

    He will also supervise the subdivisions of surgery, pertaining to bones and joints, in a manner which will permit the complete surgical harmony necessary for cooperation in treatment of these cases by either general or orthopedic surgeons, in formations from front to rear. To insure a minimum loss of function to the parts involved, uniform cooperation must be maintained by the chief consultant, surgical services, during both early treatment and all stages of convalescence.

    5. To carry out the provisions of this circular, the chief consultant, surgical services, will make such provisions as are deemed necessary to insure a complete survey of these cases at regular intervals, and determine if the treatment is progressing in a satisfactory manner. Consultants in orthopedic surgery who are charged with the supervision of such cases within hospital centers and other formations will ordinarily be called in consultation


    935

    for special cases, through the commanding officers of the units in question, and the consultants will report to him prior to completion of their investigations. Commanding officers of hospitals are expected to freely utilize the services of these consultants in the manner described above. Any recommendation made by them as to change of treatment, or transfer to some other professional service or hospital, will ordinarily, if the military situation permits, receive favorable consideration.

    6. It is not the intention of this order to interfere with the routine work of hospitals, but to insure to the soldier proper supervision during the time of his treatment and the period of his convalescence.

      M. W. IRELAND,
       Brigadier General, M. C., N. A., Chief Surgeon.


    Circular No. 30.
    FRANCE, May 23, 1918.

    1. Auxiliary optical units supplying and repairing of spectacles.-(a) An auxiliary optical unit has been sent to each of the following stations, viz, Base Hospital No. 6; Base Hospital No. 8; Camp Hospital No. 27; Base Hospital No. 1; Base Hospital No. 18; attending surgeon's office, general headquarters; Base Hospital No. 17; Base Hospital No. 23.

    A central optical unit has been sent to the instrument repair shop of the medical supply depot in Paris.

    (b) Prescriptions for spectacles, to be supplied free of charge to officers, nurses, and enlisted men of the American Expeditionary Forces may be sent to the commanding officers of these stations.

    These standard spectacles are of nickel, steel, round glass, and any combination of lens can be supplied or repairs made on short notice.

    Unusual prescriptions and ordinary prescriptions for troops near Paris may be sent to the central unit. This unit will also fit glass eyes or upon request will send to base hospitals assorted sets of eyes for selection.

    It will also repair any optical instruments used in hospitals.

    (c) Prescriptions should include not only the lens prescription, but accurate measurements for frame, stating the following dimensions, viz, pupilary distance; temporal width; height of crest above pupilary line; width of bridge at the base; inset or outset, in millimeters; length of temple.

    As the size of the lens will be the same in all cases, namely 40 mm., it will not be necessary to state that dimension.

    2. Historical records.-(a) With a view to securing material from which the medical and surgical history of the war may eventually be written, base surgeons and division surgeons will prepare and maintain a historical record of the Medical Department activities of the commands of which they are in charge.

    (b) Commanding officers of base, camp, and other hospitals, hospital train, and other independent organizations of the Medical Department will also maintain such a record.

    (c) The historical data need not be voluminous nor trivial, but should be sufficiently complete so that from them in connection with the regular official and clinical records of the organization a report to date of its activities can at any time be made. The historical records, if not already begun, will be initiated without delay and written up from the beginning of the activities of the organization or command in connection with the present war and they will be maintained by careful notation of all matters of historical interest involving the organization.

    3. Replacement of X-ray tubes.-Broken X-ray tubes will be sent to the repair shop, Paris, by messenger, who will carry back the replacement tube. Unless urgent, two or more tubes should be sent at one time. If the travel involved requires an order from the commanding general, Services of Supply, a request for such should be made to these headquarters.

    4. Travel orders and classification of patients discharged from hospital under General Order 41, general headquarters, 1918.-Orders directing the travel of patients discharged to duty from Services of Supply hospitals should in each instance indicate the classification to which the man belongs under General Order 41, general headquarters. In the case of men of B and C classes, copies of reports of disability boards on the prescribed form should be attached to travel orders.


    936

    The authority for issuing the travel order should be indicated therein as: "G. O. 11 S. O. S., 1918."

    5. Admission of officers and soldiers to Services of Supply hospitals.-The attention of commanding officers of Services of Supply hospitals is called to the following extract of General Order 46, general headquarters, the provisions of which have been disregarded in number of instances. Prompt rendition of the required report is enjoined:

    SEC. VII (par. 4.) To insure the information reaching the unit commander, as to the admission of an officer or soldier of his command to a Services of Supply hospital, the Services of Supply hospital commanding officer who receives the individual will notify the unit commander at once.

    6. Demands for chloride of lime or chlorine products.-The supply situation is such that all demands for chloride of lime or chlorine products should be restricted to those which are absolutely of an emergency type, and requirements should be the lowest possible.

    7. Nurses' regulation uniforms.-The regulation uniform is to be worn by nurses and reserve nurses of the Army Nurse Corps at all times, and is as follows:

    A suit, waist, and hat, of prescribed color and pattern for outdoor wear; gray or white uniforms, aprons, and caps, will be worn while on duty in hospital, and shall be made in accordance with specifications furnished by the office of the Surgeon General, but reserve nurses will wear caps made in accordance with specifications furnished by the Red Cross; white, tan, or black shoes, high or low, may be worn, but pumps, French heels, and fancy shoes will not be allowed; the United States pin and the insignia of the Army Nurse Corps should be worn, but not fancy pins or furs. There are no occasions when the wearing of civilian dress will be permitted, and any individual modification of the regulation uniform will not be allowed.

    M. W. IRELAND,
      Brigadier General, M. C., N. A., Chief Surgeon.



    Circular No. 31
       FRANCE, May 23, 1918.

    Subject: evacuation of French and British patients in A. E. F. hospitals; effects of allied patients dying in A. E. F. hospitals.

    1. Paragraphs 2 and 3, Section XIV, and paragraph 2, Section XVI, "Sick and wounded reports for the American Expeditionary Forces," are revoked.

    2. The following translation of extracts from Circular 684 Ci/7, Sous-Secretaire d'Etat du Service de Sante, of April 6, 1918, are published for the information and guidance of medical officers:
     AMERICAN SOLDIERS IN FRENCH SANITARY FORMATIONS
    The French sanitary formations must keep only American sick and wounded who can not be evacuated without inconvenience. Consequently, as soon as an American patient is susceptible of being evacuated, he will be evacuated to the nearest American hospital without other formality than a previous understanding with the chief surgeon of that hospital.

    If, for any reason, the transfer of the patient necessitates the presence of nurses, the surgeon of the American hospital should be requested to send one or two nurses to insure the transfer in satisfactory conditions.

    Medico-surgical documents which may be useful to the American doctors regarding the patient will follow the latter, those of confidential nature being sent under closed envelope.
     FRENCH SOLDIERS IN AMERICAN SANITARY FORMATIONS

    French soldiers hospitalized in American sanitary formations will be evacuated to the nearest French hospital as soon as their transfer can be made without risk.

    The evacuation of the sick and wounded will take place without any other formality than a previous understanding with the medicin chef of the French hospital, who will furnish one or several nurses if necessary.

    All medico-surgical documents will follow the patient under closed envelope.


    937


     

    AMERICAN SOLDIERS DEAD IN FRENCH HOSPITALS

    (a) Hospitals of the zone of the army.-In conformity with steps foreseen for allied soldiers in the instructions of July 2, 1916, the property of American soldiers dead in French hospitals will be forwarded to the "Chef de Bureau de Compatibilite du Service de Sante aux Armees," No. 1 Rue Lacretell, Paris, where they will be transmitted to the commanding officer, effects depot, base section No. 1, at St. Nazaire.

    Cash willl be forwarded by order on the Treasury made out to the commanding officer of this last named depot.

    (b) Hospitals of the zone of the interior (includes regional hospitals of the army zone).-The forwarding of soldiers' personal property will be made by the administration officer to the commanding officer, effects depot, base section No. 1, at St. Nazaire.
     FRENCH SOLDIERS DEAD IN AMERICAN HOSPITALS

    (a) Hospitals of the zone of the army.-The personal property of French soldiers dead in American hospitals will be forwarded to the French military mission with the American Army at Chaumont.

    (b) Hospitals of the zone of the interior (includes regional hospitals of the army zone).-The personal property will be turned over to the commanding officer of the nearest French hospital, permanent military hospital, or complementary hospital, who will look after the settlement.

    NOTE.-In all cases mentioned above it will be necessary to make out in a complete manner on a form of accompanying model an inventory of the personal property; in each case the inventory will be forwarded at the same time as the personal property to the consignee:

    (Translation of form to be utilized in accompanying personal property of soldiers forwarded)

    Ministry of war, Office of Pensions, Bureau of Successions, Paris, 1 Rue Lacretelle (15th)

    Numbers  {Of the present form.
       {Of the parcel.

    From------------------------------------------------------------------------------------------------------------------------------------------------------------------
    Address ----------------------------------------------------------------------------------------------------------------------------------------------------------------
    Name of the soldier --------------------------------------------------------------------------------------------------------------------------------------------------
    Surnamesb -------------------------------------------------------------------------------------------------------------------------------------------------------------
    Regiment ---------------------------------------------------------------------------------------------------------------------------------------------------------------
    Rank ------------------------------------------------------------------------------------ Class ------------------------------------------------------------------------
    Place of enlistment ---------------------------------------------------------------------------------------------------------------------------------------------------
    Number of enlistment -----------------------------------------------------------------------------------------------------------------------------------------------
    Died at -------------------------------------------------------------------------------------------------------------------------------------------------------------------
    On the -------------------------------------------------------------------------------------------------------------------------------------------------------------------
    Address of family ----------------------------------------------------------------------------------------------------------------------------------------------------
    -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------

    (a) Amount of cash comprised in the shipment -----------. Indicate whether cash has been forwarded in any other way ------------------,
    how much -----------------, and to whom forwarded ----------------------------------------------.
    (b) Savings Book No. ----------------------
    (c) Detailed statement of amount and objects forwarded ---------------------------------------------------------------------------------------------------
    Date ----------------  19l--
    (Signature of sender) -----------------------------

    NOTE.-Send the form and shipment to the above address.

      aIndicate name of hospital and address.
      bAll surnames and in their proper order.

    938


     

    EVACUATION OF BRITISH PATIENTS


    3. British patients in American hospitals fit to travel should be evacuated to Paris. The office of the assistant director medical services, British Expeditionary Force, No. 6, Rue Capucines, Paris, should be given 24 hours' notice by telegraph of date and hour of arrival of patients. Patients should be evacuated by express train and should be routed so as not to arrive in Paris late at night.

    The personal effects of British soldiers dying in A. E. F. hospitals should be sent to the deputy adjutant general (effects branch), headquarters, third Echelon, British Expeditionary Force, France. Public clothing and equipment should be sent to the commanding officer, ordnance base, British Expeditionary Force, France.

    M. W. IRELAND,
    Brigadier General, M. C., N. A., Chief Surgeon.


       AMERICAN EXPEDITIONARY FORCES,
      France, June 7, 1918.

    Circular No. 32.

    1. The following "don'ts" for the guidance of medical officers in gas warfare have been prepared by the medical director of the gas service and are hereby published.
     THIRTY "DON'TS" WITH WHICH EVERY MEDICAL OFFICER IN THE AMERICAN EXPEDITIONARY FORCES SHOULD BE THOROUGHLY FAMILIAR

    1. Don't fail to realize that gas warfare is the most dangerous enemy confronting our army to-day and that a great number of patients will be gassed.

    2. Don't fail to keep thoroughly posted in all matters pertaining to warfare gasses.

    3. Don't forget that common sense and good judgment are the essential requirements in treating gassed patients.

    4. Don't fail to realize that the enemy uses every kind of device in his endeavors to make gas attacks serious.

    5. Don't fail to realize that the enemy uses many different kinds of gasses, sometimes alone, at other times mixed together. Each gas produces its separate and distinct line of symptoms, and therefore requires its own particular line of treatment.

    6. Don't forget that all gassed cases require: First, rest; second, warmth; third, fresh air; fourth, attention.

    7. Don't permit gassed men to walk, talk, or move about.

    8. Don't fail to realize that all gassed cases should be considered as serious until proven otherwise.

    9. Don't fail to keep all gassed cases under strict observation during the first 48 hours.

    10. Don't forget that lung irritants such as phosgene and chlorine act early and that deaths in the trenches or front lines during a gas attack are probably due to one of these gasses.

    11. Don't forget that the lesions produced by warfare gasses are: (a) Lesions resulting from local actions of the gas; (b) lesions due to complications and mechanical results of local action; (c) lesions due to general toxic effects.

    12. Don't forget that disturbances caused by mustard gas are characterized by more or less late symptoms of irritation and by vesicle formation in the integuments and mucous membranes, especially the conjunctival, nasal, pharyngeal, and laryngeal, which are produced chiefly by direct action of the vapor and small droplets which are acid.

    13. Don't forget that broncho-pneumonia resulting from secondary infections often follow mustard gas poisoning.

    14. Don't forget that clothing, linen, blankets, etc., remain for a long time impregnated with mustard gas.

    15. Don't forget that fumes and vapor of mustard gas remain in certain localities for days following gas attacks.


    939

    16. Don't forget that essentials indicated in the treatment of mustard gas poisoning are: First, removal of clothing; second, neutralizing of acid gas with an alkaline substance; third, avoiding contact with soiled clothing; fourth, treatment of the eyes, lesions of mucous membranes, lesions of the respiratory tract, lesions of the digestive tract, and lesions of the skin.

    17. Don't forget that cases of irritant gas poisoning, with severe odema of the lungs, may often be saved by prompt and copious bleeding.

    18. Don't forget that cases of gas poisoning with marked cyanosis are benefited by oxygen inhalations, which in order to be efficient should be given continuously. The oxygen to be administered either by mask or introduced into the posterior nares by means of a small rubber catheter connected with the oxygen tank through a double tube in a bottle half filled with water.

    19. Don't place too much reliance on drugs in the treatment of gassed cases.

    20. Don't forget that disorders of the heart which arise after gassing will in some cases make soldiers unfit for active fighting in the front areas.

    21. Don't bandage the eyes. Pressure bandage over the eyes locks up the lids and retains the secretations, which after a term of hours may become purulent.

    22. Don't forget that in treating eye symptoms following mustard gas poisoning, it is most important that the use of eye shades or dark glasses should not be continued beyond the inflammatory stage, otherwise functional photophobia is likely to result.

    23. Don't forget that one group of symptoms often seen in all forms of poisoning-i. e. dyspnoa, pain in the chest, palpitation, rapid pulse, dizziness, and fatigue are closely associated with nervous symptoms more frequently than other cases. They cause the most frequent contributions of partial or complete unfitness for further military duty.

    24. Don't forget that the symptoms enumerated above rarely follow mustard gas poisoning.

    25. Don't forget that in this class of patients prolonged rest in bed is contraindicated. They should be given graduated exercises, and their physiological reaction to these should be carefully noted.

    26. Don't forget that prolonged stay in hospitals is particularly apt to exaggerate neurotic conditions which are difficult to overcome.

    27. Don't forget that vomiting and stomach trouble which persist after mustard gas poisoning is usually functional, especially when occurring some months later.

    28. Don't forget that the nervous symptoms which follow gas poisoning are generally functional, resembling exactly "traumatic neurosis."

    29. Don't forget that pulmonary cases following mustard gas poisoning are the most important. They entail prolonged absence from military duty and may simulate pulmonary tuberculosis so closely that it will be difficult to decide, in some cases, whether tuberculosis exists or not.

    30. Don't forget that it is often difficult to differentiate between slightly gassed cases and malingering, so don't be misled by the latter condition.

       M. W. IRELAND,
    Brigadier General, M. C., N. A., Chief Surgeon.


    Circular No. 33.

       AMERICAN EXPEDITIONARY FORCES,
      France, June 12, 1918.

    1. Hospitalization and evacuation of cases of pulmonary tuberculosis and suspected pulmonary tuberculosis.-(a) Collecting and observation centers have been established at the hospitals indicated below for cases of pulmonary tuberculosis and suspected pulmonary tuberculosis which may occur in the American Expeditionary Forces.

    (b) In future the diagnosis "pulmonary tuberculosis" should be limited to cases in which tubercle bacilli are found in the sputa. Cases in which this diagnosis has been established should be evacuated to Base Hospital No. 8, at Savenay, or to Base Hospital No. 3, at Vauclaire, which are designated as collecting centers for these cases during the period preceding their evacuation to the United States.


    940

    (c) Cases of suspected tuberculosis should be diagnosed "tuberculosis, observation." Such cases should be evacuated to Base Hospitals No. 8, No. 3, or No. 20, at Chatel Guyon, which are designated as observation centers.

    (d) Base Hospital No. 3 will receive only such cases as originate in base sections No. 2, No. 6, and No. 7. For cases originating elsewhere the hospital most convenient to the locality will be selected.

    2. Return to duty of student officers and soldiers from army and corps schools.-Instructions have been received from the commander in chief directing that student officers and soldiers from army and corps schools who have been admitted to hospitals will be returned to the school upon being evacuated to duty as of class A.

    3. Travel orders to individuals or units forwarded to the advance section.-The following instructions of the commander in chief, A. E. F., are published for the information and guidance of medical officers:

    (a) Hereafter all individuals or units forwarded to the advance section will be given travel orders indicating the organization to which they are to be sent, and will be directed to report to the proper regulating officer, who knows the location of all organizations and will see that they are forwarded to the proper destination.

    (b) In case of doubt as to which is the proper regulating officer to whom they should be directed to report, information will be obtained by the officer arranging for the movement from the headquarters, Services of Supply.

    All such individuals or detachments should be furnished with rations to include two days' travel beyond the time of their expected arrival at the regulating station.

    By order of the commander in chief.

    4. Etiquette of visits to French hospitals.-Correspondence recently received from the French Service de Sante indicates that in certain cases medical officers of the American Expeditionary Forces have visited American patients in French hospitals without first calling on the medecin chef of the hospital to get his permission.

    It is a military principle which governs in all armies, to which the French attach much importance, that an officer should not go into any military organization for the purpose of inspecting without first calling on the commanding officer of that organization to get his permission. It is very desirable when the visit is one of inspection, and not merely a personal visit to individual patients, that the medecin chef or an officer designated by him should accompany the American medical officers. This is an important matter of military administration, as well as military courtesy, which all medical officers should be careful to observe.

    5. Method of requisitioning fuel.-The attention of commanding officers of hospitals is invited to the provisions of General Order 19, Services of Supply, 1918, which order makes certain changes in the method of requisitioning fuel. The chief quartermaster advises that, as far as possible, supplies of fuel for hospitals for winter use be secured and stocked during the summer. It is especially desired that emergency requisitions for fuel be reduced to a minimum. Proper anticipation of the demand for wood is fully as essential as that for coal.

    6. Worker's permits for all nurses.-Attention is again invited to the fact that all nurses must be provided with worker's permits. These are furnished as prescribed in General Order 63, A. E. F., 1917. Three unmounted photographs, not to exceed 3½ by 2½, name of the nurse, permanent station, and number of passport, if any, must be furnished. Requests for worker's permits should be forwarded to this office, giving the data stated above.
     

    7. Vouchers and pay rolls to be sent through proper channels.-Paragraph 1, Circular No. 14, office of the chief surgeon, headquarters lines of communication, A. E. F., December 4, 1917, is modified as follows:
     

    All vouchers and pay rolls will hereafter be sent through proper channels directly to this office instead of to the officer in charge, intermediate medical supply depot No. 3. Requisitions will continue to be sent as directed in the circular quoted.

    8. Report of all divisions surgeons.-(a) All division surgeons will report immediately to this office by wire the designations of all field hospitals operating under their control and subsequently any change in status in field hospitals, such as the opening, closing, consolidation, reorganization, or abandonment of such units as soon as such changes occur.

    (b) For the purpose of reporting sick and wounded under the new system, all medical organizations which do not habitually hold patients for more than three days will be con-


    941

    sidered as without hospitalization facilities. All units which care for patients for a period longer than three days will be considered as hospitals regardless of official designation. All units in the sections of the Services of Supply falling under the latter class, but which are not officially designated as hospitals, will be instructed by the section surgeon to begin reporting as hospitals and to make requisition on medical supply depot No. 3 for necessary forms. Requisitions for Form No. 1, M. D., A. E. F., will be filled as soon as supply is available. Section surgeons will notify this office of all such units in their sections.

    M. W. IRELAND,


    Brigadier General, M. C., N. A., Chief Surgeon.


    Circular No. 34.

    AMERICAN EXPEDITIONARY FORCES,
    OFFICE OF THE CHIEF SURGEON,
    France, June 12, 1918.

    The following information will be given the widest possible circulation among the medical officers of the American Expeditionary Forces. Each medical officer should possess and keep at hand a copy of this circular.


    SHORT RÉSUMÉ OF THE SYMPTOMS AND TREATMENT OF POISONING BY IRRITANT GASESa
     The gases which have been met with most commonly up to the present time may be divided schematically into three classes:

    (1) Suffocative gases, which exercise their main effect on the lung tissue (chlorine, phosgene, diphosgene, chloropicrin).

    (2) Vesicants, the prime effect of which is exercised upon the skin conjunctivitæ and upper air passages (dichlorethyl sulphide-mustard gas or Yperite).

    (3) Pure lachrimatory gases (Xylyl-bromide).

    Gas may be liberated from cylinders in clouds, a method not now commonly employed or from shells.

    The general aim of the enemy in the present use of gas shells is to fire simultaneously shells of different types, some of which will cause so much sensory irritation that the man will discard his respirator and then become vulnerable to lethal shells, phosgene and similar substances. Owing to this mixture of shells the symptoms reported by patients are often very confusing.b

    For this purpose several arsenical compounds have been tried.
     SYMPTOMS OF GAS POISONING
    Suffocative gases.-Suffocative gases which are relatively nonirritative on inhalation in the concentrations ordinarily used, induce some hours after their entrance an intense odema of the lungs. Through the great outpouring of fluid into the lung tissue the patient drowns in his own serum; the blood becomes greatly condensed and viscious; there is marked polycythæmia; the capillary flow is obstructed; thromboses are not uncommon; a greatly increased strain is put upon the right heart; the patient suffers from intense oxygen want.
     

    Sequence of events.-The immediate effects of irritation of the eyes may be prominent at first, but as a rule quickly pass off; within 3 to 12 hours after exposure to the gas the main symptoms, asphyxia and prostration, due to affection of the lung alveoli and accumulation of fluid in them, appear. In this state the patient's respiration is rapid and usually accompanied by pain (often intense) in the chest; there may be fits of coughing, but the amount of expectoration is very variable, being profuse in some cases and very scanty in others; in the more severe cases the patient is restless and anxious, or may be semicomatose with muttering delirium. Therefore many patients will be unable to give a definite account of their symptoms as loss of memory of immediate events may last for several days. Patients with severe pulmonary odema fall into two groups.
     

    aMuch of this material has been extracted from the valuable reports of the British Chemical Warfare Medical Committee and from the excellent report of Lieut. Col. H. L. Gilchrist, issued by the office of the Chief of Gas Service, A. E. F., Mar. 15, 1918.
    bMedical Research Committee: Reports of the Chemical Warfare Medical Committee, No. 3. The symptoms and treatment of the late effects of gas poisoning, Apr. 10, 1918, p. 3.


    942

    (a) Those with definite venous engorgement. In these the face is congested, the lips blue, and the superficial veins of the face may be visibly distended. There is true hyperpnoa, i.e., the breathing is not only increased in frequency but the actual amount of air reaching the lungs is greater than normal. The pulse is full and of good tension, and the rate is not often much above 100.
     

    (b) Those with collapse. In these the face is pale and the lips of a leaden color. The breathing is shallow, so that there is but little hyperpnoa. The pulse is rapid (130 to 140) and weak.

    In patients who recover, the odema fluid is absorbed within a few days; in some cases signs of bronchitis or broncho-pneumonia, due to a secondary infection, persist for some time but in most cases the lung returns to a condition which is normal except for the presence of some disruptive emphysema. In consequence, however, of the odema of the lungs during the early stage, deficient oxygenation of the blood occurs, unless prevented by the administration of oxygen. The deficient oxygenation gives rise to widespread temporary injury in the various systems---------------------.
     

    2. Vesicants.-The only one hitherto employed is dichlorethyl sulphide, an oily liquid used in shells, and scattered from them to the ground, where it slowly evaporates. This not only attacks those in the immediate vicinity of the shell burst, but may affect those who may walk over the contaminated ground later. The fluid may be spattered also on clothing, shell casings, rifles, etc., and may thus become effective through direct contamination of the skin.

    The main action of this group is an irritant one on the skin, eyes, and respiratory passages.

    Special symptoms.-(a) Early: These are insignificant, nothing being noticed immediately except a smell reminiscent of mustard, from which the gas derives its name (mustard gas). A soldier may not realize for many hours that he has been exposed to gas, until the more important delayed symptoms develop.

    (b) Delayed: These are the principal symptoms of this group and appear 3 to 24 hours after being gassed. They occur usually in the following order, and approximately after the intervals stated.

    (i) Conjunctivitis (3 hours). This rapidly becomes very acute, and is accompanied by intense photophobia and swelling of the lids, which may cause closure of the eyes for days.

    (ii) Vomiting and epigastric pain (4 to 8 hours). These symptoms appear together as a rule, and are apt to be persistent and intractable.

    (iii) Burns (12 hours). Widespread erythema with local vesication occurs, going on to definite burns. The commonest sites are the axillæ, genitals, and back, but no area may be exempt. The affected surfaces frequently develop very marked pigmentation. Deep burns sometimes occur when the liquid itself comes into contact with the clothes or skin.

    (iv) Laryngitis, pharyngitis, tracheitis, and bronchitis (24 to 48 hours). These are the most dangerous symptoms. The degree and extent of the lesion may vary from a simple irritation of the surface to an ulceration of the mucous membrane of the whole passages, followed by infection of the raw surfaces. These conditions may be so extensive and severe as to cause death by themselves or in consequence of the development of broncho-pneumonia.

    In a certain number of cases with severe involvement of the respiratory organs, which recover, there has evidently been some interference with the proper oxygenation of the blood, which may give rise eventually to symptoms resembling the after effects of the suffocative gases * * *.

    When a soldier is protected by the respirator, the respiratory and eye symptoms are absent or slight.c
      TREATMENT

    Suffocative gases.-The grave symptoms here are due mainly to the intense pulmonary odema. The conditions which we have to combat are essentially: (a) Oxygen want, (b) condensation of blood, (c) overburdening of the right heart. Our main aims are: (a) Rest, (b) warmth, (c) Oxygen, (d) bleeding.

    (a) Rest: Protect the patient from all unnecessary physical effort in order to reduce the oxygen needed. Do not disturb him at the advanced aid station by questioning; his life may depend on the care with which he is handled in the early stage.

    All the gassed should be stretcher cases. Small oxygen tubes, if available, should be carried in each ambulance in the proportion of one to each stretcher case, and exchanged at the evacuation hospital for freshly filled tubes; these can of course be used only when the ambulance has passed out of the gassed area.

    cMedical Research Committee: Reports of the Chemical Warfare Medical Committee No. 3. The symptoms and treatment of the late effects of gas poisoning. April 10, 1918, pp. 3-4.



     

    943

    Give the patient fresh air. Do not close the ambulance too tightly unless it be very dusty.

    (b) Warmth: Warmth is important. Cold and shivering mean an increased production of CO2 and an increased demand for oxygen. The clothes must be removed at the earliest moment, for they hold gas and may be dangerous not only to the patient but to those about him; warm covering must however, be provided.

    (c) Oxygen: The administration of oxygen in all dyspnoic, cyanotic patients is of vital importance. The administration should be so nearly continuous as possible up to the point of the disappearance of the cyanosis, and should be continually repeated whenever the demand is evident.

    (d) Bleeding: In patients who are cyanotic and show engorgement of the venous system, bleeding is indicated. By venesection we combat-

    (1) Oedema of the lungs.

    (2) The condensation of the blood; for with the abstraction of the polycythæmic blood, fluid is drawn from the lungs and the tissues, and the circulatory medium becomes less viscous.

    (3) The overburdening of the right heart.

    The bleeding should be early and free, from 2 to 600 c. c.

    Bleeding is inadvisable, nay dangerous, in the patient who is pale and gray and in collapse.

    If the heart's action be rapid or feeble, bleeding may be preceded by an intramuscular injection, 15 minutes before the venesection, of ¼ mg. (gr. 1/250) digitaline cristalisée Nativelle. This may, if necessary, be repeated once or twice in the next 24 hours, and continued later by the mouth if necessary.

    In the early stages, during the period of distressing restlessness and agitation and pulmonary odema, morphia may be necessary. Its action as a respiratory depressant is believed by some to be dangerous; and the administration of oxygen, if it suffices, is the safest and the best means of quieting the agitation. Where the distress and physical effort associated with the struggles of the patient are great, morphia 0.016 (gr. ¼), hypodermically, may be demanded, but at the same time it should be remembered that in collapse, dulling of the respiratory center may turn the scale against the patient.

    Treatment of the pale, gray cases with collapse.-Oxygen is here the main aim, and the administration should be practically continuous.

    Never bleed these patients. Bleed only those with venous congestion.

    Rest, warmth, and oxygen are the mainstays of treatment. Atropine and adrenaline are contraindicated. These drugs place and increased strain on the heart. It is best to abstain from intravenous salt solution injections. The fluid introduced puts an extra burden on the heart, is soon absorbed into the tissues, and may increase the pulmonary odema. In grave cardiac weakness, preparations of camphor or caffeine may be given hypodermically, and digitalis may be indicated, according to the nature of case.

    Relapses-In any patient who has had pulmonary odema it may, within the first few days, recur on slight exertion or even without apparent cause, and if there have been any definite symptoms of odema of the lungs the patient should be kept in bed for a week.

    Smoking should be absolutely prohibited and convalescents should not be allowed to smoke in the ward in which these patients lie.

    Patients whose symptoms have been mild should, if possible, be put on graduated exercises as soon as they are out of bed, and under military discipline as soon as possible. Mild cases should be back in the line in about two weeks. Severe cases may have to remain in the hospital for three or four weeks and thereafter spend several weeks in a convalescent camp.

    Great care should be taken to protect the convalescent from secondary infections. Wherever it is possible beds should be isolated one from another by sheets, as in acute respiratory infections, for secondary bronchitis and broncho-pneumonia are not uncommon and the danger of cross infection should be provided against.

    Vesicant gases.-The symptoms, here, are usually delayed from 3 to 24 hours, and dangerous symptoms do not, as a rule, appear for from 24 to 48 hours after exposure, but



    944

    pulmonary odema and symptoms similar to those observed in the suffocative cases may occur; moreover, the patient may have had a double exposure to different sorts of gas. All the precautions, therefore, above mentioned should be observed at the outset, but other special steps must be taken.

    Disposition of clothes.-Wherever exposure to a vesicant gas is suspected, the use of external warmth should be avoided if the clothes have not previously been removed. The application of heat favors the diffusion of the gas.

    Remove the clothes as soon as possible, but protect the patient from exposure during the process.

    After removal, the clothes should be sterilized in wet steam for 30 minutes; in dry heat for 15 minutes; exposed to the air for 15 minutes. This may be carried out in the Thresh sterilizer, and may have to be repeated twice, although two or even one treatment may be efficacious. While waiting for sterilization, have the clothes placed outside the quarters, in the open. All who handle the clothes must be protected by respirators and special oiled clothing and gloves.

    Removal of the poison from the skin.-The patient should be thoroughly bathed in a warm room in soap and water at the earliest possible moment. Areas which have been specially exposed may first be covered for a few minutes by a paste of 25 to 50 per cent chloride of lime in water and then washed with warm water. Bathing with 0.05 per cent permanganate of potassium is said to be useful.

    Treatment of the skin and mucous membranes.-When the skin is dry, erythematous areas may be powdered with subnitrate or subcarbonate of bismuth (oxide of zinc), talcum, or any simple nonirritating powder. Moist and raw surfaces may also be powdered with the same substances or a powder consisting of oxide of zinc, carbonate of magnesia, carbonate of lime, 200 gr.; talcum powder, 400 gr., and protected from the bed clothes by cribs, or covered by a nonabsorbent dressing.

    If a moist dressing be preferred, a solution consisting of sodium chloride, 70 gr.; sodium bicarbonate, 150 gr.; water, 5,000 gr. may be used-simply limewater.

    Blisters should be carefully attended to. The contents of the vesicles are poisonous and irritating to the surrounding skin; the blisters should, therefore, be opened carefully and the contents taken up with absorbent cotton, which should promptly be burned. Interdigital areas should be washed carefully daily, powdered and bandaged.

    Fatty salves, in the early stages, are inadvisable, as any undestroyed poison which remains on the skin may be diffused underneath.

    Later, deep and painful burns are much relieved by treatment with ambrine.

    The eyes should be irrigated immediately with warm alkaline solutions such as the above mentioned solution of sodium chloride, sodium bicarbonate, and water. After this, some nonirritating oil such as liquid albolene should be instilled. The patient should be kept in a dark room, or the eyes shaded. Compresses soaked in this solution may give comfort in the acute stage. In severe cases, frequent (every 2 to 3 hours) irrigation of the conjuctiva with simple boric solutions (sodii boratis 0.65) (aquæ camphoræ 30), followed by the instillation of liquid albolene, should be carried out.

    The nose should be sprayed with a warm alkaline solution (sod. chloride, sod. bicarbonate, and water, as above) and also with liquid albolene, to which a little menthol may be added (such as the preparation known as "Chloretone inhalant").

    The mouth should be rinsed with alkaline washes and gargles.

    The laryngeal inflammations may be relieved by inhalation of: Menthol 0.65, tinct. benzoini comp. ad, 30, of which 5 c. c. are added to 500 c. c. steaming water.

    Secondary respiratory infections.-"Mustard" cases may develop grave secondary bronchitis, with broncho-pneumonia. In the treatment of such instances there is nothing specific. Every precaution should, however, be taken to prevent cross infection. The beds of all patients with purulent bronchitis and broncho-pneumonia should be screened one from another and from their neighbors.

    Sequels of gas poisoning.-In soldiers who have been "gassed," especially with phosgene, symptoms similar to those characterizing D. A. H. (effort syndrome) are not uncommon-dyspnoa on exertion, pain in the chest, palpitation, dizziness, fatigue on exertion, disturbed



    945

    sleep with dreams, paroxysms of coughing, and even asthmalike attacks. These patients are often polycythæmic. Nervous manifestations unassociated with apparent organic lesion are common.

    Get these patients out of bed and start carefully graduated exercises, sending them as soon as possible to a special training camp.

    "Functional" photophobia and blepharospasm are frequent, but eye shades and colored glasses should be discontinued as soon as the acute inflammatory stage is over. When this has passed, the use of eye drops of a solution of:
     
     
     

    Zinci sulphatis

    0.065-0.13 (gr. I-II)

    Acidi borici

    3.75 (3T)

    Aquæ

    30 (3T)

    is said to give relief. If corneal ulcers or iritis, which are not common, be present they must be treated in the usual manner. Threatening though the ocular manifestations may be, recovery is usually complete. Grave damage to the uveal tract is rare. It is important not to overtreat the eyes.

    In all cases preserve an optimistic attitude; the great majority of gassed patients recover completely.

    Do not let the patients become introspective or "hospitalized." Keep them occupied in mind and body. Get the "mustard" gas cases who have no respiratory involvement out of bed in two or three days if possible. Remove the eye shades as soon as the acute inflammatory stage is over. Send the men out of doors; look out for their employment or amusement, and get them under army discipline as soon as may be. Far too many convalescent "gassed" cases tend to accumulate, uncared for, in base hospitals. The responsibility of the medical officer does not end with the disappearance of the dangerous symptoms. See to it that the patient does not become a psychoneurotic.

    Attention to these details may save a considerable wastage of men.

      M. W. IRELAND,
       Brigadier General, Chief Surgeon.
     


    Circular No. 35. AMERICAN EXPEDITIONARY FORCES,
    France, June 13, 1918.
     
     THE MANAGEMENT OF MENTAL DISEASES AND NEUROSES IN THE AMERICAN EXPEDITIONARY FORCES

    Absence of the auxiliary civil facilities that simplify the management of mental cases in the Army in home territory, and the extraordinary incidence of functional nervous diseases in all armies in the present war, have made it necessary to provide special facilities and methods of procedure in the American Expeditionary Forces. These disorders, by their very nature, interfere with the morale and efficiency of troops in war. Their proper management in the hospitals and organizations in which they first come to notice and their wise disposition and reclassification subsequently will not only increase military efficiency, but in the case of war neuroses, will tend to diminish to a considerable extent their incidence.

    This circular is issued in order that all medical officers may become familiar with the facilities that have been provided for the diagnosis, transportation, and treatment of soldiers with these disorders. These facilities will be modified from time to time as changing conditions necessitate, but the general plan of management here outlined will be followed:
     I. MENTAL CASES (INSANITY, MENTAL DEFICIENCY, OBSERVATION CASES)

    (a) Provisions for prompt diagnosis and early care.-Tactical divisions: Each tactical division in the American Expeditionary Forces and in the United States is provided with a psychiatrist whose duty it is, under the direction of the division surgeon, to examine all mental cases coming to attention in the division and to make recommendations for their evacuation or other disposition. The psychiatrists will be detailed from the division sanitary personnel. Their specific duties are defined in Circular No. 5, chief surgeon's office, A. E. F.

    They will examine enlisted men brought before general courts-martial, as provided by War Department order of March 28, 1918. They will also examine all other military delin-



    946

    quents brought to their attention, especially those in whom self-inflicted wounds or malingering is suspected. Except under exceptional circumstances, no cases of this kind will be evacuated to the rear until examined by the division psychiatrists. In the case of prisoners accused of crimes, the maximum punishment of which is death, the division psychiatrist should, whenever practicable, have the assistance of a consultant in psychiatry.

    Base hospitals: A neurologist or a psychiatrist has been assigned to each base hospital or group of base hospitals in the same vicinity. This provision makes it possible for mental cases that first come to attention in such hospitals to receive early diagnosis and treatment and prompt evacuation to hospitals provided with special facilities for their care.

    (b) Provisions for hospital care.-Advance section, Services of Supply: There has been provided in connection with Base Hospital No. 116 a neuropsychiatric department of 72 beds, which will act as a collecting and evacuating point for mental cases from other base hospitals, from tactical divisions, and from training areas.

    When observation cases or patients with frank mental disease or defect are recommended by the division surgeon, upon the advice of division psychiatrists, for transfer to this collecting station, the commanding officer of Base Hospital No. 116 will be notified by telegraph or telephone and will thereupon send a sufficient number of attendants to bring such patients to the hospital in safety. It is necessary, in making such requests, to state the number of patients and the amount of supervision that they will require en route. When practicable, the ambulance service to be established in connection with Base Hospital No. 117 will be employed for this purpose. In all such cases, the diagnosis will be "Observation, mental," the type of disease being added in parentheses.

    It is very important that mental cases be accompanied by records in which the circumstances under which their condition came to notice are fully stated. It is obvious that, without such information, the medical officers who have the responsibility of dealing with these cases will often have difficulty in arriving at a diagnosis or in making suitable recommendations for their disposition.

    Base hospitals in the advance section will transfer to this collecting station all mental cases except those which can readily be retained until sent for by the psychiatric department of one of the base hospitals at a base port, and those in whom complications or other reasons render a transfer undesirable. Effort will be made to provide all base hospitals with several nurses or enlisted men of the Medical Department who have had experience in the care of mental cases. With such attendants it will be unnecessary to place guards in observation or mental wards. Commanding officers will protect these cases from the ridicule to which they are sometimes subjected even in hospitals.

    Intermediate section: At least one of the large base hospital centers which it is proposed to establish in this section will ultimately have in connection with it a neuropsychiatric department similar to that at Base Hospital No. 116. Hospitals in this section will, in the meantime, evacuate their mental cases to Base Hospital No. 8 in the manner specified in Paragraph I (c) of this circular.

    Base sections Nos. 1 and 2: A psychiatric department, with a capacity of 152 patients, has been provided in connection with Base Hospital No. 8. This and a similar one to be established in connection with a base hospital center in base section No. 2 will provide the chief facilities for the classification and continued care of mental cases in the American Expeditionary Forces.

    Base section No. 3: Mental cases among American troops serving with British organizations will be evacuated to England in the same manner as other sick and wounded from the same organizations. In England a neuropsychiatric department will be provided for the reception, continued care, and classification of cases from British clearing hospitals for mental diseases and from other hospitals in Great Britain.

    Base section No. 4: Any mental cases coming to notice in this section will be evacuated to base section No. 3.

    Base section No. 5: Psychiatric wards will be provided at a base port. These wards will receive only cases which have been classified "class D" at Base Hospital No. 8, and whose condition is such that they can be transported to home territory with the minimum of care and supervision. This ward will receive no other cases, but will provide temporary care for soldiers who are found insane upon their arrival from the United States.



    947

    Base sections Nos. 6 and 7: Mental cases arising in these sections will be evacuated to a base hospital at the port of base section No. 2.

    French hospitals: Mental cases that have been evacuated from the front into French military hospitals will be transferred as soon as practicable to the most accessible neuropsychiatric department of an American base hospital center.

    (c) Transportation.-The neuropsychiatric department at Base Hospital No. 116 will send for patients to other base hospitals in the advance section, Services of Supply, and to tactical divisions and training areas as provided in Paragraph I (b) of this circular. The neuropsychiatric departments of base hospital centers to be established in the intermediate section, Services of Supply, will send for patients in the same manner.

    The psychiatric departments of Base Hospital No. 8 and the base hospital center in base section No. 2 will send for patients to any base hospital which is nearer to them than to a collecting station.

    As mental cases of all degrees of severity can be safely and comfortably provided for at these collecting stations, they will be retained until a sufficient number have accumulated so that they can be evacuated in parties, the attendance being provided by the psychiatric department at the base port to which they are sent. Ordinarily, regular passenger trains will be used; but in special instances and where the number of patients warrants it, transfers will be made in a car set aside for this purpose on an American hospital train destined for a base port to which they are to be sent. In this case, as in all others, attendance will be provided by the psychiatric department receiving the convoy.

    Evacuation to home territory of patients classified "class D" will be made in accordance with special arrangement which it is not necessary to outline in this circular.

    (d) Disability boards for mental cases.-Disability boards for mental cases will be convened at neuropsychiatric departments of base hospital centers and at psychiatric departments at base ports. Other disability boards should not pass upon these cases, but should refer them to one of the points at which such boards are authorized. All mental cases to be transported in France will be given the tentative diagnosis of "observation, mental," except those transported to their final destination on American hospital trains.

    Disability boards will be guided by Circular No. 24, chief surgeon's office, 1918, in passing upon mental cases.

    II. FUNCTIONAL NERVOUS DISEASES AND CONCUSSION CASES

    (a) General consideration.-The proper management of these conditions which are commonly included in the designation "shell shock" is regarded by this office as a matter of much importance. This term, which, unfortunately, is being used indiscriminately by medical officers as well as patients, includes a number of different conditions depending upon many different causes and requiring for their successful management several entirely different methods of procedure. Many patients in whom severe concussion symptoms follow being blown up by shells or buried in dugouts can be returned to duty, and it is possible to return a much larger proportion of those cases in which purely psychoneurotic symptoms develop under shell fire or in training, if they are skillfully managed. The return of these cases to their own organizations after a short period of treatment has a very favorable effect in lessening the incidence among their comrades of disorders in the second group mentioned. If, on the other hand, a large proportion of these patients are evacuated indiscriminately to hospitals in the Services of Supply or to home territory, the effect will be to increase their incidence.

    For this reason a special hospital for these cases, Base Hospital No. 117, has been established, and an ambulance service has been provided in connection with this hospital by which cases can be received directly from tactical divisions at the front. At this hospital the resources found most useful in the British and French special hospitals for these cases are employed. Success in their treatment depends very largely upon the attitude of medical officers generally toward the special problems in diagnosis and management which they present. For this reason regimental medical officers should guard against making an unfavorable prognosis even in cases presenting severe symptoms.



    948

    (b) Treatment.-Tactical divisions: The advice of the division psychiatrists should be utilized to the fullest extent in the early treatment of these cases in division sanitary organizations and in the selection of cases for evacuation to hospitals in the Services of Supply. It will be found advisable, whenever practicable, to receive such cases in special wards in one field hospital and to evacuate cases to hospitals in the Services of Supply only upon the recommendation of the division psychiatrist. This officer will advise with regimental medical officers regarding the management of nervous manifestations when they first come to attention at the front.

    Hospitals in the Services of Supply in France: It is expected that a very large proportion of these cases will be admitted directly from their organizations to Base Hospital No. 117 and that relatively few, unless complicated by wounds, gassing, or other conditions, will be received in other base hospitals. Other base hospitals will promptly transfer suitable cases to Base Hospital No. 117 except in these instances in which it is thought that they can return directly to duty and those in which the outlook seems so unfavorable, from constitutional neuropathic tendencies or other factors, that their reclassification is probable. Cases in which there is some doubt as to whether an organic or functional disorder is present should be transferred to Base Hospital No. 117. No cases having wounds requiring much surgical attention should be sent to Base Hospital No. 117. All cases in which there is doubt as to the best disposition should be brought to the attention of the consultant in neuropsychiatry for the hospital.

    Hospitals in the Services of Supply in England: A special hospital for war neuroses will be provided in England which will be organized and conducted upon the same lines and will perform the same functions as Base Hospital No. 117. American soldiers serving with British organizations will be transferred to this hospital from the British clearing hospital for these cases or from other hospitals in England.

    French hospitals: American patients with these disorders in French military hospitals will be evacuated to Base Hospital No. 117 or to the nearest neuropsychiatric department of a base hospital center.

    (c) Disability boards for functional nervous diseases and concussion cases.-Disability boards for these cases will be convened at Base Hospital No. 117, neuropsychiatric departments of base hospital centers, and psychiatric departments of base hospitals at base ports. No other disability boards should pass upon these cases.

       M. W. IRELAND,
       Brigadier General, N. A., Chief Surgeon.


    Circular No. 36.

    AMERICAN EXPEDITIONARY FORCES,
    France, June 11, 1918.

    Subject: Promotion in the Medical Reserve Corps.

    1. The Medical Reserve Corps has not heretofore received promotions so as to fill up the proportions to which the corps is entitled by law, because of the many difficulties which have presented themselves in working out a system which would be just and satisfactory.

    2. Great inequalities occurred in the original commissioning of medical reserve officers by which men of mature age and high standing in the medical profession were made junior to others who were younger and of less professional experience. Further inequalities have been created by the promotion in the United States of younger officers who afterwards came to France with the increased rank which had been denied to members of the Medical Reserve Corps of the American Expeditionary Forces.

    3. A plan has been, however, now prepared in this office which has met the approval of the commander in chief and which it is desired to put immediately into operation. This plan recognizes that several factors should be considered in determining the rank of a member of the medical profession coming into the Army in time of war to give voluntary service.

    (a) The first is age and the length of his professional experience, which constitutes, generally speaking, the asset of greatest value to the Government which he brings into the service.



    949

    (b) The second is the length of his active service, which determines his military experience.

    (c) The third is the character of his military service, and whether it has been distinguished by unusual self-denial, gallantry, efficiency, or hardships which would entitle the candidate to advancement beyond others of the same professional and military experience. On the other hand, this factor may be one of inefficiency or ill conduct which would in justice demand the withholding of promotion, or even separation from the service.

    4. In order to accumulate the data for the determination of these factors in each case, it will be necessary to have commanding officers and senior medical officers furnish recommendations in the case of officers of the Medical Reserve Corps serving under them. An individual report upon a separate sheet of paper should be given in the case of each officer, whether considered deserving of promotion or not, except those under the draft age of 31 years. Officers under the draft age will not be promoted except in special cases where the officer has rendered unusually distinguished service and has been more than a year on active duty. This report should in each case give the following information:

    (1) Full name and rank.
    (2) Date of birth.
    (3) Date of graduation in medicine and institution, if these can be ascertained.
    (4) Date when ordered on active duty under Reserve Corps commission.
    (5) Previous active military service, if any, either in the United States Army or with the National Guard when called into the United States service.
    (6) Character of service of the officer:

    (a) Has it been of a satisfactory and creditable character, such as, when his age, professional experience, and length of service being considered, would entitle him to a higher grade; or

    (b) Has it been fairly satisfactory in positions not of great responsibility, but not such as would warrant promotion to a higher grade; or

    (c) Is the officer, on account of professional ignorance, indolence, bad habits, or moral delinquency of any sort, undesirable for the military service. In this case, as full a statement as is practicable should be made of all the facts throwing light upon the shortcomings of the officer; and it should be stated whether he has been brought before a board of officers under General Order 45, general headquarters, A. E. F., 1918.

    5. Copies of this circular and the blank forms for making the reports will be sent by this office to the base surgeons of sections, who will be charged with distributing them to all medical organizations in their sections except the base hospitals, to which the forms will be sent direct in order to save time and clerical labor; also to division surgeons, who will be charged with supplying them to the senior medical officers of all medical units in the divisions. In each case the report will be prepared by the immediate medical superior of the medical reserve officer to be reported upon, and they will be forwarded through the military channels.

      M. W. IRELAND,
       Brigadier General, M. C., N. A., Chief Surgeon.

       FRANCE, June 11, 1918.
     FORM FOR REPORT AS TO THE CHARACTER OF SERVICES AND QUALIFICATIONS OF MEDICAL RESERVE CORPS OFFICERS

    1. Full name and rank -------------------------------------------------------------------------------------------------------------------------------------------
    2. Date of birth ---------------------------------------------------------------------------------------------------------------------------------------------------
    3. Medical school from which graduated, with date of graduation ---------------------------------------------------------------------------------
    4. Date when ordered into active service on Reserve Corps commission -------------------------------------------------------------------------
    5. Previous active military service, either in United States Army or with National Guard in United States service --------------------
    6. Character of service of officer:

    (a) Has it been of a satisfactory and creditable character such as, when his age, professional experience and length of service are considered, would entitle him to a higher grade; or



    950

    (b) Has it been fairly satisfactory in positions not of great responsibility, but not such as would warrant promotion to a higher grade; or

    (c) Is the officer, on account of professional ignorance, indolence, bad habits, or moral delinquency of any sort, undesirable for the military service? In this case, as full a statement as is practicable should be made of all the facts throwing light upon the shortcomings of the officer, in order that he may be brought before a board for the determination of his fitness for the service. Any available evidence in the form of correspondence or documents which is available should be forwarded in such cases.

    (State at beginning of answer whether service has been of class A, B, or C, and write remarks thereafter.)



    Circular No. 37.

      AMERICAN EXPEDITIONARY FORCES,
    France, June 22, 1918.

    1. Food and nutrition section.-Announcement is made of the organization of a food and nutrition section in the division of sanitation, office of the chief surgeon, A. E. F. This section will be located at Dijon, under the supervision of the director of laboratories and infectious diseases, and its functions shall be to inspect, investigate, and make recommendations concerning those factors directly affecting the nutrition of troops of the American Expeditionary Forces. The section is authorized to advise concerning the suitability of rations and dietaries, and all changes or substitutions proposed in rations and dietaries for troops, hospitals, or prison camps; and in cooperation with the Quartermaster Department the section will devise and propose measures for the conservation of food.

    2. Official letters and telegrams.-Official letters and telegrams should be addressed to the chief surgeon, A. E. F., and not to individual officers or divisions of his office.

    3. Billets or shelter tents.-The attention of commanding officers of ambulance companies, field hospitals, and other mobile medical units is invited to the fact that Medical Department soldiers attached to these units should be sheltered in the same way as other soldiers at the front, namely, by billets or shelter tents, it not being practicable to issue tentage for the shelter of soldiers at the front. Commanding officers of the above-named organizations will therefore turn in to the nearest quartermaster depot the large pyramidal tents issued to ambulance organizations and field hospitals for the use of enlisted personnel, and such wall tents as are issued for the use of officers not entitled to tentage in the field.

    4. Surgical operations.-(a) Surgical operations of election for chronic conditions which existed before the war and do not incapacitate for the performance of ordinary duty will not as a rule be performed during periods of military activity, and will only be done in well equipped base or camp hospitals of the American Expeditionary Forces.

    (b) Hernias should be operated upon subject to the foregoing restrictions, bearing in mind military convenience and the extent of present or threatened disability.

    (c) Operations for varicocele should as a rule not be performed at all.

    (d) Removal of tonsils is not to be done, except when marked destruction to respiration exists, or when they are a source of infection in a systemic disease.

    (e) Hemorrhoids should be operated upon subject to the restrictions of paragraph 1.

    (f) Special instructions for the handling of orthopedic patients are in course of preparation.

    5. Orders involving travel of over 10 persons.-When orders, involving travel of over 10 persons, are received by the commanding officer of a base hospital or other sanitary formations of the Services of Supply, he should at once notify the railroad transportation officer at his station and should not comply with the order until notified by the railroad transportation officer that a schedule has been arranged.

    If no railroad transportation officer is at the point where the movement originates, details of the movement should be wired to the troop bureau of the transportation department at these headquarters, with request that proper arrangements be made.

    6. Proper handling and disposition of slightly wounded men.-Attention is directed to the importance of early, proper handling and disposition of slightly wounded men in all hospital formations. While the handling of seriously wounded usually entails a greater exercise of technical skill, the claims of the slightly wounded for equal attention may be



    951

    overlooked. It must be borne in mind that a neglected or improperly treated slight wound may have serious consequences and cause prolonged hospitalization. Slightly wounded men form the greatest military asset among all those admitted to hospitals, in that their early return to duty can be looked for if properly treated. The tendency in some hospitals is to delegate the care and treatment of slightly wounded men to the medical officers young in experience and skill in surgery.

    Without deflecting the full measure of attention to be given to serious cases, surgical personnel at hospitals should be so assigned as to bring skill and attention to bear upon slightly wounded men equal to that given to more serious cases, carrying into effect that principle of military surgery which contemplates the greatest good to the greatest number.

    7. Telegraphic and mail communications.-All communications, both telegraphic and mail, intended for the chief surgeon, A. E. F., should be addressed to the chief surgeon, A. E. F., Services of Supply, and not general headquarters.

    8. Reports of Y. M. C. A. personnel.-For all Y. M. C. A. personnel treated in American Expeditionary Forces formations the following information will be sent to the Y. M. C. A. headquarters, 12 Rue D'Aguesseau, Paris: (a) Date of entry to hospital, (b) diagnosis, (c) disposition, (d) date of disposition, (e) any facts pertinent to the further care of the case.

    9. Autopsy reports.-In the future, all autopsy reports will be made in triplicate. One copy will be sent to the chief surgeon's office, one direct to the central medical laboratory, U. S. A. P. O. No. 721, and one to the commanding officer of the medical unit for which the autopsy is performed.

    10. Disposition of ordnance equipment.-The attention of commanding officers of hospitals is invited to the fact that all available ordnance equipment is needed, and such equipment should not be allowed to accumulate in hospitals. It should be turned in to a salvage officer when there is one near the hospital, with instructions to ship it to advance ordnance depot No. 1, Is-sur-Tille. If there is no salvage squad in the vicinity of the hospital, it should be shipped by the commanding officer of the hospital direct to advance ordnance depot No. 1, Is-sur-Tille.

    11. Prescriptions for lenses.-Prescriptions for glasses are being received at the central optical unit in one-eighth diopter, or multiples thereof, which necessitates grinding the one-fourth diopter stock lenses. It has been found by experience that for all practical purposes a correction down to one-fourth of a diopter is sufficient. Hereafter, prescriptions for lenses will not be written in less than one-fourth subdivisions of a diopter.

       M. W. IRELAND,
       Brigadier General, M. C., N. A. Chief Surgeon.


    Circular No. 38.

    AMERICAN EXPEDITIONARY FORCES,
      France, July 1, 1918.

    1. Class D patients not to be sent to St. Nazaire.-Class D patients intended for evacuation to the United States via St. Nazaire will be sent to Base Hospital No. 8, at Savenay, and not to St. Nazaire.

    2. Change of circular No. 31.-Paragraph 3, under "Evacuation of British patients," Circular No. 31, American Expeditionary Force, May 23, 1918, is rescinded, and the following substituted therefor:

    (a) To carry out the wishes of the director general, medical service British armies in France, all British patients fit for travel discharged from American base hospitals in France will be ordered to report to D. D. M. S., Rouen, and not to A. D. M. S., Paris. Telegraphic report will be made to D. D. M. S., Rouen, British Expeditionary Force, and at the same time to medical communications, British Expeditionary Force, stating number of patients, time and place of departure, probable time of arrival at Rouen.

    (b) The effects of deceased British soldiers should be sent to "The D. A. G., effects branch, general headquarters, third Echelon, British Expeditionary Force," and public clothing and equipment to the commanding officer, ordnance base, British Expeditionary Force. Unless otherwise directed, commanding officers of hospitals, in returning British officers and soldiers from hospital to place directed, will furnish their transportation on "Order of transport, model A," indicating on it in red ink ''British Expeditionary Force."



    952

    (c) The provisions of the first sentence under "French soldiers in American sanitary formations," Circular No. 31, A. E. F., May 23, 1918, do not apply to those hospitals where a definite number of beds has been reserved for the reception of French patients, and when this number has not been exceeded.

    3. Disposition of sick and wounded of American Expeditionary Forces on duty with British Expeditionary Force.-In accordance with agreement of May 6, 1918, between the British War Office and representatives of the American Expeditionary Forces, sick and wounded of American Expeditionary Force troops on duty with the British Expeditionary Force are to be evacuated into British Expeditionary Force hospitals. As far as practicable, this evacuation will be into hospitals staffed by American sanitary units.

    4. Instructions pertaining to evacuation of patients to United States.-(a) Surgeons of base sections will be responsible for and regulate the evacuation of class D cases to the United States from hospitals at base ports. They will keep informed as to the number and types of cases awaiting evacuation, the dates of departure, and carrying capacity of transports and hospital ships, in order that there may be no delay in the movement of sick and wounded. They will see that transport surgeons receive lists of patients and the necessary papers pertaining to the cases which are to be sent to the United States, (see instructions on "Field medical card," and par. 7, Sec. VI, p. 9, and par. 1, Sec. VIII, p. 10, "Sick and wounded reports for the A. E. F."), including the classification of mental and other cases. They will obtain from transport surgeons receipts for patients and the papers pertaining thereto, as well as receipts for valuables and effects of insane and helpless cases.

    (b) When patients of class D collect at any base port in such numbers that they can not be properly cared for, and the facilities for evacuating them to the United States by transport are insufficient, the base surgeon will send such cases as deemed advisable to another base section, in accordance with such agreement as is made with the base surgeon of that section.

    (c) Surgeons of base sections, on request of surgeons of other base sections, will make the necessary preparations for the reception and embarkation of patients sent to their respective ports with the view to evacuation to the United States. They will also assist surgeons of other base sections to obtain sufficient information, so as to enable them to send patients at the proper time for embarkation.

    (d) Under the provisions of article 1, of an agreement entered into by the Secretaries of War and Navy, March 28, 1918, the Navy is charged with the care of sick and wounded of the Army sent from France or England to the United States, except those shipped on Army transports, but, the Army, on request of the Navy, will render such assistance in personnel and material as may be necessary. It will readily be seen that it would be impossible at the present time to estimate, for the different ports, the number of personnel and character and amount of material that the Navy might require from the Army under the provisions of the above article, but in order that the Army may be able to carry out its part of the contract as far as possible, the following will be observed:

    a. Base surgeons will investigate and determine the character and amount of material (referred to under art. 1, par. C, of the above-mentioned agreement) that will likely be required by transports entering their respective ports, and they will make timely requisitions therefor.

    b. Whenever the Navy requests personnel under the provisions of the above-mentioned agreement, base surgeons will recommend to their respective base commanders, for detail with the Navy, such assistance as is available in the different sanitary organizations of their respective base sections, without depleting the efficiency of any organization to such an extent that its required work can not be satisfactorily accomplished. When such men are detailed with the Navy, a telegraphic report will be sent to the chief surgeon, A. E. F., stating all particulars, in order that the men may be replaced as soon as practicable.

    c. Should the personnel or material requested by the Navy not be available at the time, base surgeons will take proper steps to retain ashore such cases as the transport surgeons would be unable to properly care for.

    (e) When class D cases are evacuated to the United States on any vessel other than naval transports or naval hospital ships, the surgeons of the base section from which the vessel sails will, before patients are taken aboard, make the necessary preparations for proper medical attention, supplies, and personnel for their care en route.



    953

    (f) Surgeons of base sections will submit to this office lists of all patients evacuated to the United States from the ports in their sections. In addition to giving name, rank, organization, and diagnosis, the name of the ship will be stated, with a numerical summary outlined as follows: Sitting cases; lying cases (insane requiring restraint; other mental diseases); sick (tuberculosis; all others); wounded (received in action; all other injuries).

    5. Instructions pertaining to prompt action of disability boards and early disposition of cases classified.-The attention of commanding officers of hospitals is called particularly to the necessity for prompt action of disability boards, and for early disposition of cases that have been classified. In order to determine the length of time that cases recommended to disability boards for classification remain in hospital without being acted upon, commanding officers of base hospitals will submit to the chief surgeon, A. E. F., Services of Supply, a weekly report of all cases which have been recommended for the action of disability boards, and which remain in hospital for two weeks without completion of board proceedings. This report will be forwarded every Saturday, and will show in each case the name, diagnosis, date of admission to hospital, date on which the case was recommended to be sent before the board, and reason for delay in classification. This report will also show in each case the name, diagnosis, and date of recommendation of disability boards, of all men who have been classified by boards and who have not been disposed of within two weeks after the boards' recommendation.

    6. Instructions to disability boards in regard to classification of mental cases at base ports.-

    (a) For the information and guidance of surgeons of base sections, surgeons on transports, liners, and hospital ships, disability boards at hospitals at base ports will classify all mental cases destined for transfer to the United States into the following groups, making entry on board proceedings in each case: "Close supervision"; "ordinary supervision"; "no special supervision."

    (b) Cases designated for "close supervision" should be placed in compartments or rooms on shipboard, being constantly guarded by reliable attendants, and not allowed to go on deck.

    (c) Cases designated for "ordinary supervision" can be placed in the sick bay, with the same supervision as is given to ordinary sick and wounded.

    (d) Cases designated for "no special supervision" can sleep in ordinary bunks.

    Many cases of feeble-mindedness and nondepressed psychoneurotics may fall under this class.

    (e) The greatest care must be exercised in the classification of mental cases, and where doubt exists in any case, the proceedings of the board will show the entry "close supervision".

    7. Letter from the Surgeon General of the Army.-The following letter from the Surgeon General of the Army is quoted for the guidance of the medical officers of the American Expeditionary Forces, and the information called for will be entered on the sick and wounded card whenever known:

    All medical officers are requested in the future to give the name of the causative organism in addition to the diagnosis of the kind of pneumonia and the type of pneumococcus whenever known.

    Thus, pneumonia, lobar, should, if practicable be reported as:
       Pneumonia, lobar, pneumococcus, type 1.
       Pneumonia, lobar, pneumococcus, type 2.
       Pneumonia, lobar, pneumococcus, type 3.
       Pneumonia, lobar, pneumococcus, type 3.
       Pneumonia, lobar, pneumococcus, type 4.
       Pneumonia, lobar, pneumococcus, type unclassified.

    Also broncho-pneumonia should, if practicable, be reported as:
       Broncho-pneumonia, pneumococcus, type 1.
       Broncho-pneumonia, pneumococcus, type 2.
       Broncho-pneumonia, pneumococcus, type 3.
       Broncho-pneumonia, pneumococcus, type 4.
       Broncho-pneumonia, pneumococcus, type unclassified.
       Broncho-pneumonia, streptococcus, hæmolyticus.
       Broncho-pneumonia, streptococcus, other types.
       Broncho-pneumonia, streptococcus, unclassified.
       Broncho-pneumonia, other organisms, unclassified.



    954

    8. The new plan of promotion in the Medical Reserve Corps and Dental Reserve Corps.- The following letter has been received from the adjutant general, A. E. F., which explains clearly the recently approved plan for promotion of the medical reserve officers serving with the American Expeditionary Forces. It has also been extended to the Dental Reserve Corps, and the Surgeon General has been requested to adopt it for these corps in the United States. The corrective promotions authorized in the first paragraph will be made as rapidly as the reports called for by Circular 36 are received, and then promotions will be made according to the roster. Precedence in the roster will be determined by age and length of service, except that a value will also be given for distinguished service, including wounds and decorations received and mention for conspicuous gallantry:

    GENERAL HEADQUARTERS,
      AMERICAN EXPEDITIONARY FORCES.

    From: The adjutant general,
    To: The chief surgeon, A. E. F. (through C. G., S. O. S.)
    Subject: Promotions.

    1. Referring to your memorandum of May 7, 1918, regarding promotion of Medical Reserve Corps officers, you will submit recommendations for promotions to the grade of major of all medical reserve officers above the age of 40, and to the grade of captain of all the lieutenants above the age of 35, whom you may desire to recommend

    2. The following will be considered the policy that will govern in regard to the promotion of officers of the Medical Reserve Corps in the American Expeditionary Forces:

    Policy governing promotion of medical reserve officer.-(a) All officers of the Medical Corps in Europe will be placed on a roster according to age in each grade. An officer's age will be determined by his actual age plus four months for each month of service.

    (b) All lieutenants whose actual age is above 31, and who have completed one year's service, shall be eligible for recommendation for promotion to captain.

    (c) Promotion in general will be according to seniority, as determined by these rosters.

    (d) Taking the number of first lieutenants of the Medical Reserve Corps in the American Expeditionary Forces at any time as a basis, the number of officers in grade of captain and major shall not be greater than that authorized by the proportion of one lieutenant to three and nine-tenths captains to one and seven-tenths majors (approximately the proportion between the same grades in the regular Medical Corps at the time of the passage of the medical reserve law).

    (e) Recommendation on the part of the military superior of each officer, with a statement that his services have been satisfactory, will be required in each case of recommendation for promotion.

    3. The policy with regard to promotion of officers in the Dental Reserve Corps shall be the same as that outlined above for the officers of the Medical Reserve Corps. The chief surgeon is authorized to forward at once any recommendations for promotions which he believes should be made for the purpose of rectifying inequalities in grade due to mistakes in original appointments.

    By command of General Pershing:
      (Signed) W. P. BARNETT, Adjutant General.

    9. Oxygen tanks.-The necessity of keeping tanks containing oxygen under covered storage as much as possible is pointed out. Excessive heat causes the plug in the safety valve to be blown out, thereby emptying the tank.

    10. Appliances for fire protection.-Requests for apparatus of this character should hereafter be made direct to the chief of the bureau of fire prevention, these headquarters, by separate requisition. These items should not be included in requisitions made on the medical supply depots.

    M. W. IRELAND,
       Brigadier General, M. C., N. A., Chief Surgeon.
     


    Circular No. 39.

    AMERICAN EXPEDITIONARY FORCES,
       France, July 12, 1918.
     LIGHT DIETS IN BASE HOSPITALS

    1. The following menus for hospital light diets are sent out as suggestions for the guidance of mess officers. They are based upon a series prepared for use in a base hospital in the United States which proved by experience to work satisfactorily at that place. The



    955

    same menus may be repeated each week indefinitely, as any one man is seldom on light diet for more than two weeks. It is probable that the price of some of the articles mentioned may be prohibitive and that some others may be unobtainable. Substitutes will, of course, be made in such instances.

    2. By this system the mess officer knows in advance what items will be required and can take measures to keep his stock complete.

    3. In preparing menus from Table 2 it should be borne in mind that the total number of calories for each diet should be between 2,000 and 2,500. "Cup" has the same significance in all tables.

    4. It is believed that menus prepared from either Table 1 or Table 2 will conform to the practices of the best civil hospitals in the United States.
     TABLE I.-Menus for light diets for one week

    NOTE.-In these menus "cup" means approximately one-half pint of material prepared ready to serve. The "slices of bread" refer to those of the 1-pound loaf or to the half slices of the large Army loaf.
     

    SUNDAY

    Calories

    Breakfast:

    1 orange, or equivalent in fresh fruit

    75

    1 cup cornmeal mush with sugar and milk

    200

    2 slices bread with butter

    175

    1 cup coffee, half milk

    200

     

    650

    Dinner:

     

    Chicken fricassee, medium service

    150

    1 baked potato, medium size

    150

    2 slices bread with butter

    175

    1 cup tapioca pudding

    250

    1 cup cocoa, half milk

    240

     

    965

    Supper:

     

    1 soft-boiled egg

    80

    1 cup Farina with sugar and milk

    250

    ¾ cup stewed peaches

    250

    2 slices bread with butter

    175

    1 cup coffee

    ---
     

    755

     

    Total:

     

    2,370

    MONDAY

     

    Breakfast:

     

    2/3 cup stewed prunes 

    250

    1 cup oatmeal with sugar and milk

    200

    2 slices bread with butter

    175

    1 cup coffee, half milk

    200

     

    825

    Dinner:

     

    1 cup chicken soup

    100

    2 soda crackers

    50

    1 poached egg

    80

    ½ baked sweet potato

    150

    1 cup jelly

    200

    1 cup coffee

    ---
     

    580

    Supper:

     

    1 cup custard

    300

    1 cup rice with milk and sugar

    200

    ¾ cup stewed apricots

    250

    2 slices bread with butter

    175

     

    925

     

    Total:

     

    2,330

    TUESDAY

     

    Breakfast:

     

    1 baked apple

    200

    1 cup Farina with sugar and milk

    200

    2 slices bread with butter

    175

    1 cup coffee, half milk

    200

     

    775

    Dinner:

     

    1 cup creamed chipped beef

    200

    2 slices bread with butter

    175

    ½ cup ice cream

    225

    1 cup cocoa, half milk

    240

     

    840

    Supper:

     

    1 poached egg on toast

    125

    1 cup hominy with sugar and milk

    250

    2 slices bread with butter

    175

    ¾ cup stewed pears

    125

     

    675

     

    Total:

     

    2,290

    WEDNESDAY

     

    Breakfast:

     

    2 slices pineapple

    200

    1 cup oatmeal with milk and sugar

    200

    2 slices buttered toast

    175

    1 cup coffee, half milk

    200

     

    775

    Dinner:

     

    Chicken fricassee, medium service

    150

    1 medium baked potato

    150

    2 slices bread with butter

    175

    1 cup bread pudding

    250

    1 cup cocoa, half milk

    240

     

    965

    Supper:

     

    1 soft-boiled egg

    80

    1 cup rice with milk and sugar

    200

    2 slices bread with butter

    175

    1 orange

    75

     

    530

     

    Total

     

    2,270

    THURSDAY

     

    Breakfast:

     

    2/3 cup stewed prunes

    230

    1 cup hominy with milk and sugar

    250

    2 rolls with butter

    175

    1 cup coffee

     
     

    655

    Dinner:

     

    1 cup chicken broth with croutons

    100

    1 egg as omelet

    80

    ½ baked sweet potato

    150

    1 cup Farina pudding

    250

    1 cup coffee

     
     

    755

    Supper:

     

    1 cup tomato spaghetti

    100

    2 slices bread with butter

    175

    2 slices pineapple

    200

    1 cup cocoa, half milk

    240

     

    715

     

    Total:

     

    2,125

    FRIDAY

     

    Breakfast:

     

    1 orange, or equivalent in fresh fruit

    75

    1 cup oatmeal with milk and sugar

    200

    2 slices buttered toast

    175

    1 cup coffee, half milk

    200

     

    650

    Dinner:

     

    1 cup creamed codfish

    200

    2 soda biscuits

    50

    2 slices bread with butter

    175

    1 cup tapioca pudding

    250

    1 cup cocoa, half milk

    240

     

    915

    Supper:

     

    1 soft-boiled egg

    80

    1 cup Farina with milk and sugar

    200

    2 slices buttered toast

    175

    ¾ cup stewed peaches

    250

     

    705

     

    Total:

     

    2,270

    SATURDAY

     

    Breakfast:

     

    1 baked apple

    200

    1 cup Farina with sugar and milk

    200

    2 rolls with butter

    175

    1 cup coffee, half milk

    200

     

    775

    Dinner:

     

    1 egg as omelet

    80

    1 medium baked potato

    150

    1 cup creamed carrots

    100

    2 slices bread with butter

    175

    1 cup junket

    150

    1 cup cocoa, half milk

    240

     

    895

    Supper:

     

    1 poached egg on toast

    125

    1 cup corn meal mush with milk and sugar

    200

    2 slices buttered toast

    175

    2/3 cup apple sauce

    150

     

    650

     

    Total:

     

    2,320



    957
     TABLE II.-For preparation of menus for light hospital diet
     

    BREAKFAST

    Take one

         

    Take one

     

     

    Take one

    Take one

    DINNER

     

    Take one1

    Take one

    Take one2

    Take one

    Take one3

    Take one

     

    Take one

    SUPPER

    Take one

    Take one marked "S"

     

     

    Take one

     

     

    Take one

    Take one

    Cereals

    Meats and meat substitutes

    Vegetables

    Bread and butter

    Soups

    Desserts

    Fruits

    Drinks

    High starch

    Green

    Rice.
    Oatmeal.
    Farina.
    Hominy.

    Eggs (S).
    Chicken.
    Fish.
    Beef or mutton.
    Chipped beef.
    Macaroni and spaghetti with tomatoes serves for both meat and vegetables (S).

    Baked white potatoes.
    Baked sweet potatoes.

    Spinach.
    Lettuce.
    Tomatoes.
    Carrots.
    Green peas.

    Liberty.
    Rye.
    White.
    Graham.
    Whole wheat.
    Toast.
    Rolls.
    Crackers.4

    Beef soup.
    Beef broth.
    Chicken soup.
    Chicken broth.
    Noodle.
    Vegetable.5
    Barley.
    Chowder.
    Boullion.

    Custard.
    Ice cream.
    Gelatine jellies.
    Puddings.
    Farina.
    Tapioca.
    Cornstarch.
    Rice.
    Fruit bread.

    Raw:

    Apple.
    Orange.

    Baked apple.
    Canned or stewed, fresh:

    Apples.
    Cherries.
    Peaches.
    Pears.
    Plums.

    Dried, stewed.6

    Apples.
    Apricots.
    Peaches.
    Prunes.

    Milk.
    Coffee.
    Cocoa.
    Tea.

    1Omit this item if thick soup is served.
    2Omit this item if soup is served.
    3Omit this item if green vegetable is served.
    4Not to be served to replace bread, but with soups.
    5For many cases should be strained before serving.
    6Do not serve more than one dried fruit on any one day.



    958
     TABLE III.-Caloric values of small quantities of foods listed in Table II as prepared ready to serve

    [Note that these values can, in the nature of the case, be only approximate. They should, however, be of some assistance in helping the mess officer or dietitian to approximate the proper value for the day's rations] 
     

     

    Calories

    Cereals:

     

    1 cup of cereal with milk and sugar

    200

    1 egg

    80

    Meats:

     

    1 cup creamed chipped beef or 1 cup creamed codfish

    200

    1 cup creamed chicken

    400

    Beef, mutton, or chicken, small service

    100

    Vegetables:

     

    1 cup tomato macaroni

    100

    1 medium potato, white

    100

    1 medium potato, sweet

    200

    1 cup tomato, canned spinach, or lettuce

    50

    1 cup creamed carrots

    100

    1 cup creamed peas

    225

    Bread, 1 slice, or 1 roll, or ½ slice of Army loaf

    50

    Butter, 1 service (40 to pound)

    85

    Soups:

     

    1 cup thin soup

    50

    1 cup thick soup

    100-200

    Desserts:

     

    1 cup custard

    300

    1 cup ice cream

    300

    1 cup gelatine jelly

    200

    1 cup pudding

    250

    Fruits, raw:

     

    1 apple, large

    100

    1 orange, large

    100

    Baked, 1 apple, large, with sugar

    200

    Canned or stewed fresh fruit:

     

    1 cup apple sauce

    250

    3 large halves apricots with juice

    100

    1 slice pineapple with juice

    100

    3 halves pears with juice

    100

    1 cup cherries (stewed)

    100

    1 cup stewed dried fruit

    400

    Drinks:

     

    1 pint milk

    800

    1 cup cocoa

    240

    1 cup coffee, half milk

    200

    M. W. IRELAND,
    Brigadier General, M. C., N. A., Chief Surgeon.

     


    Circular No. 40.

       AMERICAN EXPEDITIONARY FORCES,
    France, July 20, 1918.

    1. Circular No. 2, office chief surgeon, A. E. F., dated general headquarters, A. E. F., November, 1917, is amended in so far as it relates to the director of laboratories, A. E. F.

    2. A division of the office of the chief surgeon, A. E. F., is hereby created, to be known as the division of laboratories and infectious diseases. This division will be an integral part of the office of the chief surgeon, A. E. F., and will be responsible to him through the chief of the division of sanitation. The central organization of this division will consist of a director and the necessary number of assistants. The office of this division will be located in the city in which the central medical department laboratory, A. E. F., has been established (A. P. O. No. 721). Col. J. T. Siler, M. C., N. A., is designated as the director of the division and the following-named officers are designated as his assistants: Lieut. Col. George B. Foster, jr., M. C., N. A., assistant to director section of laboratories; Maj. R. P. Strong, M. R. C., assistant to director section of infectious diseases; Maj. Wm. J. Elser, M. R. C., assistant to director section of laboratories; Maj. Hans Zinsser, M. R. C., assistant to director section of infectious diseases; Maj. P. A. Shaffer, S. C., assistant to director section of food and nutrition; Maj. Louis B. Wilson, M. R. C., assistant to director section of laboratories; Capt. Ward J. MacNeal, M. R. C., assistant to director section of laboratories.

    3. This division is charged with the following general duties:

    Section of laboratories.-(a) Representative of the chief surgeon in all matters relating to the laboratory service.

    (b) Organization and general supervision of all laboratories and the assignment of special personnel.



    959

    (c) Advisor to the supply division, chief surgeon's office, in the purchase and distribution of laboratory equipment and supplies.

    (d) Publication of circulars relating to standardization of technical methods; collection of specimens and other matters of technical interest to the laboratory service.

    (e) Collection and distribution of literature relating to practical and definite advances in laboratory methods.

    (f) Collection and compilation of statistics on routine and special technical work done in laboratories.

    (g) Instruction of Medical Department personnel in general and special laboratory technique.

    (h) Distribution and replenishment of transportable laboratory equipment.

    (i) Cooperation and coordination with the Chemical Warfare Service, A. E. F., in the supply of personnel and equipment.

    (j) Supervision of the collection of museum specimens and photographic records of Medical Department activities.

    Section of infectious diseases.-(a) Advisor of the chief surgeon in matters relating to the prevention and control of transmissible diseases.

    (b) Collection and distribution of literature and preparation of circulars relating to methods of prevention and control of transmissible diseases.

    (c) General supervision of laboratory research.

    (d) Advisory supervision of all activities looking to the control of transmissible diseases including direct liaison with division surgeon.

    (e) Assignment of specially trained personnel and equipment for the investigation of epidemics or threatened epidemics.

    (f) Experimental investigation of suggested prophylactic methods for the prevention of infectious diseases and recommendations relative to their general adoption.

    (g) Collection of epidemiological data on infectious diseases.

    (h) Cooperation and coordination with the water supply service, A. E. F., in the supervision and control of water supplies.

    Section of food and nutrition.-(a) Representing the chief surgeon in matters affecting the nutrition of the troops.

    (b) Investigating Army food requirements and consumption.

    (c) Acting in an advisory capacity in the formulation of rations and dietaries for the American Expeditionary Forces.

    (d) Inspecting food supplies and mess conditions with troops, hospitals, and prison camps.

    (e) Giving instruction in food inspection and handling, mess management, and other measures for the maintenance of nutrition and the conservation of food.

    4. The laboratories for the American Expeditionary Forces will be of two general types-stationary and transportable. The stationary laboratories will include the central Medical Department laboratory, base laboratories for the sections of the Services of Supply and for selected districts where necessary, Army laboratories where necessary, base hospital laboratories for individual base hospitals, base laboratories for base hospital centers, and laboratories for camp hospitals.

    Transportable laboratories will be organized for evacuation and mobile hospitals and for divisions. Their equipment will consist of standardized expandable units in chests, and their personnel will be specially trained for the duties which they will perform.

    5. Instructions concerning the laboratory service of general interest to all Medical Department units functioning with the American Expeditionary Forces will be issued in circulars from this office.

    6. The director of the division of laboratories and infectious diseases is authorized to issue special letters and circulars of instruction governing the organization and activities of this division.

       M. W. IRELAND,
      Brigadier General, M. C., N. A., Chief Surgeon.



    960

    Circular No. 41.

       AMERICAN EXPEDITIONARY FORCES,
      France, July 22, 1918.

    1. Reports and returns.-Commanding officers of base hospitals will forward reports and returns relating to matters named below through the commanding officer of the hospital center, and direct to the office of the chief surgeon, if the base hospital is not included in a hospital center: Hospital fund statements; sanitary reports; personnel reports; return of enlisted force, Medical Department; report of epidemic diseases; hospital construction and repair.

    Commanding officers of hospital centers will take appropriate action upon sanitary, epidemic diseases, and hospital construction and repair reports. The other reports named will be forwarded without action.

    Reports of sick and wounded and weekly reports of venereal disease will be forwarded by commanding officers of each base hospital direct to the office of the chief surgeon.

    Copies of epidemic and of venereal-disease reports will be furnished to the surgeon of the section in which the base hospital is located.

    2. Gratuities to cooks.-In compliance with decision of the Judge Advocate General (40, 200 J. A. G., October 13, 1916), effective August 1, no gratuities from the hospital fund will be paid to soldiers of the Medical Department holding the statutory grade of cook. Gratuities paid under authority obtained, both while in the United States and on duty with the American Expeditionary Forces, will be discontinued.

    3. Students.-Information has been received from the United States that it is not the policy of the War Department to approve the application of any enlisted men for return from overseas to the United States for the purpose of entering educational institutions. This policy applies to medical, dental, and veterinary students.

    4. Tobacco.-The attention of commanding officers of hospitals is invited to the fact that tobacco has been added to the ration, and it becomes the obligation of the mess officer to furnish it to such patients in hospital as desire to smoke and are authorized to do so. The commutation value of the ration has not been increased on this account, but is believed be ample, if the proper steps are taken to secure good mess administration and prevent waste, to stand this additional expenditure.

    5. Salvarsan (arsenobenzol).-On account of difficulties which have occurred in alkalizing and administering this drug under war conditions, the chief surgeon has directed that its issue be confined to the base hospitals, all of which have the proper equipment and technique for its administration. Novarsenobenzol will be supplied to all other hospitals and units, and it alone will be issued after the exhaustion of the present stock of arsenobenzol.

    6. Clinical records.-Clinical records, temperature charts, and other detailed descriptions of treatment will not be forwarded with monthly report of sick and wounded, by any hospital. They are hospital records and will be retained as such.

    7. Property accountability.-The attention of all medical officers, and especially those who are accountable for medical property, is called to the following cable received at general headquarters, A. E. F., June 12, 1918:

    PERSHING, AMEXFORCE:

    Paragraph 4. Medical officers returning to United States should be provided with certificates of nonindebtedness to the Government.
     * * * * * * *

       MC CAIN.

    8. Religion.-The religion of every patient admitted to a hospital ward should, as soon as practicable, be ascertained by the ward medical officers and appropriate entry thereof made on the patient's field medical card, such as Roman Catholic, Protestant, Jewish, etc.

    9. Change in report of epidemic diseases.-Section XII of Sick and Wounded Reports, effective June 15, 1918, calls for telegraphic or telephonic report of measles and German measles. Report by wire of these two diseases is considered unnecessary, and report by mail will be substituted.

    10. Requisitions for antigas clothing and gas masks.-These items have been included in some requisitions for medical supplies made upon advance medical supply depot No. 1.



    961

    In accordance with General Order 53, general headquarters, 1917, the same are supplied by the Chemical Warfare Service, A. E. F., and should not be included in requisitions for medical supplies.

    11. Heating stoves.-The commanding officers of all base hospitals except type A (newly constructed hospitals), camp hospitals, convalescent hospitals, and evacuation hospitals will immediately submit to the chief quartermaster, through this office, requisitions for the number of large, medium, and small size heating stoves required in addition to the ones now on hand; also the requisite number of joints of pipe and elbows, with the necessary feet of stove wire.

    In arriving at the required numbers of each of these articles, commanding officers must continually bear in mind the exceeding difficulty with which all articles of this nature are secured, also the likelihood of extreme scarcity of fuel during the coming winter. In this connection, stoves should be so located as to reduce the number of pipes and elbows necessary to a minimum.

    12. Expenditures.-Vouchers submitted for purchases made under the authority of paragraph 4, Circular No. 15, office of chief surgeon, line of communications, which reads as follows: "The commanding officer of each base hospital is authorized to expend from Medical Department funds a sum not to exceed $100 per month for the purchase of equipment and supplies properly chargeable under regulations against such funds," will bear the signature of the commanding officer of the hospital either as a certifying officer or as the approving officer.

    This allowance will be confined to the emergency purchase of articles on the supply table and in amounts sufficient only to bridge over the period pending the receipt of supplies from the depot. Supplies furnished by other departments will not be purchased, as such are not properly chargeable against Medical Department appropriations. Authority to purchase items which have been erased from the medical supply table or of any item in an amount in excess of the immediate needs must be approved either by this office or the section surgeon.

    The reserve of medical supplies is now such that requisitions based upon future requirements can be filled, and many emergency purchases or requisitions can now be taken as evidence of poor administration of the supply department of the hospital.

    13. Papers for publication.-The attention of all medical officers is called to the following memorandum which has been received from the Surgeon General. Papers for publication should be sent through the office of the chief surgeon:

    Attention is called to the memorandum quoted below, which was issued March 27, 1918. In many instances paragraph 3 has been overlooked. It is essential that this office receive in duplicate all professional papers submitted for authority to publish:

    "1. Attention of medical officers is directed to the provisions of paragraph 423, M. M. D. Medical officers will not publish professional papers requiring reference to official records or to experience gained in the discharge of their duties without the previous authority of the Surgeon General.

    "2. Numerous scientific papers written by officers of the Medical Department have recently appeared in the medical press without specific authority from this office. This practice will be discontinued, and the above regulations will be strictly complied with.

    "3. Officers desiring the publication of professional papers will submit two copies to the Surgeon General, with request for permission to publish same. Upon approval, a copy will be forwarded to the journal designated by the officer for publication."

       M. W. IRELAND,
    Brigadier General M. C., N. A., Chief Surgeon.


    Circular No. 42:

       AMERICAN EXPEDITIONARY FORCES,
      France, July 27, 1918.
     COLLECTION OF MUSEUM MATERIAL FOR MEDICAL EDUCATION AND RESEARCH

    1. Object.-This circular is for the information of those branches of the service whose cooperation and assistance are necessary to enable the Army Medical Museum to discharge its duty of collecting all those things which may be used for medical education and research, or which may be of historic interest. This material will consist of pathologic specimens,



    962

    bacteria, animal parasites, missiles, armor, instruments, apparatus, casts, models, paintings, drawings, diagrams, charts, statistical tables, cinema films, photographs, radiographs, lantern slides, and other things pertaining to the preservation of the health and the prevention and treatment of the diseases of United States soldiers, or the history of the Medical Department of the Army.

    2. Scope.-In France all collections will be limited to those things which can not be obtained readily in the United States, or which are necessary for study in the American Expeditionary Forces. More specifically those will relate principally to war wounds, especially lesions of bones and vital organs, gas poisoning, trench foot, gas gangrene, traumatic and "shell" shock, to infections and parasitic diseases of special menace to the American Expeditionary Forces, and to material of historic interest. Other material may be included if obviously desirable. It is requested that all medical officers in the American Expeditionary Forces cognizant of desirable museum material which they are not in position to direct into proper collection channels, should notify the director of laboratories, A. E. F. (museum unit), A. P. O. 721.

    3. Responsibility.-It is the duty of each medical officer in the American Expeditionary Forces to direct into proper channels all such desirable material coming to his notice. In each medical unit the pathologist, or, in his absence, some other medical officer, will be responsible or the collection, preservation, and shipment of all such material obtainable in the unit.

    4. Use in American Expeditionary Forces.-Collected material required for investigation in the American Expeditionary Forces will be shipped as early and as directly as possible to the groups of officers conducting the investigations in such manner and quantity as they may request through the director of laboratories, A. E. F. After serving the needs of the immediate investigation, this material, if still of value, will be preserved for use elsewhere.

    Requests for material required for teaching in the American Expeditionary Forces should be made to the director of laboratories, A. E. F., who will direct from what source it shall be supplied.

    5. Concentration points.-All other collected material will be shipped without unnecessary delay directly to concentration points as follows:

    (a) To the central Medical Department laboratory from all hospitals in the southeastern portion of the zone of advance and from other hospitals to which the central Medical Department laboratory is most readily accessible.

    (b) To American Red Cross Military Hospital No. 2 from all hospitals in the middle section of the zone of advance to which it is most readily accessible.

    (c) To United States Base Hospital No. 4 (British Expeditionary Force No. 9 General Hospital) from all hospitals in the northern portion of the zone of advance to which it is most readily accessible.

    (d) To United States base laboratory of base section No. 1 or to United States Base laboratory of base section No. 2 from all hospitals to which either of the above points is most readily accessible.

    The local railway transport officer should be consulted as to the most accessible point for concentration of packages at the time shipment is to be made.

    6. Final disposition.-At the concentration points the museum unit will take charge of the further preparation of all material and its shipment to the Army Medical Museum. There it will be catalogued and such portions of it as are necessary immediately redistributed as loans in accordance with a recent decision of the Surgeon General's office, as follows:

    (a) Teaching material to United States Army schools for medical officers.

    (b) Teaching and certain research material to the under graduate medical schools of the United States (all of which are now under the supervision of the Surgeon General's office.)

    (c) All historic and surplus material will be held in the Army Medical Museum for local use or further loans.

    7. Pathologic specimens.-All pathologic specimens suggested in paragraph 2 from both operations and autopsies should be preserved as follows:

    (a) Gross specimens: These should be dissected enough to disclose the character of the lesion and to permit proper fixation. The surface blood should be rapidly washed off with weak formalin (1 per cent or previously used). Each should have securely attached to it



     963

    a tag of starched cloth or thick tough paper on which is heavily written in black lead pencil or typewriting the name, rank, and organization of the patient, the anatomical name of the specimen, the diagnosis of the lesion, the hospital number, the serial number of the specimen (if autopsy material, the autopsy number), and the date of collection. Each specimen should be fixed, and preserved until shipped, in five to ten times its volume of Kaiserling No. 1 solution, the formula of which is as follows:
     

    Potassium nitrate, 15 grams.
    Potassium acetate, 30 grams.
    Formalin, 200 c.c.
    Water, 1,000 c.c.


    These materials may be requisitioned.

    Sodium salts may be used instead of potassium. If materials for other methods of color preservation are at hand, they may be used, but the specimens kept separate from others in shipping. If no salts are obtainable, 10 per cent formalin may be used. Hollow organs, large intestines, etc., should be filled with the solution to their normal size and caliber. Where time permits, the vessels of large specimens should be injected with the solution.

    The solution fixes very rapidly and rigidly, so that it is necessary to use care when specimens are placed in it that they are not deformed by pressure. Soft organs (brains, lungs, etc.) which may be injured by pressure should be fixed in individual containers (jars, granite-ware pails, or pans, kegs, etc.). Other tissues may be fixed, several together, in tubs, barrels, casks, etc.

    Specimens should not be placed in containers in contact with metal nor in new wooden vessels the walls of which may contain tannin. If new wooden vessels are used they should be coated inside with paraffin. Large containers-earthenware jars, barrels, casks, etc.-should be obtained locally. Wide-mouth bottles and small specimen jars may be obtained by requisition.

    After preliminary fixation, the specimens should be changed at least once to fresh fluid, which may be reduced in strength to 10 per cent formalin. Delicate specimens such as pieces of intestine or blood vessels need to be carried through the entire Kaiserling process rapidly if a brilliant color is to be preserved. With all other specimens only the No. 1 solution need be used.

    Where the specimen is a bone, the soft parts should be left attached and the specimens treated similarly to lesions of soft tissues alone.

    (b) Material for microscopic examination: Tissues intended especially for microscopic examination should be cut with a sharp knife or razor into thin blocks (not over 0.5 cm. thick) and placed immediately into twenty to fifty times their volume of fixative (Zenker's fluid, formal Zenker, neutral Zenker, 10 per cent formalin, 95 per cent alcohol, or other). Their source should be accurately noted, described, and sketched. Their subsequent treatment should be that appropriate for the fixative. Special attention is called to the necessity for fixing tissues intended for cytologic study as soon as possible (under two hours) after circulation in the part has ceased. Wide-mouthed bottles or small glass jars tightly closed should be used as containers for histologic material.

    8. Shipment.-When pathologic specimens have been fixed for two weeks or more they should be well padded with absorbent cotton wetted with the solution in which they have been last immersed, then wrapped in waterproof paper (to be obtained by requisition) and packed with paper, excelsior, hay, or similar material in a strong wooden or tin box or a barrel and shipped to the most accessible point of concentration. (See pars. 5 and 6.) Each package should be marked with the hospital number, the serial numbers of the specimens, the autopsy number, if any, and date of shipment.

    At the same time there should be forwarded by mail or courier an inventory of the contents of each package, accompanied by abstracts of the clinical records of operation specimens and of clinical and autopsy records of autopsy specimens. The name of the pathologist or other medical officer who may be specially interested in the specimen should be given.



    964

    Army Regulations authorize transportation of all museum material by the Quartermaster Corps. Packages of specimens weighing 7 pounds or less should be directed on a penalty envelope marked official and delivered to an American post office of the military postal express service, with explanations of their character and the importance of their prompt delivery to prevent spoiling.

    9. Bacteria.-Army Regulations provide that cultures of all pathogenic bacteria isolated in the American Expeditionary Forces shall be sent to the central Medical Department laboratory for confirmatory identification. The museum supply will therefore be drawn from the central Medical Department laboratory.

    10. Microscopic slides.-Microscopic slides containing data which can not readily be duplicated in other material sent from the same source should be sent to the appropriate concentration point.

    11. Animal parasites.-Specimens of animal parasites-if possible living-such as lice, fleas, mites, bugs, flies, mosquitoes, worms, etc., should be sent to the central Medical Department laboratory for confirmatory identification. The museum supply will be drawn from this concentration point.

    12. Missiles.-For the psychic effect, a missile removed from the body of a wounded soldier may be given to him if he wishes to keep it. However, he may be induced to relinquish his claim when the scientific value of the comparative study of such missiles and their preservation in a museum is explained to him. The place and character of all missiles in amputation material should at least be accurately described and, if possible, sketched. All missiles and foreign bodies removed at autopsies should be carefully preserved, if possible in situ, with the pathological specimen. When it is necessary to remove them, their location and wound effects should be minutely described, the description, if possible, being accompanied by photographs or sketches.

    13. Armor.-Armor, such as helmets, or other protective body covering showing the effects of missiles, gases, etc., should, whenever obtainable, be preserved, with full data concerning the incidents of their use, and shipped to the nearest concentration point.

    14. Instruments and apparatus.-All instruments and apparatus of special value which have been developed or materially modified in the American Expeditionary Forces should be photographed, accurately described, and, if it seems desirable, models made and sent to the nearest concentration point.

    15. Casts and models.-The number of skilled cast and model makers in the American Expeditionary Forces is extremely limited. When a medical officer has some specimen, or series of specimens or cases, showing results of operations which he wishes to have illustrated in wax or plaster, he should make application to the director of laboratories, A. E. F. (museum unit), A. P. O. 721, for the services of a model maker.

    16. Paintings, drawings, diagrams, etc.-It is believed that in many hospital units there may be found men capable of making diagrams and sketches furnishing graphic records of teaching or historic value to the Medical Department. Well-trained medical illustrators, on the other hand, are scarce and their services, to be utilized in an economical manner, must be centrally controlled. Medical officers having material of scientific value, particularly in the fields noted in paragraph 2, and who are without the assistance of capable medical illustrators in their hospital units, should apply to the director of laboratories, A. E. F. (museum unit), A. P. O. 721, to have an artist assigned for temporary duty.

    17. Cinema films.-There are few subjects (e. g., patients with "shell" shock, the technique of new operations, etc.) records of which it may be desirable to preserve in moving-picture films. Applications for the services of a cinema camerist for this work should be made to the director of laboratories, A. E. F. (museum unit), A. P. O. 721.

    18. Photographs.-General Order No. 78, general headquarters, A. E. F., May 25, 1918, amends previous orders as follows: "The Medical Department, A. E. F., is charged with technical photography connected with the recording of photographic processes of surgical and pathological matters." For the proper discharge of this duty each hospital unit should have on its personnel, either in the laboratory or Roentgenographic department, at least one man capable of taking good technical photographs of medical subjects. A standard laboratory photographic outfit should be requisitioned by each base hospital not already



    965

    equipped. It is assumed that all developing will be done in the X-ray dark room, where will be available a ruby light, and all necessary chemicals for development and fixation of plates and prints.

    In addition, the following expendable materials may be requisitioned:

    Plates, Lumiere orthochromatique:
      Series C, 13 by 18 cm.
      Series C, 5 by 7 inches.
      Series C, 4 by 5 inches.
    Plates, Lumiere ordinaire, slow series C, 3¼ by 4 inches.
    Plates, Lumiere, autochrome, for color photography, 3¼ by 4 inches.
    Printing paper, glossy:
      Soft, 5 by 7 inches.
      Soft, 4 by 5 inches.
      Medium, 5 by 7 inches.
      Medium, 4 by 5 inches.
      Hard, 5 by 7 inches.
      Hard, 4 by 5 inches.
    Lantern slide covers, clear glass, 3¼ by 4 inches.
    Lantern slide gummed binding strips, 100 in package.
    Lantern slide gummed labels, 100 in package, 1 by 10 cm.
    Metol, or substitute therefor, 1 ounce bottles.
      Hydroquinone, ¼-pound bottle.
      Metachinone, concentrated for Lumiere autochrome plates, 125-c. c. bottle.
      Potassium bromide, xls 10 grams in bottle.
      Sodium carbonate, bulk.
      Sodium bichromate, 1 ounce bottles.
      Sodium hyposulphite, bulk.
      Sodium sulphite, bulk.
      Acid, acetic, 1-pound bottles.
      Acid, sulphuric, ½-pound in ggs. bottle.
      Alumen, ½-pound bottle.
      Alumen, chrome, 1-pound bottles.
      Ammonia, 1-pound bottles.
      Plate varnish, Lumiere gum damar, 50 c. c. in bottle.
      Autochrome color screens, 2-inch.
      Autochrome color screens, holders.
      "Virida" paper for dark-room light for autochromes, 6 sheets in set.

    Photographic records should be made of interesting lesions, particularly in the fields noted in paragraph 2, and of those things of medical, surgical, or pathological interest in the hospital which may be of value for teaching, research, or for their historical connection. Copies of these should be forwarded by mail or courier to the central Medical Department laboratory, (museum unit), A. P. O. 721, as soon as made, and the negatives reserved for subsequent shipment to the most accessible concentration point.

    19. Radiographs.-Radiographs, especially those in series or illustrating wound conditions of their treatment which may be of value for teaching, should be copied in prints or lantern slides which should be forwarded by mail or courier with full data to the central Medical Department laboratory (museum unit), A. P. O. 721.

    20. Original publication.-All pathological specimens, casts, models, paintings, drawings, photographs, radiograms, etc., should be accompanied by the name of the medical officer collecting them, and of the medical officer, if any specifically interested in their subject matter. This is important, not only for the occasional necessity for retracing them back to their origin for additional data, but also that the privilege of original publication of the data by the officer with whom they originated may be respected.

    21. Supplies.-All requisitions for supplies will be prepared and forwarded by medical supply officer of the hospital unit. Requisitions for laboratory supplies only will be made



    966

    in quadruplicate, one copy being retained and three copies forwarded to the director of the division of laboratories and infectious diseases, office of the chief surgeon, A. P. O. 721, and it is desired that as far as possible requisitions be timed so as to permit shipment thereupon to be included in larger shipments from supply depots on ordinary requisitions. These special requisitions, therefore, should be sent approximately 10 days prior to larger requisitions contemplated, and should bear notation that shipment should be held pending the receipt of requisition of general supplies.

      M. W. IRELAND,
      Brigadier General, M. C., N. A., Chief Surgeon.


    Circular No. 43:

       AMERICAN EXPEDITIONARY FORCES,
    August 1, 1918.

    1. Recommendations for promotions in the Medical Reserve Corps.-The attention of commanding officers of hospitals and other senior medical officers is invited to the fact that the form on the back of Circular 36 should not be used for the recommendation of majors, M. R. C., because such promotions take these officers out of the Medical Reserve Corps and into the National Army. Promotions of this sort must necessarily be limited to a small class of specially capable officers, occupying positions of unusual administrative or professional importance. Such recommendations should, when made, be in the form of a special report giving with great fullness all the reasons for the promotion. They should not be made at the request of the officer interested, or except when such promotions are obviously to the interest of the service. The blank form with Circular 36 should be used, therefore, only for captains and for lieutenants about the age of 31 who are class A men.

    The responsibility rests with officers making recommendations to see to it that elderly men who have no administrative capacity, and no unusual professional accomplishments which would fit them for the grade of major-in other words, men who belong to class B- are not recommended for promotion as class A men. Lieutenants within the draft age should only be recommended for promotion in unusual and exceptional circumstances, where the individual has received a military decoration, or wound, or is a man of very unusual professional ability and occupying a position of such importance as to make his promotion of obvious advantage to the service.

    2. Returning men to duty with 20th Engineers.-Attention of all medical officers is invited to the fact that the 20th Engineers is a large regiment and the companies are designated by battalions. It is therefore necessary to always state the battalion number in connection with the company letter whenever men from this regiment are returned to duty.

    3. Messengers.-Under authority granted by the commanding general, Services of Supply, in the future when requisitions for X-ray tubes are made on any medical supply depot, the organization making the requisition will, upon receipt of notification that the tubes are available, send the necessary number of messengers to the medical supply depot in question for the purpose of carrying back the tubes. Two tubes will be all that one man can handle.

    4. Repair of typewriters.-The question of the repair of typewriters has been taken over by the Quartermaster Department. Hereafter all typewriters needing repair should be shipped to the typewriter repair shop, Tours, notification of the fact of shipment being made to the commanding officer thereof. Upon completion of repairs, machines will be returned to the medical units who forwarded them.

    5. Convalescent homes.-Arrangements have been made with the American Red Cross that nurses for whom a period of change is desired for convalescence after illness may be sent to the "American Red Cross convalescent home and vacation hotel," at Le Croisie, near St. Nazaire, during the summer months instead of to Cannes as formerly.

    It should be understood that in order to take advantage of this arrangement authority should be requested from the chief surgeon, A. E. F., to send the nurse or nurses to this convalescent home on a status of absent sick for convalescence with a statement as to the physical condition which requires this change. Nurses for whom this authority has been



    967

    granted should not be placed on a status of sick leave, no authority being granted for sick leave to nurses.

    It is not the intention to send nurses to the convalescent homes whose physical condition is such that they are in need of nursing care. Only those who are fully able to care for themselves should be sent.

    6. Charge for subsistence of civilians sick in hospital.-Changes, Army Regulations No. 69, provide that the charge of subsistence of civilian patients in hospital on the footing of enlisted men will be an amount equal to the commutation rate prescribed for enlisted patients plus 10 cents a day.

    7. Prompt evacuation of class D patients.-Attention is directed to the policy of this office with respect to the disposition of all class D patients. It is not intended to hold patients for prolonged periods of observation and study who are clearly destined to fall within this class, no matter how much professional interest they excite.

    Such cases should be placed before disability boards promptly for classification, and as soon as they are able to travel by ordinary train they should be sent to Base Hospital No. 8, at Savenay, with a view to their transfer to the United States. If not able to bear travel upon ordinary trains, all such patients should be sent on the hospital train which will be routed regularly to collect such cases as are able to bear the journey to the United States.

    Therefore, as soon as a patient is classified as of class D he should be considered as destined for transfer to the United States, since the intention is to evacuate to the United States all mutilated and disabled men for treatment, reconstruction, reeducation, and final disposition. The necessity for this policy lies in the fact that the hospitalization program in the American Expeditionary Forces is based upon a definite priority schedule of building and of housing material, and also of tonnage space for medical supplies on ships from home ports, in direct ratio to the number of troops in France. The hospitalization program in the United States also contemplates the reception of a constant stream of evacuables from the zone of operations.

    8. Biological products.-The following biological products have been selected by the chief veterinarian as all that are necessary for the American Expeditionary Forces. Supply depots and base laboratories will carry these only in stock:

      (a) Serum antitetanic.
      (b) Serum antistreptococcic.
      (c) Mallein intradermal.

    9. Authority to authorize expenditures and approve vouchers on Medical Department funds.-Authority to authorize expenditures and to approve vouchers for purchases properly chargeable against Medical Department funds, in sums not to exceed $250, is granted to the commanding officers of all hospital centers and to the chief surgeons of armies.

    The authority to authorize expenditures and to approve vouchers for purchases properly chargeable against Medical Department funds, in sums not to exceed $100, is hereby granted to chief surgeons of army corps.

    10. Hospital trains.-When the commanding officer of a hospital is informed of the arrival of a train of patients for his hospital he will send an experienced medical officer and a sufficient number of enlisted men to unload patients from the train. This work is not to be done by the train personnel except in emergency.

    Commanding officers of base hospitals are authorized to issue expendable medical and surgical supplies to the commanding officer of hospital trains, taking the memorandum receipt of the commanding officer of the train as a voucher for property return.

    11. Mail.-It has been reported to the chief surgeon's office that some medical officers on duty in wards where there are mental cases are in doubt as to their power to prevent the mailing of letters from mental cases of an obscene or abusive nature, or letters on trivial subjects, to prominent persons. Commanding officers of hospitals should regulate this matter and see that letters of this character are not placed in the mails.

    M. W. IRELAND,
       Brigadier General, M. C., N. A., Chief Surgeon.



    968

    Circular No. 44.

    AMERICAN EXPEDITIONARY FORCES,
       August 3, 1918.

    1. System of evacuation of wounded.-The following report of the system of evacuation of the wounded adopted by the regimental surgeon, -th Infantry, is published for the information of regimental surgeons:

    1. I made a reconnaissance the night of June -th of all roads and paths between P----- road and B----- farm, including a personal reconnaissance of B----- , N-----, Bois la' M----- roads, etc., for suitable routes for ambulances; especial attention was given to safety of ambulances, speed and comfort of wounded, and avoidance of traffic congestion.

    2. Outline the following system as the result of this study, which was very successfully followed during and after the attack:

    On June -th, 1918, an advance station was organized at M-----, including 3 medical officers, 8 Hospital Corps men, and 20 litter bearers. Ample supplies were stored in the dugout in which this station was located. At T----- farm another dressing station was established, with 3 medical officers, 8 Hospital Corps men, and 15 litter bearers, with reserve supply of litter bearers and corps men and medical supplies always available for forwarding to any point where added assistance might be needed. An advance station of the -d Infantry was located at B-----. Their evacuation and operation of the station was under my supervision. One surgeon, one sergeant, and one private went forward from M----- with the assaulting waves, and they established a dressing station at V-----. The stretcher bearers worked for this station, and the prompt need with which first aid was given at the forward station undoubtedly saved a large number of lives. At La N----- farm an advance medical supply depot was established and a reserve ambulance station. This was in the hands of 1 medical officer and 1 noncommissioned officer in charge of ambulance and medical supplies. The regimental infirmary included the regimental surgeon and 3 assistants, with 5 medical officers in reserve to be forwarded to the point of greatest need, and was located at B----- farm.

    3. Thirty-five ambulances were in service for the evacuation of wounded from the battalion aid station through the regimental infirmary to Field Hospital No. -. At the time of our assault there were 2 ambulances in waiting at M----- station, 2 at B-----, and 2 at T----- farm. Four ambulances were at the intermediate station at La N----- farm. As soon as a loaded ambulance going to the rear passed La N----- farm, the noncommissioned officer stationed there sent an empty ambulance forward to replace it; in this way there were always two, and no more than two, ambulances at each battalion aid station. As soon as the loaded ambulance reached B----- farm, another empty ambulance was sent forward to replace the ambulance at the intermediate station at La N----- farm. This system cut down congestion on the roads and enabled us to have ambulances always available and secured the greatest efficiency in the use of each ambulance.

    4. Under the system of evacuation outlined, many wounded had reached the field hospital at B----- within one hour after the first assaulting waves had left their lines of departure. When the -d Infantry dressing station was demolished by artillery, killing one medical officer and wounding another, it was possible to replace them by two of the medical officers held in reserve for this purpose within 15 minutes after the accident and before there was any accumulation of wounded at the station.

    Hospital Corps men held in reserve were forwarded to each of the battalion stations as they were needed, and when the pressure relaxed they returned to the reserve station. This arrangement allowed an elasticity which kept wounded from congregating at any station and kept a steady, constant stream of evacuations to the rear. It enabled us to evacuate the major part of approximately ----- cases before midnight. At 3.30 a. m., excepting straggling cases, there were no wounded in any of the dressing stations or in the regimental infirmary, all having been sent to the rear.

    The cases handled included about -----  Americans, about ----- each of French and Germans, each of which received hot drinks and additional medical aid at the regimental infirmary before being sent to the field hospital at B----- . I left the regimental infirmary before being sent to the field hospital at B-----. I left the regimental infirmary in care of a Medical Reserve Corps captain and in a motor cycle side car made the rounds of the forward stations, apportioning the reserve surgeons and litter bearers according to the need of the stations at that time, and supervised the forwarding of medical supplies as they were needed.

    2. Shortage of personnel.-Because of the shortage of Medical Department personnel trained in the care of mental cases, it is directed that commanding officers of all base and evacuation hospitals or other Medical Department units forward to this office the names of any nurses or men who have had such training and who are not at present performing such duties.



    969

    3. Prisoners of war.-As soon as prisoners of war who have been under treatment in a United States Army hospital are ready to be evacuated to the C. P. W. E., the commanding officer of the hospital should notify the provost marshal general, who will send the necessary guard to escort them to the C. P. W. E. In order to economize on the number of escorts sent to the hospitals, these prisoners of war should be evacuated from the hospital in groups of five or more.

    4. Lipo vaccines.-The following letter from the Surgeon General is quoted for your information:

    I beg to inform you that the Army Medical School is now practically ready to begin furnishing triple lipo vaccine in place of triple typhoid saline vaccine. The lipo vaccine has the great advantage over the saline of being administered in a single dose. The oil permits this, since it diminishes the rapidity of absorption, and a large dose can be administered, which is absorbed gradually over a long period. It is expected in the course of a few months to stop the manufacture of the saline vaccine altogether. The quantity of machinery apparatus, necessary to this change in the method of manufacture is delaying the output for a short time only. So far this month, 30 liters have been issued, and we will soon be in position to issue not less than 150 liters per month.

    After the typhoid vaccine is well on the way a similar oil vaccine will be made to be used against pneumonia, dysentery, cholera, plague, and perhaps streptococcus infections.

    5. Medical war diaries.-Beginning with July 1, 1918, and in connection with medical histories of camps, depot brigades, and base hospitals recently filed in the Surgeon General's office, it is directed that medical war diaries be kept henceforth in these stations until the close of the war. These diaries shall be regarded as the literary property of the division of medical and surgical history of the war, Surgeon General's office, and must be entirely disassociated from the ordinary military and medical records of camps and base hospitals.

    Attention is called to the fact that these records are to be regarded as stationary; i. e., the medical records of the division surgeon of a mobilized division must not be confused with the permanent medical history records of the camp or other stations in which the division has temporarily been quartered or through which it passes. The latter records must remain in the station until the end of the war as the ultimate property of the Surgeon General's office, and should not be removed by any outgoing division surgeon.

    It is requested, however, that each outgoing camp or division surgeon transmit to this office (division of medical and surgical history) a carbon of his own individual contribution to the war medical diary up to the time of his departure from the station.

    Medical war diaries of camps and base hospitals shall be made up of brief but circumstantial entries of any events in the history of these stations which have influenced their sanitary status; e. g., outbreaks of epidemic diseases of major or minor importance, fires or other accidents, important changes in personnel, medical administration, sanitation, new therapeutic measures and sanitary devices introduced, new construction whether by enlargement of existing buildings or erection of new buildings, incidence of unusual diseases or complications of disease, unusual surgical cases and operations performed, or any other feature of like interest.

      M. W. IRELAND,
      Brigadier General, Chief Surgeon.



    Circular No. 45.

       AMERICAN EXPEDITIONARY FORCES,
    France, August 13, 1918

    I. Circular No. 6 is amended to read as follows:

    1. The attention of medical officers, A. E. F., is directed to the absolute necessity for the prophylactic administration of antitetanic serum (A. T. S.) under the following conditions:

    (a) Immediately after the receipt of a wound of whatever nature or severity.
    (b) Upon the recognition of so-called trench foot, with or without skin abrasions.
    (c) In cases of frost bite.
    (d) During operations performed under conditions of unsatisfactory asepsis; e. g., emergency operations, operations for hemorrhoids, fistulæ, or any conditions where fecal contamination is a possibility.



    970

    (e) During secondary operations necessary in the course of the treatment of wounds received seven or more days previously.

    (f) Following the manipulations incident to the reduction of compound fractures or dislocations, after the removal of adherent drains, or any other procedure resulting in a serious disturbance of the healing processes in a wound seven or more days old.

    2. One prophylactic dose of 1,000 units of tetanus antitoxin will be given to all wounded whatever the nature or severity of the wound, as promptly as possible after the infliction of the wound if a battle casualty, preferably at the battalion aid station. This dose should be given subcutaneously preferably over the lower abdomen. A second dose of 1,000 units will be given in every case after an interval of seven days.

    3. In severe injuries where prolonged suppurative processes persist, especially when fecal contamination of the wound per rectum or through intestinal fistulæ is present and when much tissue necrosis occurs, three or even four doses may be indicated. The attending medical officer must bear this in mind and exercise judgment accordingly in the individual case.

    4. There is no objection to the use of 1,500 units for the initial and the second prophylactic doses, but doses of 1,000 units each afford sufficient protection. (NOTE.-Tetanus antitoxin from the United States usually contains 1,500 units to the dose.)

    5. The serum should be administered by or under the immediate supervision of a medical officer. If for any reason this is impossible, it should be given by some responsible member of the Medical Department.

    6. All injections, with amounts and dates, signed by the officer administering them, will be entered on patient's field medical card, by the letters A. T. S. followed by the date and hour. In the case of the freshly wounded the letter T should be marked plainly upon the patient's forehead with an indelible pencil.

    7. Absence of any records on the patient's card or face as indicated in the preceding paragraph is to be accepted as evidence that the A. T. S. has not been given. The first medical officer to assume subsequent control of a patient thus neglected should administer the serum immediately.

    8. Medical officers who are thus compelled to administer A. T. S., because of the failure of any medical officer or officers previously responsible for this administration to carry out the above instructions, must make an immediate report of such ommissions to the chief surgeon, A. E. F., through the director of general surgery, with sufficient data to establish the time and circumstances of the omission.

    II. Patients dying on hospital trains.-Commanding officers of base hospitals will receive from hospital trains the remains of any patients dying en route, and will arrange for their burial and render the necessary reports called for by existing orders.

    III. Civilian employees for hospital centers.-Authority is hereby granted to commanding officers of hospital centers to authorize the employment of such civilian employees as may be necessary for the administration of the base hospitals under their command. The employment of these civilians must be in accordance with existing regulations; and attention is invited to Bulletin No. 14, headquarters, line of communications, February 13, 1918, and General Order No. 7, headquarters, services of supply, March 11, 1918.

    IV. Address of director of professional service.-Attention of all medical officers is invited to the fact that the address of the director of professional service is A. P. O. 706, and that of the consultants is A. P. O. 731. Considerable mail is coming to this office for these services and addressed to post office 717. These cause a delay and unnecessary work in this office.

    V. Transportation of wounded in trucks.-Trucks can be used to great advantage for transportation of wounded where the distances are not too great. Twelve litter cases can be carried in a 3-ton truck. In loading, 3 litters are first placed transversely in the upper tier, with handles resting on the edges of the sideboards of the truck box; then 3 longitudinally in the bed of the wagon; then 3 more transversely in the upper tier; and finally 3 more on the floor of the truck longitudinally. The tailboard of the truck remains open. The stirrups of the 3 rear litters in the lower tier fit into the opening between the body of the truck and the tailboard. In order to keep the rear patients from rolling out, one open litter is placed on edge at the back of the truck, with its lower handles resting on the side-



    971

    boards and the upper handles supported by the rear bow of the truck. It requires 12 minutes for 4 men to load 12 patients. Where there is a bank beside the road, it can be conveniently used for loading the upper tier.

    VI. Promotion and demotion of enlisted men, Medical Department.-The commanding officers of hospital centers are authorized to promote and demote enlisted men of the Medical Department between the grades of private and sergeant, first class, inclusive. They will sign warrants "for the chief surgeon" for men promoted under this authority. The number of men promoted will not exceed the percentages authorized by law. Recommendations for promotions of soldiers of the Medical Department to the grade of master hospital sergeant and hospital sergeant will be forwarded to this office for approval.

    VII. Visits of French ladies to American wounded.-Authority has been granted the Association of French Homes (Foyers Francais) to issue to ladies who are members of that society permits which will entitle them to visit American wounded in military hospitals of the American Expeditionary Forces. The society has been informed, however, that these visits can, as a rule, be only made during the regular visiting hours prescribed by the commanding officer of the hospital or hospital center.

    VIII. Anthrax.-The following letter from the Surgeon General, of July 6, 1918, is quoted for your information:

    1. I am directed by the Surgeon General to inform you that the number of cases of anthrax being reported to this office is sufficient to attract attention at this time. Anthrax, so far as reported, has without exception appeared on the face or neck, and shaving brushes have fallen under suspicion, and in some cases anthrax organisms have been isolated from them. For this reason, it is necessary that each case of anthrax coming to your attention be examined critically; that the man's shaving brush, talcum powder, and other shaving accessories be obtained; that the organism be sought for with great thoroughness. For the purpose of testing brushes, it is recommended that inoculations of bristles from the brush be made into rabbits, guinea pigs, and rats; nothing short of this may give conclusive results. Report should be made to this office of each case, giving the clinical history, the etiology, the results of the examination of supposedly infected material. The shaving brush or other article from which the anthrax bacillus may be isolated must also be forwarded to this office, with full information as to its source, name of the maker, and other data to facilitate its identification.

       M. W. IRELAND,
       Brigadier General, Chief Surgeon.



    Circular No. 46.

    AMERICAN EXPEDITIONARY FORCES,
      France, August 16, 1918.

    1. Upon the recommendation of the chief consultant in surgery, and with the approval of the director of professional services, the following instructions are published for the information and guidance of all concerned:
     INSTRUCTIONS CONCERNING THE TREATMENT IN ORTHOPEDIC CONDITIONS, INCLUDING FRACTURES AND JOINT INJURIES

    2. The work of the division of orthopedic surgery in the medical organization of the Army divides itself quite clearly into two parts, one having to do with the preparation of the men for the expected combat, and the other assisting in their recovery if wounded. The first endeavors to see that they are so trained that there will be the greatest possible vigor for the combat, and that physical defects which might have rendered them ineffective are corrected. The second has to do with the treatment of the men if injured, so that there will be the least possible ultimate crippling or interference with function. The first has to do with saving men for service who would otherwise be discharged as physically unfit and also, as the result of careful training, increasing the number of days that should be expected of the men for active duty. The second has to do with the saving for service of men who but for such work might not have lived, or, had they lived, been so crippled as to be of no use to the Army.



    972

    3. Without such methods of treatment available for those needing such care in the precombat or training period, large numbers of men will be lost for active duty, as the ordinary medical measures can only give temporary relief.

    4. Without such methods in cases of combat or other injury there will be much unnecessary loss of function and much of the acute surgical treatment will be purposeless.

    5. In each of the large hospital centers, a base hospital with special personnel and equipment for caring for such cases will be installed, while in the detached base hospitals special services will be established so that there will be the least possible transferring of cases from one hospital to another.

    6. Consultants in orthopedic surgery will be assigned to groups of hospitals, whose function it will be to keep in touch with the orthopedic work of the given group. These consultants should be freely used by the staff of the respective hospitals and can be reached through the commanding officers of hospital centers.

    7. To best accomplish the purposes of the division and to make the services of its members available the following instructions will govern:
     AMPUTATIONS

    8. Cases of amputation of either extremity will be assigned as soon as possible to the orthopedic service for the needed special treatment. A guillotine amputation, for instance, without other injuries, can usually be moved without risk in one week, and with suitable measures rapid closure of the wound is usually possible so that the artificial leg can be fitted and the man get about without crutches many times in from four to five weeks from the time of injury. It is desirable that transfer to the orthopedic service take place as early as possible before contractures have taken place so that the temporary artificial limb, in case that is desirable, can be most favorably fitted and the muscles used to the best advantage.
     

    TENDON INJURIES OR INFLAMMATIONS

    9. The cases of injury to the tendons or inflammation in or about the tendons should be assigned as soon as the primary wound healing is well established, or as soon as the acute inflammatory reaction has subsided to the orthopedic service. Early transfer to these special services is important in order that the treatment having to do with the full restoration of function in the part that has been injured or inflamed may be established at the earliest possible moment and before adhesions have formed or become organized.
     FLAT FEET, WEAK FEET, OR PRONATED FEET

    10. Cases of flat, weak, or pronated feet associated with pain, swelling, or inflammation, when admitted to a hospital should be assigned to the orthopedic service. As soon as the acute symptoms have passed, the cases should be transferred to the nearest convalescent camp. From here, in keeping with the degree of difficulty, the cases should be transferred for full duty or to the orthopedic training camp, depot division, for training to fully overcome the weakness, or for noncombat duty under class C classification.

    11. No cases of uncomplicated flat foot should be exempted from service or recommended for transfer to the United States, as all can be made useful for military service.
     

    SPINAL STRAINS, WEAK BACKS, CHRONIC BACKACHES

    12. The cases of weak, painful, or lame backs, or of sprain of the spinal or sacro-iliac joints, should be assigned to the orthopedic service. From here they should be transferred to the nearest convalescent camp as soon as the acute symptoms have passed, and from there, after a reasonable time, they should be transferred either for full duty or for noncombat duty under class C classification.
     GENERAL BAD POSTURE

    13. Cases of general bad posture, which is commonly associated with lack of vitality or general endurance as well as being part of the condition leading to weak feet and weak backs, should be sent for training in the orthopedic training camp, depot division.



    973
     

    FRACTURES

    14. For all cases of fracture of bones other than of the head or face, or of extensive muscle injuries, it is of the utmost importance that proper splints be applied at the earliest possible moment so that the transfer of the patients to the hospital in which treatment is to be given, is associated with the least possible damage to the tissue adjacent to the injured bone. The Thomas leg splint, the hinged half-ring splint, the Thomas hinged arm splint (Murray modification), the Cabot posterior splint, and the ladder splinting are the appliances most needed for such work.

    15. In case the fracture is compound, the wound treatment at the evacuation or other hospitals should follow the principles outlined by the chief consultant of surgical services.

    16. After the primary wound treatment has been given, these cases should be transferred to the orthopedic service, in which the most approved methods for the early restoration of function to the injured part will be available. An effort should be made to transfer the cases to such services, wherever possible, within a week or 10 days of the time of injury, this being the most favorable time as regards bone repair. All fracture cases which, for any reason, can not or should not be transferred to one of the services as indicated above, should be reported to the senior consultant in orthopedic surgery, or to the orthopedic consultant of the special area.

    17. Simple fractures should not be converted into open fractures except under very exceptional conditions or after consultation with one of the orthopedic consultants. A result which may not be as perfect anatomically as might have been obtained by open operation may, nevertheless, be functionally good. This is so commonly the case that the risk of infection, which is greater under the war conditions than in civil life, should be avoided whenever possible.
     JOINT INJURIES

    18. All injuries of the joints should be protected with the same care for transport to the hospital in which the treatment is to be given as has been indicated for fractures. Suitable splints should be applied immediately, and the standardized list of splints of the Army provides types that will meet all the needs.

    19. In case the injury is associated with open wounds, the principles of the wound treatment are those which have been laid down by the chief consultant of general surgery.

    20. Since in all such injuries ultimate function of the joint is the chief requisite, treatment having for its purpose the restoration of function should be instituted as soon as possible, and for this purpose it is desirable that cases of such injury be transferred, as soon as the primary wound treatment has been given, to the orthopedic service. It is important that such transfer be made before unnecessary adhesions have formed so that the restoration of function can be obtained with the least possible loss of time. In all such functional restoration it should be clearly understood that while motion is to be encouraged at the earliest possible moment, it should consist entirely of active motions performed by the patient, in which case the reflex muscular contraction will protect the joint from undue injury. All passive motion should be avoided.

    21. Operations upon the joints that are not emergency in character should not be performed until after consultation with one of the consultants in orthopedic surgery.
     TRANSFER TO UNITED STATES

    22. It will be the policy to send to the United States, as soon as transportable, all cases that are of class D type, or cases in which prolonged treatment will be required for restoration to duty.

      M. W. IRELAND,
    Brigadier General, M. C., N. A., Chief Surgeon.


    Circular No. 47.

       AMERICAN EXPEDITIONARY FORCES,
      August 28, 1918.

    I. The following memorandum from general headquarters, American Expeditionary Forces, is published for the information of all medical officers concerned. Strict observance of the instructions that only class A men, fit for immediate combat duty, be sent to replacement battalions is enjoined:



    974

    1. Complaints are reaching these headquarters that hospitals are sending men to replacement battalions who are not fit for class A or immediate combat duty. The commanding general of the First Corps reports this matter to these headquarters and is advised in substance as per the telegram being sent out to-day:

    "Following furnished for your information and guidance. Commanding general, First Corps, recently forwarded these headquarters complaint that men other than class A were sometimes being sent to replacement battalions, and requested authority to send all class B, C, D men to depot division for disposal. Our indorsement August 19 approved this request, with statement men sent to replacement battalion must be class A, fit for immediate assignment to combat duty, and was never contemplated that class B, C, D men be sent those battalions. Chief surgeon has been directed to circulate this information to medical officers concerned.

       "MOSELEY."

    II. Discharge of civilian patients from hospitals.-In a recent case a civilian employee of the Army was admitted to hospital as a soldier, was transferred to another hospital as such, and upon discharge from the hospital for duty was issued the uniform of an American soldier. He was later arrested on the charge of illegally wearing the uniform. Commanding officers of hospitals should take every possible precaution in issuing uniforms to patients being discharged from hospital that they are only given to those entitled to wear them.

    III. Appliances.-Requisitions for all appliances which require heat or power should show in the column "Remarks" whether gas or electricity is available; and, if the latter, the type of current, voltage, and cycle will be designated. This applies in particular to X-ray, dental, and laboratory equipment.

    IV. Prolonged active hospital treatment.-Patients have recently been evacuated from the front to Services of Supply hospitals "For continuation of antisyphilitic treatment." General orders and circulars issued on this subject provide that "Only cases presenting complications indicating the necessity of prolonged active hospital treatment will be transferred back from the regimental lines." In this connection, attention of all medical officers is called to paragraph 5, section 1, General Order 34, general headquarters, 1917, and paragraph 5, Circular 15, office of chief surgeon, 1917.

    V. To registrars of all hospitals.-The copies of Form 22, A. G. O., received in this office are in many cases so illegible as to be unavailable for use. Unless better copies are sent, it will be necessary in a large proportion of the reports to require that new sets be made out and forwarded. To obviate this necessity it is suggested that first and third, or second and third, copies of the original impressions be forwarded to this office.

    VI. Evacuating officers and soldiers from hospitals.-There have been frequent complaints that orders governing the evacuation of officers and soldiers from hospitals were not being complied with. Commanding officers of hospital centers and hospitals are charged with the duty of seeing that all the officers of their command concerned with the evacuation of patients from hospitals are thoroughly familiar with the orders governing this subject. In this connection attention is called to section 7, General Orders 111, general headquarters 1918; section 2, General Orders 11, Services of Supply, 1918; section 1, General Orders 41, general headquarters, 1918; and Circular Letter 6-A, office of chief surgeon, 1918.

    VII. Records to accompany patients on evacuation from hospitals.-1. Attention of all medical officers is called to the instructions on the field cards, which state that these cards are to be securely fastened to the patient's clothing. These instructions are not being carried out, and as a result patients and their cards are becoming separated and there is a great confusion of records. In some cases when patients are being evacuated by hospital trains the field cards are turned over in bulk to the train commanders. This method of transfer of field cards is not authorized, and train commanders are hereby instructed not to accept field cards in this manner.

    2. Many patients are being received at hospitals in base ports for evacuation to the United States without adequate records of previous condition. Attention is called to the requirements of General Orders 41, general headquarters, 1918; section 1, paragraph 8; and to the Manual of Sick and Wounded Reports, sections 6 and 7, and section 9, paragraph 12.

    3. In making report, disability boards will use card Form No. 25, statistical section, A. G. O.

    VIII. Personal property of patients.-It has been reported that articles of value have been turned in, without receipt, by great numbers of wounded soldiers at field, evacuation,



    975

    and other hospitals and that on their being evacuated to other hospitals these articles have not been returned to them. Commanding officers of hospitals should give this matter their attention and endeavor to see that personal property belonging to their patients accompanies them upon evacuation.

    IX. Fire protection.-The following suggestion is made to this office by the bureau of fire protection:

    In hospitals where different types of construction have been used, commanding officers should keep in mind in making assignments of patients to wards that on account of difficulties of evacuation in case of fire the more serious bed patients should, whenever practicable, be placed in less inflammable wards.

    X. Ordnance equipment.-Commanding officers of hospitals in and adjacent to Paris are informed that all ordnance equipment, with the exception of guns and ammunition, should be shipped to the American salvage depot, St. Pierre des Corps. All firearms and ammunition should be shipped to the advance ordnance depot No. 1, at Is-sur-Tille. Guns should be securely packed in boxes or tied together and well wrapped so that they may arrive in as good condition as possible. All salvaged clothing which is not required can be turned in to the American salvage depot, 110 Boulevard de Hospital, Paris.

    XI. Requisitions for X-ray supplies.-A Roentgenologist has been attached to intermediate medical supply depot No. 3 for the purpose of acting upon requisitions for X-ray supplies. Hereafter requisitions for X-ray supplies will be listed separately as heretofore but will be sent direct to the intermediate medical supply depot No. 3, A. P. O. No. 737.

    XII. Emergency medical teams.-The medical teams heretofore known as "gas teams," or "shock teams," will be known in the future as "emergency medical teams." They are to be used in emergencies for the medical care of the wounded (especially chest wounds) and for those suffering from surgical shock as well as gas.

    XIII. Front-line packages.-It is directed that commanding officers of Services of Supply hospitals stop the practice of making requisitions for the "front-line packages" prepared by the Red Cross. There dressings are expensive and not specially suited to regular hospital work. They are intended for use at the front only.

    XIV. Rest rooms for nurses.-The building of Red Cross amusement rooms and rest rooms for nurses has unfortunately been much delayed at many base hospitals on account of the demand for more beds for patients and the necessity for using all available material and labor to provide the additional room needed for the sick and wounded.

       M. W. IRELAND,
       Major General, M. C., Chief Surgeon.


    Circular No. 48:
    AMERICAN EXPEDITIONARY FORCES,
       September 9, 1918.

    I. Official relations between medical and veterinary personnel.-(1) The veterinary service of the American Expeditionary Forces is by special order now placed under the authority of the chief surgeon, and the Veterinary Corps will in the future function under Special Regulation 70, dated Washington, December 15, 1917.

    This special regulation is not to be interpreted as placing individual veterinary officers or veterinary organizations under the authority of medical officers. On the other hand, it is to be interpreted as placing all detachments of veterinary personnel in an independent status with reference to other Medical Department personnel.

    The senior veterinary officer of any organization or station, therefore, would bear the same relationship to the commanding officer thereof as does the senior medical officer, and, as a detachment commander, he has the same responsibility for the care, instruction, and discipline of his men.

    (2) Senior veterinary officers are not to be considered as assistants or subordinates to corresponding medical officers. It is not contemplated that correspondence, reports, or returns emanating from or pertaining to the Veterinary Corps will pass through the office of medical officers as part of the routine channel of communication.



    976

    (3) Requisitions for veterinary supplies will be forwarded as follows: (a) Organizations with divisions through division veterinarian, and upon his approval, in the manner as laid down by General Order 44. (b) Officers commanding veterinary hospitals and other independent units direct to proper supply depot.

    (4) Although the independence of action outlined herein is expected to govern official relations between the medical and veterinary services, it should not be forgotten that the activities of both are in contact at several points and that frequently occasion arises when the medical officer, by reason of longer service and broader experience, can be of material assistance to the veterinary officer. This is particularly true as regards army, corps, and division surgeons and veterinarians.

    Senior medical officers will therefore cooperate with veterinarians and assist them by counsel and advice in the handling of duties newer to many of them. While the veterinarian should welcome such assistance, he should at the same time cultivate independence and authority in his department and avoid submitting himself to such supervisory action as would tend to destroy his initiative and sense of responsibility.

    II. Telegraphic reports.-Commanding officers of hospitals in making telegraphic reports to the British authorities of deaths of British officers and soldiers should indicate in the report the number or name of the hospital from which the report is being made.

    III. Inspection.-It has been brought to the attention of this office that isolated detachments connected with divisions, and with the Services of Supply, sometimes fail to undergo the regular inspections for venereal disease. The attention of all responsible medical officers is called to this oversight.

    IV. Treatment of Y. M. C. A. personnel.-The requirements of Circular 37, paragraph 8 calling for reports to be submitted to Y. M. C. A. headquarters for Y. M. C. A. personnel treated in American Expeditionary Forces medical formations are not being observed. In many cases diagnoses are not given or anything indicating the condition of the patient on discharge from hospital. These reports should be addressed to medical section, Y. M. C. A. headquarters, No. 12 Rue D 'Aguesseau, Paris, which change of address will be noted.

    V. Rating of enlisted men.-Commanding officers of hospital centers are authorized to rate enlisted men under paragraph 1420½, Army Regulations. Report of any ratings made under this authority will be forwarded to this office.

    VI. Carrel-Dakin tubing.-There is great difficulty in meeting the needs for Carrel Dakin tubing. Every effort must, therefore, be made to conserve the supply. The commanding officers of hospitals will give such instructions as to insure that the tubing after use will be cleansed and sterlized and again used, and that all received at the hospital in excess of the needs of the hospital will, after cleaning and sterilization, be returned to the nearest supply depot.

    VII. Nurses.-Any member of the Army Nurse Corps who marries while on active service in France will be returned immediately to the United States for duty and will not be discharged in France. Report of the marriage of any nurse will be immediately reported to this office by the proper commanding officer.

    VIII. Ordnance equipment.-Decision has been rendered that mess equipment and canteens should be issued to patients upon discharge from hospitals, whether patients are to go to replacement organizations or to convalescent camps. The commanding officers of hospitals are instructed to maintain a sufficient supply of this ordnance equipment to issue to patients upon discharge.

    IX. Reports of issues of ordnance to patients discharged from hospital.-Circular letter No. 6-A, from this office, requiring that ordnance property issued to patients leaving hospitals be dropped on a monthly abstract of issues showing the quantity of each kind of article issued during the month and giving the names of the soldiers to whom such uniform equipment has been issued, is with the consent of the chief ordnance officer amended so that the names of the soldiers to whom these articles are issued will not be required.

    X. Conservation of supplies.-The necessity for the utmost economy in all surgical dressings and supplies is obvious. Not only the limitations imposed by the tonnage situation, but the enormous increase in the burden thrown upon the manufacturer, makes this essential. Gauze and bandages should be repeatedly washed and sterilized. Rubber gloves should be



     977

    cleaned and tested. Wastage in catgut should be avoided by insistence upon an economical method of tying. Ether should be conserved. Only by the cooperation by the entire surgical staff of each hospital can the desired conservation of supplies be brought about, and the importance of this subject should be repeatedy impressed upon all concerned. The Surgeon General reports some most satisfactory results in the United States through efforts at conservation and suggests the following method:

    While the varying equipments of different hospitals may modify the method used for the reclamation of gauze and bandages, the following method is suggested: Each surgical ward and dressing room should be equipped with two galvanized-iron buckets with a cover, lined by a paper bag in one of which should be put all blood-stained and slightly soiled dressings; in the other, pus-stained dressings. These buckets should be taken twice daily-oftener, if necessary-to the room where dressings are washed. If no laundry equipment, or laundry machinery, is available, the gauze and bandages can be washed by hand, using heavy rubber gloves for this purpose. Previous to washing, the slightly stained and blood-stained dressings should be soaked for 12 hours in cold water containing one-tenth per cent of chloride of lime; the pus-stained dressings in a solution containing one-tenth of 1 per cent chloride of lime and one-half of 1 per cent washing soda. If washed by hand, these dressings should be boiled for at least one hour. When laundry machinery is available, or in the larger hospitals which are now being furnished with equipment for the reclamation of re-use knitted gauze, ordinary gauze and bandages may also be reclaimed. The gauze and bandages should be put in mesh bags, soaked for 12 hours as directed above, boiled for 1 hour, transferred to the washing machine, and, if a rotary tumbler is available, can be dried in the bags in this tumbler. If this is not available, gauze and bandages can be passed through a wringer and hung on lines to dry. After drying dressings should be sorted, folded, put in packages, and sterilized in the ordinary way for 30 minutes at 15 to 30 pounds pressure, on two successive days. Careful bacteriological tests should be made from time to time to test its sterility.

       M. W. IRELAND,
    Major General, M. C., Chief Surgeon.


    Circular No. 49.

       AMERICAN EXPEDITIONARY FORCES,
      September 18, 1918.

    I. Preparation of gum-salt solution.-Prepared solution of gum-salt for intravenous infusion in cases of hemorrhage and shock will be limited to field, mobile, evacuation, and advanced base hospitals really functioning as evacuation hospitals, where, during active periods blood transfusion may be impossible of accomplishment. Such hospitals may obtain gum-salt solution from the nearest Army medical dump or from the central Medical Department laboratory. The solution is issued in 500 c. c. automatic stoppered bottles, 12 bottles to a case. Both cases and bottles are obtained with great difficulty, and empty bottles and cases must be returned in order to receive replenishments.

    In base hospitals, generally, blood transfusion should be the procedure of election and intravenous infusion of gum-salt solution resorted to only in emergency. The small stock of gum-salt solution necessary to meet those emergencies should be prepared locally, by each base hospital for its own use. Directions for the preparation of the solution may be obtained from the director of laboratories, A. P. O. 721.

    In order that all the acacia that is available may be conserved for use in the preparation of gum-salt solution, its issue from supply depots for dispensary use is interdicted.

    Requisitions for acacia in small quantities, not to exceed 5 pounds in the instance of base hospitals, will be honored, provided the notation: "For preparation of gum-salt solution" is entered opposite this item in the column of remarks.

    II. Transfusion sets.-On several occasions requisitions for transfusion sets have been received from base hospitals with the explanation that the transfusion set formerly on hand had been taken to an advanced field, evacuation, or mobile hospital by some member of the staff on detached service with a "shock team."

    The impression has been gathered, apparently, that transfusion sets issued to individuals, upon completing the course in resuscitation at the central Medical Department laboratory, were for their personal use. This impression is erroneous, as each set was destined for use in the hospital to which the individual returned, and should have been turned over to the supply officer of the hospital.



    978

    All transfusion sets now in the possession of individuals will be turned in to the supply officer of the hospital to which they are permanently attached. Transfusion sets have been issued to advanced hospitals, and reserve supplies have been placed in Army medical dumps. These supplies are adequate for the use of "shock teams" serving temporarily at advanced hospitals.

    III. "Shock teams."-It is directed that emergency medical teams ("shock teams"), when once formed, be left intact by commanding officers of Medical Department units unless specific authority to change personnel of these teams is obtained from the office of the chief surgeon or from the director of professional services.

    IV. Purchase of foodstuffs.-The following letter from general headquarters is quoted for the information of all concerned:

    We are in receipt of information from the French mission, general headquarters, A. E. F., stating that in certain localities American troops are offering prices for foodstuffs in excess of the prices fixed by the French authorities. This practice is obviously bad in whatever way considered.

    Please take necessary steps to have the troops under your command pay no more for their open-market purchases of foodstuffs than the price fixed and published by the French authorities.

    V. Coast Artillery casuals.-All Coast Artillery casuals discharged from hospitals as of class A shall be sent to Angers.

    VI. Epidemic disease.-The attention of surgeons of all organizations and commanding officers of all Medical Department units is again called to the necessity for prompt report to the local French civil and military authorities of all cases of epidemic disease. This report should give the name and organization of patient.

    VII. Clinical records.-It is desired that the clinical records of patients treated in Services of Supply hospitals be as complete as circumstances will permit. Form 55, Medical Department, will be used for this purpose. Form 55-A will be made out for all patients, but only such other parts of Form 55 will be used as are of interest or value in the individual case. The clinical record for completed cases will be filed in the hospital in which the case is completed. When patients are transferred from one Services of Supply hospital to another, Form 55 will be placed in the envelope with the field medical card.

    VIII. Construction at base hospitals and hospital centers.-Many cases have occurred recently where patients were evacuated from one hospital to another without sufficient rations. In travel of this sort there are many and unexpected delays. In addition to the cooked rations issued for the expected length of the journey, a reserve of cooked or travel rations for at least 36 hours over and above ordinary schedule time should be issued for each patient. The number of such travel rations issued can be noted on the travel order and patients required to turn in rations unused on arrival.

    IX. Reports.-Circular No. 28, section on allied patients in American Expeditionary Forces' hospitals, is modified to read as follows:

    "PAR. 2. When French military patients are admitted to, discharged from, or die in, American military hospitals in the French zone of the armies, notification of the fact will be sent within 24 hours, on Form 52, Medical Department, to American statistical section, 10 Rue St. Anne, Paris."

    "PAR. 7. A separate daily list of casualties and changes of patients in hospitals, Form 22, A. G. O., S. D., A. E. F., will be made out for all British patients; two copies will be forwarded to the deputy adjutant general's office, Third Echelon, British Expeditionary Force, France, and another to medical communications, British Expeditionary Force, France. No copy will be sent to the chief surgeon, A. E. F., the monthly report called for in 1-b being sufficient."

    X. Patients to be examined by board of officers.-It is desired that in the future no patients be transferred from hospital, either to duty or convalescent camp, without having been examined by a board of medical officers. In most cases disability boards already appointed can act upon all such cases. Where the time of disability boards is fully occupied with class D cases, a board, to consist of the chief of service and ward surgeon, can act upon cases going to duty or convalescent camp. Complete physical examination will not usually be required in such cases, and no formal record of the proceedings of the board other than a note by the senior member on the patient's clinical record.



    979

    XI. Hospital fund.-In view of the fact that irregularities in the hospital fund of a base hospital have been discovered, the following recommendations have been made by the officers conducting the investigation will be carried out in all base hospitals:

    The commanding officer of each base hospital in the American Expeditionary Forces will appoint an auditing committee for the hospital fund, with instructions to make a careful examination of the hospital fund accounts from the time of the establishment of the hospital in France, with a view to determine if funds due from all sources have been collected and accounted for, and also to take necessary steps to see that the fund is carefully and methodically audited each month hereafter.

    A cash book will be kept by the custodian of the hospital fund in every hospital in such manner as to show the daily receipts and expenditures from the hospital fund.

    Patients who are charged board in hospitals should, if they are not able to pay their mess bills, sign an acknowledgment showing their indebtedness. The accounts of pay patients should be checked against the daily lists of patients received and discharged so as to show that the full amounts due are paid.

    Arrangements will be made to secure the services of skilled accountants who will from time to time be sent to base hospitals to investigate their hospital fund accounts.

       M. W. IRELAND,
    Major General, M. C., Chief Surgeon.



    Circular No. 50:

    AMERICAN EXPEDITIONARY FORCES,
       October 4, 1918.

    I. (1) Instructions regarding hospitalization and evacuation of patients with disease or injury of the eye, ear, nose, throat, and maxillo-facial region.-In general, the policy as regards hospitalization and evacuation of these cases is as follows:

    (a) Simple cases should, whenever possible, be retained for treatment with their organization or be treated in near-by camp, field, or evacuation hospital.

    (b) Cases not suitable to be retained with organizations but which will be fit for return to duty in the American Expeditionary Forces within a reasonable time should be transferred to the nearest camp or base hospital.

    (c) Cases which are permanently unfit for duty in the American Expeditionary Forces, or which will require prolonged treatment to render them fit for duty, should be classified as "D" and evacuated as soon as safely transportable to the United States. Class D cases, in which healing might be materially retarded by delay or interruption of treatment incident to evacuation to the United States, or which have unsightly wounds of the face or neck that could be materially helped within a reasonable time, should be retained for primary treatment in the American Expeditionary Forces.

    The treatment of cases retained in France must involve the least possible amount of transportation from one hospital to another, and facilities will be provided in each hospital center and in the larger base hospitals not connected with hospital centers for the treatment of this class of cases. Base Hospital No. 115, located at Vichy, has more elaborate equipment for this class of cases.

    Consultants in the different specialities will be located at certain hospitals, whose services can be called upon by neighboring hospitals. Addresses where these consultants can be reached will be published from time to time.

    (2) Ophthalmic cases.-Routine refractions and vision examinations for troops should be done in the nearest hospital serving these troops. Ophthalmic cases which require more elaborate treatment than can be given in isolated camp or base hospitals and which do not come within the provisions of paragraph 1 (c) above, should be transferred to the nearest hospital center, or upon recommendation of the local or senior consultant in ophthalmology be transferred to Base Hospital No. 115, Vichy.

    (3) Ear, nose, and throat cases.-Cases of disease or injury of the ear, nose, or throat which require more elaborate treatment than can be given in isolated camp or base hospitals and which do not come within the provisions of paragraph 1 (c) above, should be trans-



    980

    ferred to the nearest hospital center, or, upon recommendation of the local or senior consultant in oto-laryngology, be transferred to Base Hospital No. 116, Vichy.

    (4) Maxillo-facial cases.-Cases evacuated to the Paris district will be treated at the American Red Cross Military Hospital No. 1. Other cases that can not be treated in the hospital in which they are situated may, on request of the local or senior consultant in maxillo-facial surgery, be evacuated to a base hospital or hospital center where there is a maxillo-facial service, or to Base Hospital No. 115, Vichy.

    Maxillo-facial cases requiring only occasional surgical or dental supervision may be sent from the base hospitals to convalescent camps to await further examination or operation.

    No maxillo-facial case should be evacuated to the United States until the patient can open his mouth sufficiently and has the pharyngeal muscle control necessary to obviate the danger of aspiration during seasickness.

    Cases that have been recently repaired should be retained in hospital until the sutured wound is safely healed.

    II. British soldiers in American hospitals.-Pursuant to recommendation from the British authorities, the following instructions will govern visits of relatives to dangerously ill British soldiers in American hospitals:

    (a) In all cases requests for relatives to visit British soldiers dangerously ill in American hospitals should be sent to the A. D. M. S., Paris, and not direct to the relative of the patient.

    (b) When the American hospital is located outside of Paris or its near vicinity request should be made to the A. D. M. S., Paris, and at the same time there should be a statement as to whether suitable accommodations for the relatives of the soldier exist at the place where the American hospital is situated. In those cases where it is not possible to accommodate relatives it is not proposed to make arrangements for the relative to visit.

    III. Evacuation of orthopedic cases.-Some confusion has resulted from apparent conflict of instructions in Circular Letter A-1 and Circular 46, Office of Chief Surgeon. All instructions regarding evacuation of this class of cases, issued prior to Circular 46, are revoked.

    IV. Pail collection system.-Reports have been received at this office that in certain of the hospitals where the pail collection system is used, urine and other human excreta has been dumped into the sewer system. Attention of all responsible officers is called to the fact that where the pail system is used the sewer system is provided for sink waste only and that there is no purification system adequate to care for human excreta. Steps should be taken at once to prevent a recurrence of this faulty method of using the sewer system.

    V. Ordnance property.-The following information, received from the chief ordnance officer, is repeated for all concerned:

    It has come to the attention of this office that the "pouch for small articles, model 1916," which is furnished the Medical Department by the Ordnance Department, has been incorrectly called "pouch for adhesive tape and foot powder." The supply division of the Ordnance Department has been notified to discontinue the use of this name, "pouch for adhesive tape and foot powder."

    VI. Reports.-The following revisions in the Manual of Sick and Wounded Reports for the American Expeditionary Forces, revision of September 15, will be noted, effective October 1:

    Section IX, paragraph 11 (p. 9), sentence "Cases transferred to convalescent camps will be considered completed as far as the records are concerned," is revoked.

    Section XXI, paragraph 2 (p. 51), is revoked.

    In the future all convalescent camps will report as do base hospitals carrying patients on sick report. Hospitals will not consider that cases are completed when the patients are transferred to convalescent camps.

    VII. Promotions.-Since the issue of Circular 36, of this office, explaining the general principles of the system of promotion by roster in the Medical Department, two very important orders have appeared which, while not upsetting this scheme, have modified it to a certain extent. The first of these was Bulletin 59, general headquarters, dated August 16, which abolished distinctions between the Regular Army, National Army, National Guard, and Reserve Corps, merging all of these in the United States Army. It also announces that the principle of selection will govern for promotions.



    981

    General Order 162, general headquarters, dated September 24, gives the rules under which promotions are made and states that they will be temporary appointments made by the commander in chief, pending approval by the War Department.

    The general effect of these orders is to give greater importance to the factor of special qualifications in determining the roster number. The value of this factor is determined by the chief surgeon and is based upon the reports received of the officer in the "Report of character of services and qualifications" on the form published in connection with Circular 36 (known as C. S. and Q. report). General Order 24 has been revoked, and at least half of the data required thereby have been eliminated. If the Form C. S. and Q. is accurately made out, it furnishes all the data necessary. Attention is, however, invited to the importance of its being signed, with date and station, by the officer making the report. Attention is also called to the fact that a statement of the physical condition is required which, however, need not be the elaborate report upon the prescribed form heretofore required. The requirement is simply:

    (d) A certificate that the officer has been examined by a medical officer and found physically fit to perform the duties of the grade to which he is recommended for promotion will be forwarded with the recommendation.

    If an officer is temporarily disabled by wounds or sickness, a careful statement of the nature of the disability and the length of time which it will probably prevent him from performing his duty should be given, with a statement that the officer is with the exception of the disability noted physically fit to perform the duties of the grade to which he is recommended.

    M. W. IRELAND,
    Major General, M. C., Chief Surgeon.


    Circular No. 51:

    AMERICAN EXPEDITIONARY FORCES,
    October 12, 1918.
     
     

    PNEUMONIA, ITS PREVENTION AND MANAGEMENT

    THE PREVENTION OF PNEUMONIA

    The present epidemic of respiratory infection in the American Expeditionary Forces is largely influenzal in character, with a rather high incidence of secondary pneumonia due usually to pneumococci or streptococci and occasionally to influenza bacilli and possibly to meningococci. The mortality has been in the neighborhood of 30 per cent. As primary pneumonia is likely to increase with the advent of colder weather, medical officers are reminded that the prevalence of pneumonia, as well as of other respiratory infections, in armies in the field depends particularly upon:

    (1) Overcrowding.
    (2) Exposure to wet and cold.
    (3) Fatigue, whether induced by overwork, a long journey, loss of sleep, or nervous exhaustion from worry.

    Crowding forces the occupants in barracks or billets into close personal contact, and the greatest danger from it in relation to the occurrence and spread of respiratory infections is obviously in the increased opportunity furnished for droplet infection of the healthy inmates from those who already harbor pathogenic micro-organisms in their noses or throats.

    In epidemics of pneumonia or of influenza, the disease is undoubtedly usually spread from man to man through the secretions or discharges from the mouth, nose, or other parts of the respiratory tract, and an individual who harbors virulent pneumoccoci or streptococci or influenza bacilli is obviously very likely to infect his cosleepers by coughing or sneezing, or even speaking loudly in close proximity to them.

    In the present epidemic, the great majority of the cases of pneumonia are secondary to influenza-the natural resistance of the individual having been first broken down by this disease, secondary infection of the respiratory tract with pneumococci or streptococci has occurred.



    982

    In Panama, where climatic conditions were not severe, pneumonia was prevalent, particularly on account of overcrowding, and the same was found to be true among the workers in the South African mines. Prevention consisted particularly in scattering the individuals and giving them separate dwellings in place of barracks.

    Overcrowding.-In relation to overcrowding, Medical War Manual No. 1, for 1917, authorized by the Secretary of War under the supervision of the Surgeon General and Council of National Defense, states that whenever possible the floor space per enlisted man should be 80 square feet, affording 960 cubic feet, and should never be less than 10 by 6 feet, or 60 square feet, which with a ceiling 12 feet high would afford 720 cubic feet. This manual further states that should an epidemic occur and should the soldiers be overcrowded, it may be assumed axiomatically that the epidemic can not be checked by other sanitary measures alone, but must be combined with measures to relieve the overcrowding. Owing to the shortage of lumber and materials, it was thought necessary in the American Expeditionary Forces to reduce the space per man to 1 linear foot, or 20 square feet-one-third of the minimum amount recommended. The order directs that bunks shall be 2 feet 8 inches wide by 6 feet 6 inches, double tier, in sets of four, 2 feet 8 inches apart, giving 1 linear foot of Adrian barracks per man. It is hoped that conditions will soon be such that this allowance may be increased. In the meantime, an effort must be made to prevent droplet infection by other means between the men sleeping side by side in barracks. A board partition 2 feet high may be built between the two adjoining bunks. Until this is done, wires may be run 2 feet above the bunks and the shelter tents suspended upon them between the adjoining bunks. Similar precautions should be taken in billets and tents. This is a more practical arrangement than placing the head to the feet of the adjacent sleeper. In cases where the overcrowding is excessive and the weather fine, the advisability of bivouacing the men in the open air under shelter tents, or other canvas, should be considered. If this is done, additional blankets obviously should be supplied. Relief from the dangers of overcrowding should be the first important consideration in connection with the checking of the present epidemic. Distance between beds is the important factor, not cubic space, in the prevention of the spreading of pneumonia infections. Crowding in recreation rooms at cinematograph entertainments, etc., should at present time be prevented as much as possible.

    Wet and cold.-Wet and cold are also important predisposing factors in pneumonia epidemics. A lowered condition of vitality from cold favors particulary the development of such infectious diseases as pneumonia and influenza, by lowering the resistance of the bronchial and pulmonary tissues to infection. Experiments suggest that infections with these diseases are favored by cold and chilling through the stimulation of the mucous glands with resulting closure of the small bronchioles with plugs of mucus. It is well known that the functions of the leucocytes are disturbed by cold, and it seems likely that phagocytosis may play an important rôle in connection with the mechanism of immunity in pneumonia, and that immunity is in this disease particularly related to the functions of the leucocytes. The movements and phagocytic action of the leucocytes occur most favorably at about the temperature of the normal body. Exposure of the skin to cold and wet leads to chilling of the leucocytes during their repeated passage through the skin capillaries, which may diminish their functional activity, and thus lower resistance to a point at which infection may occur. It should be borne in mind that cold wet feet produce a general reaction of the body and not only a local one, and that this condition also predisposes to infection. Cold and wet have less unfavorable action when accompanied by energetic muscular exercises, if a condition of fatigue is not reached. Additional efforts should be made to provide for the prompt removal and drying of the wet clothing of the soldier, and additional blankets at night must be insisted upon.

    Fatigue.-It should be borne in mind that fatigue induced by overwork and also by lack of sleep and worry in connection with wet and cold has been one reason for the excessive mortality from pneumonia in armies in the field. It is well known that normal resistance to infection may be broken down by fatigue.

    Early detection.-Greater attention should be paid by medical officers to the early discovery of cases of colds, cases of influenza, and other respiratory infections, and to prompt isolation and treatment of such cases. Carriers undoubtedly play an important rôle in disseminating pneumococci, streptococci, and influenza bacilli as well as meningococci.



    983

    Warning against spitting.-Men should be specifically instructed at this time against expectorating in quarters, and the danger of sneezing and coughing and of speaking in close proximity to the face explained.

    THE MANAGEMENT OF PNEUMONIA

    1. Pneumonia, especially as it occurs among troops, and as it is now present in the American Expeditionary Forces, must be regarded as a highly contagious disease, and it must be managed with the same precautions as are taken in the care of other contagious diseases.

    2. The epidemics of influenza now prevalent in many widely separated parts of France have at least one point in common; i. e., the occurrence of pneumonia as an incidence of the disease, a complication, or a sequel. The pneumonia is usually of a patchy type, different slightly in its characteristics in different regions, but characterized by rapid progress, great respiratory distress, frequency of early collapse, and high mortality. The causative organism may not always be the same; pneumococcus, streptococcus, and the influenza bacilli and occasionally the meningococcus all seem to contribute their share.

    3. Early isolation and hospitalization of pneumonia as well as of influenza and similar respiratory infections will do much to prevent the spread of the disease and lower the mortality. Cases should be hospitalized, when possible in medical formations where they may remain until recovery, even though the initial trip by ambulance may be somewhat lengthened. Cases of pneumonia in the earliest stages withstand transportation fairly well, but later in the disease after they are hospitalized, they are greatly injured by moving. Numerous cases of respiratory infections have been evacuated by train or by motor, to arrive at their destination some hours later in profound collapse, to die within a very short time. Moving a case of pneumonia to make room for a battle casualty may kill the pneumonia patient and not aid the wounded, and the practice should not be tolerated.

    4. Isolation or segregation should be practiced in all cases of respiratory infection and such isolation should start in the field. Upon arrival at the hospital the cases of respiratory infection should be received in wards devoted to the observation of cases with respiratory infection; or if it is possible to make an absolute diagnosis on admission to the hospital, the case may be sent directly to the ward designated to receive cases suffering from that particular type of infection. The observation ward for respiratory diseases should be cubicled, a sheet or other partition being placed between adjacent beds. It is desirable that an accurate diagnosis be made as soon as possible of cases in this ward so that they may be transferred immediately to those wards designated to receive cases suffering from the different types of respiratory infection. All cases of uncomplicated influenza should be isolated in separate wards as rigidly as if they were cases of measles, and all beds should be cubicled. No cases of pneumonia should be sent to these wards, and should a patient with influenza develop pneumonia he should be immediately removed to a pneumonia ward. Cases of pneumonia should be segregated in wards set aside for this purpose. These wards should be cubicled. The reason why such rigid isolation and employment of the cubicled system is imperative is due to the fact that, first, cases of influenza are highly susceptible to pneumonia and may be infected with great readiness by a pneumonia patient in the near proximity, and, secondly, that the lobular type of pneumonia may be caused by several varieties of organisms, and should a patient with a pneumococcal pneumonia be placed next to one with a streptococcus pneumonia either one or both patients might readily contract a double infection. The course of the disease in such double infections is much more serious and the mortality much higher than in single infections. Cross infections will, therefore, be less common and the mortality reduced by cubicle isolation for all respiratory infections. The practice of receiving respiratory infections of unknown origin in wards with other medical or surgical cases is reprehensible and is responsible for many fatal cases of pneumonia in individuals who might otherwise have been returned to duty within a short time. Cubicle isolation may most readily be carried out by screening with sheets. This can be done by posts and the use of wire and can be adapted for tents as well as for wards. It is only necessary that the screen should reach midway between the foot and head of the bed, halfway between the bed and the floor, and 2½ to 3 feet above the level of the patient. It is, however, highly important that the screen should extend several inches beyond the head of the bed.



    984

    5. Protection of medical officers, nurses, and personnel with gowns and fresh and clean gauze masks is important, both to prevent spread of infection among them and to prevent their transmitting infection to others. Attendants should be examined with the view to finding carriers: When found, these should be disinfected. Masking of all individuals who come in contact with cases of respiratory infection and fever, except in case of extreme urgency, and then only with precautions to prevent the transmission of the disease to others. Patients should be masked while being moved.

    6. Special attention must be paid to all cases of respiratory infection, with fever with relation to the development of signs of pneumonia. It is often impossible at the outset to distinguish between cases of influenza, without consolidation, and actual pneumonia. All cases, with fever and with symptoms referable to the respiratory tract, must be viewed with suspicion and hospitalized, and the physical signs must be carefully watched.

    7. Bacteriological examination in order to determine the infecting organism is important, not only from the standpoint of specific therapy, but also to facilitate the management of cases of different etiology. It must be remembered that pneumonia is really a group of diseases, with certain common signs and symptoms. The promiscuous mingling of cases of pneumonia, without determination of the infecting organism, is as harmful as the mingling of measles, scarlet fever, and smallpox.

    8. Specific therapy, when possible, is advisable. This will at present be limited to cases of pneumonia due to pneumococcus, type 1. The indiscriminate use of serum, without proper type determination, is ill-advised, not only on account of the fact that it subjects the patient to unnecessary inconvenience, discomfort, and possibly danger, but on account of the fact that serum is scarce, and must be saved for the cases in which it is actually indicated. The polyvalent serum may be used in type 1 cases, as its titer for the type 1 organism is as high as that of the monovalent type 1 serum. The use of polyvalent serum in cases other than those due to pneumococcus, type 1, is not advised.

    9. General treatment should be directed toward sustaining the patient and guarding against collapse. Under no circumstances should a patient with pneumonia, or suspected of having pneumonia, be allowed to walk, and after he is put to bed he should not be permitted to sit up for any reason whatsoever. He must be kept warm, but must be assured a continuous supply of fresh air. Fluids should be given freely from the start, and the patient should be induced to take them frequently and in considerable amounts. Sponge baths should be used to combat high temperatures.

    10. Early cyanosis and collapse are characteristic of the present form of pneumonia. Treatment aimed to prevent and to combat circulatory failure should be instituted promptly on making the diagnosis of pneumonia. The early use of digitalis has been shown to reduce mortality, and is advised. It may be given in the form of a standard tincture, of which a total amount of 30 c. c. (1 fluid ounce) should usually be given. The following schedule may be followed.

    If seen on the first or second day:
     

    Day of digitalis therapy

    1

    2

    3

    4

    5

    6

    7

    8

    9

    Total amount of standard tincture to be given in divided doses on the days indicated

    5

    5

    0

    5

    5

    0

    0

    5

    5

    Minims

    lxxv

    lxxv

    ---

    lxxv

    lxxv

    ---

    ---

    lxxv

    lxxv

    If seen on the third day, or later:
     

    Day of digitalis therapy

    1

    2

    3

    4

    5

    6

    7

    Total amount of standard tincture to be given in divided doses (c.c.)

    10

    10

    0

    5

    0

    0

    5

    Minims

    cl

    cl

    ---

    lxxv

    ---

    ---

    lxxv

    The hospitals should supply themselves with a standard tincture of digitalis. Do not use pills which are insoluble. Other stimulants, notably citrated caffeine and camphorated oil, may be used by hypodermic injection when collapse occurs or is imminent. The use of strychine has not been shown to be of value.



    985

    11. Morphine is of great value to control severe coughing, to relieve the pain of pleuritis, and to secure rest for the patient. It should be used without hesitation. For the troublesome tympanites that frequently occur, turpentine stupes, given while a small catheter is inserted in the rectum, are of value.

    12. Most careful attention must be paid to the physical signs, particularly with relation to spread of the consolidation and to fluid in the chest. When the physical signs suggest fluid exploratory puncture, the microscopic and bacteriological examination of the fluid obtained should be performed promptly. Exploratory respiration is a simple procedure, with little danger or discomfort to the patient. Local anesthesia may be induced by freezing or by intracutaneous and subcutaneous injection of cocaine or novocaine. When clear or even slight turbid fluid is obtained, even when the infecting organisms are demonstrated in the fluid, treatment by repeated aspiration with the Potain aspirator is followed by the best results. When purulent fluid is found, or in cases where fluid previously clear becomes purulent, operation is advised, with postoperative measures necessary to insure free drainage.

    13. Convalescence must be managed with care, both as to the condition of the patient and as to his transmitting the disease to others. Development of pleural exudate late in the disease, or during convalescence, is not uncommon, and frequent physical examination must not be neglected. Relapse or spread may also occur after the temperature has been normal for several days, and the patient should not be permitted to sit up or move about until 7 to 10 days have elapsed. During this period isolation should be practiced as during the acute stage of the disease. The use of mildly antiseptic solutions in the mouth and nasal passages is of value in reducing the number of carriers. Patients should not be allowed to mingle with other patients, and should not be evacuated until all signs of infection of the respiratory tract have disappeared.

    14. Recovery and return to duty will be slow. The final stages of recovery will best be provided for in convalescent camps. No patient who has had pneumonia should be evacuated to a convalescent camp until his temperature has been normal for at least two weeks, and in cases where the infection has been severe or prolonged this period will be materially increased. The patient should be free from cough and other physical signs should be normal.

       WALTER D. MCCAW,
    Colonel, Medical Corps, Chief Surgeon.



    Circular No. 52.

    AMERICAN EXPEDITIONARY FORCES,
    October 22, 1918.

    I. Recommendations for appointments.-The following paragraphs of a letter, adjutant general's office, is quoted:

    1. With reference to the cases of * * * and * * * action has been taken to withdraw the recommendation contained in courier letters from these headquarters to The Adjutant General of the Army, that these men be appointed as officers in the United States Army.

    2. Chiefs of staff departments and other services are expected to take the necessary steps to insure that only persons fully qualified are recommended by them for appointment, and it is desired that greater care be exercised in the future that recommendations from the office of the chief surgeon conform to the above requirements.

    II. X-ray therapy.-The following hospitals are designated as being the only ones qualified, at present, to administer X-ray therapy: Base Hospitals Nos. 15, 28, 32, 20, 18, 9, 6, American Red Cross Military Hospital No. 1.

    When it becomes necessary to administer X-ray therapy, either because it is immediately indicated or in the event that a patient requiring it need not be evacuated to the United States, and he is in some other hospital, he will be transferred to one of the above-designated hospitals.

    III. Base Hospital No. 8.-Hospital trains and detachments of patients hitherto ordered to Base Hospital No. 8 will hereafter be directed to report to the commanding officer hospital center, Savenay.

    IV. List of B and C class personnel.-The commanding officer of each Medical Department unit will forward to this office, with the least practicable delay, a nominal list, showing all B and C class personnel, with branch of service, now on duty with his unit, with statement of the number returned to duty reclassified as class A.



    986

    Attention is invited to the fact that paragraph 5, section 1, General Order No. 41, c. s., requires reexamination of all class B officers and soldiers at least every two months. This order is apparently not being complied with.

    V. Soldiers qualified as opticians.-The commanding officer of each Medical Department unit will report by mail to this office, with the least practicable delay, the names of all Medical Department soldiers belonging to his command who are qualified as opticians.

    VI. Telegrams to be numbered serially.-The adjutant general informs this office that telegrams are frequently received from base hospitals, especially at hospital centers, in which the particular unit sending the telegram can not be identified. In order to avoid this, each base hospital should number its telegrams serially and state immediately after the serial number the numerical designation, as, for example, the first telegram of Base Hospital No. 25 under this system, would begin "1 BH 25 Allerey."

    This would not be necessary, however, where the commanding officer of a hospital center preferred to send all telegrams through his office and signed with his name. Only one serial list for the center would be kept in such case, and the telegrams would begin, "1 HC Allerey."

    VII. Nurses' names.-Commanding officers of all medical units to which nurses are attached will, if they have not already furnished this information, forward to this office the name in full of all nurses of the Regular Army Corps, and the places from which they were assigned, as given in original letters of appointment. Special attention will be given to the correct spelling of the names of nurses and places.

    VIII. Change of station of nurses.-When making a change of station, either for temporary or permanent duty, the letter of appointment of the nurse, with the required information as to pay, etc., indorsed thereon, should be carried by her and delivered to the commanding officer or chief nurse at her new station. Failure to carry out this procedure in the past has caused difficulties in the matter of the pay of the nurse.

    In order to avoid delay in the receipt of baggage, nurses who are traveling under orders should be instructed to give it their personal attention when changing trains.

    IX. Amendment to Circular No. 45.-Paragraph 8, Section I, Circular 45, office of chief surgeon, c. s., is amended to read:

    Medical officers, who are compelled to administer antitetanus serum by reason of the failure of medical officers through whom the patient has passed to administer the same, will make immediate report of said failure, with sufficient data to establish the circumstances of the omission, directly to the surgeon of the division from which the case came, or in case the patient belongs to a higher or separate organization to the senior medical officer of that organization.

    X. Requisitions for medical supplies.-All organizations in base section No. 1, other than base hospitals and hospital center depots, will submit their requisitions for medical supplies to the surgeon, base section No. 1, A. P. O. No. 701, and will hereafter submit none direct to intermediate medical supply depot No. 3, Cosne.

    Upon the approval of the section surgeon, the requisitions will be sent to the medical supply depot, base section No. 1, for issue.

    XI. Address of American statistical section.-The address of the American statistical section, to which reports of French military patients hospitalized in American military hospitals in the French zone of the armies are sent, has been changed from No. 10 Rue Saint Anne, Paris, to No. 7 Rue Tilsitt, Paris. Hereafter all American Expeditionary Forces hospitals in the French zone of the armies will send reports to the latter address.

    XII. Identification tags.-The removal of identification tags from the persons of patients during the process of evacuating them from the front, especially from groups of patients who have been bathed as an antigas measure or as a routine to admission to hospital, has caused the erroneous return of soldiers' identification tags to others. In one recent instance a soldier's tags were erroneously placed on another who subsequently died and was buried and reported as dead under the name of the former. This one mistake gave rise to much needless grief and administrative difficulties.

    The removal of identification tags as a routine while bathing patients either, as an antigas measure or on admission to hospitals, is prohibited. When for any reason, other than the above, it becomes necessary to remove a soldier's identification tags the utmost care will be exercised in preventing the possibility of their being placed on another.



    987

    XIII. Base Hospital No. 66.-Base Hospital No. 66 is hereby detached from hospital center, Bazoilles, and will operate as a base hospital directly under the chief surgeon, A. E. F.

       WALTER D. MCCAW,
      Colonel, Medical Corps, Chief Surgeon.



    Circular No. 53:

      AMERICAN EXPEDITIONARY FORCES,
       October 29, 1918.

    I. The following extract from assistant chief of staff, G-4, is published for information of all concerned:

    1. A serious situation has arisen with regard to the telegraph and telephone systems of the American Expeditionary Forces, and attention is directed to the necessity of exercising the most rigid economy in their use, particularly the long-distance telephone service. During the past three months, the use of the long-distance telephone service has increased 70 per cent, and during the same period it has been possible, through the most strenuous efforts, to increase the telephone and telegraph services only 25 per cent. Until recently, there has been a margin of safety in the facilities, but this has now been entirely absorbed by the tremendous increase in the number of telegrams and long-distance telephone calls. If this increase continues, a very serious congestion will soon result.

    2. It is not desired to issue any hard and fast rules to restrict the use of the long-distance telephone and telegraph. It is believed, however, that a reading of paragraph 1 above explains fully the present situation, and the necessity of some action to reduce the number of long-distance telephone calls and telegrams sent. It is desired that this reduction be made by the chiefs of the services, themselves.

    3. The following means of communication are now available, and are arranged in the order in which they should be used:

    (a) Mail.
    (b) Courier and messenger service.
    (c) Telegraph.
    (d) Long-distance telephone service.

    4. It is desired that each chief of a service prepare and put into operation at once a system which will reduce the number of long-distance telephone calls and telegrams in use by his service. It is desired that a memorandum be sent to this office (G-4), giving an outline of the system devised and the means adopted for its execution.

    It is desired that every effort be made to use the mail, courier, and messenger service wherever possible among the Medical Department units, and it is thought that, except in immediate emergency, any message which can be delivered within 24 hours should be sent by this service rather than by telegraph or telephone. There will be certain exceptions to this rule, such as the weekly report on Form 211, which must be consolidated in one office and then forwarded on to another office for consolidation, thereby consuming three days for delivery to this office instead of one. In cases such as this the telegraph will be used.

    II. Daily and weekly telegraphic bed report.-With regard to daily telegraphic bed report from base hospitals and the weekly telegraphic bed report from camp hospitals, constancy with reference to personnel should now be eliminated. This refers to item E. Hereafter item E will be designated to indicate the total number of beds which can be utilized in the event of emergency, consideration being given to bed space in tentage, halls, and corridors of the hospitals.

    III. Unloading of freight cars.-The French railways are taxed to their utmost to meet the demands made upon them. Facility of transport is vital to the American Expeditionary Forces. Reports have been made that cars containing medical supplies have been delayed at destination pending unloading.

    It is desired that all Medical Department organizations having to do with such supplies take the necessary steps to prevent the least delay in the unloading and release of cars. Orders require that this be done within 24 hours.

    IV. Commissions in the Sanitary Corps.-With reference to Bulletin No. 30, c. s., these headquarters, the attention of all medical officers is invited to the fact that the Medical Department, within the next few months, will have urgent need of large numbers of well-qualified soldiers at present in the Medical Department who may be suitable for commission in the Sanitary Corps. It is desired that, before recommending a soldier for commission in another department, the commanding officer of a Medical Department unit satisfy himself that the soldier recommended is better fitted for commission in some other branch of the service than in the Sanitary Corps.



    988

    V. Nurses.-With reference to paragraph 7, Circular 48, the policy outlined therein has been changed and following adopted:

    "Nurses marrying in France will be sent to base section No. 3 for duty, and no leave to visit France will be allowed after they shall have reported in England."

    VI. Vocational education.-There is some misunderstanding among disabled soldiers affecting the matters of vocational education. It is important that erroneous ideas be corrected, and medical officers are urged to set the men straight. The terms of the following letter should be understood and communicated to disabled soldiers by medical officers and the facts in the letter should be placed on the bulletin board in each hospital.

    Subject: The vocational rehabilitation act (Smith-Sears Act) to provide vocational education for disabled persons discharged from the military or naval forces.

    Question 1. What is the vocational rehabilitation act?

    Answer. It is an act of Congress appropriating the funds and providing the means for giving every disabled person discharged from the military or naval forces a vocational education free.

    Question 2. Who is entitled to a vocational education under the provision of this act?

    Answer. Every war-disabled person whose physical disability entitles him to any compensation under the regulations of the Bureau of War Risk Insurance.

    Question 3. Will the person who elects to secure vocational training under the provision of this act receive a monthly compensation during the period of time he is pursuing his vocational training?

    Answer. Yes. He will receive a monthly compensation equal to the amount of his monthly pay for the last month of his active service, or the amount of his monthly compensation allowed by the Bureau of War Risk Insurance, whichever amount is the greater. His family will receive the family allowance in the same manner as if he were an enlisted man.

    Question 4. Will the fact that he has secured a vocational education, and thereby increased his earning power, in any way change the amount of compensation he should receive from the Bureau of War Risk Insurance?

    Answer. No. The compensation he will receive from the Bureau of War Risk Insurance is calculated on the basis of his physical disability and not on the basis of his economic efficiency. A vocational education will not lower his compensation from the war risk insurance.

    Question 5. Under whose supervision and administration will the vocational training be given?

    Answer. The Federal Board for Vocational Education, of Washington.

    Question 6. What types of vocational education will the Federal Board for Vocational Education provide for these men?

    Answer. Training for every vocation will be provided. Any vocation in the fields of industrial, commercial, agricultural, technical, and professional education is open for him. His past vocational experience, his physical disabilities, his own desires and aptitudes will determine the vocation he elects, in which to take his training. He will be given scientific information concerning the economic advantages of the different vocations by technical experts.

    Question 7. Where will the training be given?

    Answer. In the vocational and technical schools, colleges, and universities of the United States. All courses will be under the supervision of the Federal Board for Vocational Education.

      (Signed) EDWIN L. HOLTON,
      Special agent, Federal Board for Vocational Education.

    VII. Change in paragraph II, Circular No. 52, office of chief surgeon.

    The list of hospitals designated in Paragraph II, Circular 52, office of chief surgeon, October 22, 1916, as being the only ones qualified, at present, to administer X-ray therapy, has been changed as follows: Base hospitals Nos. 6, 7, 9, 15, 20, 28, 30, 32, 38, 115, 116, Mars hospital center, American Red Cross Military Hospital No. 1.

      WALTER D. MCCAW,
       Colonel, Medical Corps, Chief Surgeon.



    Circular No. 54.

      AMERICAN EXPEDITIONARY FORCES,
       November 9, 1918.

    I. Data necessary for promotion.-Attention is called to the requirement of General Order 162, A. E. F., 1918, that a statement of the current physical condition of an officer shall be made as an accompaniment to any request or recommendation for promotion. This is mandatory, and if the certification is not made it must involve annoying delay to everyone concerned.


    989

    Papers covering promotions must be acted on by superior local medical authority prior to submission to this office.

    Recommendations for promotion of officers of the Sanitary Corps will be made on the blank for character of service and qualifications, as in the case of medical, dental, and veterinary officers. The only citation which requires omission in this blank is the fourth, which specified the medical school from which graduated. However, should the officer be a graduate of a high school, college, or university, the citation may be made under this paragraph.

    II. Travel orders.-Complaint has been made that hospitals evacuating patients to other hospitals have failed to furnish attendants accompanying them with sufficient copies of travel orders to get commutation of rations and return transportation. In order to avoid unnecessary duplication of work at the hospital where these patients are received, hospitals will furnish attendants the necessary copies of orders for commutation and return transportation.

    III. Claims for damages to French property.-Claims made for damages to French property have been erroneously paid out of hospital fund. Such payments are not to be made in the future, either out of hospital fund or out of Medical Department appropriations.

    In this connection, attention is invited to section 4, paragraph E, General Orders, No. 50, general headquarters, A. E. F., dated March 30, 1918, which establishes a renting, requisition, and claims service for the American Expeditionary Forces and outlines procedure for handling damage claims; and attention is also invited to section 4, General Orders, No. 78, general headquarters, A. E. F., dated May 25, 1918, which quotes an act of Congress appropriating specific sums for the payment of such damages.

    IV. Middle initial or number to be given in reports.-Attention is invited to the following letter from the chief paymaster, United States Marines. Care will be taken to follow the instructions as requested in this letter:

    1. Numerous cases have arisen in which we are unable to distinguish certain men on account of no middle initial being given in your reports to this office of men returning to the United States on account of disability.

    2. It is requested that whenever possible the middle initial be given, or in the absence of such information that the man's number be given. Whenever it is impossible to give either the number or the initial, it is requested that the company organization be designated instead of regimental organization.

    V. Property of French soldiers.-The chief of the French mission states that the provisions of Circular 31, office chief surgeon, May 23, 1918, regarding the personal property of French soldiers who die in American hospitals, are not being carried out. The attention of all Medical Department organizations is called to this circular, and the directions contained therein will be carefully and strictly followed in the future.

    VI. Religion of patient to be entered on field medical card.-Attention is invited to paragraph 8, Circular 41, office chief surgeon, July 22, 1918, which provides that, as soon as practicable, the religion of every patient admitted to a hospital ward will be ascertained by the ward medical officer and appropriate entry thereon made on the patient's field medical card. These instructions will be carefully followed, as it has been reported that this is very often neglected.

    VII. Reporting of French military patients.-The attention of all commanding officers of American hospitals in the zone of the interior is again directed to instructions governing the reporting of French military patients to the Franco-American section of the region and not to the American statistical section, No. 7 Rue Tilsitt, Paris.

    VIII. Nurses and civilians.-In many cases the number of nurses and civilians assigned to duty have not been entered on weekly strength return of hospitals. In future, care will be exercised to have these returns complete in every respect.

    IX. Nurses' uniform.-The uniform of all nurses, including the cap, must conform in all respects to that of the Army Nurse Corps. The use of  the Red Cross cap will be discontinued by the reserve nurses of the Army Nurse Corps.

    X. Sick leave for nurses, Army Nurse Corps.-Bulletin 43, War Department, July 22, 1918, states that nurses shall be entitled to sick leave with pay not exceeding 30 days in any one calendar year in cases of illness or injury incurred in the line of duty. Nurses while so absent are entitled to commutation of rations at rate fixed by Army Regulations. When



    990

    sent to convalescent homes or hotels provided by the American Red Cross, nurses will be charged for subsistence at the same rate as will be paid to them by the Government as commutation of rations.

    XI. Original papers on the surgery of the war.-The editor of The Military Surgeon is anxious to secure original papers on the surgery of the war, especially reports on regional surgeries. Medical officers of the American Expeditionary Forces are requested, when forwarding papers to this office for publication in the United States, to state if they wish them to be published in The Military Surgeon. This will also apply to professional papers other than surgical.

    XII. Requisitions for medical supplies.-All organizations in base section No. 2, other than base hospitals and hospital center depots, will submit their requisitions for medical supplies to the surgeon, base section No. 2, A. P. O. No. 705, and will hereafter submit none direct to intermediate medical supply depot No. 3, Cosne.

    Upon the approval of the section surgeon, the requisitions will be sent to the medical supply depot, base section No. 2, for issue.

    XIII. Applications for transfer.-In order that applications for transfer from one branch of the service to another, forwarded by officers and soldiers while sick in hospital, may be acted upon intelligently, the following information will be indorsed upon all such applications forwarded to higher authority for action:

    (a) Whether the applicant is a patient; and if so,

    (b) The nature of his disability, whether wounds or sickness, with a brief description thereof.

    (c) Probable date when applicant will be returned to duty.

    (d) The class in which he will probably be discharged from the hospital.

    XIV. Alphabetical list of officers on duty in the office of the chief surgeon showing rank, department, and telephone number:
     

    Officer

    Rank

    Department

    Telephone No.

    Officer

    Rank

    Department

    Telephone No.

    McCaw, Walter D.

    Colonel

    Chief surgeon

    549

    Brown, John D.

    First lieutenant

    Dental

    256

    Glennan, James D.

    Brigadier general

    Hospital

    51-1

    Calder, J. W. 

    .do.

    Transportation

    50-2

    Winter, Francis A.

    Colonel

    Assistant chief surgeon

    57

    Douglas, Malcolm C.

    .do.

    .do.

    50-2

    Fife, James D.

    .do.

    Hospital

    55-1

    Evans, John E.

    .do.

    Hospital

    51-2

    Fisher, Henry C.

    .do.

    Inspection

    57

    Emerson, Bertrand, jr.

    .do.

    Supply

    257-2

    Oliver, Robert T.

    .do.

    Dental

    50-1

    Fenton, William J.

    .do.

    Det.

    448-2

    Shaw, Henry A.

    .do.

    Sanitation

    57-1

    Foster, Elliott O.

    .do.

    Finance and accounting

    538-1

    Whitcomb, Clement C.

    .do.

    Supply

    261-2

    Goodyear, Russell W.

    .do.

    .do.

    538-1

    Aitken, John J.

    Lieutenant colonel

    Veterinary

    252-1

    Hanford, Harry C.

    .do.

    Hospital

    51-2

    Clarke, Howard

    .do.

    Transportation

    256-1

    Mael, Jesse H.

    .do.

    Personnel

    253-1

    Culler, Robert M.

    .do.

    .do.

    256-1

    Mannix, Daniel E.

    .do.

    .do.

    246-2

    Harmon, Daniel W.

    .do.

    Sick and wounded.

    524-1

    Mims, Martin D.

    .do.

    Hospital

    51-2

    Johnson, Thomas H.

    .do.

    Hospital

    468-1

    Mueller, Frederick W.

    .do.

    .do.

    55-1

    McDiarmid, Norman L.

    .do.

    Supply

    257-1

    Murray, Joseph E.

    .do.

    Transportation

    256-2

    Shepard, John L.

    .do.

    Hospital

    569-1

    Ross, Frank A.

    .do.

    Sick and wounded

    524-1

    Thearle, William H.

    .do.

    Personnel

    253-1

    Yohe, Edward L.

    .do.

    Dental

    256

    Welles, Edward M., jr.

    .do.

    .do.

    253-1

    Russell, George E.

    .do.

    Hospital

    51-2

    White, David S.

    .do.

    Veterinary

    252-1

    Rich, Harold 

    .do.

    .do.

    51-2

    Weed, Frank W.

    .do.

    Hospital

    569-1

    de Grange, Garrett S., jr.

    .do.

    .do.

    51-2

    Bemis, Harold E.

    Major

    Veterinary

    252-1

    Skelly, Patrick J.

    .do.

    Sick and wounded

    524-1

    Dickson, Robert A.

    .do.

    Administration

    255

    Engel, William E.

    .do.

    Records

    59-1

    Emerson, Haven

    .do.

    Sanitation

    59-2

    Bibby, Henry L.

    Captain

    Prom

    448-1

    Fielden, John S.C., jr.

    .do.

    Supply

    257-2

    Delafield, Robert H.

    Second lieutenant

    Sick and wounded

    524-1

    Rice, William S.

    .do.

    Dental

    50-1

    Duffield, Thomas J.

    .do.

    Sanitation

    59-2

    Williams, Linsly R.

    .do.

    Sanitation

    59-2

    Powell, George E.

    .do.

    Veterinary

    533

    Thompson, Richard K.

    Captain

    Dental

    50-1

    McComb, Robert P.

    .do.

    .do.

    533

    Whitcomb, Walter D.

    .do.

    Finance and accounting.

    538

    Proctor, Arthur W.

    .do.

    Supply

    261-2

    Barney, James E.

    First lieutenant.

    Transportation

    50-2

    Scott, Ernest E.

    .do.

    Hospital

    269-1

    Berry, Eugene J.

    .do.

    Finance and accounting

    538

    Benett, Lowell

    Second lieutenant

    Reference library

    ---

    Bolton, Ray

    .do.

    Veterinary

    533

    Bissonette, Geo. A.

    .do.

    Transportation

    50-2

     

    Nelson, Arthur E.

    .do.

    Sick and wounded

    524-1

    WALTER D. MCCAW,
      Colonel, Medical Corps, Chief Surgeon.



    991

    Circular No. 55:
      AMERICAN EXPEDITIONARY FORCES,
      December 12, 1918.
     
     DISTRIBUTION OF MEDICAL SUPPLIES IN THE AMERICAN EXPEDITIONARY FORCES OUTLINING LINES OF SUPPLY AND DECENTRALIZATION OF BOTH REQUISITIONS AND SUPPLIES

    I. The following outline of medical supply department activities from front to rear will obtain in the future operations of this department.

    (a) Divisional medical supply dumps.-On a basis of one to each division.

    Activities: To supply divisional troops and to stock only such items as are needed by combat divisions. Items of stock carried to be identical in all divisional supply dumps the amount of each item to be carried and controlled by a maximum stock list.

    (b) Army park medical supply dumps.-On a basis of one to each army corps.

    Activities: To supply divisional medical supply dumps and in emergency to surrounding medical units. Stock items to be the same as those carried by divisional medical supply dumps. The amount of stock to be carried on items to be based on the number of combat divisions concerned in the sector supplied.

    (c) Army medical supply depots.-On a basis of one to each Army.

    Activities: To supply army park medical supply dumps, evacuation hospitals, field hospitals, ambulance companies, mobile hospitals, mobile surgical units, veterinary field units, and such other units as specially designated. Stock items to be carried should meet all the requirements of the units concerned and should also be based on a maximum stock list.

    (d) Services of Supply medical supply depots.-Number prescribed by the chief surgeon, A. E. F.

    Activities: To supply army medical supply depots and designated Services of Supply medical units. The stock in these Services of Supply depots in advance positions to fully cover all the items carried at army medical supply depots, as well as the surrounding Services of Supply medical units.

    (e) Controlled stores.-Includes all medical supplies in storage at base ports or other designated Services of Supply depots, the issues from which are under the direct control of the chief surgeon, A. E. F.

    Activities: To furnish supplies to all depots and initial equipment to new units being installed.

    (f) Medical supply depots at hospital centers.-Number prescribed by the chief surgeon A. E. F.

    Activities: To furnish supplies to the hospitals of the group concerned to any other units specially designated by the chief surgeon, A. E. F. Hospital centers not having depots should consolidate requisitions and forward same direct to the chief surgeon, A. E. F., A. P. O. 717.

    Depot control.-While the chief surgeon, A. E. F., controls all activities of the Medical Department, the immediate control of the army dumps and army medical supply depots is vested in the chief surgeon of the army concerned. The immediate control of all other medical supply depots being under the chief surgeon, A. E. F.

    II. Decentralization of requisitions.-Hereafter all requisitions, except those specially exempted below originating in the Services of Supply will be acted upon by the chief surgeon of the section concerned, who will modify the requisition and forward same to designated depot for issue.

    This modification will be final and any question thereto should be taken up by the depot concerned with the surgeon of the section approving the requisition.

    Exceptions.-Requisitions from medical supply depots and medical supply depots at hospital centers and for initial equipment of medical units will be sent direct to the office of the chief surgeon, A. E. F., A. P. O. 717, for his action.

    Requisitions for laboratory supplies, except from medical supply depots, will be sent direct to the director, central laboratory, A. P. O. 721, Dijon, for his action; same will then be forwarded to the designated depot.



    992

    Requisitions for X-ray supplies covering initial equipment-i. e., base hospital X-ray outfits, portable X-ray outfits and bedside units-will be forwarded to technical consultant, Roentgenology, A. P. O. 702.

    X-ray supplies such as plates, chemicals, etc., will be included in requisitions for medical supplies and referred to the section surgeon, but they must appear under separate heading, X-ray supplies.

    Requisitions for veterinary supplies follow the course of medical requisitions except for initial equipment of units, which will be forwarded to the chief surgeon, A. E. F., direct.

    Requisitions for dental supplies follow the course of medical requisitions except for initial equipment of base hospitals; i. e., base dental outfits, which will be sent direct to chief surgeon, A. E. F.

    III. Pending the installation of additional depots, the following sections will be supplied by medical supply depots as follows:

    Base section 1, 4, 5, by base medical supply depot No. 1, St. Nazaire.

    Base sections 2, 6, 7, by base medical supply depot No. 2, Bordeaux.

    Intermediate section and Paris district by intermediate medical supply depot No. 3, Cosne.

    Advance section, Services of Supply, by advance medical supply depot No. 1, Is-sur-Tille.

    Surgeons of sections will take the necessary steps to notify the unit now in their sections and new units arriving as to the proper channels for medical supply requisitions as above outlined.

    IV. This circular does not modify the method of handling requisitions in combat sectors.

      WALTER D. MCCAW,
       Colonel, Medical Corps, Chief Surgeon.



    Circular No. 56.

    AMERICAN EXPEDITIONARY FORCES,
      November 19, 1918.

    I. Made-up surgical dressings.-Because of the immense amount of devoted labor given by the women of America, through the American Red Cross, there is now available in France a sufficient supply of made-up surgical dressings to warrant the issue to and use in all hospitals of these prepared dressings.

    It is desired therefore that requisitions be submitted for these dressings and that requisitions for gauze, plain, be consequently reduced. These dressings are of two classes:

    First, already sterilized.-The supply of this type is limited, and issue will be made to field and evacuation hospitals, and they should be used only in times of stress or where opportunities for sterilization are inadequate. Requisitions for these dressings should call for "Dressings for evacuation hospital use, sterilized."

    In ordinary times dressings of the following type should be used:

    Second, prepared and wrapped ready for sterilization but not sterile.-These supplies are stocked in all medical supply depots and dumps and in Red Cross storehouses. They should ordinarily be obtained from the medical supply depot by original requisitions. Case lots should be asked for. For the initial stock, requisition should be submitted to this office. The attached list approximates 10 carloads, and requisition may be submitted in the form of a request for 10 carloads, or a specified portion thereof. (In this case the shipment will be prorated.) Subsequent requisitions should call for case lots of dressings needed:



    993-994
     

    10-carload lot of assorted surgical dressings

    [To be used as basis for requisitions by medical supply depots, A. E. F.] 

     

    Number of cases

    Dressings

    Dressings used as:

     

     

    Sponges-

     

     

    Gauze wipes-

     

     

    2 by 2

    10

    200,000

    4 by 4

    23

    207,000

    Gauze finger sponges

    8

    128,000

    Gauze squares, 9 by 9

    2

    72,000

    Folded gauze strips

    10

    45,000

     

     

    652,000

    Compresses-

     

     

    Sterile dressing pads, 8 by 4

    20

    120,000

    Gauze compresses-

     

     

    4 by 4

    20

    127,000

    9 by 9

    20

    66,000

     

     

    313,000

    Packing and padding-

     

     

    Gauze rolls, 5 yards by 4½

    12

    4,200

    Gauze rolls, 3 yards by 4½

    20

    25,000

    Laparatomy pads-

     

     

    12 by 12

    2

    1,300

    6 by 6

    1

    1,000

    4 by 16

    2

    1,400

     

     

    32,900

    Absorbent-

     

     

    U. D. pads, type 1-

     

     

    Cotton, 8 by 12

    40

    22,000

    Oakum, 8 by 12

    12

    4,680

    U. D. pads, type 1-

     

     

    Cotton, 14 by 20

    40

    8,000

    Oakum, 14 by 20

    15

    2,250

    U. D. pads type 1, cotton, 12 by 24

    80

    14,400

    Split irrigating pads, 21 by 16

    10

    1,000

     

     

    52,330

    Bed pads-

     

     

    U. D. pads, type 2-

     

     

    11½ by 18

    40

    10,800

    18 by 23

    60

    6,000

     

     

    16,800

    Drains-Gauze packing, 2 by 1 yard, ½ by 1 yard

    5

    10,000

    Body bandages:

     

     

    Abdomen-

     

     

    Many-tailed bandages, 48 by 12

    6

    4,800

    Abdominal bandages-

     

     

    Muslin, 48 by 18

    8

    4,000

    Flannel, 52 by 12

    4

    1,000

    Scultetus, flannel

    10

    4,000

     

     

    13,800

    Perineal, T bandages, 53 by 7

    5

    3,500

    Head and chin, four-tailed bandages, 36 by 8

    3

    3,000

    Arm and various slings

    25

    12,500

    Eyes-

     

     

    Double-eye bandages

    4

    2,000

    Single-eye bandages

    2

    1,000

     

     

    3,000

    Pneumonia jackets

    14

    1,400

    Accessories used with splints:

     

     

    Supports-

     

     

    Support slings-

     

     

    No. 1, 8 by 21

    2

    3,200

    No. 2, 5½ by 16

    2

    5,000

    No. 3, 7 by 23

    1

    1,400

    Rubber cloth support slings (wooden ends), 8 by 24

    ½

    250

    Canvas support slings (wooden ends), 8 by 24

    ½

    250

    Canvas swathes, 18 by 22

    ½

    100

    Straps and buckles-

     

     

    1½ by 4 yards

    1

    4,000

    1½ by 2 yards

    1

    2,400

    Heel rings

    1

    630

     

     

    17,230

    For traction-

     

     

    Anklets

    ---

    500

    Elbow traction bands

    1

    1,000

    Traction bands, flannel, 10 by 5, 16 by 7, 23 by 7

    3

    5,000

    Adhesive plaster

    10

    500

    Shot bagsa

    1

    22,000

    Canvas weight bags

    1

    1,820

     

     

    28,820

    Accessories used with plaster:

     

     

    Sheet wading, 5-inch

    30

    4,500

    Crinoline-

     

     

    5-inch

    10

    10,000

    Bolts

    2

    ---

    Felt, 100 yards

    1

    ---

    Canvas hammocks, 20 by 42

    1

    290

     

     

    14,890

    Bandages:

     

     

    Gauze bandages, 3 inches by 5 yards

    15

    37,500

    Muslin bandages, bias-

     

     

    3-inch

    2

    1,200

    4-inch

    2

    1,200

    5-inch

    1

    600

    6-inch

    4

    3,200

    Muslin bandages, straights-

     

     

    5 by 5

    8

    8,000

    4 by 5

    6

    4,800

    5 by 5

    1

    600

    Flannel bandages, straights-

     

     

    3 by 5

    3

    3,000

    4 by 5

    2

    1,600

    Jackinette, 500 yards

    1

    61,700

    aIn stock, but not being replaced.

    II. Reconstruction aides.-Reconstruction aides are civil employees under contract with the Surgeon General. They are subject to the orders of the commanding officer of the units to which assigned and will be under the direct charge of the chief nurse. They are entitled to such pay and emoluments as are set forth in contracts.

    Their especial function is to carry out the instructions of the medical staff in the rehabilitation of wounded in methods of physical and occupational therapy.

    When assigned to duty at hospitals they are subject to the same regulations which govern nurses, and when their services are not required in their special work they may be temporarily assigned to duty as nurses' aides.

    The necessary reports will be made by the chief nurse and forwarded through regular channels.

    III. Expendable property.-The following articles of medical property will be considered expendable property: Crutches, canes, and splints of all kinds.

    To expedite the evacuation of patients, commanding officers of hospitals and hospital trains are authorized to exchange bath robes (convalescents' gowns), blankets, liters, pajama coats, and pajama trousers on a numerical basis except where it is found to be more practicable to transfer the property by exchange of invoices and receipts.

    WALTER D. MCCAW,
      Colonel, Medical Corps, Chief Surgeon.


    Circular No. 57.
      AMERICAN EXPEDITIONARY FORCES,
       November 20, 1918.

    I. Duties of professional consultants.-(1) The duties of the professional consultants will be to supervise the clinical work of the American Expeditionary Forces. They will be assigned to hospital centers, districts, armies, army corps, and divisions, as the necessity demands, on recommendation of the chief consultant of their respective services, by the proper military authority.



    995

    (2) In order that the individual consultant may perform his duties effectively, he will make frequent visits to the hospitals or other medical organizations in his territory, as may be required. He shall spend so much time in each hospital as in his judgment may be necessary in order to acquaint himself thoroughly with the character and quality of the work done therein.

    (3) It is the duty of the consultant to supervise the professional work, as to his department, of the organization or organizations to which he is assigned. He will give advice, instruction, and actual demonstrations as to the best and most efficacious methods of treatment in order that the work of his department may conform to the recognized and accepted standards of the best civil and military practice.

    He will make recommendations to the commanding officer as to the ability and professional fitness of individual medical officers of his department. The commanding officer will take the necessary steps to carry the recommendations of the consultant into effect. A copy of the recommendations of the consultant will be forwarded to the senior consultant for his information. In case of difference of opinion between the commanding officer and the consultant, the decision rests with the commanding officer on whom, in all military organizations, the ultimate responsibility rests. This does not interdict the right of appeal to higher military authority.

    (4) In order that the supervision and direction of the clinical care of the sick and wounded may be consistent throughout, consultants will recommend to commanding officers of hospitals in their respective areas the names of those suitable for appointment as chiefs of clinical services and specialists in those hospitals.

    (5) Consultants will render regular monthly reports of their activities. These reports will embody the nature of the clinical work of the organizations in their jurisdiction, the character and quality of the work, and fitness of individual medical officers in their departments. These reports will be submitted to the senior consultant, through the commanding officer of the hospital center, or in base hospitals operating separately, the commanding officer of the hospital, or through the surgeon of the unit to which they are assigned.

    (6) The commanding officers of units in the district assigned to a consultant will afford proper and necessary facilities to the consultant in the performance of his duties.

    (7) The consultant will report to the commanding officer immediately on his arrival at, and before his departure from, any unit which is within the sphere of this action.

    II. Assignment of personnel.-Commanding officers of hospital centers may make such changes of assignment of personnel on duty with units belonging to their centers as may be necessary or desirable. This authority will not be construed to cover personnel belonging to units, such as field hospitals or ambulance company which are not permanently assigned to the center. All changes of assignment made under this authority will be promptly reported to this office.

    III. Class B men.-Men of class B held at hospitals in accordance with telegraphic instructions, chief surgeon's office, October 25, 1918, will be held as classified men, after disability boards have acted upon them, and not as patients.

    IV. Artificial eyes.-Four centers have been established where men requiring artificial eyes can best have them fitted. Base Hospital No. 115 at Vichy is the principal center. The others are base optical unit, Medical Department repair shop, Paris; Base Hospital No. 8, Savenay; and Base Hospital No. 29, London. Cases requiring plastics on the eyelids or orbit prior to the fitting of an artificial eye should be routed to Base Hospital No. 113 if practical. Such cases appearing in Paris may be sent to American Red Cross Military Hospitals Nos. 1 or 2.

    V. Trachoma.-Cases of trachoma which occur among the troops can be treated in the base hospitals, but precautions should be taken to prevent any danger of spread of the disease. Special care of towels and handkerchiefs is most necessary. Severe cases likely to require long treatment with resulting impairment of vision should be classified "D" and routed accordingly.

    VI. Civilian employees.-(l) Supplementing paragraph 3, Circular No. 45, chief surgeon's office, dated August 13,  1918, commanding officers of hospital centers are directed to report to the office of the chief surgeon (F. and A. Division), all authorities for the employ-



    996

    ment of civilians granted by them to date to commanding officers of base hospitals under their command, and also to forward to the same office copies of all similar authorities hereinafter granted by them. Attention of commanding officers of hospital centers is invited to section 3, paragraph 2, General Order No. 32, general headquarters, A. E. F., dated February 13, 1918, and also to section 5, General Order No. 131, general headquarters, A. E. F., dated August 7, 1918, which regulates employment of civilian personnel.

    (2) Supplementing section 2, paragraph 1, Circular 16, chief surgeon's office, dated March 28, 1918, and section 1, Circular 23, chief surgeon's office, dated April 22, 1918, commanding officers of hospitals and other units functioning as such, are directed to have payment of civilians, whenever possible, made from the hospital fund and reimbursement to such fund secured in the method provided in section 2, paragraph 1, Circular No. 16, chief surgeon's office. Payment of civilians should be made by Quartermaster Corps disbursing officers only when sufficient balance is not on hand in the hospital fund. Whenever civilians are paid from the hospital fund, the original pay roll, properly signed and executed, with memorandum voucher attached, should be sent to the disbursing officer, Medical Department, office chief surgeon, A. P. O. 717, for reimbursement by one check drawn to the order of the hospital fund. These original rolls should bear the following properly
    signed certificates:

    (a) I certify that I have witnessed the payment of this roll and that the amount paid each employee was such as is set opposite their respective names.

       ------------------------------------------------------------
       Signature.

    (b) I hereby certify that payment of this roll was made from hospital fund, Base Hospital No. -------, and hereby request that said hospital fund be reimbursed the amount of francs -----------------.

       --------------------------------------------------------------
      Custodian, Hospital Fund.

    VII. Surgical instruments.-Any surplus instruments held by medical units will be turned in at once to the instrument repair shop, 11 ter Rue de La Revolte, Paris, France.

    The same procedure will obtain where medical units are discontinued. All instruments shipped in compliance with the above instruction will be properly invoiced to commanding officer of the instrument repair shop.

    VIII. Paragraph 3, Circular 28, office of chief surgeon, c. s., is amended by substituting the following:

    When French and allied military patients are admitted to, discharged from, or die in, American military hospitals in the French zone of the interior, notification of the fact will be sent within 24 hours to the Franco-American section of the region (Service de Sante), on Form 52, which will contain: Surname, Christian name, regiment, serial number, place of enlistment (if possible), nationality, date of admission, source of admission, nature of wound or disease, and, if in line of duty, complications, mode and date of discharge, or date of death and place of burial, name of hospital in which patient is being treated.

    IX. Patients remaining in hospital December 31, 1918.-A remaining card, Form 52, will be made out for each patient in hospital on December 31. It will be identical with Form 52 as used for completed cases except that in space 16, "Disposition," the entry "Remaining in hospital" will be made, and in space 17, "Date of disposition," the entry "December 31, 1918," will appear.

    A nominal check list of these will be made with the word "Supplemental" appearing on the form at the top. The sheet, together with the cards, will be submitted with the regular monthly report for December.

    WALTER D. MCCAW,
      Colonel, Medical Corps, Chief Surgeon.


    Circular No. 58:
    AMERICAN EXPEDITIONARY FORCES,
       December 2, 1918.

    I. Collection of museum material for medical education and research (supplement to Circular No. 42).-The cessation of hostilities makes necessary the following additional directions concerning the collection, preservation, and shipment of specimens for the Army Medical Museum:



    997

    PAR. 2. Scope.-Since opportunity is past for obtaining pathologic material showing recent war injuries, efforts will now be made to obtain material showing such injuries in all stages of healing. Serial graphic records by photographs and drawings will be made of typical or otherwise interesting cases. Amputated and resected material will be preserved. Also all lesions from war injuries in cases coming to autopsy. It is believed such specimens will be of inestimable value in the study of the treatment of wounds, gas burns, trench foot, etc.

    PAR. 7. Pathologic specimens.-(a) To prevent overhardening during long delays which may occur in transporting specimens to the United States, all gross pathologic specimens, after short preliminary fixation in Kaiserling No. 1, if not carried through the entire Kaiserling process, will be placed in fresh Kaiserling No. 1, which contains only 10 per cent of formalin.

    PAR. 8. Shipment.-To avoid loss during long delays in transit in France, when possible specimens will be shipped by motor transport to concentration points. (See par. 5, Circular 42.) If rail transport must be used, pathologic specimens will be well padded with waste absorbent cotton, moss dressing, or paper, packed closely in kegs, barrels, or casks, which will then be headed and filled with half-strength Kaiserling No. 1 and shipped by "Grand Vitesse." Where large numbers of specimens have been collected and capable packers are not available, application for assistance will be made to the director of laboratories, A. E. F. (museum unit), A. P. O. 721.

    PAR. 18. Photographs.-By authority first and fourth indorsements, O. C. S. 200/2065 C. S. O., the Medical Department, through the Signal Corps, now has full authority to make photographs of subjects pertaining to the Medical Department. Commanding officers of hospitals will take immediate steps to procure photographs for illustrating the history of their organizations.

    II. Proceeds from sale of garbage.-(l) Decision of the judge advocate states that proceeds from the sale of kitchen refuse at hospitals belongs to the hospital funds of the organizations.

    (2) Commanding officers are therefore instructed to make contracts locally for the sale of same, and place proceeds therefrom in the hospital funds.

    (3) If proceeds previously received have been turned over to the Quartermaster Corps, effort should be made by commanding officers of hospitals to secure refund, either from the local disbursing quartermaster or by sending claims with all details to this office (F. and A. Division).

    III. Camphor.-Due to the difficulty of obtaining camphor, it is desired that every effort be made to conserve it.

    IV. Return of buildings occupied for hospital purposes.-No agreement should be made between commanding officers of hospitals and local French authorities for the return of buildings occupied for hospital purposes, as this office has been repeatedly informed by the French central authorities that local authorities are not competent to act on the premises. This transfer should be only done after receiving directions from the chief surgeon of the American Expeditionary Forces in the case of base hospitals, and the section surgeons of the Services of Supply in the case of camp hospitals.

    It has been reported to this office that a number of base hospitals have evacuated patients who should not have been moved, with a view to demobilizing the hospitals.

    Action such as this will not facilitate the departure of Medical Department units to the United States, but will in fact retard it. Greater care than ever must be exercised in treatment and evacuation of patients. This office will make proper recommendation, when the time arrives, as to ordering the units to the United States.

    V. Medical Department property.-All officers accountable for Medical Department property who are carrying Red Cross property on their returns are instructed to drop this property from their returns, making a certificate to this effect to the chief surgeon, F. and A. Division, giving the number of the voucher on which the property was dropped.

    Although there is no formal accountability for Red Cross property (see par. 3, Circular 3, B. G. and L. O. C., August 28, 1917), responsibility, however, for this class of property rests with the commanding officers of hospitals and other organizations who should be prepared at all times to give and account of the use to which this property has been put.



    998

    VI. Medical journals and books.-Standard medical journals and books are available in the medical supply depots and the medical research and intelligence department of the Red Cross, Hotel Regina, Paris. Application for such books should be made through the usual channels. Base hospitals will be supplied from the Army stock, and camp and evacuation hospitals from the Red Cross stock. If nonstandard books are not available in one stock, request will be referred, if approved, to the other.

    The medical research and intelligence department of the Red Cross, Hotel Regina, Paris, will be glad to review the literature on any special subject in which a medical officer is interested, and to furnish him an abstract of the results. Correspondence may be made direct.

    VII. Repairs or installation of X-ray apparatus.-In case of repairs needing the attention of an X-ray officer of the Sanitary Corps the commanding officer of the hospital should wire the office of the technical consultant in Roentgenology, A. P. O. 702, who will direct the proper officer to make the repair. A brief, explicit statement of repair needed will expedite service.

    In case of portable or bedside transformer, wire the above office for a replacement and send damaged part to medical repair shop No. 1, X-ray division, 11 Bis Avenue de la Revolte, Neuilly, Paris.

    No officer for the installation of new equipment will be sent unless the telegram to the above office states that machine is on hand and that current is available.

    VIII. Personnel available for transfer.-Commanding officers of Medical Department units and detachments will report, by mail, to this office on the 15th and the last day of each month the names of any officers, nurses, or men who can be spared for return to the United States or for duty elsewhere in the American Expeditionary Forces.

    IX. The following information will be furnished this office, when units are sailing for the United States:

    The immediate commanding officer of each medical department formation will make a final return showing all members of the Medical Department present for duty with his organization, on date of departure to the United States.

    Division surgeons will make a separate return of all members of the Medical Department serving in their divisions and not included on other returns.

    Separate return will be made of all personnel, present for duty, in the following order: Officers of the Medical Corps; officers of the Dental Corps; officers of the Veterinary Corps; all to be listed alphabetically according to grade.

    Separate return will be made of all enlisted personnel, present for duty, alphabetically according to grade, the soldier's serial number, name, and rank will be recorded in the following manner:

    Serial No.: 14278
    Surname: Brown,
    Christian name: William E.
    Rank:

    Separate return will be made of all civilian employees and members of the Army Nurse Corps.

    The return will be prepared on letter or cap paper (typewritten). The return will then be forwarded to the chief surgeon, A. E. F., through the base surgeon, who will take such memoranda therefrom as he may require, and will without delay transmit it by informal indorsement to this office.

    X. Sick leave of absence.-In granting sick leaves of absence under paragraph 2, General Order 7, Services of  Supply, c. s., attention of all commanding officers is invited to paragraph 9, General Order 6, General Headquarters, c. s. In this connection, Paris is in the French zone of the armies, and leave should never be granted to visit Paris except in very exceptional cases.

    XI. Travel orders.-Reports have been received at this office that the commanding officers of base hospitals, in sending men to depot divisions and casual camps, are not complying with the requirements of General Order 111, General Headquarters, c. s. In order that there may be no mistake, the travel orders of officers and soldiers evacuated from hospital not only as of classes B and C, but also of class A, will state clearly the classification to which the officer or man belongs. Especial attention will be given the fact that sufficient



    999

    number of orders must accompany each group in order that the commanding officer of the depot division or casual camp may have the proper records immediately on receipt of a man or group of men.

    WALTER D. MCCAW,
      Colonel Medical Corps, Chief Surgeon.


    Circular No. 59:
      AMERICAN EXPEDITIONARY FORCES,
    December 9, 1918.
     

    I. PNEUMOCOCCUS LIPO-VACCINE

    1. The following directions for vaccination against lobar pneumonia and for making the necessary records are published for the information and guidance of medical officers of the American Expeditionary Forces.

    2. Each cubic centimeter of the pneumococcus lipo-vaccine contains 15,000 million pneumococci of Type I and 15,000 million of Type II. On standing in the cold, some of the fats may separate and cause a precipitate. This will disappear on standing a short time at room temperature.

    3. A single dose of 1 c. c. of this vaccine is sufficient. It is especially important that it be given subcutaneously, not intravenously, intramuscularly, or under the fascia. In order to insure this, you will pick up a fold of skin and inject into the subcutaneous tissue of that fold. Practically all the severe reactions that have been reported have been due to neglect of this precaution. The deep injection of this vaccine may lead to fat embolism and defeats the object of the inoculation.

    4. No person should be vaccinated who is not perfectly healthy and free from fever. The temperature will be taken before vaccination is begun and, in doubtful cases, the urine should be examined; if fever or any other symptoms of illness are present, the procedure should be postponed. This precaution is necessary to avoid vaccinating men who may be in the incubation stage of a fever. Neither beer nor alcohol in any form should be drunk on the day of treatment. It is advisable to give the vaccine about 4 o'clock in the afternoon, and the men should be required to remain in quarters for 24 hours after the injection.

    5. A sick and wounded card is to be made out for each person vaccinated, giving the type of vaccine employed, batch number for its identification, and the dosage. This card is to be marked "For vaccination record only" and sent direct to the office of the chief surgeon, A. E. F., A. P. O. 717. Enter on the service record, date, type, and dose of vaccination.

    6. The pneumococcus lipo-vaccine may be obtained by requisition from base laboratories in accordance with paragraph 10, Memorandum No. 21, office chief surgeon, division of laboratories and infectious diseases, September 18, 1918.

    7. Vaccination against lobar pneumonia is not compulsory, and the use of pneumococcus lipo-vaccine in the American Expeditionary Forces must be made only with the consent of the patient.
     

    II. TYPHOID LIPO-VACCINE

    1. The following information is furnished for the guidance of the medical officers of the American Expeditionary Forces.

    2. As rapidly as the supply of triple lipo-vaccine is increased it will be sent in filling requisitions for triple typhoid saline vaccine. Requisitions should be made to the nearest base laboratory in accordance with paragraph 10, Memorandum No. 21, office of chief surgeon, division of laboratories and infectious diseases, September 18, 1918.

    3. Triple typhoid lipo-vaccine contains in each cubic centimeter 2,500 million Bacillus typhosus, 2,500 million Bacillus paratyphosus A; and 2,500 million Bacillus paratyphosus B. On standing in the cold some of the fats may separate and cause a precipitate. This will disappear on standing a short time at room temperature.

    4. A single dose (not three) of 1 c. c. of the lipo-vaccine is sufficient. It is especially important that this vaccine be given subcutaneously and not intravenously, intramuscularly,



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    or under the fascia. To insure this, a fold of skin is picked up and the injection made into the subcutaneous tissue of that fold. Practically all the severe reactions that have been reported have been due to neglect of this precaution. The deep injection of the lipo-vaccine defeats the object of its use and in addition may lead to fat embolism.

    5. The precautions to be taken regarding the absence of temperature or disease are the same as are given for the typhoid vaccine in Circular No. 16, War Department, office of the Surgeon General, March 20, 1916. It is advisable to give the vaccine about 4 o'clock in the afternoon, and the man should be required to remain in quarters for 24 hours.

    6. After the injection, the record of the vaccine should be kept on Form No. 81, that form being modified by writing "Lipo" after "Triple vaccine," and by striking out "First" in the "Dose" column, and by striking out all columns in the "Second" and "Third" doses. The batch number of the vaccine should always be entered on the card.

       WALTER D. MCCAW,
      Colonel, Medical Corps, Chief Surgeon.


    Circular No. 60.

    AMERICAN EXPEDITIONARY FORCES,
    CHIEF SURGEON'S OFFICE, SERVICES OF SUPPLY,
       December 16, 1918.
     
     DIPHTHERIA AND DIPHTHERIA CARRIERS IN THE ARMY
    I. Bacillus diphtheriæ.-(a) True diphtheria bacilli when freshly isolated and examined in young cultures (24 hours on Loeffler's blood serum) have fairly typical morphology and staining reactions which usually serve to differentiate them from other organisms.

    (b) Their positive identification may be made upon morphology and staining reactions plus cultural characteristics.

    (c) B. diphtheriæ may be divided into two groups-virulent and avirulent-which are indistinguishable from each other morphologically, tinctorially, and culturally, but may be positively differentiated by guinea-pig inoculation.

    (d) Practically speaking, an avirulent strain of diphtheria bacilli never acquires virulence, and a virulent strain retains its virulence with great tenacity.

    II. Etiology.-Clinical diphtheria is produced only by virulent diphtheria bacilli.

    III. Diphtheria bacillus carriers.-(a) Single throat cultures from healthy individuals of various ages reveal B. diphtheriæ in 1 per cent to 30 per cent. The average incidence appears to be 3 to 4 per cent.

    (b) Among the bacillus carriers the per cent of carriers with virulent bacilli varies greatly, but is commonly found to be 10 to 15 per cent of carriers.
     

    (c) The carrier stage may be temporary or chronic. Sometimes diphtheria bacilli disappear from the throat of a carrier within a few days after they find lodgment there; in other cases they persist for weeks, months, or even years.

    (d) If daily cultures are taken from the throats of chronic carriers, very interesting and instructive results may be obtained; (1) Positive cultures may be obtained for a number of consecutive days extending perhaps over weeks. (2) A majority of the cultures may be positive, with occasional negatives interspersed among the positives. (3) A majority of the cultures may be negative, with occasional positive cultures. (4) A carrier who has been giving regularly positive cultures for a number of days may show irregular results for a time and then give entirely negative cultures for a number of successive cultures, to be followed still later by regularly positive cultures, and this condition of affairs may repeat itself many times. (5) The growth of diphtheria bacilli is not confined to the surface of the mucous membrane; colonies have been demonstrated in the depths of the tonsillar tissue, and the condition described under (4) above is probably to be explained by the successive coming to the surface of these deep colonies as the superficial layers of the tonsils are gradually exfoliated. (6) Virulent and avirulent bacilli
    are rarely, if ever, found in the throat of a carrier at the same time.



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    IV. Sterilization of carriers.-To free carriers of virulent diphtheria, a great number of methods have been tried. The only one which has met with any considerable degree of success in chronic carriers has been tonsillectomy. This will not prove universally successful, as in some cases the nidus may be elsewhere than in the tonsils, as, for example, in the accessory sinuses.

    V. The rôle of carriers in the spread of diphtheria.-The rôle of carriers who have not been in close contact with an active clinical case of diphtheria in the spread of diphtheria does not seem to be important. This is obvious when it is recalled that 85 to 90 per cent of all carriers harbor only nonvirulent bacilli, and that infection does not readily occur from the remaining 10 to 15 per cent who constitute a possible source of infection for susceptible individuals.

    VI. The detection of carriers.-A single throat culture from any large number of people would probably reveal less than half the actual number of carriers present. Two cultures, taken with an interval of a week or two between, would probably reveal twice the number of carriers found on a single culturing. If six or seven cultures were taken with an interval of a week or two between cultures, the number of carriers remaining undiscovered would probably be very small. Nasal cultures might show a few additional carriers, but very few.

    Isolation of healthy carriers is impracticable because (1) of the labor involved in detecting all the carriers. (2) If all the carriers among any large group of persons were detected, their number would be too great. (3) The only method of sterilizing chronic carriers (tonsillectomy) that has met with much success could hardly be recommended as a routine procedure, and without this many of them will remain carriers indefinitely. (4) They do not constitute a menace serious enough to justify any of the above procedures. (5) Finally, if for any reason an attempt is made to detect and isolate carriers, virulence tests should be performed and the carriers of avirulent organisms should be disregarded.

    VII. The diphtheria patient.-While the healthy carrier of even virulent diphtheria bacilli does not constitute a serious danger to persons in contact with him, the same can not be said of the individual suffering from clinical diphtheria. The disease is readily transmissible, both by direct contact and by moist discharges from the nose and mouth. Strict isolation of all cases should be carried out and thorough disinfection of all clothing, bedding, and other articles that have been used by the patient subsequent to his infection. It is possible that persons who have recently become carriers by contact with a diphtheria patient may be a greater source of danger in the spread of the disease than the ordinary healthy carrier who has not been recently in contact with the disease; therefore, all those who are in intimate contact with a person at the time of, or just prior to, his development of diphtheria should be isolated until the incubation period of the disease has passed or until they can be shown to be free from the infection by at least two negative throat cultures. All nurses and orderlies in attendance upon cases
    of diphtheria should be isolated during the whole of the time that they are in charge of such patients and for a period thereafter equal to the incubation period of the disease, or until they are shown free from the infection by at least three successive negative throat cultures at intervals of three days.

    VIII. The incubation period.-The incubation period of diphtheria is from 2 to 5 days, oftenest 2 days, and under experimental conditions has been found to be short as 24 hours.

    IX. Treatment with diphtheria antitoxin.- Diphtheria antitoxin given in adequate doses sufficiently early in the diseases will effect a prompt cure in practically 100 per cent of cases. There should be no mortality where antitoxin is given within 24 hours of the development of symptoms. For adults weighing 90 pounds or over, the amount of antitoxin required in the treatment of cases is as follows: Mild cases, 3,000 to 5,000 units; moderate, 5,000 to 10,000 units; severe,d 10,000 to 20,000 units; malignant, 20,000 to 40,000 units.

    Cases of laryngeal diphtheria, moderate cases seen late at the time of the first injection, and cases of diphtheria occurring as a complication of the exanthemata should be classified and treated as "severe" cases.

    In all cases a single dose of the proper amount, as indicated in the schedule, is recommended.

    dWhen given intravenously, one-half the amounts stated.



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    It is recommended that the methods of administration be as follows:

    Mild cases, subcutaneous or intramuscular.
    Moderate cases, intramuscular or subcutaneous.
    Severe cases, intramuscular or subcutaneous or intravenous.
    Malignant cases, intravenous or intramuscular.

    Some point on the surface of the body should be chosen for the injection, as where there is an abundance of subcutaneous cellular tissue-the abdomen or infrascapular region. Before the remedy is administered, the skin should be sterilized at the point of injection with tincture of iodine or other disinfectant. The syringe should be thoroughly sterilized. It is better not to employ massage over the point of injection.
     

    THE EARLY ADMINISTRATION OF ANTITOXIN

    The earlier the remedy is administered the more certain and rapid is the effect. In cases of any severity where diphtheria is suspected, it is far better to administer the remedy at once, making a culture at the same time, than to delay the treatment until a diagnosis has been made by bacteriologic examination. The first injection should be large enough to control the disease. One large dose given early is far more efficacious than the same amount in divided doses. Severe cases and those in which the administration of antitoxin has been delayed, or cases which are progressive because of an insufficient first dose, should receive a large intravenous injection whenever feasible. In this way the full value of antitoxin is obtained at once, whereas the absorption from the subcutaneous injection is so slow that many hours must elapse before any great amount of antitoxin has found its way into the general circulation. It must be warmed to the body temperature and given very gradually.

    X. Anaphylaxis.-While it must be admitted that anaphylactic shock may follow the administration of diphtheria antitoxin serum and that this danger is slightly greater when the serum is given by the intravenous route than when given subcutaneously or intramuscularly, instances of serious consequences from therapeutic use of diphtheria antitoxin are so rare that there is no justification in withholding antitoxin in clinical diphtheria. Desensitization may with advantage be attempted in cases of known sensitiveness to horse serum.

    XI. Immunity.-(a) Natural immunity: Experience has shown that approximately 50 per cent of mankind are naturally immune against diphtheria. This immunity is due to the presence, naturally, of a small amount of diphtheria antitoxin circulating in the blood. This immunity once established apparently lasts throughout life. The Schick test: The presence of natural or artificial immunity may be determined by the Schick test. This test consists in the intradermal injection of a small amount of diphtheria toxin; if antitoxin is present (natural immunity) the toxin injected will be neutralized and no reaction will follow. If no antitoxin is present (as in a susceptible individual) the toxin will give rise to an inflammatory reaction at the site of inoculation, a positive reaction. Technique of the Schick test. The test consists in the intracutaneous injection of one-fiftieth M. L. D. diphtheria toxin in volume of 0.1 c. c. The M. L. D. (minimum lethal dose) of toxin is that amount which will kill a 250-gram guinea pig in 4 to 5 days. For the injection, a 1 c. c. hypodermic syringe with very small sharp needle is necessary, and the
    injection may conveniently be made into the skin of forearm.

    (b) Susceptibility.-It seems highly probable that people who give a negative Schick test may be exposed freely to diphtheria without danger of their contracting the disease, while persons giving a positive Schick test so exposed are likely to contract the disease.

    (c) Active immunization.-Susceptible individuals may be actively immunized against diphtheria by the injection of toxin-antitoxin mixtures, and such immunity is probably fairly lasting, in some instances persisting throughout life.

    (d) Passive immunization.-Susceptible individuals may be passively immunized against diphtheria by the injection of antitoxin. Such immunity reaches its maximum degree immediately, if the antitoxin is injected intravenously, and after about 48 hours following subcutaneous injection. Passive immunity following the usual prophylactic dose of 1,000 units of antitoxin gives the individual a temporary immunity against natural infection, but the immunity is transitory, diminishing rapidly and usually lost in ten days or



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    two weeks. Rarely persons may retain some demonstrable degree of immunity as long as three weeks. Subsequent use of antitoxin for passive immunity in the same individual develops even a briefer protection.

    (e) Prophylactic use of antitoxin.-Experience has abundantly demonstrated the almost absolute power of a prophylactic injection of antitoxin in preventing the development of diphtheria in persons who have been exposed to the disease. It probably has no effect in preventing the lodgment and growth of bacilli in the throats of such persons, and it is conceivable that the bacilli which have lodged in the throats of such persons might persist and give rise to the disease after the transient immunity conferred by the antitoxin has disappeared. That this frequently happens is not borne out by experience. It is evident, however, from what has been said about natural immunity, that in approximately 50 per cent of persons there is no need of giving prophylactic injections of antitoxin, since this proportion of humans are naturally immune. If prophylactic injections are to be given, it is worth while to perform a preliminary Schick test and give antitoxin only to those who are thus shown to be susceptible by a positive reaction.

    XII. Prevention of spread of diphtheria.-Undoubtedly the most important measure in preventing the spread of diphtheria is the prompt recognition of cases as soon as they develop, and effective isolation of them. It is undoubtedly true that many cases are not immediately recognized and that they give rise to a spread of the disease among their associates.

    At a time when diphtheria is prevalent, frequent throat inspections should be made of all individuals exposed, or who may have been exposed, and any person having a throat that looks at all suspicious should be isolated and regarded as having diphtheria until negative cultures prove that the suspicion is unfounded. This measure alone, if efficiently carried out, will probably serve to prevent any spread of the disease.

    XIII. A typical case of diphtheria.-It should be borne in mind that not infrequently cases of diphtheria occur in which the typical appearance of the throat is lacking, and the symptoms may be so mild that they may be overlooked. The pharynx in these cases may present a beefy red appearance, with perhaps a few pinhead-sized patches, and the symptoms consist in little more than a feeling of malaise on the part of the patient. The thermometer will usually reveal a slight elevation of temperature, and it is these cases that may escape isolation and by freely mingling with their associates give rise to a spread of the disease.

    XIV. Wholesale measures in dealing with epidemics illogical and valueless.-There are certain measures that have become so well established in dealing with epidemics of diphtheria that to question them is sure to arouse the antagonism of those whose ideas have become fixed by tradition. These are the wholesale taking of throat cultures and the prophylactic administration of antitoxin. A knowledge of the practical limitations of application of wholesale culturing to organizations or groups among which diphtheria has appeared, and the poverty of actual results in detecting the insignificant incidence of carriers of virulent B. diphtheriæ, should suffice to forbid the practice. Similarly, the uselessness of administering diphtheria antitoxin to insusceptibles and the temporary character of the protection given to susceptibles by passive diphtheria immunization will serve to put an end to the routine use of diphtheria antitoxin without Schick reaction control for
    prophylactic purposes in an organization where diptheria has appeared.

    XV. Selective immunization.-We may next consider the advisability of determining the susceptible individuals, either in a camp or among those who presumably have been most exposed to the danger of infection, and of giving prophylactic doses of antitoxin to those of persons or of applying other precautionary measures to them. The susceptible individuals may be discovered by means of the Schick test. The results may be known at the end of 48 hours. If a camp of 5,000 men be tested, 25 per cent, or 1,250, may be found susceptible, and these are the only ones who run any risk of developing diphtheria and to whom the prophylactic injection of antitoxin could be of any use.

    If the Schick test is applied to a small group (those who have been more intimately exposed to the disease), one will have to deal with a proportionately smaller number of individuals.



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    XVI. Principles for management of diphtheria outbreak.-In all preventive measures the two main objects to be accomplished should be kept clearly in mind: (I) the protection of the individual; (II) the protection of the community. We should also keep clearly in mind what we consider constitutes the danger to the individual and what, to the community.

    I. The danger to the individual is that he may develop diphtheria.

    II. The danger to the community, as usually considered, is that diphtheria may be spread by: (a) Diphtheria bacillus carriers; (b) the failure properly to isolate recognized cases of diphtheria; (c) contact with persons who are in the incubation period of the disease; (d) unrecognized cases of diphtheria with which healthy persons are allowed to come in free contact.

    I. The danger to the individual that he may develop diphtheria.-Among adults there is a 75 per cent factor of safety to start with, represented by natural immunity. This is further increased by the chance that of the 25 per cent of susceptible adults exposed to diphtheria not all of them will have diphtheria bacilli implanted in throats-a chance, however, that for the sake of safety we will not consider. Of any group of individuals exposed to diphtheria, the susceptible ones may be determined by the Schick reaction. It is obviously unnecessary to give a prophylactic dose of antitoxin to any but the susceptible persons. The time necessary to determine the result of the Schick reaction is 48 hours and during this period all the contacts should be kept in isolation. The incubation period of the disease is given at "from two to five days, most often two," so that by the time the result of the Schick test is known most of those who are going to develop the disease will already have manifested signs of symptoms. The Schick test has therefore been unnecessary. Antitoxin given in the first 24 hours of the disease is curative in practically 100 per cent of cases. Therefore, if isolation and observation only of the contact is employed without the prophylactic use of antitoxin or the Schick test, the occasional individual who develops the disease under the conditions has lost little if anything, and the large majority of contacts have experienced no inconvenience other than a very short isolation.

    II. Danger to community.-(a) From carriers: There is no danger from the carrier of nonvirulent bacilli, and the danger from the ordinary healthy carriers of virulent bacilli is so slight that it does not seem practical to take any measures against it.

    (b) The necessity of carefully isolating all recognized cases of diphtheria is so universally acknowledged and practically carried out that no further discussion of this point seems necessary.

    (c) That persons in the incubation period of the disease constitute a distinct danger is certain, and the prompt isolation of persons who are in contact with diphtheria cases is an important measure. Fortunately the short incubation period of the disease makes necessary only a very brief isolation. If these contacts are isolated and a daily observation made of their throats and symptoms, no other measures are necessary unless suspicious symptoms arise. In such cases cultures should be made and antitoxin given according to the nature of the developments.

    (d) Unrecognized cases of diphtheria: It is probable that these cases are the most potent agents in giving rise to the spread of the disease. At a time when diphtheria is prevalent, the most important measure, other than the isolation and treatment of the recognized cases of diphtheria, is the search for the mild cases which might otherwise escape detection. Daily inspection of throats, with an inquiry as to symptoms, will serve to discover all suspicious cases. If these are isolated as they are discovered, a culture taken, and in sufficiently suggestive cases antitoxin given, no serious spread of the disease need be feared. The taking of cultures may be limited in these cases, and to the routine procedure covered by Army orders for the discharge of patients convalescent from diphtheria and to those who have been in attendance on diphtheria.

    The Schick reaction may be of value in eliminating 75 per cent of the individuals constituting any group as naturally immune and therefore unnecessary to be kept under observation as possible subjects of diphtheria. It may further be of use in selecting naturally immune persons to serve as attendants on diphtheria patients, and, finally, if active immunization against diphtheria should be undertaken, it will discover those persons who stand in need of immunization.

       WALTER D. MCCAW,
       Colonel, Medical Corps, Chief Surgeon.



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    Circular No. 61:

       AMERICAN EXPEDITIONARY FORCES,
    OFFICE OF THE CHIEF SURGEON, SERVICES OF SUPPLY,
    December 18, 1918.

    I. The following salient points are noticed in a recent report, based on actual observations, of the nutritional officer, chief surgeon's office:
     MESS SERVICE TO PATIENTS
    1. Mess lines of soldiers are to be avoided if possible. Two systems of avoiding this are in operation in American Expeditionary Force hospitals:

    First. Tickets with different times for presentation at the mess hall are issued to the various groups of men.

    Second. Patients are conducted by noncommissioned officers to the mess hall in squads.

    In either case the men must be checked to see that their number corresponds with that called for by the diet slips. Patients in pajamas and slippers must not be allowed in lines and exposed to the weather.
     DIETITIANS
    2. Attention is again directed to Circular 27, office of chief surgeon, c. s., which has evidently not been carefully read. Dietitians are not cooks. Their duties may be defined as follows:

    (a) The dietitian.-It is her duty to prepare menus for all patients in the hospital. She is to see that the food is properly prepared and served. She should see that the menus are served as written.

    (b) She should be present in the kitchens during the preparation of meals. However, during the service she should divide her time between the wards and mess hall in such a way that she may know whether the food is being properly served throughout the hospital. She, or her assistant, is responsible for the issuing of the food to the wards. She should also report to the commanding officer defects of service found in the wards, that these may be corrected through proper channels. Defects of preparation or service found in the mess hall or kitchen should be reported to the mess officer.

    (c) She is directly responsible for the preparation of special diets and for special items or modification of the three listed diets. She should, however, be supplied with sufficient help to relieve her from all the details of preparation of these items. It is her duty to advise with the heads of the services, ward surgeons, or nurses, as may be necessary, to insure the patients getting food that is adapted to their needs, while at the same time the kitchen may be relieved of preparing unnecessary specials.

    3. In the absence of regularly qualified dietitians, Circular 39, office of chief surgeon, c. s., should prove invaluable, attention particularly being invited to Table II, page 4. Two corrections, as follows, are to be made in Table III: (1) the caloric value of a pint of milk is about 300 calories; (2) one cup of coffee, half milk, contains about 150 calories.
     

    CHIEF MESS OFFICER
    4. Large centers should include a chief mess officer as a part of the administrative personnel for the center. Among others, his duties should include the following for the entire center:

    (a) Purchaser and distributor of articles of mess.

    (b) Inspection of all messes.

    (c) Consultant for unit mess officers.

    (d) The organization of schools for cooks, bakers, and mess sergeants.

    (e) Acting, for a short term, as hospital mess officer in any unit in the center where the regular mess officer is temporarily incapacitated.

    Where an officer running one of the hospital messes in a center has acted as purchaser for the center, the results have proven entirely unsatisfactory. One hospital gets fed; the others go without.



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    II. Long-distance telephone calls.-A report from the chief signal officer shows that long-distance telephone calls originated by the Medical Corps were in November, 21.7 per cent more numerous than the average for the previous three months. Attention is called to Circular No. 53, and it is directed that long-distance calls be not made for communications of a trivial nature.

    III. Nurses to pay their own expenses.-Commanding officers will direct the attention of all nurses to the fact that when passing through Paris under orders they must pay their own expenses and request reimbursement later from the quartermaster and must not call upon the Red Cross for lodging. The Red Cross up to the present time has had arrangements with the Continental Hotel in Paris to take nurses as guests and render the bill to the Red Cross. The Red Cross has notified this office that this arrangement will be discontinued immediately.

    IV. Medical supplies.-In case of shortages of medical supplies received, General Order No. 57, headquarters Services of Supply, November 21, 1918, will be consulted and the procedure therein outlined followed.

    V. The instrument repair shop.-The instrument repair shop is now located at Parc des Princes, Porte St. Cloud, Paris.

    VI. Medical Department property of organizations changing station.-Officers accountable for Medical Department property are directed, upon change of station of their organization, to submit to this office, by letter, a brief report showing the status of their Medical Department property, what disposition has been made thereof, under what authority, etc.

    VII. Salvage medical field supplies.-Salvage medical field supplies will be shipped to officer in charge, medical supply depot, Montierchaume, Indre, properly invoiced.

    VIII. Disposal of records of hospitals.-(l) The attention of all hospital commanders is called to Circular 73, War Department, November 18, 1918, which prescribes methods for the disposal of the records of organizations which are being disbanded.

    (2) In addition, it is directed that each hospital upon final closing of its work as an organization in the American Expeditionary Forces, shall send its final report of sick and wounded, including (a) final report of sick and wounded for the period since last report, per Section XI, Manual Sick and Wounded Department, A. E. F., dated September 15, 1918; (b) retained file of copies of Forms 22, 647, and 648; (c) retained register index cards Form 52, to the office of the chief surgeon, A. E. F., Tours, in the personal charge of the registrar and such personnel as he may deem necessary in addition. After examination of these records and the making of the necessary corrections in them the registrar will be given a clearance receipt.

    (3) In the case of medical units (infirmaries, etc.) other than hospitals, which function as hospitals and are required to render sick and wounded reports, the final report and records may be forwarded in charge of a responsible soldier, preferably one who has had to do with the preparation of the records and reports.

    (4) Such records as are to be sent to Washington in accordance with Circular 73 may be sent by postal express. Such records, relating to Medical Department work or personnel, as Circular 73 designates to be left at camp headquarters should instead be sent to the office of the chief surgeon, to be kept until checked against by Washington.

    (5) The supply of Circular 73 is limited, but as soon as sufficient quantities are received they will be distributed.

    IX. Property.-Medical officers accountable for property, when returning to the United States, should report their departure by letter to this office (finance and accounting division). Statement of property charged against them will be forwarded to the office of the surgeon general for settlement. In case transfer of property is made to another accountable officer in the same unit, clearance of departing officer's accountability will be expedited if the officer before his departure submits a final return to this office (finance and accounting division). If a unit is disbanded and property turned into salvage or supply depots, transfer should be made in the usual manner. When vouchers covering above are forwarded to this office, certificate that all property has been disposed of should accompany the last voucher. In this case also clearance of departing officer's accountability will be expedited if he submits before his departure final return to this office (finance and accounting division). Medical Department officers responsible for but not accountable for property should clear their responsibility to
    accountable officer before their departure.



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    X. Lice.-A recent inspection of patients received from base hospitals at classification camps shows that 12 per cent are infested with lice. This appears due to the fact that pubic and axillary hairs are not carefully inspected for presence of nits.

    In future, in addition to usual manner of disinfestation, the pubic and axillary hairs will be clipped.

    XI. Advance medical supply depot No. 2.-Advance medical supply depot No. 2 has been established by the Services of Supply at Treves, Germany, to furnish medical supplies to armies and all other medical units in Germany.

    WALTER D. MCCAW,
       Colonel, Medical Corps, Chief Surgeon.


    Circular No. 62.
    AMERICAN EXPEDITIONARY FORCES,
      CHIEF SURGEON'S OFFICE, SERVICES OF SUPPLY,
      December 23, 1918.
     
     
    EPIDEMIC CEREBRO-SPINAL MENINGITIS (CEREBRO-SPINAL FEVER)
    The following bulletin is published to amplify and modify the instructions relative to the handling of epidemic cerebro-spinal meningitis heretofore issued from this office, more particularly those incorporated in the bulletin on transmissible diseases and the use of therapeutic sera.

    Clinical manifestations.-The early signs and symptoms of cerebro-spinal fever are those common to many other acute infections. Headache is almost always present. Vomiting is often an early manifestation. Fever is almost invariably present. Constipation is a fairly constant symptom. The pulse is relatively slow in relation to the temperature. Changed mental activity, varying from a slightly increased delay in cerebation, marked apathy, drowsiness to restlessness or even violent delirium, is generally present. A petechial rash about the shoulders, arms, and pelvis occurs in about a fifth of the cases. When such manifestations as these are present, cerebro-spinal fever should be considered in the differential diagnosis, and, in case of doubt, a blood culture should be taken and the advisability of spinal puncture weighed.

    More characteristic manifestations include stiffness of the neck, tending to increase upon continued movement of the examination, retraction of the head, sluggishness and inequality of the pupils, stiffening of the hamstring muscles (Kernig's sign), incontinence or retention of urine, and sudden deafness, total or partial. Such manifestations, unless adequately explained as due to a cause other than meningitis, are imperative indications for spinal puncture.

    Specific diagnosis.-Diagnosis depends upon the recognition of the meningococcus in the fluids derived from the patient. Meningitis, with all its clinical manifestations, may be caused by any one of several other organisms without the meningococcus being present. Such forms of meningitis do not possess the epidemic tendencies of the meningococcus meningitis, a fact which renders their bacteriological differentiation very important.

    For diagnostic purposes the meningococcus is sought in the nasopharynx, in the circulating blood, and in the cerebro-spinal fluid. In specimens from the nasopharynx many other bacteria are likely to be met with. In the circulating blood and in the spinal fluid the bacteriology is ordinarily simple.

    Cerebrospinal fluid is obtained by lumbar puncture in the median line between the fourth and fifth lumbar vertebræ. This point is on a line joining the summits of the iliac crests. The fluid should be collected in a series of sterile tubes. The normal fluid is water clear and contains less than 10 leukocytes per cubic millimeter. In meningitis the fluid is usually, but not always, under increased pressure and more or less turbid, and the number of leukocytes is greatly increased. Cultures should be made at once by spreading a drop of the fluid over the surface of a suitable medium in a Petri dish. Gordon's trypsin agare to which has

    eGordon's trypsin agar may be obtained from the central Medical Department laboratory or from the nearest base laboratory.



    1008

    been added ether-laked blood is recommended, but glucose agar mixed with blood or with laked blood may be used. A portion of the fluid should be mixed with an equal volume of plain broth and incubated, and a portion should be incubated without the addition of any other medium. All media should be incubated before use, should be warm when inoculated, and kept at 37° thereafter. The sediment should be smeared on slides, stained with Wright's or Leishman's stain, and examined with the oil immersion objective, observing the numerical relations of red blood cells, various types of white cells, morphology and position of the bacteria present. A second smear should be stained by Gram's method. The presence of Gram-negative intracellular diplococci in the spinal fluid warrants a provisional diagnosis of meningococcus meningitis. Identification of the organism in cultures will be considered subsequently.

    If clinical diagnosis of cerebrospinal fever has been made, a dose of polyvalent antimeningococcus serum should be given at once through the same needle that is used for obtaining the specimen of spinal fluid, without waiting for the bacteriological report. The prompt introduction of this first dose of serum is of utmost importance to the patient. It is best run in by gravity, very slowly, 2 c. c. per minute, the total dose being 15 to 40 c. c., or two-thirds of the volume of fluid removed.

    Blood culture may give positive results in cerebrospinal fever before clinical manifestations of meningitis are evident, especially in fulminant cases. At least three agar plates and two broth cultures should be made with a total quanity of 10 c. c. of blood. Gram-negative diplococci appearing in pure culture in these media warrant a tentative diagnosis of cerebrospinal fever. The final identification of the organism will be subsequently considered.

    Cultures from the naso-pharynx give positive results in the large majority of cases of cerebrospinal fever but, on account of the admixture of other micro-organisms in the specimen, material from this region is less suited for rapid diagnosis of the active case of meningitis than is the cerebrospinal fluid. However, may individuals are infected with meningococcus in the upper respiratory passages without the infection extending to the blood stream or to the meninges. Such individuals may show no clinical evidence of the infection. Their detection, segregation, and treatment constitutes an important part of the procedure for restricting the spread of cerebrospinal fever. As a general rule the examination of the naso-pharynx for meningococci should be resorted to only in active or convalescent patients and in persons who have been very closely associated with such patients. General surveys of entire regiments or brigades by this method in a search for carriers are, as a rule, unwarranted.

    The specimen should be obtained from the mucous membrane of the naso-pharynx without contamination from the mouth or palate, because the presence of saliva and of the normal buccal or pharyngeal bacteria interferes with the subsequent detection of meningococci in the specimen. A considerable degree of technical skill is essential in getting the specimen. In some cases a protected swab (West swab) will be of service. The material from the naso-pharynx should be placed at once on the surface of hæmoglobin agar plates and kept warm. It may be spread at once or after a brief interval, if more convenient. The medium is prepared by mixing ether-laked blood with Gordon's trypsin agar. Rabbit's blood or human blood (10 c. c.) may be used, laked by the addition of ether (5 c. c.) and distilled water (90) and added (1:50) to the melted agar, previously cooled to 45° C. The mixed medium is then poured into Petri dishes, allowed to harden, and warmed to 37° before use. After inoculation the plates are kept warm until transferred to the incubater at 37° C.

    Identification of the meningococcus.-Gram-negative diplococci found in cultures from the cerebro-spinal fluid or from the circulating blood should be subcultured to trypsin agar without blood enrichment, for testing against specific agglutinating sera. Colonies of Gram-negative diplococci found on the plates inoculated with pharyngeal mucus require more critical scrutiny because other Gram-negative cocci are frequently met with on such plates. The colonies should be examined after 16 to 24 hours incubation, first with the naked eye and then with a lens magnifying about 10 diameters. The meningococcus colony presents a glistening appearance and has a bluish-gray tint by reflected light (black background). It is transparent, colorless, or very slightly yellow, by transmitted light. Its margin is



    1009

    smooth and circular. The lenticular character of the colony allows an inverted image of window bars or other objects to be seen by looking through it. The colony less than 24 hours old shows no internal markings.

    Suspicious colonies, whether derived from cerebrospinal fluid, circulating blood, or pharyngeal mucous membrane, should be transplanted to trypsin agar without hæmoglobin enrichment. On the next day these cultures are examined by Gram's stain and then subjected to agglutination with specific serum. For this purpose the growth is suspended in salt solution, thoroughly shaken, and heated in a water bath at 65°  C. for 30 minutes to kill the bacteria and destroy the autolysin. To prepare the suspension of suitable concentration for the tests, one measures out 0.1 c. c. into a clear test tube 12 mm. in diameter. A measured amount of salt solution or of clear water is then run in from a burette or graduated pipette until the diluted suspension is just perceptibly turbid, read by daylight, in comparison with a control tube of the diluent. This end-point concentration is assumed to represent approximately 100,000,000 cocci per cubic centimeter. One then calculates the approximate concentration of the original suspension and the volume to which it must be diluted in order to obtain a suspension of approximately 2,000,000,000 cocci per cubic centimeter. Salt solution, together with sufficient 5 per cent carbolic acid to furnish 0.5 per cent of this preservative in the final volume, is then added up to this volume and the whole thoroughly mixed. Such a suspension, heated, diluted, and phenolated, may be kept for several months.

    For the agglutination test the specific sera to be employed are prepared in 1 to 100 dilutions and at the same time normal control sera of horse in 1 to 25 and 1 to 50 and of rabbit in 1 to 25 dilution. Equal volumes of the bacterial suspension and of the dilute serum are mixed in each   instance in a series of tubes so that the final serum dilutions are 1 to 200 for the immune sera and 1 to 50 and 1 to 100 for the control normal horse serum and 1 to 50 for the normal rabbit control. All the tubes are plugged with colon or corks and immersed in a water bath at 55°  C. for 16 hours. Under these conditions a true meningococcus should not be agglutinated in the normal control sera, but should be completely agglutinated by one of the specific type sera and by the polyvalent immune serum. Micrococcus flavus will be agglutinated in the normal control as well as the others. For critical investigations it is well to employ agglutinating sera of each type in graded dilutions as well as polyvalent serum, and to control the activity of each diluted serum by running it against a known standard-type suspension at the same time that the unknown cocci are being tested. When a large number of cultures have to be tested under field conditions one will often employ only polyvalent diagnostic serum and the normal serum control.

    The supply of meningococcus type sera available in the American Expeditionary Forces is somewhat uncertain. Three sources of supply are being utilized and the sera supplied may be from any one of these. They are designated as follows:
     

    I

    Rockefeller Institute meningococcus diagnostic type sera

    II

    Pasteur Institute meningococcus diagnostic type sera

    III

    Gordon meningococcus diagnostic type sera

    Normal meningococcus.

    Type A.

    Type I.

    Intermediate A.

    Type B.

    Type II.

    Intermediate B.

    Type C.

    Type III.

    Parameningococcus.

    Type D.

    Type IV.

    Polyvalent.

    Normal horse serum control.

    Normal rabbit serum control.

    The mutual relationships of the recognized types in these different classifications are still somewhat uncertain.

    Serum treatment.-Aseptic technic is essential. The serum should have a temperature of about 40° C. when injected. At the first spinal puncture, when indicated, polyvalent antimeningococcus serum should be injected at a rate not to exceed 2 c. c. per minute. The amount introduced should be about two-thirds of the volume of spinal fluid withdrawn. Following the injection, the patient should lie with his head somewhat below the level of the buttocks to favor the diffusion of the heavier serum to the head. Immediately afterward, especially in severe cases, 50 to 100 c. c. of the serum should be very slowly introduced



    1010

    intravenously, not faster than 1 c. c. per minute for the first 10 minutes, but at a gradually increasing rate after that if no untoward symtoms appear.

    In severe cases the spinal puncture should be repeated twice at intervals of 8 to 12 hours, giving a further intraspinal injection of serum each time. After that the interval may be lengthened to 24 hours. Even in patients who show most marked improvement after the first injection, a second puncture after 24 hours, with injection of serum, should always be performed. The character of the spinal fluid withdrawn, in conjunction with the clinical signs, is a guide for continuing or stopping the intraspinal treatment. Repetition of intravenous injection is usually necessary also.

    Anaphylaxis.-Serious intoxication from injection of horse serum is not likely to occur after intraspinal injection. It may occur when intravenous injection is done and, for this reason, the first part of the serum should always be introduced very slowly and the injection interrupted at the first sign of distress. Hypersensitiveness to horse serum is often present in persons who have previously been injected with serum, but it exists also in other persons.

    To avoid the dangers of hypersensitiveness, 1 c. c. of the serum may be injected subcutaneously, followed after an hour by the slow intravenous injection of the full dose. Where time permits, one may first give a subcutaneous injection of 0.5 c. c. of serum diluted with 0.5
    c. c. of salt solution, followed after 5 minutes by a second subcutaneous dose of 1 c. c. of serum, and 15 minutes later by a third subcutaneous dose of 5 c. c. of serum. One hour later the intravenous injection of the full dose should be begun. Injections should always be made slowly, with careful attention to the patient's condition, and the serum should be warm when injected.

    Fear of anaphylaxis should never prevent the use of serum when indicated. Careful technic and slow administration will go far to avoid serious accidents of this nature.

    Contacts.-Military experience has shown that a single case of cerebrospinal fever, isolated and properly cared for as soon as the disease is recognized, is ordinarily not followed by subsequent cases in his immediate associates. Those who have been immediately associated with the patient, especially at mess and in sleeping quarters, should be segregated in roomy, light, and clean quarters and eat at a separate mess for a period of two weeks, at the end of which period they may be returned to their proper organization, in the event that no other cases have developed. When, however, more than one case has appeared in a given small group of men, the immediate associates require not only segregation but also bacteriological examination and treatment.

    The amount of time devoted to the examination of contacts will have to depend upon the circumstances, such as the extent and character of the epidemic, the number of contacts to be handled, and the amount of trained help available for the purpose. It is not well to make a pretense of elaborate surveys of contacts when the danger is not considered sufficient to warrant employing the necessary personnel actually to do the work in an efficient manner.

    According to available facilities, the pharyngeal culture may be taken only once, or a duplicate set may be made on the following day. In any case the men should be segregated before the examinations are begun, and when possible those with coughs and colds should be segregated apart from the others. Separate, clean, airy, and light quarters under strict quarantine should be provided for them. Their treatment as carriers should begin directly after the desired number of specimens has been obtained for bacteriological examination. In addition to general hygienic measures such as cleanliness, good food, properly regulated work, play, and rest, the local antiseptic treatment of the upper respiratory passages may with advantage be tried. Various medicaments may be used. Dichloramine-T in chlorcosane, administered by atomizer, is a convenient agent with which to begin. This antiseptic treatment may prevent to some extent the spread of the infection to previously uninfected men who may be in company with actual carriers while awaiting the result of the laboratory examination.

    As soon as a negative result has been reached in these first laboratory examinations, the particular man may be released to his organization. In this way the number of men held in segregation can be very much reduced within two days. Suspicious or positive laboratory results warrant retaining the respective individuals in segregation for further observation.



    1011

    After six days the antiseptic treatment of the positive cases should be discontinued for 24 hours before new cultures are taken, after which the treatment may again be continued. At the end of another week the treatment should be stopped for 24 hours before the third bacteriological examination. The treatment may then again be continued until the laboratory reports have been received. All men found negative at these two examinations should be returned to their organizations. The remaining men should be transferred to a segregation barracks or available hospital formation for treatment as chronic carriers.

    General hygienic measures.-In any command in which an outbreak of cerebrospinal fever has developed, general measures should be instituted at once to improve the living conditions and prevent the spread of respiratory infections among the men. Overcrowding in billets and barracks should be relieved by placing part of the men in tents. Those with coughs and colds should be quartered apart from the others. Distance between heads of adjacent sleepers should be increased by head to foot arrangement of bunks, or the bunks should be separated by wooden partitions or by shelter halves so hung as to separate the sleepers.

    Sleeping quarters should be fully ventilated day and night, and blankets, mattresses, and clothing should be aired and exposed to sunlight daily, weather permitting.

    A special place for drying clothing should be provided, and clothing, wet or dry, should not be allowed at the head of the bunk.

    Dust in quarters should be avoided by cleanliness and by dampening dirt floors with a disinfecting solution.

    All personal equipment-mess kits, pipes, clothing, towels, toilet articles-must be used only by a single individual, and all mess equipment washed and rinsed in boiling water after use.

    The entire command should be examined daily, preferably in the afternoon, to detect beginning illness. Lounging in quarters during the day should be avoided, and sick should be hospitalized at once. Pillows should be prohibited unless they have been properly disinfected before being issued to new troops.

    Careless coughing and sneezing should be prohibited and promiscuous spitting promptly and severely penalized. Gauze masks, not less than eight thicknesses, or the combat gas masks, may be worn during cleaning operations involving exposure to dust. The former should be immersed in boiling water after use.

       WALTER D. MCCAW,
    Colonel, Medical Corps, Chief Surgeon.


    Circular No. 63.
       AMERICAN EXPEDITIONARY FORCES,
      OFFICE OF THE CHIEF SURGEON, SERVICES OF SUPPLY,
      December 30, 1918.

    I. Roentgenograms.-Directions for selection and shipping of Roentgenograms for the Army Medical Museum, Washington, D. C.:

    The commanding officer of each base or camp hospital in the American Expeditionary Forces will have all Roentgenograms on file in his hospital examined by the hospital Roentgenologist with a view to selecting those suitable for preservation in the Army Medical Museum. In hospital centers or groups the work should be done under the direction of the consulting Roentgenologist for the group.

    The following directions will be observed:

    1. Discard all technically imperfect plates unless of unusual interest.

    2. Discard all normal or negative plates.

    3. In selecting plates, emphasis should not be placed upon the bizarre or unusual. It should be kept in mind that this collection of Roentgenograms is to be used especially for teaching purposes.

    4. Gastro-intestinal and genito-urinary plates are not desired unless related to war trauma.



    1012

    5. Plates especially desired are those of good technical quality illustrating all war wounds and diseases of the chest.

    6. Each plate or film should be plainly marked with the date, patient's name, number, and organization.

    7. Each plate or film will be accompanied by the clinical history; autopsy records, if any; personal observations by the Roentgenologist; and all other data throwing light on the case.

    8. Plates should be packed with great care, having in mind the special liability to breakage in overseas shipment. The plates should be placed face to face in pasteboard boxes and then in wooden cases well protected with excelsior, paper, or straw. Each box will be marked in both French and English to denote the fragile nature of its contents.

    9. Films should be packed in tin cases and sealed.

    10. Each box should be numbered and addressed to the Army Medical Museum, Washington, D. C., via -------------------------- (port).

    11. When shipment is made, Col. Joseph E. Siler, central laboratory, Dijon, will be notified of the fact giving the number of the French ordre de transport, number of car in which shipped, and the name of the port to which shipped.

    12. The senior consultant in Roentgenology will be notified by letter when shipment is made, giving the number of plates and films shipped, the ordre de transport number, and number of the car.

    13. Any additional advice needed may be obtained by letter to the senior consultant in Roentgenology, headquarters medical and surgical consultants, A. P. O. 731.

    II. Epidemic disease.-Pursuant to request of the French Service de Sante, the chief surgeon directs that the surgeons of all organizations and commanding officers of medical units promptly notify the local French military and civil authorities upon the appearance in their organization of any epidemic disease.

    Attention is called to the general neglect by medical officers, particularly those of hospital formations, base, camp, and field, of the requirement that they shall notify the local French military and civil authorities (the médecin chief de place and the mairé or prefet) of all cases of communicable diseases as soon as diagnosed or admitted to their organization. The letter from the chief surgeon, line of communications, of January 28, 1918, is quoted, and compliance will be expected.

    It is of considerable importance that every case of any of the diseases specified in Section XII, Sick and Wounded Reports, be reported to the French authorities at the same time that it is reported to the chief surgeon, A. E. F.

    III. Vacancies in permanent Medical Corps.-The Surgeon General writes as follows to the chief surgeon, A. E. F.:

    There is, at present, a large number of vacancies in the permanent Medical Corps of the Army, and it is desired to take advantage of the present conditions to fill them with desirable men-preferably with those who have had some military service in the present war.

    It is therefore requested that you give careful consideration to the selection of suitable officers and that you make a special effort to interest medical officers who have demonstrated their ability and fitness.

    The attention of all medical officers who may be considering entry into the regular corps is called to the fact that rank therein dates from entry, and, if they should decide that they wish to remain in the Army permanently, each week of delay may mean loss of rank which would affect them during their entire service.

    IV. Commutation value of the ration.-This office has been advised by the chief quartermaster that the commutation value of the ration has been fixed at $0.58 for the months of January, February, and March, 1919. Amounts collected by hospitals from local quartermasters should therefore be $0.68 or $0.83, according to whether or not commissary privleges are available.

    V. Clothing for army nurses.-The chief quartermaster advises that he has now in stock hats, overcoats, Norfolk suits, gray ward uniforms, raincoats, shoes, rubbers, silk and cotton waists, and that those articles of clothing are for free issue to all Army nurses whose pay does not exceed $75 per month. Commanding officers of base hospitals and hospital cen-



    1013

    ters will consolidate the requisitions submitted by the various members of their unit, and submit same direct to the office of the chief quartermaster, care being taken to furnish exact sizes of shoes and other garments desired.

    Requisitions will be restricted to actual requirements only. All requisitions must be approved by chief nurses, who will assure themselves of the actual need of articles requested.

    Sales to nurses whose pay exceeds $75 per month will be made at cost prices as follows:
     

    Shoes

    $6.31

    Silk waists

    $5.22

    Overcoats

    $27.86

    Norfolk suits

    $30.00

    Raincoats

    $5.60

    Hats

    $3.17

    Uniforms, gray, ward

    $3.00

    Waists, cotton

    $ .73

    VI. Paragraph 229, Manual for the Medical Department, 1916, is changed, as follows:

    229. Upon the discharge from the hospital of patients permanently disabled, they may retain the appliances then in their use which are necessary for their comfort and safety; and the accountable officer will drop the same from his next return of medical property, submitting a certificate explaining the circumstances as a voucher for so doing, to which will be appended the patient's receipt for the appliance.

    VII. General office supplies.-Attention is invited to General Order 50, headquarters, Services of Supply, transferring the procurement and distribution of standard office supplies, heretofore issued by the Medical Department, to the chief quartermaster. The following items are excepted from the provisions of this order, and will be required for as heretofore by Medical Department units:

    Books, prescription, paragraph 240.
    Binders, loose-leaf, for medical history of post.
    Files, Shannon, for clinical history.
    Labels, for dispensary sets.
    Labels, for vials.
    Labels, poison, assorted.
    Pads, prescription.


    Requisition for office supplies (stationery, office furniture, etc.) will in the future be made on the Quartermaster Department by all Medical Department units.

    VIII. Baggage of patients.-Commanding officers of all base, camp, and evacuation hospitals will notify the central baggage office, A. P. O. 713, Gievres, of the respective departure for the United States of sick and wounded, under their care, and of the location of their baggage, as   well as a list of all patients who have already been evacuated. This information will greatly assist the baggage service in getting baggage to its owner before the owner departs for the United States.

    IX. Publications.-The War Department desires complete files of all publications made by different organizations in the American Expeditionary Forces.

    Complete files, whenever possible, will be forwarded to J. Terquom, Paris agent for the Library of Congress, No. 19 Rue Scribe, Paris. This office will be notified whenever files of a publication are forwarded to Paris.

    X. Proper papers to accompany men evacuated from base hospitals.-Reports are being received that base hospitals are careless in forwarding men to base ports for evacuation to the United States without proper papers. The greatest care must be exercised by all base hospitals evacuating patients to base ports to see that all papers are complete, with proper number of copies of each paper, especially those relating to disability boards and orders directing travel. These points have been covered many times, and it appears that they are not being followed in a conscientious and painstaking manner.

    XI. Broken splints.-Instructions previously issued, directing the shipment to splint repair shop, Dijon, of broken splints, are hereby revoked. In view of the fact that this shop has been discontinued, these splints will in the future be turned in to the nearest medical supply issue depot.

      WALTER D. MCCAW,
      Colonel, Medical Corps, Chief Surgeon.



    1014

    Circular No. 64:

    AMERICAN EXPEDITIONARY FORCES,
      OFFICE OF THE CHIEF SURGEON, SERVICES OF SUPPLY,
      January 7, 1918.

    I. Hospital fund.-(1) Organizations returning to the United States: All medical organizations in the American Expeditionary Forces which are under order to return, or which in the future receive orders to return, to the United States as a unit shall, as long before their departure as is practicable, close out their accounts, and send in a complete report to this office (finance and accounting division) of the condition of the hospital fund, giving in detail any accounts which remain unpaid or amounts due to the fund which remain uncollected, together with the number of enlisted personnel in the unit. Instructions will be issued by this office as to what portion of the fund may be retained by the organization. The balance, if any, will be forwarded to this office, to be credited to the United States Army hospital fund; checks or negotiable papers being made payable to "trustee, United States Army hospital fund." The final account will be audited by the hospital council, and the proceedings shown in the face of the statement.

    (2) Organizations disbanding: Any organization which disbands or for any other reason ceases to exist as a unit will submit, after audit by the hospital council, a final statement on Form 49, M. D., showing the proceedings of the council, properly signed on the face of the statement, and turn in all funds to this office to be credited to the United States Army hospital fund; checks or negotiable papers being made payable to "trustee, United States Army hospital fund." Upon receipt and acceptance of the final statement the custodian will be cleared of all accountability for the funds of his organization.

    (3) Transfer of funds: No organization under orders to disband or return to the United States shall transfer funds to any organization without authority from this office.

    (4) Disposal of funds: Custodians of funds will be held responsible for the improper disbursement of the funds for purchases of articles which are not proper expenditures from the hospital fund.

    (5) Transfer of fund: Any officer who is custodian of a fund and who is transferred from his organization, or for any other reason is to be absent for a period of more than l0 days, will submit a final statement on Form 49, M. D., showing the following properly signed certificates:

    I certify that to the best of my knowledge the following is a complete and accurate statement of all outstanding debts and obligations payable from this fund, and to have transferred to my successor --------------------------------------- , the sum of --------------------------, being the balance on hand this date of the hospital fund of ----------------------------------------------------------------------------------------------------.

    I certify to have received the sum of ---------------------------------, from ------------------------------------------------------------------------------------------------
    being the balance on hand this date of hospital fund of -----------------------------------------------------------------------------------------------------------.

    Until the final statement bearing the above properly signed certificates is received, the present custodian will be held responsible for the funds of his organization.

    II. Purchase of medical supplies.-All purchases of medical supplies in Paris will be made through the office of the medical purchases, room 507, Elysee Palace Hotel, in that city, when same are properly authorized.

    The practice of obtaining medical supplies from the French Government through local Service de Sante formations, and having same vouchered to the Medical Supply Department, United States Army, payment to be made on consolidated bill by a medical disbursing officer, will be discontinued at once.

    Authority for purchases must be obtained before purchase is made from the chief surgeon, A. E. F., except on purchases covered by Circular 15, paragraph 4, office of the chief surgeon, dated December 15, 1917, which applies to detached base hospitals, and Circular 43, paragraph 9, dated August 1, 1918.

    Hereafter a copy of the authority for purchase will accompany the voucher; this in addition to the usual notation of authority on the face of the voucher. Copy of Form No. 12 accompanying the voucher will have entered thereon the property voucher number of the accountable officer.

    III. History and clinical records.-Reports have been received in this office that proper histories and clinical records, including laboratory and X-ray blanks, are not being



    1015

    forwarded with patients evacuated to the United States. Such history and clinical record as may be necessary for the proper care and understanding of the case must accompany each patient upon his evacuation.

    IV. Operations.-It has been evident for some time that a large number of operations are being performed that are not absolutely necessary. In this connection attention is called to Circular 37, office of chief surgeon, June 22, 1918, with special reference to paragraph 4 thereof.

    V. Leather jerkins available for issue to Army nurses.-Leather jerkins are now available for issue to Army nurses. Requisition therefor should be made upon the local quartermaster, approved by the chief nurse of the unit, stating that the nature of the nurse's duty requires the jerkin.

    VI. Returning class A patients to duty.-In returning class A patients to duty with organizations, men must be equipped with the following: 2 blankets, 1 overcoat, 1 blouse, 1 pair breeches, 1 suit of underwear, 2 pairs socks, 1 pair shoes, 1 overseas cap, 1 mess kit, toilet articles. Requisitions will be made immediately on the Quartermaster Department and Ordnance Department to carry these instructions into effect.

    Before returning men direct to organizations, the organization commander will be telegraphed as to ability to receive them.

    VII. Y. M. C. A. patients in military hospitals.-Y. M. C. A. secretaries and workers who are patients in military hospitals for wounds or any other cause will, when able to travel, be sent to the Paris headquarters of the Y. M. C. A., where adequate arrangements are made for their future care and transportation.

    VIII. Vaccination against typhoid and paratyphoid fevers.-Typhoid fever has been recognized in several different organizations in the American Expeditionary Forces, especially those recently engaged in active military operations. Medical officers should be on the alert to detect this disease early in its course. Typhoid and paratyphoid fever should be considered in the differential diagnosis of all obscure pyrexias. Early blood culture is advised.

    Triple typhoid lipo-vaccine is available for immunization of the men of those organizations in which outbreaks of these fevers have appeared. Whenever as many as two cases occur in the same company, within a period of one month, the vaccination of the entire company is advised. If scattered cases amounting to one-half of 1 per cent of the strength of the organization occur in a battalion or a regiment, within a period of one month, immediate inoculation of the entire organization with lipo-vaccine should be undertaken. Only one dose of this vaccine is required. It must be injected into the subcutaneous areolar tissue. The precautions and contraindications are the same as for the saline vaccine previously employed. In this connection your attention is invited to Circular 59, this office.

    IX. Lice.-Reports still continue that patients are evacuated from base hospitals who are lousy. This reflects not only upon the cleanliness of the hospital but the care and administration as well. Commanding officers will take proper steps to see that every patient is carefully examined and when found infested with lice will have effective treatment for their eradication.

    X. Convalescent home for nurses at Antibes, near Cannes.-The American Red Cross has opened another convalescent home for nurses at Antibes, near Cannes. Eighty nurses can be cared for after January 6 and a maximum of 200 about January 15. All convalescent nurses should go to Antibes, and arrangements should be made before they leave their stations to secure reservations at Paris. Many convalescent nurses are reported to have arrived at Cannes physically exhausted on account of difficulty in securing accommodations on board the train.

    Commanding officers of Medical Department formations will in the future forward to this office a carbon copy of their daily reports on Forms Nos. 647 and 648, A. G. O.

    XI. Neuropsychiatrists.-The senior consultant in neuropsychiatry recommends, and this office approves, the retention of neuropsychiatrists in tactical divisions. In at least one case, the division neuropsychiatrist has been relieved from duty with the division because no allowance was made for his assignment to the division by tables of organization. This difficulty could easily be obviated by assigning him to the Sanitary Train.



    1016

    XII. Quartermaster personnel.-Upon the abandonment of hospitalization from various places, commanding officers concerned are instructed that all Quartermaster Corps personnel, not pertaining to statutory units, as they become surplus will be sent to the Quartermaster casual depot, Camp Clayton, Chateau-du Loir (Sarthe), and the chief quartermaster notified of action taken.

       WALTER D. MCCAW,
    Colonel, Medical Corps, Chief Surgeon.



    Circular No. 65.
       AMERICAN EXPEDITIONARY FORCES,
       OFFICE OF THE CHIEF SURGEON, SERVICES OF SUPPLY,
      January 15, 1919.

    I. Monthly reports, sick and wounded.-The following circular letter, Surgeon General's office, November 14, 1918, is quoted for the information of all:

    1. All responsible medical officers are urgently requested to prepare and forward as soon as practicable after the close of the calendar year all the monthly reports of sick and wounded for the year.

    2. It is recognized that in large hospitals, and particularly during extensive epidemics, that it is impossible to prepare and forward the report within five days as required by the N. M. D. Certainly, however, it should be possible to prepare and forward the reports some time during the succeeding months. In many instances reports are several months delinquent. Requests for information are being constantly received from other Government agencies for information which it is difficult or impossible to furnish for this reason. It was impossible to begin the final tabulation of the statistics for the year 1917 until the 1st of May of the year 1918 because so many reports were delinquent. Even after the 1st of May, 1918, a good many reports for the year 1917 were received.

    3. Reports for the year 1918 must be forwarded to this office not later than January 31, 1919.

    II. Salvage of supplies belonging to the British and French medical services.-(1) All supplies received in salvage belonging to the British medical supply service should be shipped to ordnance officer, Graville, Le Havre.

    (2) All medical supplies received in salvage belonging to the Service de Sante medical service should be disposed of as follows: A list covering the property in question in each "region" should be sent to the "directeur du Service de Sante" of the region concerned, who will issue instructions covering its disposition.

    III. Registrars.-The attention of all registrars is called to typographical error in Manual of Sick and Wounded Reports for the American Expeditionary Forces. In Section XI, paragraph 1, line 6, the parentheses should read "(See Sec. VI, par. 7, and Sec. VIII)."

    In the monthly sick and wounded report the cases transferred to the United States differ in no way from cases completed in other manner except that the field medical envelopes and contents accompany the patient instead of being forwarded as a part of the report.

    IV. Gas for anæsthesia.-Hereafter nitrous oxide gas and oxygen will be furnished by medical supply depots only. Empty nitrous oxide tanks will be shipped to American Red Cross nitrous oxide plant, Montereau (Seine-et-Marne), and empty oxygen tanks to the nearest medical supply depot.

    V. Nurses.-(1) Incidents have occurred where Army nurses traveling under orders changing station, and nurses suffering from physical disability traveling between hospitals or to base ports for return to the United States, have encountered great difficulties and discomforts at railroad stations, in boarding trains, in securing seats, in changing cars, and at places of arrival, and have occasionally had to spend the night in railroad stations.

    (2) Hereafter it will be the duty of commanding officers of hospitals or other units forwarding nurses to see that seats are obtained and that nurses and their baggage are put aboard trains, and, after a study of the time-tables and changes, to telegraph the commanding officer of any hospital at places where changes of trains are made, or at places of destination, or to surgeons of base sections in the case of nurses arriving at base ports, giving the number of nurses, the time of arrival, and destination.



    1017

    (3) It will be the duty of any medical officer receiving this message to have some one meet the train, arrange for transportation, assistance with baggage, place to remain at hospitals or other suitable quarters overnight when necessary, to notify the medical officer at the next place where assistance is desired, and to give any help that may be required.

    VI. General Order No. 1, c. s., headquarters, Services of Supply.-The attention of all commanding officers of Medical Department units is invited to General Order No. 1, c. s., headquarters, Services of Supply.

    VII. Special articles of clothing not issued generally.-The commanding general, Services of Supply, directs that commanding officers of all hospitals handle special articles of clothing not issued generally to all enlisted men in such a manner that they will be returned to their original owners in a serviceable condition upon their discharge from the hospital.

    VIII. Neuropsychiatric patients.-In the future no neuropsychiatric patients will be transferred to Base Hospital No. 117, La Fauche (Haute Marne). This hospital is in the process of being closed and abandoned.

    IX. Improper classification of patients in hospital.-Many reports, general and specific, are being received regarding improper classification of patients in hospital. Men have been returned to duty as class A before their wounds were properly healed and when dressings have been necessary. It is imperative that greater care and attention be given to the proper classification of patients in hospital. Commanding officers will, either personally or by delegation of a thoroughly  reliable medical officer, supervise this work. The reports received reflect seriously upon the care and attention given by classification boards to the patients in hospital.

    X. Baggage department.-Regarding the establishment of a baggage department and the handling of baggage of patients in hospital, attention of commanding officers of all hospitals is invited to Bulletin 48, headquarters, Services of Supply, December 3, 1918, and General Orders, No. 62, December 5, 1918, headquarters, Services of Supply.

    XI. Typhoid fever and paratyphoid fever.-All medical officers, and especially those in charge of hospitals, and particularly those on duty in medical wards of hospitals, are advised to note carefully and follow precisely the precautions with regard to the handling, diagnosis, and release after convalescence of cases of suspected or diagnosed typhoid and paratyphoid fevers, as given in sections 184 and 185, of Article III, of the Manual of the Medical Department:

    184. Early detection of all cases of typhoid fever is necessary, especially those of mild or ambulant type, and of all typhoid carriers or excretors. Undetermined fevers should be regarded with suspicion and handled like typhoid until that disease is excluded. Specimens of blood from suspected cases should be sent promptly to the nearest laboratory for diagnosis.

    185. No patient convalescent from typhoid should be released from isolation until three successive examinations of his stools and urine, collected at six-day intervals, have shown him to be free from typhoid bacilli.

    XII. Commanding officers of hospitals to notify commanding officers of organizations.-In view of the present prevalence of typhoid fever in the American Expeditionary Forces, it is directed that commanding officers of hospitals notify by telegraph the commanding officers of organizations from which the patient has been admitted, as soon as a case of typhoid or paratyphoid fever has been suspected or diagnosed. This report will be sent at the same time as, and in addition to, the telegraphic report sent to the office of the chief surgeon, in compliance with Section XII of the Sick and Wounded Reports.

    XIII. Professional reports.-The office of the director in charge of professional services has been closed in our reports. All professional reports required by consultants should be forwarded direct to the office of the chief surgeon.

    XIV. Class A men.-Surgeons of the base ports who are charged with the evacuation of patients report that there are an increasing number of class A men, or men to become class A shortly after their arrival in port hospitals, being evacuated to base ports with the idea of their being sent to the United States. This is contrary to all instructions. Commanding officers and evacuating officers will give special attention to this and see that none of this type of patients are sent to the ports.

       WALTER D. MCCAW,
      Colonel, Medical Corps, Chief Surgeon.



    1018

    Circular No. 66:

       AMERICAN EXPEDITIONARY FORCES,
    OFFICE OF THE CHIEF SURGEON, SERVICES OF SUPPLY,
       February 4, 1919.

    I. Cafeteria system of messing patients.-(1) During the crisis when personnel and equipment were being worked to the utmost limit, the line, or cafeteria, system of feeding patients was in many cases the only practicable one.

    (2) Now that the number of patients is reduced to the normal capacity of the units it is desired that the table service be substituted for patients as rapidly as possible.

    (3) Inspectors have reported on the presence of patients in pajamas and gowns standing in line in inclement weather. This should under no circumstances be allowed to occur, and the substitution of table service for line will prevent this most undesirable condition.

    (4) It is not expected that the table service can be used in all cases for large personnel and casuals on duty status, as in these cases the line system is perhaps the only feasible one. It is, however, desired that patients will not be messed in the line system.

    II. Sales of excess medical property.-Sales to private individuals or associations can only be made through the French Government and should be taken up with the "bureau liquidation stocks de guerre," giving a list of medical supplies wanted with sufficient description to enable the supply department to identify items requested with regular stock. Sales may be made direct to all Governments of the Allied forces, Red Cross, Y. M. C. A., and Knights of Columbus. Requests from all these latter sources should be forwarded to the office of the chief surgeon, A. E. F., with a list of items attached. The final decision covering all sales is made by the general sales board under instructions of the War Department.

    III. Accountability for medical supplies.-Section 3, Circular 3, office of the chief surgeon, line of communications, is hereby rescinded. All property received from whatever source, such as Red Cross, donation or purchase, will be taken up and accounted for in the same manner as regular supplies. All initial equipment of hospitals from the United States whose initial equipment camp from the Red Cross sources should be taken up on property return.

    Property belonging to the French Government, Service de Sante, to hotels under lease, etc., that has not been purchased by the United States Government will not be taken up on property return.

    IV. Hospital funds-collection of amounts due from officer patients.-Referring to collection of amounts due to fund from officer patients as provided for in Bulletin No. 40, headquarters, Services of Supply, 1918, every effort will be made, by correspondence or other suitable method, to secure payment of amounts due from officers indebted for subsistence received while undergoing treatment, in order that the number of names placed upon the Quartermaster Corps stoppage circular may be reduced to a minimum. Attention is invited to the fact that Bulletin No. 40, headquarters, Services of Supply, 1918, affords a method of collection only after every other means of collection by direct correspondence has been exhausted without success, and that it was not the intention to relieve commanding officers, custodians of funds, or mess officers from responsibility in regard to such collections. In future, requests to place delinquent accounts upon stoppage
    circular must be accompanied by statement covering details of efforts previously made to collect such accounts.

    V. Narcotics.-In view of that fact that soldiers of the Medical Department have been recently arrested for selling morphine and cocaine stolen from the Medical Department, the attention of officers is invited to the importance of carefully carrying out the regulations as prescribed in paragraphs 240 and 241, Manual of the Medical Department, for the care of narcotics. They should be kept at all times under lock and key, and the expenditures checked up to the end of each month against the prescriptions. Care should be taken not to carry on hand too large a stock of these drugs, and quantities in excess should be turned into a medical supply depot. Care should be taken not to dispense narcotic drugs by salvage, as it is difficult to keep track of them in this way. They should in all cases where practical be turned into medical supply depots direct.

    VI. Hospital fund.-The second certificate mentioned in section 1, paragraph 5, Circular No. 64, dated January 7, 1919, is hereby amended to read as follows:

    I certify to have received the sum of ----------, from ---------------------------------------------------------, being the balance on hand this date of hospital fund of -----------------------------------------------------------.



    1019

    VII. Daily reports of changes.-Commanding officers of Medical Department formations will forward to this office carbon copies of their daily reports of changes on Form 647 and 648, S. D., A. G. O.

    VIII. Daily reports of casualties and changes.-In the future daily reports of casualties and changes, on Forms 647 and 648, will be rendered separately for the permanent Medical Department personnel of the hospitals and for casual detachments of patients and convalescents. Consolidation of these reports on one sheet leads to confusion in the central records office.

    IX. Orders for return of Medical Department organizations to the United States.-The provisions of paragraph 2, section 5, Embarkation Orders, No. 13, will be complied with only after receipt of formal orders for the return of the Medical Department organizations to the United States. A great deal of confusion is resulting at present through commanding officers of base hospitals and other Medical Department units reporting to G-1, these headquarters, after receipt of notice from this office that they were to prepare for return to the United States. This notification is not final notice, which is only given by G-4, these headquarters.

    X. Class B and C men.-Many men evacuated from hospitals as of class B and C are still being received at the American embarkation center, Le Mans, presumably intended for return to the United States. The second depot division was discontinued at this place in accordance with telegram No. 446, G-1, Services of Supply, on December 7.

    The above practice will be discontinued, and the men forwarded in accordance with General Orders, No. 5, general headquarters, January 5, 1919.

    XI. Colored soldiers.-Complaint has been made that colored soldiers have been erroneously evacuated from hospitals to organizations consisting only of white men. This causes considerable difficulty in quartering and messing the colored men pending their departure for their proper organizations. The only colored divisions which have formed a part of the American Expeditionary Forces have been the 92d and 93d. Care will be exercised in evacuating this class of patients to prevent cause for complaint.

    XII. Lost baggage of patients.-Paragraph 2, Circular Letter No. 24-A, in which it is directed that communications regarding lost baggage of patients should be addressed to lost baggage bureau, Tours, France, is changed to read "central baggage office, Gievres, A. P. O.
    713," in accordance with General Orders 62, Services of Supply 1918.

    XIII. Members of the Army Nurse Corps.-Since the appearance of members of the Army Nurse Corps, either singly or in groups, when they are traveling or after they reach the United States will be the only indication to the casual observer of the discipline, morale, and the standards of those in responsibility for them and the standards which they have made for themselves, it is most important that instead of relaxing their efforts now that the time of demobilization draws near, chief nurses should continue to make every effort to enforce the regulations in regard to the wearing of uniform.

    XIV. Priority lists in selecting cases for evacuation.-Complaints have been made that hospitals have not made use of priority lists in selecting cases for evacuation. It is appreciated that many features enter into the selection of a group of men for transfer to the United States. It is desirable, however, that, when compatible with existing instructions, those who have been awaiting evacuation longest should be given preference to avoid discontent on the part of patients and any semblance of injustice.

    XV. Recruiting of military police.-Authority has been given to the provost marshal general to established recruiting parties in all Services of Supply hospitals for the purpose of recruiting military police from class A men. Commanding officers of hospital centers and base hospitals will give all assistance possible to these parties.

    XVI. Ordnance property.-The chief ordnance officer has directed that the following disposition be made of ordnance property upon abandonment of hospitals: Unserviceable web leather and miscellaneous equipment to intermediate salvage depot No. 8, St. Pierre de Corps; rifles, revolvers, and pistols to ordnance repair shop, Mehun; serviceable mess and personal equipment to intermediate ordnance depot No. 2, Gievres.

       WALTER D. MCCAW,
       Colonel, Medical Corps, Chief Surgeon.



    1020

    Circular No. 67.

      AMERICAN EXPEDITIONARY FORCES,
       OFFICE OF THE CHIEF SURGEON, SERVICES OF SUPPLY,
      February 8, 1919.

    I. Typhoid and paratyphoid fever.-Date of onset of typhoid and paratyphoid fever: All commanding officers of hospitals in the American Expeditionary Forces, when reporting suspected cases of typhoid or paratyphoid fever, or a case in which the diagnosis is based on clinical grounds, or a case proved by laboratory methods to be typhoid or paratyphoid, in compliance with Section XII, Sick and Wounded Reports, will add to the data now required by telegram the word "onset" and the date of the appearance of the initial symptoms of the disease; i. e., the date when the patient first felt really ill. This date is to be obtained by careful inquiry into the history of each case; the day when the patient first reports sick or when he is admitted to hospital or when he first goes to bed is not necessarily the date of onset of the disease and is not uncommonly a week or more after the true date of the onset of the disease as diagnosed by careful clinical history.

    In order to accomplish effective control of typhoid and paratyphoid fever the personal attention of the commanding officer of every hospital formation in the American Expeditionary Forces must be given to this detailed report. The office of the chief surgeon can then give immediate and accurate information to surgeons of organizations which will permit of their discovery of cases and the tracing of the source of infection among the troops.

    Typhoid and paratyphoid fever to be reported on clinical diagnosis: In order to comply with Section XII, Sick and Wounded Reports, the following will be observed:

    (a) All suspected cases of typhoid and paratyphoid fever must be reported as such by telegram without waiting for clinical or laboratory confirmation.

    (b) All cases which present a clinical picture of these diseases must be reported as clinical typhoid or paratyphoid as soon as the diagnosis of typhoid or paratyphoid is made.

    (c) All cases in which the diagnosis of typhoid or paratyphoid is confirmed by bacteriological methods or by autopsy must be reported as proved cases of these diseases.

    (d) Cases originally reported as suspected or clinical cases of typhoid or paratyphoid, if subsequently proved by laboratory methods or by autopsy to be cases of these diseases, must be again reported indicating that they are now proved cases.

    (e) If cases originally reported as suspected or clinical typhoid or paratyphoid are found subsequently not to have either of these diseases, correction of report must be made, by telegram, giving change of diagnosis.

    (f) Individuals who are found to be excreting typhoid or paratyphoid bacilli in stools or urine, but who have not been sick recently with a disease resembling typhoid or paratyphoid, must be reported as carriers. These individuals may be temporary or permanent carriers.

    (g) Individuals who are found to be excreting typhoid or paratyphoid bacilli in stools or urine and who have recently had a febrile disease known to be typhoid or paratyphoid, or a disease which in the absence of proof to the contrary and in the face of known facts might have been typhoid or paratyphoid, must be reported as convalescent carriers.

    In all instances reports to the chief surgeon will be by telegram.

    II. Evacuation of typhoid carriers.-Whenever it becomes necessary or desirable to evacuate a carrier of typhoid or paratyphoid fever to the United States, the carrier shall be evacuated as a patient on sick report. The office of the chief surgeon shall be notified of the name, rank, organization, and home address of the patient as well as of the fact and date of such evacuation. A special communication calling attention to the fact that the man is a carrier and that special precautions must be taken to avoid spread of infection shall be sent with the transfer slip or field medical card which accompanies the patient.

    III. Reports.-The attention of all medical officers is invited to the fact that personal reports of change of status should be rendered to this office as promptly as possible and that monthly personal reports should invariably be mailed on the last day of the month. These reports have been neglected to a great extent through the active operations of the past year, and it has been very difficult to keep track of locations and status of officers.

    IV. Daily reports of changes of hospital personnel and patients.-The attention of all commanding officers of Medical Department units is invited to Section IV, General Order No. 16, c. s., general headquarters, A. E. F.



    1021

    V. Psychiatric department, hospital center, Allerey.-Attention of all concerned is directed to the fact that the psychiatric department for the reception, observation, early treatment, and evacuation of mental cases is no longer in operation at the hospital center, Allerey. Paragraph 2  of Circular Letter No. 35-A should be corrected accordingly.

    VI. Base hospitals abandoned and being abandoned: (1) The following listed base hospitals have closed their records and ceased to function on the dates shown in each case:
     

    Base Hospital No. 20, Chatel Guyon (Puy de Dome), January 20, 1919.
    Base Hospital No. 30, Royat (Puy de Dome), January 20, 1919.
    Base Hospital No. 66, Neufchateau (Vosges), December 31, 1918.
    Base Hospital No. 117, La Fauche (Hte. Marne), January 12, 1919.


    (2) The following base hospitals are being abandoned:
     

    Base Hospital No. 83, Revigny (Meuse).
    Base Hospital No. 71, Vauclaire (Dordogne).
    Base Hospital No. 202, Orleans (Loiret).
    Base Hospital No. 236, Quiberon (Morbihan).
    Base Hospital No. 218, Poitiers (Vienne).


    (3) Hospitalization at the following places has been abandoned:
     

    Pau (Basses Pyrenees).
    Lourdes (Haute Pyrenees).
    Caen (Calvados).
    Autun (Saone et Loire).


    VII. Circulars Nos. 73 and 75, War Department.-Circular No. 73, War Department, November 18, 1918, and Circular No. 75, War Department, November 20, 1918, relating to the discharge of officers and soldiers, mentioned in Circular No. 61, dated December 18, 1918, this office, have been republished in General Order No. 230, general headquarters A. E. F., December 16, 1918.

    VIII. Hospitals to be furnished with dubbin, or shoe polish.-(1) By direction of the commander in chief, A. E. F., all hospitals will keep on hand, for use of hospital detachments and patients, a supply of dubbin, or shoe polish, to be used on the shoes. Commanding officers of hospitals will insist on shoes being treated with this material.

    (2) Should a supply of dubbin, or shoe polish, not be on hand, requisition will immediately be made for this material.

       WALTER D. MCCAW,
      Colonel, Medical Corps, Chief Surgeon.


    Circular No. 68.

    AMERICAN EXPEDITIONARY FORCES,
       OFFICE OF THE CHIEF SURGEON, SERVICES OF SUPPLY,
      February 8, 1919.

    I. Accountability for medical property.-Disbursing officers, property officers at medical supply depots, including base storage depots, also at base hospitals and at schools, will continue to account for medical property, as required by existing orders.

    Formal accountability for medical property is not required from any other officers.

    Invoicing and receipting for supplies transferred by disbursing officers, property officers at medical supply depots, base hospitals, and schools will be done in the manner prescribed by Army Regulations and Manual for the Medical Department, but the receipts given by all other officers than those above mentioned will be for the sole purpose of clearing the accountability of the issuing officer.

    Officers who are relieved from formal accountability for medical property which is in their care or under their control must remember that their duty to protect the interest of the Government is in no way diminished thereby. Attention is called to Section II of General Orders, No. 74, as to their duty in this connection and as to the means which will be taken to enforce proper care and use of Government property.

    II. The attention of all officers coming to Tours is invited to the fact that the address of the finance and accounting division is No. 4, Rue de Clocheville, and that the sick and wounded division is at No. 17, Place Forre-le-Roi.



    1022

    III. All medical officers are directed to remove the following drugs from salvage before turning same in to salvage depots: Morphine, cocaine, heroin, codeine, chloral, and opium preparations.

    These drugs will be sent to the nearest medical supply depot by courier, with list covering shipment; depot officer concerned receipting thereon.

       WALTER D. MCCAW,
      Colonel, Medical Corps, Chief Surgeon.



    Circular No. 69.

    AMERICAN EXPEDITIONARY FORCES,
    CHIEF SURGEON'S OFFICE, SERVICES OF SUPPLY,
      February 17, 1919.
     
     

    TYPHOID-PARATYPHOID FEVERS

    I. INTRODUCTION
     In view of the appearance and continued incidence of fevers of the typhoid-paratyphoid group in many units of the American Expeditionary Forces during the past five months, it is deemed essential to review this subject at the present time, particularly from the viewpoint of early diagnosis, prevention, and control.

    The occurrence and distribution of typhoid-paratyphoid in our troops has constantly and continuously been brought to the attention of all medical officers serving with the A. E. F. through the medium of the Weekly Bulletin of Diseases. It would appear, however, that many officers have utterly failed to grasp the significance of these reports and warnings, a fact which may be due to a false sense of security under the popular belief that vaccination against typhoid and paratyphoid gives a complete immunity even in the midst of gross unsanitary conditions.

    Notwithstanding the fact that typhoid and paratyphoid fevers are endemic in the United States, and in spite of our extensive experience with these diseases during the Spanish-American War and, later, during the period of mobilization on the Mexican border, it is evident that many medical officers have gained but little knowledge of the fundamental principles underlying prevention and control. It is also quite evident that some medical officers are grossly careless and neglectful of their duties and responsibilities as medical officers and sanitarians.

    This office realizes fully that the United States has raised, within a short period of time, an army of several millions of men who have been poorly instructed in personal hygiene and sanitation; it realizes that 2,000,000 of these men have been brought to France where they have encountered environmental conditions differing entirely from those existing in the United States; it is fully recognized that military necessity has at time rendered sanitary control extremely difficult, especially during the stress of active combat.

    To our regret, be it said, the high standards of sanitation and personal hygiene set by the Medical Department during the past 10 to 15 years have not been lived up to during the past 1½ years. This has been due to a combination of factors, the more important of which have been the lack of facilities and materials, transportation difficulties, and insufficient training and personnel. However, many medical officers serving with combatant and Services of Supply units have been able to overcome all handicaps and have by wise counsel and by eternal vigilance succeeded in keeping their units in excellent fighting trim.

    The actual physical fighting is now at an end, and the time-worn excuse that "there is a war on" will no longer be tolerated. But the fight against disease still continues.

    The greater part of the American Expeditionary Forces is now relatively stationary in training areas or with the armies of occupation, where definite sanitary measures can be instituted and enforced, where instruction of the line troops can be carried out, and where opportunity is presented to initiate rules of personal hygiene. Medical officers will therefore be held responsible for the proper supervision of the health of troops.

    Carbon copies of all general recommendations of medical officers covering sanitation and personal hygiene, promulgated officially as orders and memoranda by superior authority, will be mailed to this office.



    1023
     II. SUMMARY OF TYPHOID PARATYPHOID INCIDENCE IN THE AMERICAN EXPEDITIONARY FORCES
    In order that all medical officers in the American Expeditionary Forces may have a somewhat comprehensive view of the occurrence of these fevers in the American Expeditionary Forces, the following brief review is presented.

    (a) From June 1, 1917, to June 1, 1918, but few cases occurred. The rate was well within the limits to be expected in view of the sanitary conditions under which the troops were of necessity living. The cases were sporadic and only occasionally did secondary cases develop.

    (b) In July, 1918, a replacement unit consisting of 248 men, from Camp Cody, N. Mex., reached England with typhoid prevailing extensively; 98 men, or 39.5 per cent, had typhoid, and the case death rate was 8.42 per cent.

    It was evident from the investigation that the men were exposed to infection through contaminated drinking water while en route to the port of embarkation in the United States. The unit had been vaccinated a few months prior to the occurrence of the epidemic. Most of the patients presented the typical clinical features of typhoid. The percentage of positive bacteriological findings from the blood, feces, and urine was low, as no laboratory work could be done until late in the course of the disease.

    (c) In August, 1916, a small but severe epidemic occurred in a detachment of engineer troops stationed at Bazoilles. In this unit 15 cases of typhoid occurred, with a death rate approximating 10 per cent. Typhoid was endemic in the civil population, and the epidemic was very definitely traced to a cook in the mess of this engineer detachment who remained on duty as a cook for five days after the onset of the symptoms. The epidemic was recognized in its early stages, and in all patients the disease was confirmed bacteriologically by positive cultures from the blood and feces.

    (d) During the Chateau Thierry offensive diarrhoal diseases were very prevalent in the troops engaged (approximately 75 per cent). It was demonstrated bacteriologically, in this area, that the prevailing intestinal diseases were simple diarrhoa, bacillary dysentery, typhoid, paratyphoid A and B. The sick and wounded from this sector were evacuated to base hospitals in various parts of France. Very soon therafter this office began to receive reports of cases of typhoid, paratyphoid, and bacillary dysentery from base hospitals. In practically all instances the patients had been evacuated from the Chateau Thierry sector. The high incidence of intestinal diseases in this sector was due to the entire disregard of the rules of sanitation. "Military necessity" and the impossibility of supplying auxiliary labor troops, at that time, prevented immediate police of the battle fields. In some of the cases involved in this series the diagnosis of dysentery or typhoid was made by the pathologist at autopsy. The percentage of positive bacteriological findings was low, as the correct diagnosis, if made, was not usually
    arrived at until late in the course of the disease.

    (e) Both dysentery and typhoid-paratyphoid fevers were demonstrated to have prevailed to some extent in our troops after the St. Mihiel offensive, but the epidemics of influenza and pneumonia prevailing at that time overshadowed all other medical admissions.

    (f) Following the offensive in the Argonne sector, typhoid and paratyphoid began to be reported from practically all divisions engaged in that offensive. It is quite evident that the initial cases were due, in large part, to drinking infected water. The initial cases, however, in large part were not, in most instances, promptly diagnosed, and secondary cases from contact began to occur. In some divisions either the initial
    exposure was not great, the organizations were under good discipline, or the medical officers had a proper conception of their duties and responsibilities and but few cases occurred. In other instances the contrary was true, and many cases have occurred. As examples of the two extremes may be cited  the ----- Division, in which 5 cases occurred between October 1, 1918, and February 1, 1919, and the ----- Division, in which 115 cases occurred in the same period.

    More than 300 cases of typhoid-paratyphoid may be attributed to the Argonne offensive. Eight hundred and seventy-four typhoids and paratyphoids have been reported in



    1024

    the American Expeditionary Forces since October 1, 1918. The percentage of confirmatory laboratory diagnoses has been low on account of the fact that the clinicians frequently failed to suspect the disease in its early stages.

    (g) A small but severe epidemic occurred in the Joinville concentration area in December and January. In a group of Medical Department units (evacuation and mobile hospitals and sanitary trains) concentrated there 75 cases occurred, with a case death rate of approximately 20 per cent. The cases were suspected in the early stages of the disease, and the percentage of positive findings by culture of urine or feces has been greater than 75 per cent. The cause of this epidemic has not been completely analyzed as yet, but there is but little question that it was due to the use of infected drinking water.
     III. REPORTS OF CASES

    If epidemics are to be recognized in their incipiency and measures initiated to control and prevent further extension, it is manifestly of the utmost importance that reports of suspects and proven cases be transmitted to the medical officers of organizations directly concerned at the very earliest possible moment. The large number of troops involved, methods of evacuation, delays in transmission of reports, necessary censorship regulations, frequency of troop movements, laxity in making reports, unwarranted delay in making diagnoses, and other factors have tendered to hamper this most important instrument for the control of transmissible diseases. The medical officers charged with the supervision of the health of all organizations must know at the earliest possible moment of the diagnosis or provisional diagnosis of typhoid or paratyphoid in a member of his organization, and for this diagnosis he must depend on the ward surgeon in the camp, evacuation, mobile, base, or other hospital unit of which the patient has been evacuated. Ward surgeons and chiefs of medical service in hospitals charged with the care of these patients do not appear to comprehend their responsibility in this matter. As a matter of fact, they are jointly responsible with the medical officers of the organization for any epidemics occurring in a command if they delay, in the least, in making diagnoses or in reporting suspects or positive cases. The records of this office show that patients with typhoid have passed successively through camp, field, evacuation, and base hospitals without any documentary evidence that typhoid or paratyphoid were even suspected. There are records of a stay of two weeks or more in a single base hospital without diagnosis, and not a few records are on file showing that it remained for the pathologist to make the diagnosis at the autopsy table. If a tentative or positive diagnosis of typhoid or paratyphoid does not reach the medical officer of an organization until two or three weeks after the evacuation of the individual from the command, the damage already is done, additional individuals already are infected, and the problem of control becomes all the more difficult. If, on the contrary, ward surgeons in hospitals are keenly alive to their duties and responsibilities, will suspect typhoid and paratyphoid in all fevers of undetermined origin, will endeavor to confirm their suspicions by early blood culture, will promptly report all clinical cases as such and positive cases as such, the necessary information can be transmitted immediately to the medical officer of the organization concerned, who can in turn institute measures for the prevention of secondary cases.

    In order that reports of cases of typhoid and paratyphoid may be transmitted more promptly to the medical officer attached to organizations, the following procedure will be adopted:

    (a) Commanding officers of Medical Department units caring for the sick will be held responsible for reporting promptly by telegraph, as already provided for in Section XII, Sick and Wounded Reports; all suspected, clinical and proved cases of typhoid and paratyphoid. The commanding officers of such hospitals will hold the chiefs of their medical services directly responsible for the prompt submission of diagnoses in these cases. Any laxity or incompetency in this respect will be immediately reported to this office for necessary action.

    (b) When reporting these cases, in addition to the data now required by telegraph, the word "onset" followed by the date of appearance of the initial symptoms of the disease will be included in each case. In securing these data it must be understood that the date of "onset" is not necessarily the day on which the patient first reported sick or the date on



    1025

    which he was admitted to the hospital, but rather should be regarded as the day when the patient first had any symptoms indicative of the disease.

    (c) In reporting cases of typhoid or paratyphoid, in compliance with paragraph (a) above, the following classification will be observed:

    1. All suspected cases of typhoid and paratyphoid will be reported as "typhoid or paratyphoid suspects."

    2. All cases which present a clinical picture of these diseases will be reported as "clinical typhoid or paratyphoid," using the term "clinical typhoid or paratyphoid."

    3. All cases in which the diagnosis of typhoid or paratyphoid has been confirmed by bacteriological methods or autopsy will be reported as "proved typhoid or paratyphoid."

    4. Individuals who are found to be excreting typhoid or paratyphoid bacilli in their stools or urine and who have recently had a febrile disease presenting the clinical symptoms of typhoid or paratyphoid, will be reported as "convalescent typhoid or paratyphoid carriers."

    5. Individuals who are found to be excreting typhoid or paratyphoid bacilli in their stools or urine, but who have not been sick recently with a disease resembling typhoid or paratyphoid, will be reported as "typhoid or paratyphoid carriers."

    6. Cases originally reported as suspects or clinical cases of typhoid or paratyphoid and which have subsequently been proved, by laboratory methods or autopsy, to be one of these diseases will be again reported, stating that they are now proved cases. The telegram reporting such proved cases will indicate clearly that they have formerly been reported as suspects or clinical cases.

    7. If cases originally reported as suspects or clinical typhoid or paratyphoid are subsequently found not to have been one of these diseases, these cases will be reported by telegraph showing change of diagnosis. In all telegrams reporting such change of diagnosis, definite information will be submitted indicating that they have been reported previously as suspects or clinical cases.

    (d) All reports outlined above will be sent by telegraph to the chief surgeon, A. E. F. If the hospital unit reporting such cases is attached to one of the armies, a duplicate of this report will be submitted to the chief surgeon of the army concerned, in such manner as he may indicate. If the hospital unit is under the orders of a section surgeon, surgeon of the district of Paris, or surgeon of the American embarkation center at Le Mans, a duplicate of this report will be submitted to the section, district, or embarkation center surgeon, in such manner as he may indicate.

    Chief surgeons of the armies will establish close liaison with base, evacuation, and camp hospitals in the immediate vicinity of their commands, but not a part of their commands, to which patients from their commands are to be evacuated. If cases of typhoid or paratyphoid from armies are diagnosed in such camp, evacuation, base, or other hospitals, the commanding officers of such units will, in addition to the reports called for above, make immediate report of such cases by telephone, telegraph or courier to the chief surgeon of the army concerned.

    8. The special attention of all medical officers is invited to section 189, Article III, Manual of the Medical Department, quoted below, which will be strictly complied with.

    189. A report will be furnished in every case of typhoid fever or paratyphoid fever occurring in an officer, enlisted man, or civilian employee who has received the typhoid vaccine, describing in detail the method of arriving at diagnosis.

    Special blank forms covering the information to be submitted will be obtained on request to this office.
     IV. CLINICAL DIAGNOSIS OF TYPHOID AND PARATYPHOID FEVERS

    In view of the fact that the ordinary clinical picture of typhoid-paratyphoid is very frequently profoundly modified in vaccinated individuals, it is considered essential to enumerate briefly the usual clinical manifestations of these fevers, atypical modes of onset, differential diagnosis, and modifications of the usual clinical manifestations in vaccinated individuals.

    1. Clinical manifestations of typhoid and paratyphoid.-Typhoid fever in the unvaccinated is commonly characterized clinically by symptoms due to the gradual development



    1026

    of a general bodily infection. The onset is insidious, with lassitude, malaise, gradual step-like rise in temperature with slight morning remissions, until at the end of the first week a continuous fever of from 103º to 105º F. has been obtained. The beginning of the attack is usually associated with anorexia, headache, and frequently with diarrhoa, abdominal distress, and epistaxis. The pulse is not increased in proportion to the temperature, is of low tension and dicrotic. The tongue is coated and white and the abdomen distended and tender. From the seventh to the tenth day the rash appears in the form of slighly raised flattened papules of from 2 to 4 mm. in diameter, which can be distinctly felt, are of a rose red color, and fade on pressure. These rose spots, characteristic of typhoid and paratyphoid, appear singly or in crops, usually first on the skin of the abdomen and lower thoracic region, but may occur only on the back or extremities. The individual rose spot persists for from two to three days, after which it fades, leaving a brownish stain which persists for some time. Toward the end of the first week the spleen enlarges, and its edge can be distinctly felt below the costal margin.

    At the end of 10 days the symptom complex clinically characteristic of typhoid-continous fever, rose spots, and enlarged spleen-is usually established. To this should have been added laboratory findings of absence of leucocytosis and in the majority of instances a positive blood culture, which occurs most frequently during the early stage of the disease. One negative blood culture will not suffice, but repeated examinations at 48-hour intervals will be made in suspicious cases.

    During the second week there is continued high fever, with slight morning remissions. The pulse becomes rapid and loses its dicrotic character, the patient becomes dull and stupid, the lips are dry, the tongue is dry and covered with a dirty brownish coat and tremulous. Abdominal symptoms when present, tympanites and diarrhoa, are more pronounced, and the clinical picture becomes one of intense toxemia. In the third week, in favorable cases, the morning remissions in temperature become more marked, the fever becomes distinctly remittent in type, and toward the end of this period a gradual fall in temperature by lysis is noted. Rose spots cease to appear. In severe cases the pulse is weak, ranging from 110 to 130, and pulmonary complications, especially pneumonia and hypostatic congestion, may occur. The patient is dull and apathetic, and low muttering delirium and subsultus tendinum are common. During the fourth week convalescence begins, the temperature gradually reaches normal, the abdominal symptoms subside, the tongue becomes clear, and the desire for food returns. In
    severe cases convalescence may be delayed until the fifth or even the sixth week, in which case the fever continues high during the fourth week, and it is only toward the end of this period that marked daily remissions make their appearance.

    In individuals previously vaccinated against typhoid, but who have completely lost their immunity, infection similar to that found in the unvaccinated occurs, giving rise to the symptom complex described above as characteristic of typhoid fever.

    Infections occurring in the vaccinated individual who still possesses a certain degree of resistance to infection result in the appearance of atypical clinical pictures, such as abortive types of typhoid and paratyphoid in which the constitutional symptoms are mild but with slight febrile reaction of atypical type and few if any rose spots. The onset may be either insidious, with headache, loss of appetite and fatigue, or acute and associated with chills, vomiting, intestinal cramps, and diarrhoa. Fever may be wholly absent or evanescent in character and determined only if observations are made within the first 48 to 72 hours. A low type of temperature, with daily fluctuations of from 98.6° to 100.4°, suggestive of the presence of tuberculous disease, may persist for a week or 10 days. It is in this class of cases that blood cultures taken early in the course of the disease, and repeated if negative, frequently give definite information concerning the nature of the infection. Ambulatory types of typhoid are not uncommon, and the first indication of the existence of the disease may be furnished by the occurrence of intestinal hæmorrhage or perforation.

    The vaccinated individual protected against general systemic infection may still act as a carrier of typhoid infection, and frequently shows clinical manifestations of local disease of some portion of the gastro-intestinal tract, while the characteristic symptom complex of typhoid fever due to general infection, namely, continued fever, rose spots, and enlarged spleen, may be wholly absent.



    1027

    2. Distinctive complications.-Intestinal hæmorrhage occurs usually during the third and fourth weeks. The onset is marked by a sudden and frequently pronounced fall in temperature associated with increased gravity of the general condition and a rise in pulse rate.

    Intestinal perforation occurs usually during the third or fourth week. Patients whose sensorium is not too clouded complain of sudden paroxysmal abdominal pain, usually referred to the right hypogastric region. Signs of peritoneal irritation rapidly become manifest. Vomiting is common. Hiccough and irritability of the bladder, with frequent micturition, may be noted. Physical examination of the abdomen reveals tenderness and muscle rigidity most marked in the right hypogastric or iliac region. Obliteration of liver dullness is frequently present and constitutes an important sign. Acute abdominal symptoms associated with a suddenly appearing leukocytosis are indicative of perforation. The occurrence of intestinal hemorrhage or signs of intestinal perforation in an individual giving a history of previous ill health should always lead to the suspicion of the existence of typhoid.

    3. Atypical modes of onset.-(a) Acute onset, with symptoms simulating meningitis. Lumbar puncture differentiates.

    (b) Acute onset with intense, usually generalized bronchitis or symptoms suggestive of lobar or broncho-pneumonia.

    (c) With chills, fever, vomiting, cramplike pain in abdomen, sometimes localized in right iliac fossa and suggesting appendicitis.

    (d) With symptoms of acute nephritis. Attack begins suddenly, with nausea, vomiting, pain in lumbar region, diminution in secretion of urine, which is highly colored and contains albumin and casts.

    (e) Special mention should be made of the ambulatory type of typhoid in which the symptoms are slight, consisting simply of headache and lassitude associated with mild gastro-intestinal disturbances. The patient is at no time confined to his bed, and intestinal hemorrhage or perforation may furnish the first clue with regard to the existence of typhoid.

    (f) In the above atypical modes of onset early blood cultures are of importance in differentiation.

    4. Paratyphoid fevers.-The paratyphoid fevers, due to infection with A or B organisms, are evidenced clinically by the same general symptomatology as that of typhoid. They, however, as a rule, run a much milder course and the intense toxemia of typhoid, evidenced by marked apathy, muttering delirium, and subsultus tendinum is seldom present. The onset of paratyphoid is frequently more abrupt, with acute gastro-intestinal symptoms resembling food poisoning. The intestinal symptoms are as a rule more marked in cases of infection with paratyphoid B than in cases in which paratyphoid A is the causative factor. The fever in paratyphoid is not of as long duration nor is it as continuous as in typhoid, but is more distinctly remittent in type. Enlargement of the spleen, rose spots, and absence of leukocytosis are, as a rule, present in all three infections. Attempts have been made by some authorities to distinguish between the eruptions of paratyphoid A, paratyphoid B, and typhoid. Thus the spots in paratyphoid A are said to be larger, more macular in type, of a darker reddish hue, and to
    correspond more closely to the eruption of measles. However, histologically the rash is the same in all three instances, and it is doubtful if a clinical distinction in type of eruption can be maintained. Rose spots may be wholly lacking or may be profuse and widely distributed over the body surface. The occurrence of relapses is more frequent in paratyphoid than in typhoid proper, and particularly is that true in connection with type A infections. In contradistinction to the relapse of typhoid, that of paratyphoid is frequently more severe than the original attack. The distinction between mild typhoid, paratyphoid A, and paratyphoid B can be made definitely only by the isolation of the infecting organism from cultures of the blood, urine, or stools.

    5. Differential diagnosis-Influenza.-Many cases originally diagnosed as influenza in the American Expeditionary Forces have subsequently proven to be typhoid. The symptoms which the two diseases have in common are: Continuous fever without localizing symptoms and slow pulse associated with absence of leukocytosis. The more abrupt onset, the intensity of the headache, the severe pain in the back and eyeballs, and the early prostration occurring in influenza are distinctive. Supposed influenza in which the fever persists for more



    1028

    than four days and which is not associated with signs of respiratory involvement, such as bronchitis, usually most extensive in the lower lobes, a broncho or lobar pneumonia should be viewed with suspicion. It should be remembered that a general bronchitis is not uncommon in typhoid. The appearance of rose spots should determine typhoid. Intestinal types of supposed influenza should always be considered as possible typhoid until proven otherwise.

    Acute miliary tuberculosis.-A family history of association with tuberculous individuals, a personal history of previous attack of pleurisy or pulmonary hemorrhages, physical signs of old tuberculous pulmonary lesions, cyanosis appearing early in the disease associated with increased rate of respiration, a greater irregularity of temperature curve, and a more rapid pulse with absence of dicrotism suggest acute miliary tuberculosis. Roentgenograms of the chest and blood cultures frequently give valuable differentiation.

    Septicemia.-In cases of late typhoid admitted to the hospitals during or after three weeks of profound toxemia, together with the, by this time, distinctly remittent temperature, may suggest septicemia. The slight daily fluctuation in the general condition of the patient together with the absence of chill and leukocytosis, suggest typhoid. Blood cultures will always be made in such cases and, if negative, cultures of the stools will be made for the presence of typhoidlike organisms.

    6. Local and unexplained gastro-intestinal derangements, gastritis, acute or chronic, diarrhea, dysentery, gastro-enteritis, enter-colitis, colitis, appendicitis, cholecystitis, and acute catarrhal jaundice, all occuring with or without fever, should be regarded with suspicion when admitted from commands in which cases of typhoid or paratyphoid have occurred, and examination of the stools for the presence of typhoidlike organisms should be made.

    Medical officers will see that all cases of gastro-intestinal derangement enumerated above, as well as all fevers of undetermined origin, are subjected to careful clinical and laboratory supervision. They will under no conditions be left in quarters, but will be sent at once to camp, evacuation, mobile, or base hospitals where accurate observation of temperature at four-hour intervals will be recorded for a period of at least four days. Blood cultures will be taken in every case of fever of undetermined origin in which the temperature has persisted for a period of 48 hours and, if negative, will be repeated provided unexplained fever persists from the second to the fourth day.

    Daily physical examinations of such cases will be made, special attention being paid to physical examination of the abdomen for enlarged spleen, distention, and tenderness, either general or localized. A careful survey of the entire surface of the body will be made for the possible appearance of rose spots.

    The precautions appropriate for a case of typical proved typhoid or paratyphoid fever must be observed in all instances where atypical or undetermined fevers are held under observation, awaiting clinical or bacteriological diagnosis of specific enteric infections. The frequency with which atypical, mild, unrecognized cases of typhoid and paratyphoid fever have occurred in the American Expeditionary Forces among vaccinated men makes it absolutely essential to surround all such cases of undetermined fever with the same precautions which it is found necessary to apply to establish typhoid or paratyphoid patients, to avoid contact infections in the wards among other patients and hospital personnel.

    7. Temperature records, clinical notes, and the original reports of laboratory findings in all cases of typhoid, paratyphoid, fevers of undetermined origin, and the above-mentioned list of gastrointestinal disorders will accompany the patient if transferred to another medical unit, and will be preserved and forwarded to the office of the chief surgeon as per instructions contained in section VI, paragraphs 6-7, Sick and Wounded Reports for American Expeditionary Forces, September 15, 1918. In no instance will the clinical notes, temperature, and laboratory records of these cases be destroyed upon the completion of the case.
     V. LABORATORY DIAGNOSIS OF TYPHOID AND PARATYPHOID FEVERS

    Bacteriological procedures are of great value (1) for the certain and early diagnosis of suspected cases, (2) to determine carrier state in convalescent positive cases, (3) to detect carriers in otherwise normal individuals.

    Blood cultures offer the most certain method for early diagnosis of undetermined fevers, and it should be kept in mind that the earlier in the disease the blood culture is taken the more



    1029

    likely is the result to be positive; thus, in positive typhoid fever the chance of successful blood culture declines from 90 per cent during the first week to 40 per cent during the third week. In paratyphoid A fever, because of the frequently short and mild febrile period, the prompt and early blood culture is all the more necessary. Relapses are more common in paratyphoid than in typhoid, and taken at such a time blood culture yields positive results in every case.

    The following method of blood culture is recommended as being suitable in all cases of fever of undetermined etiology.

    (a) When laboratory facilities are at hand, take 10 c. c. of blood from a vein at the elbow. Place 3 c. c. in each of two flasks containing 100 c. c. of plain broth. Place 1 c. c. in tube of agar (melted and cooled to 45° C.), immediately mix and pour plate. Place remainder of blood in dry sterile test tube to separate serum for such serological tests as may be suggested.

    The two flasks and plate are incubated and examined the following day. Transplants are made to plain agar slants, or, better, Russell's double sugar agar. In case of development of Gram-negative motile bacilli or agar slants, emulsions should be made and agglutination tests done with immune sera for final identification.

    Frequency of nonagglutinability of recently isolated typhoid cultures should be kept in mind.f  Negative blood culture in suspected typhoid fever means little. Repeat if clinical conditions indicate.

    (b) If the blood culture specimen can not be taken directly to the laboratory, filtered sterile ox bile is most useful, 5 c. c. in a tube. To such sterile ox bile 5 c. c. of blood is added, the tube closed with a sterile paraffin cork, carefully packed, and sent for examination to the nearest laboratory. Bile medium is furnished in chest No. 1, transportable laboratory, United States Army, expeditionary force model. Additional supply of this medium may be obtained as needed from central medical department laboratory, A. P. O. 721.

    Bacteriological examination of feces is second only to blood culture as an important means of positive diagnosis. It is especially important in paratyphoid B fever.

    Typhoid or paratyphoid carriers.-Typhoid and paratyphoid patients excrete the bacilli, frequently with their urine and practically always in their feces. This is most likely to occur during the third and fourth weeks of the disease; the condition may persist throughout convalescence and not infrequently longer. It is therefore important not to release the convalescent typhoid or paratyphoid fever patient until he ceases to excrete these bacilli.

    Three negative cultures of the urine and feces at six-day intervals should be required before release of patient, the first not earlier than one week after temperature curve has become normal.

    Some persons who have never had a clinical history of the disease may excrete typhoid or paratyphoid bacilli. It is important to detect such carriers in any occupation, but especially among cooks and handlers of foodstuffs. In such a carrier survey, two examinations should be done on each individual.

    For release of patients, therefore, and detection of carriers, the examination of feces is of especial importance. It is a procedure that properly requires the most careful attention of the bacteriologist. A bit of fresh feces the size of a pea (or, better when feasible, 1 c. c. of liquid stool, obtained, if diarrhoa is not already present, by administration of a saline cathartic) is mixed with 10 c. c. of plain broth or sterile salt solution, then allowed to stand and sediment for 15 minutes. One or more loopfuls are taken from the top and placed on the surface of one plate of hardened Endo medium. This droplet is carefully carried over the surface by means of a glass elbow rod or similar spreader, and without further inoculation the same rod is used to seed a second Endo plate. In this way a satisfactory separation of the colonies may be secured. After incubation overnight, suspicious colonies are fished to plain agar slants or, better, Russell's double sugar and the identification completed by agglutination tests.

    Evacuation of typhoid carriers.-Whenever it becomes necessary or desirable to evacuate a carrier of typhoid or paratyphoid fever to the United States, the carrier shall be evacuated as a patient on sick report.
     

    fAll strains of organisms of the typhoid paratyphoid group are of special interest and should be sent to the Central Medical Department Laboratory, A. P. O. 721.




    1030

    The Widal test, in view of previous vaccination with T. A. B. vaccine, has been generally held of little or no value; however, it should be stated that the determination of agglutinin titer of patient's serum at intervals of one week and the demonstration of progressive and marked increase of agglutinin content of the blood offers, especially in the absence of positive blood culture, excellent evidence as to the etiology of the diseases. Thus in typhoid fever an agglutinin titer (Widal test) of 1 to 40 during the first week of the disease may advance to 1 to 1,280 during convalescence. In paratyphoid B fever the titer frequently advances to 1 to 2,560; however, in paratyphoid A fever it may not reach 1 to 640. Formalinized and standardized bacterial suspensions of B. typhosus, B. paratyphosus A, and B. paratyphosus B may be obtained on request from the central Medical Department laboratory, A. P. O. 721.

    Post-mortem bacteriology.-At autopsy, on suspected cases, cultures should be made from the mesenteric lymph glands and from the spleen.
     VI. PATHOLOGY

    1. The significant gross pathology of typhoid fever can be briefly summarized as an acute process found in the lymphoid elements of the intestine (chiefly the ileum) and in the enlargement and softening of the lymph nodes in the mesentery and mesocolon. These nodes in the immediate neighborhood of the lower end of the ileum, the appendix, and cæcum usually show the most marked change. The opened intestinal tract reveals hyperplasia of all the lymphoid elements, such as Peyer's patches and the solitary follicles. There may be in most unusual cases only hyperplasia of these elements, but as a rule they show injection, exudation, and rather extensive ulceration, particularly in the lower end of the ileum. The lower third of the ileum is frequently the location of an ulcerated Peyer's patch or solitary follicle that may have perforated or may have become the source of considerable hemorrhage. The mucosa of the appendix and the cæcum are, in about one-third of the cases, also the seat of typhoid ulcers.

    The spleen is usually enlarged and the pulp is semidiffluent. The parenchymatous organs are somewhat enlarged and have a cooked appearance, suggesting cloudy swelling of a moderate or extreme degree. Broncho-pneumonia is frequently present as a terminal lesion. This represents the usual list of anatomical findings disclosed to gross examination; therefore, on opening the abdomen, the first important gross features that attract attention are the size of the lymph nodes in the mesentery and the upper part of the mesocolon and the size and consistence of the spleen.

    In children these structures may be misleading and in adults afflicted with tuberculosis a confusing gross picture can be offered, but in the Army of the American Expeditionary Forces, composed of young adults, any such picture found at autopsy should be thoroughly investigated. Such investigation calls for the removal of the intestine and an examination of the intestinal mucosa for lesions related to the lymphoid elements. Any change noted should be followed with supporting evidence gained by bacteriological examination.

    It should be kept in mind that the American Army has been vaccinated against typhoid, and as a result the gross pathological picture may not be as clear as in unprotected individuals. Indeed, several protocols received indicate that there are fewer gross lesions in the intestine and that they are prone to appear in the ileum at points very near the ileocecal valve and even in the appendix and cæcum. Other records indicate that death probably occurred during a relapse since there was evidence of a few almost healed ulcers near the location of one or more acute ulcers, one of which had been perforated.

    Cases of typhoid may escape attention at autopsy if early and complete regional examinations are not conducted and recorded in a methodical manner, and it is imperative that the pathologist support any suspicion of tyhoid fever gained on gross examination by a well conducted post-mortem bacteriological examination. Cultures taken from the gall bladder and from the lumen of the bowel may offer the only positive findings of a "carrier" of the disease. Cultures offering the pathologist the best support may be taken from the spleen and lymph nodes in the drainage path of actual intestinal lesions.

    Cases possessing the pathology and bacteriology of typhoid should be entered under the cause of death at the close of protocol as typhoid fever, and then, if desired, followed in parenthetical manner with any important sequel present, such as "perforation." Several



    1031

    protocols have been received in which the complete pathological and bacteriological pictures of typhoid fever were recorded, but the cause of death was entered as "peritonitis," "perforation of the intestine," "broncho-pneumonia," "acute enterocolitis."

    Attention is directed to Section XVII of the pamphlet Sick and Wounded Reports (effective September 15, 1918). All diagnoses should conform to these instructions if a proper record of disease is to be made.
     VII. PREVENTION AND CONTROL OF TYPHOID AND PARATYPHOID FEVERS

    Typhoid fever is increasing in the American Expeditionary Forces; so are the paratyphoid fevers.

    Vaccination is a partial protection only and must be reenforced by sanitary measures.

    Faulty conditions of sanitation that may not be dangerous now will become serious menaces when the warm weather sets in. There is still time to correct many of these conditions. If this is not done, many soldiers will not get back to the United States after completion of their arduous service, and it will be in part your fault and our responsibility.

    The means of conveyance are water and food. Water may be contaminated by drainage from latrines and indiscriminately deposited defecations. Food may be contaminated by hands of carriers, by flies that come to it from latrines and uncovered feces; therefore:

    Remember that all water in France is regarded as contaminated unless it is under constant supervision of water supply personnel. See that General Order 131, general headquarters, 1918, is carried out. Do not give orders only; personally assure yourself that chlorination is properly carried out. The responsibility ultimately falls upon those charged with sanitary control and not upon the enlisted man who mixes the hypochlorites of lime with the water. Study the means of prevention of drinking at unauthorized sources. The best way to do this is to see that an adequate supply of supervised water is conveniently available wherever men work or live. Other means are the marking of water points; the removal of faucets; the placing of guards, and last, but most important, the education of the men.

    Remember that the most dangerous carriers are the ones that work in the kitchens. Enforce the washing of hands by kitchen personnel before the preparation and serving of food. Do not leave this to orders alone. Have a reliable officer or noncommissioned officer supervise this and see that the means of washing are on hand. Also remember that many cooks who have been found to be carriers have often given histories of recent intestinal disturbance; therefore, inspect your kitchen personnel at least twice a week and remove all those who are suffering or have recently suffered from diarrheas. Repeated attacks of diarrhea are particularly suspicious.

    Remember that flies breed in manure, feces, and offal of many kinds. Policing of camp and the proper disposal of all such filth will keep down the number of flies. A campaign of such policing, if now undertaken, should go far to yield results by spring. Flies alone can not spread these diseases if latrines are covered and access to feces are prevented. Look at the lids of your latrines. Correct the conditions which lead to uncovered feces in camps. Keep the food covered so that any flies that get through this cordon can not get at it.

    Remember that an outbreak of diarrhoa may mean typhoid fever. At any rate the occurrence of epidemic diarrhoa shows that there is a hole in your sanitary plan.

    Remember that, even though your camp is a model one, the neighboring civilian population may be a source of danger. Try to keep informed of typhoidlike disease in the civilian population where you are stationed.

    Remember that from the sanitary point of view the first case is the most important one. If you evacuate a suspicious case and don't hear what it has turned out to be, make inquiry through the available channels.



    1032
     CONTROL

    1. Upon the occurrence of a single case of typhoid or paratyphoid fever in a command, reinvestigate all the above conditions and correct any deficiencies discovered in the barrier or protection above described.

    Examine all vaccination records and administer a single dose of triple lipo-vaccine to all in whom there is the slightest doubt concerning completion of required vaccination.

    Request bacteriological carrier examination of your kitchen personnel from the nearest available laboratory. This had best be done through the responsible sanitary authorities.

    Before this has been done reinspect your kitchen personnel and remove all who give a history of recent diarrhoas or other intestinal disturbance.

    Prohibit the use of all uncooked vegetables and unboiled milk.

    Investigate the conditions of the neighboring civilian population as to prevalence of typhoid or typhoidlike fevers.

    2. When two or more cases occur in the same command within the same two weeks, revaccinate the entire command, in addition to the above precautions.g If the outbreak takes an epidemic proportion, add to these precautions the hand washing of all men after defecation.

    Further measures of control must be determined after epidemiologic study of the individual situation.

    Whenever typhoid or paratyphoid fever occurs in any command, the medical officer will address the officers and the men, at either roll call or retreat, instructing them in the mode of spread of intestinal diseases, in the seriousness of the situation, and in the simple methods of personal hygiene, the importance of cleanliness, and the purpose of the sanitary regulations instituted for control of these diseases.

    3. The special attention of all officers of the Medical Department is invited to sections 184 and 185, Article III, Manual of the Medical Department. Compliance is enjoined.

    4. All previous instructions from this office in conflict with regulations prescribed herein are rescinded.

    WALTER D. MCCAW,
       Colonel, Medical Corps, Chief Surgeon.


    Circular No. 70.

    AMERICAN EXPEDITIONARY FORCES,
    OFFICE OF THE CHIEF SURGEON, SERVICES OF SUPPLY,
    February 20, 1919.

    I. Hospital centers and base hospitals no longer operating.-(1) Supplementing Section VI, Circular 67, the following is a complete list of hospital centers and base hospitals that have ceased operating:
      

    HOSPITAL CENTERS

    Angers (activities taken over by Base Hospital No. 85).
    Clerment-Ferrand.
    Commercy (activities taken over by Base Hospital No. 91).
    Langres (activities taken over by Base Hospital No. 53).
    Pau.
    Vittel-Centrexeville.
    gDirections for vaccination with triple T. A. B. lipo-vaccine are being issued with the vaccine.


    1033
     

    No.

    Location

    No.

    Location

    1.

    Vichy (Allier).

    37.

    Dartford, England.

    2.

    Etretat (Seine Inferieure), with British Expeditionary Force.

    38.

    Nantes (Loire Inferieure).

    3.

    Vauclaire (Dordogne).

    39.

    (Mobile Hospital No. 39).

    4.

    Rouen (Seine Inferieure), with British Expeditionary Force.

    41.

    St. Denis (Seine).

    5.

    Boulogne (Pas de Calais), with British Expeditionary Force.

    42.

    Bazoilles (Vosges).

    6.

    Bordeaux (Gironde).

    43.

    Blois (Loire et Cher).

    7.

    Tours (Indre et Loire).

    44.

    Mesves (Nievre).

    8.

    Savenay (Loire Inferieure).

    45.

    Toul (Meurthe et Moselle).

    9.

    Chateauroux (Indre).

    46.

    Bazoilles (Vosges).

    11.

    Nantes (Loire Inferieure).

    47.

    Beaune (Cote d'Or).

    12.

    Camiers (Pas de Calais), with British Expeditionary Force.

    48.

    Mars (Nievre).

    13.

    Limoges (Haute Marne).

    49.

    Allerey (Saone et Loire).

    14.

    Mars (Nievre).

    50.

    Mesves (Nievre).

    15.

    Chaumont (Haute Marne).

    52.

    Rimaucourt (Haute Marne).

    17.

    Dijon (Cote d'Or).

    58.

    Allerey (Saone et Loire).

    18.

    Bazoilles (Vosges).

    61.

    Beaune (Cote d'Or).

    19.

    Vichy (Allier).

    62.

    Mars (Nievre).

    20.

    Chatel Guyon (Puy de Dome).

    66.

    Neufchateau (Vosges).

    21.

    Rouen (Pas de Calais), with British Expeditionary Force.

    67.

    Mesves (Nievre).

    22.

    Beau Desert (Gironde).

    68.

    Mars (Nievre).

    23.

    Vittel (Vosges).

    70.

    Allerey (Saone et Loire).

    24.

    Limoges (Haute Vienne).

    72.

    Mesves (Nievre).

    25.

    Allerey (Saone et Loire).

    76.

    Vichy (Allier).

    26.

    Allerey (Saone et Loire).

    83.

    Revigny (Meuse).

    27.

    Angers (Maine et Loire).

    84.

    Perigueux (Dordogne).

    28.

    Limoges (Haute Vienne).

    94.

    Pruniers (Loire et Cher).

    29.

    Tottenham, England.

    112.

    Brest (Finistere).

    30.

    Royat (Puy de Dome).

    115.

    Vichy (Allier).

    31.

    Contrexeville (Vosges).

    116.

    Bazoilles (Vosges).

    32.

    Contrexeville (Vosges).

    117.

    La Fauche (Haute Marne).

    33.

    Portsmouth, England.

    204.

    Hursley Park, England.

    34.

    Nantes (Loire Inferieure).

    206.

    Remorantin (Loire et Cher).

    35.

    Mars (Nievre).

    236.

    Quiberon (Morbihan).

    36.

    Vittel (Vosges).

    238.

    Rimaucourt (Haute Marne).

    (2) The following hospital centers are shortly to be abandoned:
     

    Allerey, to be abandoned when patients are evacuated.
    Beaune, to be abandoned and buildings turned over to general headquarters for use as a school. Base Hospital No. 77 to remain at this location to care for sick of the school.
    Limoges, to be abandoned when patients are evacuated.
    Vichy, to be abandoned when patients are evacuated.


    (3) Additional lists will be published in succeeding circulars as base hospitals and hospital centers cease to operate.

    II. Resharpening blades.-Machine horse clipper blades in use by veterinary hospital units should be sent to Medical Department repair shop No. 1, Paris, for resharpening. These blades upon being resharpened will be returned to the unit in question.



    1034

    III. Final report on Form No. 30.-When a base hospital, camp hospital, or medical detachment is disbanded, a final report on Form No. 30, A. G. O., will be rendered-the original forwarded to The Adjutant General of the Army, Washington, D. C., and two copies direct to the adjutant general, general headquarters, A. E. F. These returns will be made out in accordance with the printed instructions on Form No. 30, A. G. O. The records of events will show the authority for the discontinuance or breaking up of the hospital or detachment and the date and the disposition of the personnel.

    IV. The following instructions will govern with reference to requisitions for engineer stores.-Requisitions for engineer stores originating with the Services of Supply must be submitted to and acted upon by the local engineer section officer of the C. of C. and F., who, after taking the necessary action, forwards the requisition to the nearest, or the specially designated, engineer depot where it is to be filled. Requests emanating from the following sections will be forwarded to the engineer section officer at the addresses given below:

    Base section No. 1, A. P. O. 701.
    Base section No. 2, A. P. O. 705.
    Base section No. 4, A. P. O. 760.
    Base section No. 5, A. P. O. 716.
    Base section No. 6, A. P. O. 752.
    Base section No. 7, A. P. O. 735.
    Intermediate section (west), A. P. O. 713.
    Intermediate section (east), A. P. O. 708.
    Advance section, A. P. O. 731.
     
     

    V. Records of returning organizations.-Organizations returning to the United States are required by embarkation instructions No. 13 to take with them all records pertaining to the organization as an organization. This has not been done in a number of cases. Steps will be taken to insure compliance with these instructions.

    VI. Correct Mail Address.-The postmaster at A. P. O. 717-requests that members of the medical Corps, Sanitary Corps, Veterinary Corps, Army Nurse Corps, and enlisted men of the Medical Department send their correct mail address to the medical section, A. P. O. 717, upon each change of station or change to another organization. It is desired that the commanding officers of hospitals and medical detachments have this information placed on bulletin boards.

    VII. Nurses.-In addition to the instructions regarding nurses traveling given in Circular No. 65, January 19, 1919, the following is to be noted. When it is necessary for nurses to change trains at Tours or to remain at that station between trains, commanding officers of hospitals are instructed to telegraph to the headquarters commandant, Services of Supply, stating the probable hour of arrival of the nurses and the number, in order that arrangements for their accommodation may be made. The Red Cross officials at Tours are doing all in their power to assist nurses going through that city, but to prevent embarrassment it is absolutely necessary that the probable numbers expected and the time of their arrival be received beforehand.

    VIII. Disposition of surplus subsistence on disbanding of hospitals.-(1) The following decision of the Quartermaster Department is published for compliance of all hospitals:

    (2) In view of the facts set forth in letter of the chief surgeon, A. E. F., to the judge advocate, A. E. F., of the 28th of January, 1919, indicating deficits on operations hospital funds, the Quartermaster Corps is willing to purchase back from hospital funds all surplus subsistence on hand which is a good condition, and which was purchased from the Quartermaster Corps, that may be in the possession of Medical Department units at the time of their disbanding or when evacuating to the United States.

    IX. Rates of commutation for patients.-Attention of all commanding officers of hospitals is called to General Order No. 19, general headquarters A. E. F., dated January 29, 1919, which changes the rates of commutation for patients in hospital.

    X. Clearance certificates.-Attention of all commanding officers of hospitals is invited to Bulletin No. 40, headquarters, Services of Supply dated October 22, 1918. In connection with the issuance of clearance certificates, it is essential that this office (finance and accounting division), be notified immediately of indebtness of a deceased officer or of an officer departing for the United States, and that this office also be notified immediately upon expiration of the two months period in the case of officers outlined in paragraph 3 of Bulletin No. 40.

    WALTER D. MCCAW,
      Colonel, Medical Corps, Chief Surgeon.



    1035

    Circular No. 71:

      AMERICAN EXPEDITIONARY FORCES,
    OFFICE OF THE CHIEF SURGEON, SERVICES OF SUPPLY,
       March 8, 1919.

    I. Hospital centers and base hospitals no longer operating.-(1) In addition to list given in Section I-Circular 70, the following hospital centers and base hospitals have ceased operating:

    HOSPITAL CENTERS

    Beaune (Base Hospital No. 77 to be returned to United States as skeletonized organization, and personnel retained to operate Camp Hospital No. 107. Buildings have been turned over to general headquarters for use of American Expeditionary Forces University).

    Allerey (Base Hospital No. 99 to be returned to United States as skeletonized organization, and personnel retained to operate Camp Hospital No. 108. Buildings being turned over to general headquarters for use of American Expeditionary Forces University).

    BASE HOSPITALS
     

    No.

    Location

    No.

    Location

    10.

    Le Treport (Seine Inf.), with British Expeditionary Forces (All American Expeditionary Forces base Hospitals with British Expeditionary Force have ceased operating.)

    97.

    Allerey (Saone et Loire).

    40.

    Sarisbury Court, England. (All American Force base hospitals in England have ceased operating.)

    105.

    Kerhoun (Finistere.)h

    77.

    Beaune (Cote d'Or).

    112.

    Kerhuon (Finistere).h

    92.

    Kerhuon (Finistere).h

    202.

    Orleans (Loiret).

    96.

    Beaune (Cote d'Or).

    218.

    Poitiers (Vienne). Reverts to former status as Camp Hospital No. 61.

    (2) The following base hospitals are shortly to be abandoned: Base Hospitals Nos. 63, Chateauroux (Indre); 71, Vauclaire (Dordogne), and 109, Vichy (Allier).

    II. Communications.-The attention of commanding officers and of chief Nurses is called to the fact that official communications from nurses or women civilian employees addressed to the chief nurse or the director of nursing service, A. E. F., must be forwarded promptly, whether approved or disapproved and with reasons for the approval or disapproval expressed.

    III. Mail addressed to patients in hospitals which are to be discontinued.-(1) All hospitals discontinued will forward a roster of patients evacuated at the time the hospital was discontinued, together with their correct forwarding address, to the central post office, Bourges.

    (2) In case a hospital is relieved by another unit, the commanding officer of the hospital relieved will furnish the mail orderly of the hospital relieving his organization the mail orderly record on hand of all past and present personnel and patients, including all evacuated patients, with their correct forwarding address.

    IV. Death of prisoners of war.-On the death of a prisoner of war in any hospital, notification will be immediately made to the commanding officer, central prisoner of war inclosure No. 1, A. P. O. 717, giving place, time, name, number, and description of prisoner.

    V. Wound stripes.-At a recent inspection by the commander in chief it was noted that there was a shortage of wound stripes at certain hospitals. He directs that an adequate supply of these articles be kept in all hospitals. Requisitions will accordingly be made for wound stripes in order that they may be on hand at all times.

    VI. Evacuation of prisoners of war from hospitals.-When members of prisoner of war labor companies become sick and are sent to hospitals they are considered as still members of their companies. Upon evacuation from hospitals on a duty status they will be returned to their original organization or to the central prisoner of war inclosure, whichever is more convenient, and not to a labor company to which they have never belonged.

    VII. Pneumococcus vaccine.-The following additional instructions relative to records to be kept when pneumococcus lipo-vaccine is given will supplement those laid down in paragraph 5, section 1, Circular No. 59, office chief surgeon, A. E. F., series 1918.

    hNever operated as independent unit.



    1036

    When large numbers of individuals from the same unit are given prophylactic inoculations of pneumococcus vaccine, the records may be consolidated on nominal check list showing the character of vaccine used, batch number, serial number of individual, name, age, organization, date of administration.

    The consolidated lists should be forwarded to the office of the chief surgeon, A. E. F. The fact that lipo-vaccine has been given and the date of the administration should be entered on the individual record and pay book as well as on the service record of each soldier.

    VIII. Disposition of ordnance property.-Section XVI, Circular 66, is amended to read as follows:

    The chief ordnance officer has directed that the following disposition be made of ordnance property upon the abandonment of hospitals: Unserviceable web, leather, and miscellaneous equipment to intermediate salvage depot No. 8, St. Pierre-de-Corps; rifles, revolvers, and pistols to ordnance repair shops, Mehun.

    Serviceable mess and personal equipment will be disposed of as follows: Hospitals and medical units stationed east of a line drawn north and south through Gievres, to Gievres. Hospitals and medical units in base section No. 1 to base ordnance depot No. 1, Montoir; base section No. 2 to base ordnance depot No. 4, St. Sulpice; base section No. 4 to base ordnance depot No. 1, Montoir; base section No. 5 to base ordnance depot No. 1, Montoir; base section No. 7 to base ordnance depot No. 4, St. Sulpice; intermediate section, west of Gievres to Montoir, base ordnance depot No. 1; advance section to intermediate ordnance depot No. 2, Gievres.

    IX. Medical organizations under orders for return.-In order that section 1, general staff, these headquarters, may be informed concerning the whereabouts and movements of medical organizations under orders for return to the United States, the commanding officer of any separate Medical Department unit will report by wire to G-1, headquarters, Services of Supply, all movements subsequent to receipt of orders to prepare for embarkation.

    X. Salvage of quartermaster department material.-The Quartermaster Department requests that in the future the commanding officers of all hospital centers and base hospitals operating independently will not ship or endeavor to save any articles of clothing, shoes, or other quartermaster's material which can not be placed in a serviceable condition by repairs, or which have no sales value amounting to considerably more than the cost of handling and transportation.

    XI. Patient's laundry.-Circular Letter No. 71, office of the Surgeon General, February, 1919, is quoted, as follows:

    1. Amendments of paragraphs 222 and 267, Manual for the Medical Department, have been approved as follows, and will be promulgated by formal change in due course:

    Par. 222, strike out the words "before it is put away" in the first sentence, so that that sentence shall read: "The soiled clothing of patients will be washed as a part of the hospital laundry (par. 267)."

    Par. 267, change second clause so as to read: "Second, the washable clothing of patients under treatment in hospital (par. 222)."

    2. Commanding officers of hospitals will govern their action accordingly.

    XII. Records of inventions and licenses.-Circular Letter No. 59, office of the Surgeon General, dated January 29, 1919, is quoted for the information of all concerned:

    1. This office has received a request from the patent section, office of the director of purchase, storage, and traffic, for information in regard to records of inventions and licenses. In order to enable this office to furnish the information desired, you are requested to invite the attention of all medical, dental, veterinary officers, enlisted men, Medical Department, and civilian employees serving under your direction, to paragraph 4, General Orders, No. 93, War Department, 1918, and direct such officers and enlisted men, and civilian employees as may come within the purview of that order to furnish the following information to this office, attention executive officer:

    (a) Brief titles of all inventions relating to military affairs made by them.

    (b) Brief description of each invention, together with a statement as to whether or not it has been submitted to the War Department to be patented, and whether formal tender or licenses to the United States to use the same has been made.

    2. It is requested that this matter be expedited.

       WALTER D. MCCAW,
    Colonel, Medical Corps, Chief Surgeon.



    1037

    Circular No. 72.

    AMERICAN EXPEDITIONARY FORCES,
      OFFICE OF THE CHIEF SURGEON, SERVICES OF SUPPLY,
    March 15, 1919.

    I. The following general instructions will govern when units are abandoned and equipment ordered turned into medical supply depots:

    Upon receipt of instructions from the chief surgeon designating depot or other station where supplies and equipment will be turned in, the following instructions will be carried out:

    (a) The medical supply officer will in each case be advised in advance, by wire, as to the approximate number of cars to be turned into his depot, also date cars go forward, and statement in general of contents of each car. The supply officer should also be advised of the car number and O. D. T. number. In every case, copy of loading list should be inclosed in an envelope and tacked on the ceiling or some other convenient place in each car, showing contents of that particular car.

    (b) Owing to the scarcity of lumber for packing material, sandbags have been obtained from the Engineer Department for the purpose of packing linen. These sandbags will be available for issue at intermediate medical supply depot No. 2, Gievres; advance medical supply depot No. 1, Is-sur-Tille; and medical supply depot, Montierchaume. Upon receipt of orders to abandon hospital and turn in equipment, necessary requisition will be submitted for the necessary number of these sacks. Tests have been made as to the capacity of sandbags to be used, and the following results obtained:

    One sack will hold 30 sheets, 30 pajama suits, 20 mattress covers, 48 bath towels, 120 hand towels, 120 pillowcases.

    (c) Bundling of linens or other preparation of such articles for shipment: All used bed linen and hospital clothing will be freshly laundered and blankets, when necessary, will be washed and in every case the latter will be sterilized before being turned into the depot.

    Blankets will be sorted as to color and quality and then bundled as follows: Each blanket is folded once from side to side and then twice from end to end, making a surface 21 by 34 inches. They are then securely tied in bundles of 25, with folded sides all in one direction.

    Sheets will be folded as commercially received, which is as follows: Each sheet is folded from side to side twice; then endways three times and then sideways once, making a fold about 8 by 12 inches. They are then tied up in bundles of 10, or a multiple thereof, with the folded sides all in one direction.

    Pillowcases will be folded as follows: Each pillowcase is folded to one-third its width on each side and this again folded once end to end, making a surface about 7 by 18 inches. They are then put up in bundles of 12, with folded ends in one direction, and tied. Four of these smaller bundles are again tied up in one bundle, making a total of 48 pillowcases in the larger bundles.

    Towels, hand, will be folded and tied in bundles in exactly the same manner as the pillowcases, with this exception-two towels will be folded together and but six of the doubled towels will be placed in the smaller bundles. Size of towels when folded will be about 6 by 18 inches. Total of 48 towels in large bundles.

    Towels, bath, will be put up in the same manner as the small bundles of hand towels. Size when so folded is 8 by 24 inches. Total of 12 towels in a bundle.

    Pajamas should be folded as follows: The coat, buttoned, is placed bosom downward. The pants, with the legs folded together, are placed lengthways on top of coat, projecting legs of trousers being folded over so as to bring such fold even with tail of coat. The sides are then folded over to one-third the width of coat and sleeves brought down lengthways of garment. It is then folded once to bosom size and then once again to half bosom size, making a package about 8 by 12 inches. The suits are then tied in bundles of 5 or in multiples of 5, all folds in one direction.

    Pillows should be sorted as to class-as hair, feather, cotton, and French or American. Each class is then tied up in bundles of 10.

    Care should be taken to see that all bundles are neatly packed and securely tied with material of sufficient strength to obviate breaking.



    1038

    When shipped or stored, mattresses will be sorted and classed as to kind-such as hair, felt or cotton, or excelsior, and as to make as American or French or the quartermaster type.

    II. Loss of sick and wounded reports.-Owing to the increasing number of monthly sick and wounded reports that are being lost by the transportation department, it is requested that all monthly sick and wounded reports that are too bulky to be sent by mail will hereafter be sent by messenger instead of by freight or express service.

    III. Short course in reconstructive facial surgery.-A short course in reconstructive surgery of the face, facial cavities, and eyelids will be offered at Paris by Drs. Pierre Sebelean, Victor Morax, and Fernand Le Maitre. This instruction will bear special reference to war casualties. Instruction will be didactic, demonstrative, clinical, and operative on the cadaver. Classes will be limited to 12, and the courses will continue three weeks. A fee of about 50 francs will be charged to cover expenses due to the use of cadavers.

    Any eye, ear, nose, or throat surgeons desiring this course and who can be spared without replacement should forward application to this office, stating the date on which it is desired to start. The courses will begin March 24 and every three weeks thereafter.

    IV. Disposition of chronic carriers of typhoid and paratyphoid.-All chronic carriers of typhoid or paratyphoid A or B bacilli will be evacuated to the United States as patients, accompanied by a statement of the specific diagnosis and records of the laboratory proof of the carrier state.

    V. Antirabies treatment at Base Hospital 57, Paris.-Any member of the American Expeditionary Forces who has been bitten by an animal infected or proved to be rabid should be sent at once, with a complete history, to Base Hospital 57, in Paris, where antirabies treatment will be carried out. For full details as to precautions to be observed in establishing diagnosis of rabies in the attacking animal and for advised emergency treatment of the wound of the patient, see page 31, Bulletin on Transmissible Diseases and Use of Therapeutic Sera in American Expeditionary Forces, May, 1918, to be obtained from chief surgeon's office. Note that American Red Cross Military Hospital No. 2, where treatments have been carried out heretofore, has been closed and that Base Hospital 57 will be used instead.

       WALTER D. MCCAW,
      Brigadier General, Medical Department,
      Chief Surgeon.


    Circular No. 73.
      AMERICAN EXPEDITIONARY FORCES,
    OFFICE OF THE CHIEF SURGEON, SERVICES OF SUPPLY,
       France, March 23, 1919.

    I. Physical examination of permissionaires.-(1) The surgeons of all organizations are directed to make a complete physical examination of all men going on leave the day preceding or the day on which the men depart for leave areas.

    II. Sick and wounded reports.-(1) The attention of all medical officers is again invited to paragraph 2, section 11, Manual Sick and Wounded Report of the American Expeditionary Forces, which directs that all monthly sick and wounded reports be forwarded direct to the chief surgeon, A. E. F., Services of Supply. Strict compliance with these instructions is enjoined upon all.

    (2) No copy of the weekly medical report of sick and wounded patients is required by the chief surgeon, A. E. F., Services of Supply. These reports should be forwarded to the central records office at Bourges. (See General Order 100, general headquarters, A. E. F., June, 1918.)

    (3) Commanding officers of hospitals and surgeons of infirmaries functioning as hospitals who are required to render monthly sick and wounded reports will, in the future, advise this office by letter, or on Form 51-A, if no cases were completed during the month. In other words, a nil report will be required from all organizations hospitalizing patients for more than three days.

    III. Telegraphic report to central records office on death of officer or enlisted man.-(1) On the death of an officer or enlisted man, immediate telegraphic report will be made by



    1039

    commanding officer of hospital in which death occurs to the central records office, Bourges. This report will give name, rank, service, organization, serial number of enlisted man; time, place, and cause of death; whether in line of duty or not; whether result of his own misconduct or not. Confirmation copy of this telegram will be forwarded by courier service.

    IV. Service records of evacuated patients.-(1) Attention is again called to provisions of General Order, No. 23, general headquarters, 1919, regarding the procurement of service records of patients to be evacuated, and the method of transmitting the record to the station or hospital to which the patient is sent. These requirements are not being carefully followed. Immediate steps will be taken to insure their strict obedience.

    V. Material for the prospective medical history of the war.-(1) Information has reached this office that in some instances medical officers, upon leaving the service, are taking with them official charts, photographs, models, and pathological specimens, etc., which were prepared in connection with their official duties while on duty in various hospitals or camps.

    (2) It is desired that responsible medical officers inform all subordinate medical officers that all medical records, charts, drawings, models, and pathological specimens, etc., as well as all writings relating to cases in hospitals, are the property of the Medical Department of the United States Army, and must not be removed from camps or hospitals by any officer without the authority of the Surgeon General of the Army in each specific case.

    (3) It is desired that every effort be made to collect and forward to the Surgeon General's office all photographs, drawings, sketches, models, and pathological specimens, etc., in hospitals or camps which may be of use or value in the prospective medical history of the war. All pictures should be forwarded to Col. Louis C. Duncan, M. C., Army Medical Museum, Washington, D. C. Models and pathological specimens should be forwarded to Col. Charles F. Craig, M. C., curator, Army Medical Museum, Washington, D. C.

    VI. The following memorandum is quoted for the information of all concerned:
     

    Subject: Personnel ordered to the first replacement depot and base ports.

    1. In view of the fact that the majority of casual officers being released for return to the United States will be needed for duty with casual companies and casual organizations returning to the United States, instruct all officers whom you may release and order to the first replacement depot at St. Aignan-Noyers (Loie-et-Cher) or to the ports of embarkation that they may expect to be held at those places for assignment to such duty. This is to be done so that the officers may not expect to be forwarded at once from the first replacement depot to ports of embarkation or to sail on the first transport after the arrival at a port of embarkation.

    2. All soldiers becoming surplus as a result of the abandonment of depots, stations, camps, etc., who are sent to the first replacement depot at St. Aignan-Noyers (Loir-et-Cher) are subject to reassignment. Many such men now arrive at the depot with the impression that they are immediately to be returned to the United States. In order, therefore, to prevent soldiers getting such impression, instruct all class A soldiers that you may release and all organizations and detachments that are sent to the first replacement depot, because their services are no longer required on their present duty, that they are available for reassignment, that they have no priority for going home, and the fact of their being sent to the first replacement depot does not mean that they are to be immediately embarked for the United States.

    3. Soldiers released for return to the United States under the provisions of Section III, General Orders No. 8, headquarters services of supply, 1919, do not fall under the above classes as such soldiers are released for immediate return to the United States and are given immediate priority for return to the United States.

    By order of the commanding general:

       E. E. BOOTH,
      Assistant Chief of Staff, G-1.
     

    VII. Medical department entertainment.-(1) It is contemplated that the Medical Department at these headquarters will shortly produce an entertainment, and information is desired of any members of the Medical Department who may have talents along these lines. In submitting these names the qualifications should be given in detail so as to enable this office to pick out the best in the Medical Department in France.

    VIII. Report of officers admitted, evacuated, discharged, or died.-(1) In order to enable the statistical division, adjutant general's office, to answer promptly the many inquiries now being made, all base and camp hospitals will forward direct to the statistical division, adjutant general's office, general headquarters, by courier mail, a daily list of all officers admitted,



    1040

    evacuated, discharged, or who have died. The list will give the name, rank, service, and organization, and place to which sent, if evacuated or discharged. This information may be sent on any form. Copies of the reports that are at present being made, which show the same data, will be acceptable.

    IX. Association of nurses and enlisted men.-The attention of the Medical Department personnel is called to the fact that there is no authority in regulations for any such distinction between officers and enlisted men as is implied by a ruling that makes it an offense for a nurse to associate with the enlisted man and not with the officer. The association of nurses with men is to be governed by the needs of the service, by the rules and customs of polite society, and by constant consideration for the good name of the Nurse Corps of the Medical Department of the Army and of American representation in France and not by social distinctions founded on military rank. Any instructions to the contrary are revoked.

    WALTER D. MCCAW,
       Brigadier General, Medical Department,
    Chief Surgeon.


    Circular No. 74.
    AMERICAN EXPEDITIONARY FORCES,
    CHIEF SURGEON'S OFFICE,
      March 28, 1919.

    I. Economy in use of blank forms.-(1) All officers of the Medical Department are directed to see that the utmost economy is exercised in regard to blank forms. Requisitions received in this office for blank forms indicate that more are requested than are needed, or that a large wastage occurs. In either case remedial measures should be applied promptly so that the present large expenditure for printing may be curtailed as much as possible.

    II. Shoe-shining and tailoring establishments to be instituted in all hospitals possible.-(1) The commander in chief has noticed that there is an absence of smartness in the appearance of personnel and especially of convalescent patients. This criticism reflects greatly on the care and attention given to proper military duties by the medical officers of hospitals. The commanding officers of all hospitals will take proper steps to correct this deficiency.

    (2) With this in view, places will be established in each hospital where men will be able to shine their shoes, and wherever possible tailor shops where they will be able to have their uniform repaired and pressed, will be instituted.

    III. Physical classification of officers.-(1) Reports reaching this office indicate that some medical officers, members of classification boards, are both lax in their classification of officers examined and ignorant of existing instructions. The ease with which officers can apparently be classified and sent home for conditions which would not have seriously interfered with the performance of their duties prior to the cessation of hostilities is causing undesirable adverse comment and is materially interfering with the integrity of the special services and staff departments of the American Expeditionary Forces.

    IV. The following circular has been received from the Surgeon General and is published for the information of medical officers. Communications on this subject will not be sent through this office.

    Criticisms and suggestions in re medical service of the Army.-(1) A board of medical officers, consisting of Brig. Gen. Francis A. Winter, Brig. Gen. John M. T. Finney, and Col. L. A. Conner, has been appointed to consider criticisms and suggestions concerning the medical service of the Army.

    (2) With a view to correcting defects in and increasing the efficiency of the department, officers of the Medical Department, including those of the Medical, Dental, Veterinary, and Sanitary Corps, are invited to submit to the board any criticisms they may have to make of the present system and methods, together with suggestions for improvements therein.

    (3) Communications on this subject should be sent to Brig. Gen. Francis A. Winter Army Medical School, 462 Louisiana Avenue NW., Washington, D. C.

    (4) Camp surgeons, surgeons of ports of embarkation, department surgeons, commanding officers of hospitals, and other medical officers are requested to call the attention of officers to the provisions of this letter.

    By the direction of the Surgeon General:

      C. R. DARNALL,
       Colonel, M. C., United States Army.



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    V. Abandonment of hospitals.-When a base, camp, evacuation, or mobile hospital is abandoned, the commanding officer of the hospital will wire the chief surgeon's office the date upon which the hospital records are closed and the hospital ceases to function. Attention of all commanding officers concerned is invited to General Orders, No. 15, headquarters services of supply, A. E. F., dated March 8, 1919, reference to the disposition of records.

    VI. Manual of the Medical Department to govern preparation of sick and wounded reports after embarkation for the United States.-(1) The attention of commanding officers of medical units and surgeons of organizations is invited to the fact that the Manual of the Medical Department will govern in the preparation of all sick and wounded reports after embarkation for the United States. The system used in the American Expeditionary Forces will no longer apply.

    VII. Carriers of meningococcus and diphtheria bacilli.-(1) Chronic carriers of meningococcus and of proved virulent diphtheria bacilli now under observation or treatment in hospitals in the American Expeditionary Forces will be evacuated to the United States as patients, promptly. No diphtheria bacilli carrier will be evacuated unless the virulent character of the bacilli has been proved by appropriate tests upon the guinea pig.

    VIII. Autopsy protocols.-(1) It is important, in view of the continued spread and high incidence of typhoid and paratyphoid fevers, that protocols of all autopsies he forwarded to the director of laboratories, A. P. O. 721, within 24 hours of completion of the autopsy.

    (2) Failure of the pathologist at the hospital to appreciate the full significance of lesions of the enteric group of diseases in men dying with other more striking lesions, or with a clinical picture not recognized as that of typhoid fever, can be corrected by review in the office of the director of laboratories.

    (3) In this way, several incipient epidemics of typhoid have been disclosed; and because of failure to send in autopsy reports promptly, at least one of the existing local outbreaks was unrecognized for two weeks.

    WALTER D. MCCAW,
       Brigadier General, Medical Department,
    Chief Surgeon.


    Circular No. 75.
       AMERICAN EXPEDITIONARY FORCES,
       CHIEF SURGEON'S OFFICE,
    April 10, 1919.

    I. Preparation of records for final separation of officers and enlisted men from the service of the United States Army.-(1) Medical officers preparing records of physical examination of officers and enlisted men on final separation from the service in the United States Army are especially cautioned to observe the provisions of General Orders, No. 230, general headquarters, 1918, and General Orders, No. 20, general headquarters, 1919.

    (2) Attention is directed to paragraphs 1 and 2 (War Department Circular 93, November 27, 1918) quoted in General Orders, No. 20, general headquarters, 1919.

    (3) When disabilities are found which, in the opinion of medical examiners, were existant prior to induction into the service, even though the men examined were evidently placed in class A when inducted, a notation will be made setting forth reasons upon which their findings are based, in order that the examination at induction and that at discharge may be reconciled.

    (4) In view of the fact that men under treatment for physical training will not be discharged until the board of review certifies that the maximum of improvement has been obtained, or that the physical disabilities have not been exaggerated or accentuated, when men are discharged with disabilities a statement will be made to the effect that further treatment will offer no prospect for improvement in physical condition.

    II. Men evacuated without service records.-(1) Many complaints are arriving in this office from different organizations that men are being and have been evacuated without the service records being requested (see General Orders, Nos. 5 and 23, general headquarters), and without the organization being notified that the men are not to return to their organization. Regarding the cases in the past, organizations will be immediately notified as to the



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    name of men who have been evacuated from their organizations without service records, and in the future no man will be evacuated without the organization being notified and the service record being requested.

    III. Prophylaxis and prophylactic stations.-(1) The following telegram from the commander in chief has been received by this office and is published for the information and guidance of all concerned:

       HEADQUARTERS, A. E. F., April 8, 1919.

    CHIEF SURGEON, A. E. F., Tours:

    During my inspections, following points have been brought to my attention and should be remedied with all possible speed and vigor. All the following criticisms and directions apply with emphasis to leave areas everywhere.

    A. (1) Prophylactic stations are often not well organized, equipped, or administered, and this fact alone would bring discredit upon the treatment rather than confidence in its use. The equipment should be on a par with that supplied for other functions of the Medical Department. Medicines should be prepared by the pharmacist and renewed at least every second day. Warm water for washing should always be on hand to prevent delay in the administration of the treatment.

    (2) Treatment should be under direction and supervision of thoroughly trained attendants and given absolutely according to directions posted in the treatment rooms. Attendants must be carefully selected from the most intelligent and reliable men of detachments and especially trained in administration of these treatments. Their appearance, deportment, and speech should always be such as to place prophylaxis treatment on a par with other medical surgical procedures and their number should be sufficient to allow necessary reliefs.

    B. (1) Separate rooms or small buildings should be provided where treatments can be administered in private, with separate accommodations for officers where possible.

    (2) The number and distribution of stations should be such as to make prompt and convenient treatments always possible. The number at most points is entirely insufficient.

    C. (1) Individual packets should be supplied to soldiers in convoy or other duties which may carry them out of touch with prophylaxis stations. This is not at present generally done.

    (2) The physical inspections are not being systematically and efficiently carried out in cases of undiagnosed and untreated venereal disease among the troops arriving at certain stations.

    (3) The education of commands through lectures by medical officers on personal hygiene is neglected at many posts. Lectures illustrated by diagrams and drawings are one of the most effective means of urging continence.

    (4) Little or no attempt is made by surgeons to locate sources of infections. Every effort should be made in every case to trace and eliminate the source by cooperation with military police and civil authorities, and this is the surgeon's duty.

    (5) Little attention is being paid at rest points for leave and troop trains and houses of prostitution are in many cases not put out of bounds and no prophylaxis facilities are provided.

    (6) Medical officers fully provided with facilities for administering prophylaxis should accompany all troops and leave trains.

       PERSHING

    Medical officers will be held responsible for any lack of supplies.

    WALTER D. MCCAW,
      Brigadier General, Medical Department,
       Chief Surgeon.


    DIRECTIONS FOR GIVING PROPHYLAXIS

    (To be posted in all prophylactic stations)

    1. Patient will urinate and proceed as follows:

    2. Wash hands.

    3. Roll up shirt and drop trousers and drawers to knees.

    4. Pull back foreskin and wash head of penis very thoroughly with warm running water and liquid soap, great care being taken to cleanse undersurface around "G string" and back of head. After this, wash shaft of penis and adjacent part of body. If there is no running water, clean basin with clean water and liquid soap will be used. The basin, after use, will be washed with water and then partially filled with bichloride solution (1 to 1,000) and allowed to stand for at least 15 minutes before being used again.

    5. While foreskin is drawn back, wash penis, particularly the head, with warm bichloride solution (1 to 1,000). This is best done by allowing the solution to flow over it.



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    6. The attendant, without touching genitals, will inject slowly one teaspoonful of a 2 per cent solution of protargol or a 10 per cent solution of argyrol into the penis and, as the syringe is withdrawn, he will direct patient to close the opening of the penis with the thumb and forefinger and retain solution for five minutes.

    7. Pull back the foreskin; rub one teaspoonful of calomel ointment all over the head of the penis and the inner surface of the retracted foreskin, being careful to rub it in on the undersurface, around the "G string" and in the furrow behind the head. The rubbing of this ointment should continue for three minutes. After this the surplus ointment will be well rubbed over the shaft of the penis.

    8. The penis is then wrapped in a toilet paper and the patient directed not to urinate for at least four hours.

    9. If more than three hours have elapsed since exposure, the patient, after having taken the regular prophylaxis, will be directed to report twice a day for two days for an injection of 1 per cent of solution of protargol. This will be held in 10 minutes.


    Circular No. 76.
    AMERICAN EXPEDITIONARY FORCES,
    CHIEF SURGEON'S OFFICE,
      April 21, 1919.

    I. Identification disks of prisoners of war patients.-(1) Identification disks of prisoners of war patients undergoing treatment will not be removed from the patient except in case of death.

    (2) In event of the latter, one portion of the disk will be buried with the body or attached to the grave marker; the other will be transmitted to the central records office, prisoners of war information bureau.

    (3) The information bureau reports that many hospitals have been forwarding them in all cases. Such practice will be discontinued, as it causes considerable confusion.

    II. Disposition of unserviceable medical property.-(1) Commanding officers of hospitals and other medical units, upon receipt of orders to abandon and turn in equipment, will forward without delay to this office a list of all unserviceable property on hand. Upon receipt of this information, instructions will be given from this office as to disposition of same.

    III. The following telegram from general headquarters, is quoted for your guidance:

    Sd four nine eight five period Vocational strength return has been discontinued period Orders will be issued shortly period Please notify all concerned period Ulio.

    IV. Discontinuance of use of lipo-vaccines.-(1) The following circular from the office of the Surgeon General, United States Army, is published for the information and guidance of all concerned:

    Circular Letter 134.

      WAR DEPARTMENT,
    OFFICE OF THE SURGEON GENERAL,
      Washington, March 12, 1919.

    Subject: Return to saline vaccines.

    1. Beginning with date of receipt of this letter, saline triple typhoid vaccine and saline pneumococcus vaccine, types I, II, and III, will be used in place of the corresponding lipo-vaccine used to date.

    2. Lipo-vaccines were adopted as a war measure on account of their obvious advantages and have served their purpose. The technique of manufacture, however, needs further improvement, and the duration of their protective power as compared with that of saline vaccines needs further investigation. Saline vaccines will, therefore, be used as a routine and lipo-vaccines will be reserved for emergencies.

    3. All surplus lipo-vaccines will be returned to the Army Medical School, Washington, D. C., and to such place as may be directed in the American Expeditionary Forces.

    4. Saline vaccines can be obtained by direct request to the commandant, Army Medical School, Washington, D. C., as heretofore.

    By direction of the Surgeon General.

    C. R. DARNALL,
      Colonel, Medical Corps, United States Army,
    Executive Officer.



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    2. In compliance with the above instructions all lipo-vaccine (triple typhoid and pneumococcus) manufactured in the United States will be reserved for emergency use. Saline vaccine will be used as a routine.

    3. One carton from each batch number will be mailed to the commanding officer, central Medical Department laboratory, A. P. O. 721, for further study of its biological and immunological properties.

    4. Adequate supplies of triple typhoid saline vaccines are expected in France at any moment and will be distributed immediately after arrival.

    5. In connection with saline vaccines, the particular attention of all medical officers administering them is directed to the fact that it will be necessary to revert to the system of administering three doses at intervals of seven days, in accordance with instructions contained in Circular 16, Surgeon General's Office, 1916. Copy of instructions for administration will be found in each carton of the vaccines.

    6. Because of the unanticipated delay in the arrival of vaccine from the United States, and the numerous changes in the location and strength of the various organizations of the American Expeditionary Forces, all pending requisitions for typhoid lipo-vaccine heretofore submitted under the provisions of Section II, General Order 31, general headquarters, A. E. F., 1919, are hereby canceled. The surgeon (senior medical officer) of each district, camp, post, or other independent command will make requisition for the necessary saline vaccine, syringes, and needles, requisitioning for an adequate number of syringes and needles for the men to be revaccinated. If adequate supplies of syringes and needles already are on hand, that fact will be noted on requisitions and these items will be omitted.

    a. The senior medical officer on duty at the first replacement depot, St. Aignan Noyers, will be held responsible for the vaccination of all casuals passing through that depot and will make requisitions for adequate amounts of vaccine for distribution throughout the area.

    b. The division surgeon of each division of combatant troops will make a consolidated requisition for all troops constituting his division and arrange for its distribution through the divisional medical supply officer. If the division is attached to an army, the consolidated requisition will be forwarded to the chief surgeon of the army. If under the orders of the Services of Supply, the consolidated requisition will be forwarded as indicated below.

    c. Requisitions for all units, including divisions, in the American embarkation center will be forwarded to the chief surgeon of that center, who will authorize the issue of the necessary vaccine.

    d. Except as indicated above, all requisitions will be sent to the director of the division of laboratories and infectious diseases, A. P. O. 721, Dijon, for visa, and forwarded by him to the appropriate distributing center for issue. In making requisitions, each unit comprising a command will be enumerated, giving exact designation and location of unit, actual number in that unit to be vaccinated, and American post office number.

    e. Because of the scarcity of syringes and needles, the difficulty in getting a sufficiently large amount of the vaccine, and the necessity for preventing the requisitioning of vaccine for the same individuals or units by different medical officers, extreme caution is enjoined in making and forwarding these requisitions. A requisition will be forwarded until assured by direct inquiry of the next higher or subordinate medical officer that requisition for vaccine for the command has not been made.

    (7) Special attention is invited to the absolute necessity for entering the exact status of the vaccination of each individual in the soldier's individual pay record book, and in the case of officers making a similar entry in the officer's record book of captains and lieutenants or furnishing them with a certificate. These entries must be made at the time the vaccine is administered. This information must include the date of vaccination and kind of vaccine used. If saline vaccine is administered, the date and whether first, second, or third dose.

    (8) Strict compliance with instructions outlined above is enjoined. The foregoing instructions are not to be construed as requiring further revaccination with saline triple vaccine of any member of the American Expeditionary Forces who has been revaccinated with triple typhoid lipo-vaccine in France.

       WALTER D. MCCAW,
      Brigadier General, Medical Department,
       Chief Surgeon.



    1045

    Circular No. 77:

      AMERICAN EXPEDITIONARY FORCES,
       CHIEF SURGEON'S OFFICE, SERVICES OF SUPPLY,
       April 22, 1919.

    Cases of typhus fever have recently been reported in France, and it is being reported constantly from central Europe.

    Liberated people from Alsace-Lorraine and the Rhine Valley, and especially those who have been in Ukraine, Poland, and Russia, are the principal carriers of the disease. Allied prisoners returned from Germany are also special source of danger.

    It is therefore necessary that medical officers in the American Expeditionary Forces be on the alert for the appearance of the disease among United States troops.

    Typhus fever may show all gradations in severity, from mild cases to those of malignant type. The following is a brief summary of clinical evidence in a case of moderately severe typhus fever:

    Prodromes are usually so light as not to attract attention or cause complaint. The individual may have a little "indigestion," headache, or weakness. He may look tired, feel a little dizzy and "achy."

    The onset is abrupt. Severe chills and violent headache and pains in the back and limbs are the rule, while often profuse nosebleed and vomiting occur. The temperature rises rapidly to 102° or 103° F. The patient's face is flushed and his conjunctivæ injected. He feels very sick.

    The eruption appears on the fourth or fifth day. It is rarely altogether lacking. It is often abundant and widespread. It appears first on the trunk-the armpits and shoulders-then on the abdomen and limbs.

    The eruption is of two types, (1) a deep subcuticular mottling or marbling and (2) rose-colored spots about the size of a pinhead or somewhat larger. These spots at first disappear on pressure. In a few days many of them appear somewhat petechial and do not disappear under pressure. More rarely the ecchymotic character progresses to a distinctly purpuric appearance. The spots persist for 5 to 10 days.

    The fever is sudden in onset, as has been stated, and continues high, with slight remissions, to terminate at the end of the second week by a defervescence during two or three days, sometimes by crisis.

    Nervous and mental symptoms are prominent and may be present from the beginning, a mild or more active delirium, later coma-vigil, subsultus tendinum, prostration, and stupor are noted. The stuporous state of typhus is particularly characteristic.

    The pulse rate follows the temperature. The beat is full and rapid at first; later it is small and feeble.

    Respiratory tract: Bronchial catarrh is common. A dry cough at first is the rule. Later the expectoration is increased and may become profuse and even purulent.

    Differential diagnosis, in the present situation, involves a consideration of typhoid fever, influenza, and measles.

    (a) Typhoid fever shows a much more gradual onset. Injection of conjunctivæ is absent. The rash comes later, is less abundant, and the rose spots are rarely hemorrhagic; i. e., they disappear on pressure. The "typhoid state" comes later, and is more mild than in typhus. Prompt laboratory examinations will establish a positive diagnosis.

    (b) Influenza includes so many clinical pictures that it must be considered here. It may be confused with typhus during the first three or four days. But the decline of the temperature in influenza after the third or fourth day and the absence of the rash will determine the diagnosis.

    (c) Measles presents a rash that may be confused with that of typhus. But the prodromal coryza and the defervescence following the eruption distinguish it from typhus. The eruption is prominent on the face in measles; facial eruption is rare in typhus.

    Laboratory diagnosis of typhus fever.-The Felix-Weil reaction is of value. This is an agglutination of B. proteus X-19 by the serum of a patient sick with typhus fever. B. proteus X-19 is not the cause of typhus fever. The reaction is therefore, not specific. But it has considerable diagnostic value.



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    Technique.-The bacterial emulsion should be prepared from a young agar culture (16 to 18 hours old). The emulsion should be freshly prepared; old emulsions do not agglutinate well.

    The macroscopic method is used.

    Serum dilutions from 1 to 100 to 1 to several thousands are used. (Typhoid patient's serum will agglutinate B. proteus X-19 at 1 to 25 or 1 to 50 in 10 per cent of cases.)

    Time and temperature of the reaction.-Thirty-seven degrees centigrade for one hour, or room temperature 10° to 15° C. for two hours is used.

    A rapid agglutination of B. proteus X-19 in a serum dilution of 1 to 100 or 1 to 200 in 30 minutes is of great value.

    The agglutinins appear in the blood in typhus fever between the fourth and eighth days, reach their maximum titer (1 to 500 to 1 to 10,000) about the eleventh day, and decrease rapidly after the twentieth day. Agglutinins may be demonstrable in the blood of typhus convalescents as late as two months after recovery.

    Cultures of B. proteus X-19 will be furnished on application to central Medical Department laboratory, A. P. O. 721.

    Prophylaxis and sanitary control of typhus fever is based on the following facts:

    (1) It is transmitted by the body louse (Pediculus vestimenti) and perhaps also by the head louse.

    (2) The louse having bitten a typhus patient, does not become capable of transmitting the disease until nine days have elapsed.

    (3) The incubation period of the disease-that is, the lapse of time between the infectious bite and the appearance of symptoms-is 6 to 10 days.

    From these facts it follows that the most effective protection consists in careful delousing of all members of the American Expeditionary Forces.

    The early diagnosis and discovery of all cases of the disease is an essential element in prophylaxis.

    Mild or abortive cases, because they are likely to be overlooked, are a special source of danger. The possibility of the disease should be constantly borne in mind.

    In the event of the occurrence of a case, the organization and quarters will be subjected to strict quarantine.

    Men and their equipment will be deloused every third day.

    Careful examinations of the individual men will be made daily.

    Quarantine will not be lifted until 21 days after the discovery of the last case. A delousing of the men and their equipment and a disinfection of their quarters will be made on the last day of the quarantine.

    The same measures will be applied to hospitals. A rigid quarantine of all personnel coming in contact with the case will be enforced.

      WALTER D. MCCAW,
    Brigadier General, Medical Corps,
      Chief Surgeon.



    Circular No. 78.

      AMERICAN EXPEDITIONARY FORCES,
       CHIEF SURGEONS' OFFICE
      April 25, 1919.

    1. The following regulations will govern the investigation of cases of venereal disease and the control of venereal prophylaxis.

    2. All cases of venereal diseases following failure to take prophylaxis will be investigated and the reason for the failure ascertained and recorded.

    3. All cases of venereal disease which develop after having taken prophylaxis will be investigated and the cause of the failure of the treatment ascertained and recorded.

    4. Medical officers, so far as possible, will collect all men at present in their charge who have had syphilis, and explain to them the course to pursue after demobilization in order to insure a complete cure.

    5. All men who have had chancroids since enlistment will have Wassermann tests done before returning to the United States. If the blood is found positive, they will be retained



    1047

    for one course of specific treatment. If the responsibility for this treatment being given on ship or in the United States will be assumed by the medical officer, the patient may be allowed to proceed with his resignation.

    PROPHYLAXIS STATIONS

    Attendants.-The attendants will be selected from among the best men in the organization. A noncommissioned officer will be in charge of each station. The men will be instructed on the following things:

    (a) The meaning and method of obtaining surgical cleanliness.

    (b) Simple facts about pathogenic micro-organisms, with special reference to those causing venereal disease. This instruction will include laboratory demonstrations of cocci, bacilli, and spirochetæ.

    (c) Simple descriptions of the anatomy and physiology of the male and female organs.

    (d) Descriptions of the ordinary symptoms and course of the three venereal diseases.

    (e) In the making of solutions of protargol and bichloride.

    (f) Method of prophylaxis and scientific reasons for each step.

    (g) Each section surgeon will form a central school at which all men having charge of the prophylactic stations will be trained.

    (h) The importance of the work will be impressed on the attendants, and everything possible will be done to arouse their interest, pride, and a cooperative spirit in the work.

    Technique.-The technique of administration of the prophylaxis will be on a par with that of a minor surgical procedure. Anything less than this will be faulty.

    Stations.-Care will be exercised in the placing of stations; regard for privacy will be observed. At least one room will be given to the station, which will be painted white and made as inviting as possible. A waiting room for large stations is desirable. The general arrangement and cleanliness of the station will correspond to that of a modern surgical dispensary.

    Running water will be installed wherever practicable. The most economical plan is to have several faucets arranged over a washing trough made of concrete or zinc; if available, porcelain sinks (individual) are preferred. When possible, individual booths will be made by the erection of partitions or curtains. Near each faucet will be a bottle of liquid soap with a split cork. Warm water will be provided if possible. When a water system is not at hand, running water will be supplied by means of an elevated galvanized-iron can to which a pipe or hose is connected. In temporary stations where basins will be used, a sufficient supply will always be on hand to insure the cleanliness of the individual basins.

    Washing possesses the following advantages:

    (a) It has been shown that soap is germicidal for the spirochetæ pallida.

    (b) It removes mucoid substances and allows better penetration of the calomel ointment.

    (c) It opens minute wounds or cracks in which micro-organisms may have lodged and allows the calomel ointment to come in contact with them.

    (d) It mechanically removes a large portion of the organisms present.

    Bichloride solution.-The washing with bichloride solution is essential and is necessary in connection with the washing with soap and water to destroy Ducrey's bacilli, since it has been shown that neither calomel ointment nor protargol solution is germicidal for this organism. The most satisfactory method for use of the bichloride is to have a large bottle, demijohn, or earthenware vessel holding not less than a gallon, with a rubber tube attached, placed on a wall bracket just above the trough. The bichloride solution will immediately follow the soap and water.

    The following articles are the minimum requirements of a station:

    1. A Primus oil stove for sterilization.

    2. A stew pan or fish kettle with cover, for boiling.

    3. A sterilizer for the sterilization of sponges. This may be made out of two tin buckets, one slightly larger than the other so that the larger may be inverted over the smaller. A rack of some kind is placed on the bottom of the inner bucket so as to hold the sponges or other articles above the water.



    1048

    4. A long clamp for the removal of the sterile syringes, wooden spatulas, and sponges from their respective containers, thus avoiding the necessity of the patient putting his hands in these containers.

    5. A sufficient number, never less than 12, of good workable syringes.

    6. A closed receptable in which to keep the sterile syringes.

    7. A number of wooden spatulas, which will be made by the attendant. These are for the removal of the ointment from the jar.

    8. A closed glass receptable in which to keep the sterile wooden spatulas.

    9. A glass jar or some kind of vessel for the sterile gauze sponges.

    10. An adequate supply of wash basins, certainly not less than 10, if running water is not at hand.

    11. Small glasses similar to ordinary medicine glasses in which protargol will be poured just prior to its being used.

    12. A supply of gauze sponges.

    13. One 8-ounce dark-colored bottle for the stock solution of protargol.

    14. A supply of 30 per cent calomel ointment.

    15. A supply of protargol or argyrol.

    16. Some means of weighing or measuring the protargol so that small quantities of the solution may be made up, thus avoiding the necessity of using a whole ounce at one time.

    17. A supply of bichloride tablets.

    18. A small clock placed where the patient may see it.

    19. A roll of paper.

    20. A place for the patient to wash his hands.

    21. A sufficient number of small towels 8 by 10 inches so that each patient may have a clean one.

    Regulations.-1. The syringes will be sterilized by boiling and will be kept in a sterile vessel. Bichloride solution will not be used for this purpose.

    2. The calomel ointment will be removed from the container by means of sterile spatulas.

    3. Solution of protargol will be a uniform strength of 2 per cent, will be made fresh each week, and will be kept in a dark bottle. The date of making solution will be written on bottle.

    4. Protargol solution will never be left standing in an open glass.

    5. Basins will always be sterilized with bichloride solution after use.

    6. The bichloride will have a uniform strength of 1 to 1,000.

    7. Cake soap will not be used.

    8. When prophylaxis is given to any soldier who is not a member of the organization to which the station belongs, a duplicate prophylactic record will be sent on the following day to the man's organization.

    9. The data on the prophylactic cards will be transferred to a book which will be kept for permanent record.



    Circular 79.

    AMERICAN EXPEDITIONARY FORCES,
      CHIEF SURGEON'S OFFICE,
    May 9, 1919.

    I. Disposition of medical supplies.-1. On receipt of an order by a medical unit to cease to function, such medical unit will pack up and prepare for shipment all of their hospital property and turn over such to the group or center medical supply officer prior to their departure. The personnel of a medical unit will not be relieved until this is done in a satisfactory manner.

    2. The following instructions as to preparation of medical property, to be turned in to group medical supply depots, will be observed:

    This property will be classified as follows:

    (a) Articles that are new and have never been used.

    (b) Articles that have been used but which are serviceable and fit for reissue.

    (c) Articles that are unserviceable but which can be repaired at a cost not to exceed their value when so repaired.



    1049

    (d) Articles which are not worth repairing but which are of value for the raw material of which they are composed.

    After the above classification has been made, all property will be put up in compact and easily handled packages. One type of article only will be placed in the same package, and the number of articles in a package will be nearly as possible as commercially received. Whenever possible, baling, sacking, or crating should replace boxing, and except in case of large bulky articles contents should be in 5's or 6's, or multiples thereof. Fragile articles will not be packed loosely or without packing material. All enamel ware should be wrapped in paper or such material as will prevent chipping.

    (a) Medicines will be carefully packed in boxes, with excelsior. Amount in boxes will be as follows:

    1-quart in bottle, 12 bottles to box.
    1-pint or pound bottles, 25 bottles to box.
    ½-pint or ½-pound bottles, 50 bottles to box.
    3-ounce or smaller bottles, 100 bottles to box.

    Attention is called to the instructions in Circular No. 68, III, that narcotics, morphine, cocaine, etc., must not be turned in to salvage depots, but must be sent to the nearest medical supply depot.

    Save in exceptional cases, no more than 100 bottles of medicine will be packed in a case, and only one kind of medicine or size of bottles will be packed in a box. Mineral acids or inflammable or corrosive substances will be packed in sand or some noncombustible material and is preferably packed in small quantities.

    (b) Tables, bedside, French, will be tied in bundles of 5.

    (c) Tables, bedside, folding, American make, when crated will be in bundles of 10, and when not crated will be tied in bundles of 5.

    (d) Chairs, folding, will be arranged as are folding bedside tables, American make.

    (e) Bedsteads will be sorted as to kind and make and may be sent in unpacked.

    (f) Mattresses will be sorted as to kind and make and where possible will be burlapped in bundles of 5.

    (g) Bedding and linens will be arranged as indicated in Circular 72, chief surgeon's office, A. E. F., March 15, 1919, and section (b), paragraph 1, of that circular is modified as follows:

    One sack (18 by 36 inches) will hold approximately as follows: 24 sheets, 20 pajama suits, 36 bath towels.

    (h) X-ray apparatus as follows:

    (1) All fluroscopic and intensifying screens should be packed in a separate case, carefully protected from moisture and abrasion.

    (2) All X-ray tubes in good condition for service should be shipped in the same form of container as received from the depot.

    (3) Broken or punctured X-ray tubes should be broken and the metal parts wrapped up, labeled, and forwarded to the depot, where they will be taken up in place of the tube.

    (4) Plates and films should be shipped in a separate container and properly labeled.

    (5) Milliammeters should be removed from machine, excepting in the case of the bedside or the United States Army portable, and shipped in a separate box with excelsior or paper to protect them from injury.

    (6) All small parts which might become loosened or lost in shipment should be tied or wired to the part to which they belong.

    All property will be thoroughly cleaned before being turned in. Attention is invited to paragraphs 512 and 526, Manual of the Medical Department, 1919, and particularly to paragraph 524 relative to packing of typewriters.

    All unserviceable articles will be turned in as salvage only. They will be properly listed in the order and in the nomenclature of the supply table and must have a certificate, with supporting affidavits if obtainable, stating whether condition was due to fair wear and tear in the service.

    No supplies or property of any kind will be turned in to a group depot without first furnishing the medical supply officer with a list of such articles, with the approximate amounts of same, and making with that officer such arrangements as will prevent confusion in their



    1050

    receipt. Duplicate loading lists will be sent with every truck load of supplies sent to local depot. One of these copies will be returned to consigner, signed by the receiving checker.

    3. Group or center commanders will effect such cooperation on the part of the unit supply officer and the group or center medical supply officer as will aid and facilitate the work of the latter and will arrange for the detail of a sufficient force from the nonfunctioning units of his center as will be necessary for the final disposal of all medical property at such center.

    4. Group or center medical supply officers and supply officers of independent medical units will be guided by instructions contained in paragraph 2 above, wherein they apply to the preparation of their own supplies for shipment, whenever orders are issued for discontinuance of such organizations and for the final disposal of their complete stocks.

    II. Correction.-l. Attention is invited to Circular 78 (minimum requirements for prophylactic stations), item 21, which is changed to read as follows: "A sufficient number of small towels 8 or 10, so that each patient may have a clean one."

    III. Treatment of chancroids before embarkation.-1. Due to inability to procure dark field microscopes and to the absence of specially trained medical officers in certain centers, many of the cases which were diagnosed as chancroid were either chancre or mixed infections. Recent careful examinations have shown that about 40 per cent of all sores occurring in the American Expeditionary Forces are syphilitic. In view of this it is requested that the attention of all organizations under your jurisdiction be directed to collect from all of their available records the names of all men who have had chancroid. All of these men who are available will be given an immediate Wassermann, and those found positive will be given one course of the standard treatment for syphilis. These cases will not be reported, as new cases, but each will be given a syphilitic register. Those preparing for embarkation will be given treatment provided there is time before sailing, but they will not be detained for it.

    IV. Nurses' records of assignment and pay.-1. In reference to paragraph 8, Circular 52, this office, October 22, 1918, the attention of all concerned is invited to the fact that records of assignment and pay of nurses should accompany them on change of station and should not be mailed to this office. Strict compliance with these instructions is necessary in all cases to avoid delay in payment of nurses.

       WALTER D. MCCAW,
       Brigadier General, Medical Department,
      Chief Surgeon.



    Circular No. 80.
    AMERICAN EXPEDITIONARY FORCES,
       CHIEF SURGEON'S OFFICE,
       May 15, 1919.

    I. Discontinuance, central Medical Department laboratory and Army laboratory No. 1.- (1) The central Medical Department laboratory, Dijon (Cote d'Or), and United States Army laboratory No. 1, Neufchateau (Vosges), will cease to operate May 15, 1919. After that date pathological, bacteriological, and serological examinations not possible of accomplishment with the facilities at hand will be made for such units as remain in the advance section and intermediate section, by the base laboratory, intermediate section, Tours. Therapeutic biological products, containers for specimens, and prepared culture media, formerly furnished by the two laboratories mentioned above, will be obtained, after May 15, from the nearest base laboratory still operating.

    (2) Laboratory animals, agglutinating sera for diagnostic use, and amboceptor and antigen will be obtained from base laboratory, base section No. 5, Brest, by all Medical Department units in France, and in the instance of units in occupied territory in Luxembourg and Germany, from the Third Army laboratory, Coblenz, Germany.

    (3) Bacteriological cultures for confirmation of diagnosis from Medical Department units serving in the Services of Supply, A. E. F., will hereafter be sent to base laboratory, base section No. 5, Brest, those from the Third Army to Coblenz, Germany.

    (4) Pathological specimens, photographs, and other museum specimens will hereafter be carefully packed in compliance with the instructions in Circular No. 58, chief surgeon's office, A. E. F., December 2, 1918, and shipped direct to the Army Medical Museum, Seventh and B Streets SW., Washington, D. C.



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    (5) The office of the director of laboratories, Dijon (Cote d'Or), will be transferred to the office of the chief surgeon, A. E. F., Tours on June 1, 1919. All correspondence, requisitions, reports, and returns heretofore submitted to the office of the director of laboratories, Dijon (Cote d'Or), (A. P. O. No. 721) will, after June 1, be directed to the director of laboratories, chief surgeon's office, Tours (A. P. O. No. 717).

    (6) Such provisions of Memorandum No. 21, office of the chief surgeon, division of laboratories and infectious diseases, September 18, 1918, as may conflict with the above provisions, are hereby rescinded.

    II. Reports of communicable diseases when closing hospital formations.-1. In carrying out the final evacuation of patients, failure to report cases of communicable diseases which have developed in or have been admitted to the hospital within a few days prior to the evacuation is common. The confusion of the process of closing of a hospital is no excuse for the neglect of Section XII, Sick and Wounded Reports, which must be complied with promptly under all circumstances.

    III. Sale of unserviceable material and supplies.-1. The following instructions have been received from the United States Liquidation Commission, War Department:

       PARIS, May 8, 1919.

    COMMANDING GENERAL, Tours:

    Authority has been obtained from French Government for American Expeditionary Forces to sell in France unserviceable material and unserviceable supplies now on hand or such as may accumulate at the various stations throughout France.

    The unserviceable material and unserviceable supplies are defined as junk, scrap material, unserviceable salvage material and supplies, and unserviceable property and material and supplies not worth transporting to depots.

    These sales may be made under direction of the chiefs of the various services without reference to United States Liquidation Commission, War Department, for approval.

    Please advise all services interested, but instruct them to make no sales in excess of authority granted herein.

    Suggest necessary publicity be given to sales by advertising in newspapers where advisable and by handbills, posters, and circular advertisements.

      KRAUTHOFF, G. S. A.

    A-182.

    By authority of United States Liquidation Commission, War Department.

    2. Under the above authority, all unserviceable property and supplies, as well as material and supplies not worth transporting to depots, will be disposed of on the ground, after survey, under the provisions of paragraph 678, Army Regulations. It is desired that survey be instituted with a view of directing sale in compliance with the above instructions.

    3. The proceeds of sales held under the above authority will be forwarded to the receiving finance officer, office of the general sales agent, Paris.

    IV. Authority to drop property issued from depots from returns.-1. The following memorandum is quoted for guidance of all concerned:

    AMERICAN EXPEDITIONARY FORCES,
      HEADQUARTERS SERVICES OF SUPPLY,
      FOURTH SECTION, GENERAL STAFF,
      May 9, 1919.

    1. Depot and other accountable officers who have shipped property to regulating stations for distribution to combat organizations, who have been unable to obtain a receipt from the regulating officer or the combat organization concerned, are authorized to drop this property from their returns, with a certificate that the property in question was duly shipped, and that it was impossible, due to the exigencies of the service, to obtain a proper receipt for the property. This certificate should be accompanied, when possible, by the ordre de transport covering the shipment of the property, or a true copy thereof.

    2. Regulating officers have been instructed to return any invoices which they are unable to accomplish to the proper depot with all information they are able to give on the shipment in question.

    By order of the commanding general:

      J. C. RHEA, Assistant Chief of Staff, G-4.

       WALTER D. MCCAW,
      Brigadier General, Medical Department,
      Chief Surgeon.



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    Circular No. 81.

      AMERICAN EXPEDITIONARY FORCES,
      CHIEF SURGEON'S OFFICE,
    June 3, 1919.

    I. The optical division, medical repair shop, in Paris, is closed and further prescriptions will not be filled.

    II. Venereal rate.-1. The venereal rate has been rising for a month past and has now reached a point 25 per cent above its general average for several months. The attention of all medical officers is called to the fact that the Medical Department is held largely responsible for venereal rates, and that it has taken just pride in its work. There must be no relax action, and the greatest activity must be carried on to the very end. Every effort must be made to influence the enlisted men, to obtain the full and hearty cooperation of commanding and other officers, and of the military police and to maintain prophylactic stations at the highest point of efficiency. Put a good ending on a good work.

    III. Hospital funds.-1. Hospital funds do not come under the provisions of General Order 77, general headquarters, May 10, 1919. They should be accounted for to the chief surgeon in the regular manner.

    IV. Promotions in American Expeditionary Forces.-1. Medical officers are informed that no more promotions are being made in the American Expeditionary Forces, and it is therefore useless to continue to send recommendations to the chief surgeon's office. No action has been taken upon recommendations which reached this office after March 25, 1919.

    V. Property.-1. Upon transfer to the French Government of movables pertaining to the Medical Department in any section of the American Expeditionary Forces under authority contained in letter from headquarters, Services of Supply, fourth section, general staff, dated May 27, to section commanders, a report will be made, before transfer is started, to the chief surgeon's office, attention supplies division, by the section surgeon; giving location of unit and in general terms, supplies and equipment to be turned over, such as: "25-bed infirmary, 100-bed camp hospital, etc." It is essential that this information be furnished as early as practicable in order that disposition may be given on any part of equipment which it may not be desired to turn over to the French. A record will be maintained in this office of all units transferred to the French Government in order to check same against bills for final payment; also to have data showing outstanding accounts. Section surgeons are advised that it is the desire of the Medical Department to dispose of as much movable property in every instance as the French will agree to take over on the ground without shipping same into depots.

      WALTER D. MCCAW,
      Brigadier General, Medical Department,
       Chief Surgeon.


    Circular No. 82.

       AMERICAN EXPEDITIONARY FORCES,
       CHIEF SURGEON'S OFFICE,
       June 6, 1919.

    I. Disposition of records.-1. Confusion seems to exist in the minds of registrars of hospitals closing for return to the United States as to the disposition of clinical records of the Form 55 series and other similar records.

    2. These will be carried with the unit to the United States, to be held until disposition by the Surgeon General's office.

    3. The only retained records which will be accepted by the chief surgeon's office are Form 22, Form 52 (register card), and retained nominal check lists. Every unit closing its site permanently will, in compliance with Circular No. 61, chief surgeon's office, forward these records, together with final monthly report of sick and wounded, to the chief surgeon's office, in charge of the registrar and such personnel as are necessary to insure its prompt and safe delivery.

    II. The following letter is quoted for your information and guidance:



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    1. The following telegram from general headquarters, dated May 19, 1919, repeated for your information and action necessary:

    "Qualification cards of officers of staff corps have been delivered to the chiefs of services at headquarters Services of Supply, Tours. Cards for officers of divisions and corps, not a part of the Third Army, have been delivered to the personnel adjutant of their respective divisions and corps. Cards for officers on duty with base and intermediate sections, Services of Supply, not members of the staff corps, have been delivered to the personnel adjutants of these sections. In the future, requisitions for cards of officers returning to the United States will be made to the heads of staff corps departments instead of to the officers' qualification section, general headquarters. Authority for the execution of blank cards will be obtained from the head of the sections above indicated.

    "DAVIS."

    2. Hereafter application for the qualification cards of officers in the various staff corps, returning to the United States, will be made to the chief of the staff corps to which the officer belongs.

    3. If an officer is transferred from any staff corps his card will be put in a sealed envelope and given to him to present to the proper officer at his new station.

    By command of Major General Harbord.

      L. H. BASH, Adjutant General.

      WALTER D. MCCAW,
    Brigadier General, Medical Department,
      Chief Surgeon.


    Circular No. 83:

       AMERICAN EXPEDITIONARY FORCES,
    CHIEF SURGEON'S OFFICE,
      June 16, 1919.

    I. Circular Letter No. 223, office Surgeon General, is quoted herewith:

    Subject: Record card, Form 627, A. G. O., enlisted men of staff corps and departments.

    1. Attention is invited to paragraph 41, Manual for the Medical Department, which directs that:

    "When a man is enlisted for, reenlisted in, or transferred to the Medical Department, the medical officer who first receives him will prepare and forward a record card of the soldier directly to the Surgeon General, except in the case of a man stationed in the Philippines, Hawaiian, or Panama Canal Department, when the card will be sent through the department surgeon." (As amended by C. M. M. D. No. 3, September 29, 1917.)

    2. It is directed that in cases of those who have been enlisted for, reenlisted in, or transferred to the enlisted forces of the Medical Department since February 28, 1919, a record card be furnished this office and that in future paragraph 41 of the Manual for the Medical Department be strictly complied with.

    II. Sick and wounded reports.-1. Attention of all commanding officers of medical detachments is again called to the American Expeditionary Forces requirements regarding sick and wounded reports. Any medical formation habitually hospitalizing for more than three days is required to render to the chief surgeon, A. E. F., a daily report of casualties and changes for patients in hospital (Form 22), and to make monthly report on field medical card and Forms 51 and 52. Infirmaries, small post hospitals, and other similar units will invariably comply with this when so hospitalizing, and will notify the chief surgeon's office, immediately by telegraph, that they are beginning to care for patients that, heretofore, would have been hospitalized in a larger formation.

    2. Beginning with the report for July 3, weekly telegraphic report of sick and injured, Form 86, M. D., A. E. F., will be made direct to the office of the chief surgeon, A. E. F., instead of to the surgeons of first replacement depot, embarkation center, Le Mans, and district of Paris, and sections, Services of Supply. Great care will be exercised to see that the form checks before the telegram is sent. All units rendering reports mentioned in paragraph 1 are required to submit this weekly report. The above does not apply to units of the army of occupation, which will continue to report as heretofore through the surgeon of that army.

    3. At the time of report for June 26, each surgeon of section Services of Supply and independent center will forward to the chief surgeon,
    A. E. F., a final list of units sending this report through his office, giving designation, location, strength, and complete "K" line for each unit so reporting.



    1054

    III. Method of closing accountability for medical supplies upon turnover to French authorities.-1. Upon completion of turnover to the French authorities under the provisions of letter, headquarters, Services of Supply, fourth section, general staff, dated May 27, 1919, of property and supplies for which a medical property return is being rendered, an extra copy of the receipted inventory as furnished by the French and American representatives will be submitted with final return of medical property and constitute a voucher covering the entire accountability to be dropped. If it is impracticable to obtain an additional copy of this inventory signed by both representatives, a certified true copy of same will be furnished in lieu thereof.

       WALTER D. MCCAW,
      Brigadier General, Medical Department,
       Chief Surgeon.


    Circular No. 84.

       AMERICAN EXPEDITIONARY FORCES,
       CHIEF SURGEON'S OFFICE,
      July 1, 1919.

    I. Sale of property.-1. Sales of unserviceable property as indicated in Section III, Circular 80, this office, May 15, 1919, is suspended. Due notice will be given when such sales may be resumed; and when such is done, the following instructions, contained in letter, commanding general A. E. F., Services of Supply, June 29, 1919, regarding the disposal of such supplies, will be observed:

    In order to put a stop to practices which have obtained heretofore in the disposal of Government property, the following instructions will be communicated to all concerned and steps taken to see that the full intent of these instructions is complied with when sales are again authorized.

    (a) No material will be sold under the heading of scrap or junk which ought not to be so classed.

    (b) Property such as typewriters, wagons, motor vehicles, and miscellaneous machinery and equipment, which is not in immediate working order and can be so placed with little expense, will not be classed as scrap or junk. Such property and all property which can be rendered fit for good second-class sale with some slight repair will be cared for and property listed for sale.

    (c) When sales are resumed, sales of any kind, including sales of junk, will not be made at stations where there are troops until or unless it is necessary to make such sales in order not to delay the departure of troops at that station, and then only sales of material which is really junk and beyond repair.

      WALTER D. MCCAW,
    Brigadier General, Medical Department,
      Chief Surgeon.


    Circular No. 85:

    AMERICAN EXPEDITIONARY FORCES,
    CHIEF SURGEON'S OFFICE,
    July 30, 1919.

    The following revised instructions as to civilian laborers are published for the information and guidance of all concerned:

    1. Laborers of the administrative labor companies are in all cases entitled to the same medical care and infirmary treatment awarded to United States troops. When hospitalization is necessary, agreement has been made with the French Government whereby French civilian laborers will be evacuated to French civilian hospitals.

    2. In cases of emergency any laborer may be admitted to American Expeditionary Forces' hospitals, but as soon as practicable these cases should be evacuated.

    3. Cases of venereal disease are to be evacuated to the hospital when necessary in the same way as other cases, but for this class of cases French hospitals shall be used exclusively.

    4. By agreement with the French Government, the American Expeditionary Forces are not required to pay for care and subsistence for cases of venereal disease while in hospital.

    5. Transportation of sick and injured laborers to and from hospital is furnished and provided for by section 1, paragraph 4, General Order 26 Services of Supply, as follows:



    1055

    The transportation department will furnish the necessary transportation for all laborers who may be discharged, transferred, or leave by the termination of contract, upon the request of the commanding officer of the labor company to which the laborer belongs.
     

    6. Subsistence for laborers in American Expeditionary Forces' hospitals is provided for by section 1, paragraph 8, General Order 26, Services of Supply, c. s., as follows:
     

    When laborers employed under contract through the general purchasing agent are admitted to a United States military hospital, they will receive the same subsistence furnished United States troops. The Quartermaster Corps will reimburse the hospital fund at the rate prescribed in existing orders applicable when soldiers of United States Army are admitted to hospitals.
     

    7. The surgeon on duty with the labor companies will have general supervision over the sanitary conditions of these companies, reporting upon same under paragraph 5, Form No. 2, M. D. L. B.

    8. The surgeon, medical division, labor bureau, Army Service Corps, A. P. O. 717, should be notified at once by the surgeon attached to the labor company on Form No. 1, M. D. L. B., in all cases when laborer is-
     

    (1) Admitted to hospital,
    (2) Transferred to French hospital,
    (3) Dies, or
    (4) Suffers from any condition, though not necessitating admission to hospital, may have bearing on any future claims against the Government.

    The same action will be taken in cases of emergency admissions to American Expeditionary Forces' hospitals or infirmaries by the commanding officers of the latter.

    9. Diseases and injuries will be described in all reports in accordance with nomenclature prescribed in article 17, page 18, Sick and Wounded Reports for American Expeditionary Forces.

    10. It is requested that special care be taken in reporting injuries, namely, giving definitely the nature of injury, manner incurred, and anatomical parts involved.

    11. Form No. 2, M. D. L. B., will be submitted promptly each week, the week ending midnight Tuesday, and will embody all the data called for upon said report.

    12. Whenever laborers are employed or discharged, the surgeon will make a thorough physical examination embraced under the following headings: "Height," "weight," "general examination," "head," "chest," "abdomen," "genital organs and anal region," "extremities." These reports should be forwarded promptly to chief of medical division, labor bureau.

    13. Venereal disease is not necessarily a case for rejection, but all acute cases and every case that may make the individual a menace to his associates should be considered sufficient grounds for rejection. The presence of developmental and acquired abnormalities or defects, that in themselves are not sufficient cause for rejection, should always be noted on the physical examination report.

    14. All reports and correspondence relating to civilian laborers by surgeons attached to labor companies will be made to the chief of the medical division, through the base surgeon.

    By order of the chief surgeon:

      L. MITCHELL,
       Lieutenant Colonel, Medical Corps, United States Army,
       Chief, Medical Division, Labor Bureau.

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