History

Report of inspectors indicate lack of uniformity in the care and isolation ofinfectious disease in hospitals, and in many instances the steps taken arereported to be insufficient to prevent possible spread of infection anddevelopment of complications. The following procedure should be followedwhenever local conditions permit. When any or all of the necessary medicaldepartment material is lacking, requisition should be made by telegraph to thisoffice for the needed articles, attention Colonel Howard, and referring to thismemorandum as authority. Such additional precautions should be taken as aredeemed advisable by the commanding officer of the hospital.

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

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

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

3. Measles.-An allowance of at least 1,000 cubic feet per patient should beprovided in wards or barracks used for treating measles patients. Wires shouldbe arranged across measles wards and sheets, or newspapers, hung over these insuch a way as to form a screen between each two patients; or some other suitablescreening arrangement should be provided. This is with a view to preventingspread of pneumonia by droplet infection during coughing. Patients convalescentfrom measles should be retained in hospital, or in a well-warmed convalescentbarrack, for at least 10 days after the temperature has permanently returned tonormal Medical officers, nurses, and male attendants in measles wards will weargowns, caps, and face masks. Nasal discharges and sputum of patients will bedisinfected. Oral cleanliness should receive special attention. Attendants whohave 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 cupsshould be used. Particular care should be taken to disinfect thermometers andother 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 measleswards. They should not be placed in the same wards with primary lobar pneumonia.

4. Pneumonia.-Pneumonia patients should be treated in wards usedexclusively for pneumonia. Ordinary lobar pneumonias and post-measles andpost-scarlet-fever pneumonia should not be treated in the same wards. At least1,000 cubic feet of air space per patient should be provided, and all of theprecautions 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 usea mild antiseptic mouth wash as long as they remain in hospital, and should payspecial attention to oral hygiene. Special attention should be given to theearly detection of empyema.

5. Scarlet fever.-All of the precautions prescribed in measles should becarried out in the treatment of this disease. Attendants who have had scarletfever 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 havehealed, nor earlier than six weeks after the onset of the disease under anycircumstances. A urinary examination should be made before discharge fromhospital.

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

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

8. Enlisted attendants in wards for infectious diseases should wear whitecotton coats and trousers, which should be changed twice a week. These garmentsare on hand in depots and should be requisitioned for at once by the localquartermaster.

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

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

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

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

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

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

Camp Epidemiologist.

1. It is contemplated that an officer of the Medical Department with specialtraining as an epidemiologist will be assigned to each camp and cantonment whereserious epidemic disease exists. While not an officer of the division, he willbe under your jurisdiction in your capacity as camp surgeon, acting under theimmediate control of the sanitary inspector as his assistant. Where the amountof sickness warrants such action, it is desired that in each brigade a suitablemedical officer be selected who will be assigned as whole or part time assistantto the epidemiologist. One of these should be trained as an understudy with aview to having him serve as an assistant to the sanitary inspector incommunicable-disease problems when the division leaves camp. The epidemiologistshould make such reports to you as you deem necessary.

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

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

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

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

6. He should give special attention to the adequacy of the prescribedexaminations of outgoing and incoming troops for the detection of incipientcommunicable disease.

7. He should keep spot maps of infectious diseases in the camp. In thisconnection special attention must be given to the frequent movement of wholeorganizations from one barrack to another, to the change in personnel withinorganizations and from one organization to another, and to the constant arrivalof new men from outside the camp.

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

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

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

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

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

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

Contacts should be quarantined in barracks, or preferably in a quarantinecamp, and be inspected twice daily by a medical officer. Special attentionshould be given to detecting Koplik spots and early rises of temperature asdetermined by the thermometer. Men showing a rise of temperature up to 100^oshould be isolated. Daily airing of barracks and sunning of bedding should bepracticed in "contact" barracks for measles, and also for all of thebelow-mentioned infectious diseases.

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

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

(c) Pneumonia.-This disease is to be regarded as communicable. It should bedetermined in every case whether the disease is primary or secondary to measlesor scarlet fever, and records should be classified accordingly. Carefulcleansing of the floors should be practiced in a barrack where pneumonia hasdeveloped. Special attention should be given to sunning the patients' beddingand clothing. Ample ventilation and the widest separation of the heads ofadjacent sleepers: should be insisted on.

(d) Diphtheria.-Early culture of suspicious throat conditions seen byregimental surgeons should be insisted on Contacts with a case of diphtheriashould be quarantined until it is shown by both nose and throat cultures thatthey are not carriers All close contacts shown by the Schick test to benonimmune should be promptly immunized by means of antitoxin Articles which havebeen in contact with the patient and articles soiled by discharges should bedisinfected.

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

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

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

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

First. Other members of the same squad or tent.

Second. All other men in the same room.

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

In other words, the examination should be extended in increasing circlesabout a case as rapidly as time and laboratory facilities permit. While suchexaminations are being made on the smaller group, the largest group should betreated as potential carriers. All men in the largest group should bequarantined and prevented from mingling, as individuals, with others within orwithout the camp; they may, however, be permitted to attend drills and otherformations as a unit. In the meantime, sprays and gargles may be used. Wheneverit is impractical to culture the larger units at once, the inauguration ofspraying need not be delayed. If spraying is employed, it should be timed sothat it falls as closely as possible to the hour of retiring, therebydiminishing

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

All carriers, as rapidly as detected, are to be removed from the building andisolated in a quarantine camp until free from meningococci on three consecutiveexaminations, with intervals of from three to six days between examinations. Oncompletion of the examinations and removal of the carriers the quarantine may beraised.

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

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

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

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

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

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

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

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

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

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

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

[Extract No. 1.]

2. A detention camp should be established for each camp and cantonment, whereall fresh contingents of men will be held under observation for at least twoweeks, or longer if considered necessary by the division surgeon, before beingassigned to organizations in general camp. The purpose of the detention camp isthe observation of new men for a certain period to prevent the introduction ofcommunicable diseases into the nonaffected camp or cantonment from without. Nonew men should be placed in the general camp until in the judgment of thedivision surgeon it is safe to do so. The capacity of the detention camp shouldbe such that it will accommodate the full quota of each contingent expected tocomplete the organization of the division, The period of detention should beutilized for physical reexamination of the men, the vaccination and immunizationagainst typhoid and paratyphoid fevers, and such equipment and training as maybe prescribed by the camp and cantonment commanders without bringing the men indetention camp into contact with other men of the division.

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

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[Extract No. 2.]

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

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

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

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

Prophylactic Treatment of the Respiratory Tract.

1. Reports from abroad and from this country indicate that great good hasbeen accomplished in infectious diseases and in catarrhal conditions of therespiratory tract by so-called toilet of the mouth, nose, and throat. Treatmenthas been directed against inflammatory conditions of all kinds, with focalinfections in the tonsils and sinuses. Sprays, gargles, and steam-roominhalations have been effective in cleaning up carriers and curing inflammatoryconditions which have predisposed to more serious types of infection andtransmission of disease to others. The cases to be given prophylactic treatmentare cases suffering from infectious disease with the inflammatory condition ofthe air passages, chronic inflammatory condition of the nose, throat, andsinuses, severe grippes, and colds. The solution of the question as to how muchcan be accomplished by systematic prophylactic treatment in diminishinginfections of the nose, throat, and bronchii is one of the most pressing nowconfronting the medical officers of the various cantonments.

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

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

The Control of Respiratory Infections and CommunicableDiseases in Hospitals.

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

(b) If proper methods are devised to control the direct or indirectdissemination of infection it would be possible to prevent the spread ofrespiratory infections and the cross infections that may occur in highlycommunicable diseases.

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

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

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

Under the following conditions all patients should be masked-

(1) In the ambulance.-Since patients suffering from different communicablediseases may be transported, under necessity, in the same ambulance at the sametime or at different times, the danger of primary and of crossed infections isalways present. Consequently, at the time he designates the patient to beremoved by the ambulance, the regimental surgeon should also indicate whether ornot that particular patient should be masked for the protection of others in thesame ambulance.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

1. It has been demonstrated that only asmall proportion of the medical officers in the base hospitals have hadexperience in the diagnosis of the communicable diseases, especially theexanthemata, before entering the service. A considerable number have acquiredthe experience since being in the service. Others either have not had theopportunity in the service or have not been capable of availing themselves ofit.

2. In choosing the personnel of basehospitals for this country and for overseas duty, and also for evacuationhospitals, it is desirable that there should be assigned to each one a certainnumber of medical officers who are expert in the diagnosis and treatment of theexanthemata.

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

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

Care of Communicable Diseases.

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

MEMORANDUM FOR HOSPITALDIVISION.

1. The incidence of the communicablediseases (measles, mumps, meningitis, pneumonia, etc.) is very high among thetroops freshly inducted in the service. From ignorance or other motives theyfrequently do not report sick at sick call and as a result of this there mayarise serious delay in the entrance of a sick man into the hospital. To obviatethis, it would be advisable, wherever it is possible, that a rapid examinationof these troops should be made at a roll call held twice a day, as it isfrequently possible to recognize evidences of sickness by superficialexamination.

This examination could be held in thedepot brigade or in whatever barracks was set apart for lodging the incomingtroops.

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

3. Patients in whom there is asuspicion of infectious disease should wear face masks and should be sent to thebase hospital in separate ambulances unless there be several suffering from thesame disease, when they may be sent together.

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

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

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

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

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

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

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

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10. The latrinesn the observation wardshould be used by only one patient at a time.

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

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

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

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

Control of Acute Respiratory andOther Diseases.

1. The following suggestions regardingcontrol of the acute respiratory and other diseases usually conveyed bydischarges from the respiratory tract are submitted for the information andguidance of responsible medical officers. These suggestions are not to beinterpreted as supplanting existing regulations.

2. The acute respiratory and otherdiseases usually conveyed by discharges from the respiratory tract wereresponsible for the majority of the deaths from disease in camps and cantonmentsduring the winter of 1917-18, and the probabilities are that this will hold forthe coming winter. Under this heading are included pneumonia, meningitis,measles, mumps, diphtheria, tuberculosis, bronchitis, tonsillitis, and scarletfever.

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

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

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

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

7. Recent, but limited, experienceoffers promise of aid in the restriction of pneumonia by means of directvaccination. The purpose is to cautiously extend this experience during thecoming months.

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

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

9. When measles appears in anorganization the sick man should be masked and sent directly to hospital withoutdelay; all "contacts" should be carefully inspected twice daily duringthe incubation period of the disease. At these inspections the men should bestripped to the waist and the inspection should include the skin, eyes, mouth,nose, and throat. The detection of a suspicious eruption, conjunctivalcongestion, or coryza demands that the man be sent at once to hospital or to asuitable place for proper isolation and observation.

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

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

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

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

(d) It is possible-indeed, highlyprobable-that differential diagnoses were not always correctly made and thatcases of this disease and of measles were sometimes mixed in wards and crossedinfections occurred. There should he in every camp medical officers especiallyskilled in the recognition of exanthemata. All new arrivals should be carefullywatched, and, on account of the relatively short period of incubation, mostcases should be detected before assignment to organizations.

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

12. The information gained concerningthe relation between pneumonia and previous respiratory diseases, such asmeasles, bronchitis, tonsillitis, etc., is not yet satisfactory, and it is to behoped that these matters will receive more attention in the future. There isalso great need of exact knowledge concerning the relation between the weatherand pneumonia. As has been stated, the curve of this disease has fallen to anannual admission rate of about 10 per thousand during the summer, but it remainsthe most serious disease in the camps, and from time to time exacerbationsoccur.

13. The inadequacy of sick call in theearly recognition of communicable diseases is evident, When an organization isinfected, medical officers should inspect every man in the organization at leastonce a day and should be on the alert for the recognition of each communicabledisease in its earliest stages. Each case of communicable disease should he sentto hospital as soon as detected, and medical officers should be graded on theirskill and success in the early detection of these diseases. During the pastwinter the death rate in the different camps was in inverse ratio to hospitaladmissions.

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

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

16. State health officials have beenrequested to keep camp and division surgeons informed of the existence ofcommunicable diseases within their respective jurisdictions. This informationshould be utilized in receiving men from infected places and in granting menfurloughs to their homes. Responsible medical officers should use every endeavorto protect the men of their command from infection not only from within butwithout the camp.

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

18. It is the experience of last winterthat the importation of southern troops into northern camps was followed byincreased morbidity in both the arrivals and the troops already at the camp. Inseveral instances the type of the dominant pneumonia was changed after thearrival, Accessions from civilian life quite invariably introduced andintensified infections. These facts emphasize the necessity for a detention campand its proper functioning. Most competent and alert medical officers should bein medical charge of detention camps where such have been established.

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

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

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

Control of Epidemic Influenza.

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

2. The disease now epidemic is believed to have been imported from Europe,where it has been prevalent in various countries. Popularly called "Spanishinfluenza," there is nothing about it to indicate any departure from theinfluenza which has been prevalent in the United States from time to time formany years and was last seen here in Army camps and cantonments in the spring of1918.

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

which the influenza is associated.

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

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

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

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

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

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

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

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

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

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

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

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

Personal Defense Against Spanish Influenza.

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

HOW TO STRENGTHEN OUR PERSONAL DEFENSE AGAINST SPANISHINFLUENZA.

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

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

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

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

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

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

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

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

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

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

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

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

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Circular Memorandum, Surgeon General's Office, September28, 1918.

Control of Communicable Diseases.

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

2. The memorandum referred to will be strictly observed, and its requirementsas to the care of measles patients will be applied to influenza as well. Thegreatest danger in influenza epidemics lies in overcrowding hospital wards andbarracks with influenza patients, which increases the incidence of pneumoniccomplications.

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

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

Method of Handling Influenza Epidemic at a Camp.

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

2. In epidemics of influenza every effort should be made to avoidovercrowding of the uncomplicated cases with a view to forestallingcomplications. At least 100 square feet of floor space per man should beprovided, and all the precautions used which are prescribed for measles inmemorandum this office January 1, 1918.

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

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

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

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

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

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

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

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

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

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

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

8. In the barracks frequent temperatures were being taken by medical and lineofficers and by enlisted men. The methods for disinfecting the thermometers insome instances appeared inadequate.

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

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

11. Two thousand negroes who arrived at the camp from civil life between twoto five days ago were put in an area by themselves and absolutely quarantined.The guard was most efficient and no officer or enlisted man could pass throughwithout proper credentials. No influenza has occurred among these men.

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

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

In base hospital proper 383

In base hospital annex 977

In 34 division field hospitals (isolation hospital) 663

In quarters 3, 728

Total 5, 751

During this period there had been 253 deaths almost exclusively frompneumonia.

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

	Pneumonia	Influenza
Sept. 16	5	0
17	2	0
18	0	970
19	0	325
20	22	274
21	16	149
22	33	179
23	40	288
24	41	803
25	122	1,007
26	90	1,049
27	113	1,047
28	89	899

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

The annex was equipped with straw mattresses and the soldiers' ownblankets. Medical Department sheets, some pillows, pillowcases, and pajamas wereprovided. There was one female

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

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

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

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

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

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

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

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

22. Numerous circulars relative to prevention of influenza and itscomplications have been issued by the camp authorities. These are very completeand satisfactory. The whole situation has been well handled. The only seriousdefect has been the retention of mild cases in quarters, but this will shortlybe changed and perhaps was necessary at the outset, owing to the suddenness ofthe onset.

23. Report and recommendations made to commanding general:

SEPTEMBER 28, 1918.

From: ...., M. C.

To: The commanding general, Camp .

Subject: Sanitary inspection.

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

2. It is recommended:

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

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

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

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

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

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

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

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

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

(i) That, if possible, improvised corridors covered with canvas be providedto connect the lavatories with the barracks which are being used for hospitalpurposes.

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

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

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

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

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

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

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

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

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

24. Recommendations to Surgeon General:

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

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

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

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

Precautions Against Transfer of Influenza Contacts.

The following is furnished for your information and guidance:

[Night letter.]

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

SEPTEMBER 20, 1918.

COMMANDING GENERAL, NORTHEASTERN DEPARTMENT.

Boston, Mass.:

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

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

You will inform all under your control.

HARRIS.

[1st ind.]

On copy of-

220.33 (Miscl. Div.). CHA/HDH

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

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

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

Assignment of Epidemiologist to Camp.

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

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

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

Report on the Influenza and Pneumonia Epidemic.

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

(a) Composition and strength of the command.

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

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

(e) Sufficiency and suitability of clothing.

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

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

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

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

[Reporting form]

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