Medical Department of the U.S. Army in the World War
THE MEDICALDEPARTMENT OF THE
UNITED STATESARMY IN THEWORLD WAR
VOLUME VI: SANITATION
IN THE UNITED STATES
BY
COL. WESTON P. CHAMBERLAIN, M. C.
IN THE AMERICAN EXPEDITIONARY FORCES
BY
LIEUT. COL. FRANK W. WEED, M. C.
PREPARED UNDER THE DIRECTION OF
MAJ. GEN. M. W. IRELAND
The Surgeon General
WASHINGTON: GOVERNMENT PRINTING OFFICE : 1926
349
IN THE UNITED STATES
CHAPTER XVI
THE INFLUENZA EPIDEMIC OF 1918
ADMINISTRATIVE CORRESPONDENCE DEALING WITH THECONTROL OF THE EPIDEMIC
BY
COLONEL D. C.HAVEN, MC
COLONEL W. P.CHAMBERLAIN, MC
MAJOR A. G. LOVE,MC
The present discussion of influenza is confined to the widespread epidemic inthe fall of 1918, and to the many important questions relating to sanitaryadministration to which this epidemic gave rise.
The first authenticated case of influenza in the autumn epidemic of 1918occurred at Camp Devens, Mass., on September 8,1 though it was not sorecognized at the time. At that date telegraphic reports of influenza were notrequired by the Surgeon General, because this disease hitherto had notrepresented a factor of major importance in the morbidity of the Army.Consequently, the Surgeon General was not immediately so informed of theinfluenza outbreak. About the middle of September it was apparent, however, tothe Surgeon General that a most serious situation existed at Camp Devens andthat influenza was certain to spread to other stations. It was thereforerecommended to The Adjutant General, on September 25, by the Surgeon General(see correspondence infra) that during the continuance of the epidemicnew men should not be sent to Camp Devens, nor should men be sent away from thatcamp. Camp Devens was then overcrowded, having nearly 10,000 men over and aboveits normal housing capacity.2 It was pointed out that new men broughtinto the camp at this time would almost surely contract influenza and add to thealready heavy burden of caring for the sick. Further, that by transferring menfrom Camp Devens, a virulent form of disease would undoubtedly be conveyed toother stations.3 The Adjutant General, in returning thiscommunication, stated that it was impossible to cancel the movement ofregistrants who were due at Camp Devens on September 25, but that orders hadbeen issued to cancel the movement of 3,000 registrants who were due to reporton October 7. Influenza had by this time made its appearance at Camp Dix, andsimilar action was recommended with respect to sending new men to Camp Dix, N.J., and to sending men away from that station, as had been advised for CampDevens. The War Department canceled all future movements of registrants to CampDix during the continuance of the epidemic.4
Based on a memorandum from the Acting Surgeon General, dated September 19,1918, The Adjutant General, on September 20, directed that all possibleprecautions be taken against the transfer of influenza contacts from camp tocamp, but that transfer of officers and men not contacts should be carried outas promptly as ordered.5 The effect of these instructions was torestrict movements of troops very slightly, if at all. Under orders previouslyissued, camp commanders were not authorized to transfer "contacts" ofany communicable disease. On the other hand, practically all men in the infectedcamps had been exposed to influenza and the transfer of any of them to otherstations resulted in the bringing of the disease to stations previouslyuninfected.
350
On September 26 the influenza situation was reviewed in a letter addressed tothe Chief of Staff, by the Surgeon General.5 As at this time 18 campswere heavily infected, emphasis was laid on the fact that the disease was now nolonger local, and that the restrictive measures recommended for Camp Devens andCamp Dix in the earlier communication should be applied to all militarystations. It was then predicted that, if the experience at Camp Devens berepeated in the other National Army camps, our losses by death would amount to8,000 or 10,000 men in the 16 cantonments alone. Unfortunately, this predictionwas justified. In the summary of the Surgeon General's review of the situationit was recommended that all draft calls of registrants destined for severelyinfected camps be canceled and that transfer of personnel from one station toanother be reduced to the minimum required by urgent military necessity,especially restricting movements from an infected to a noninfected camp and viceversa.
Influenza-pneumonia epidemics also developed on troop ships bound for Europeat this time.7 Many cables were received from the AmericanExpeditionary Forces indicating explosive outbreaks of the disease en route withhigh fatalities among troops. It was reported that soldiers were arrivingimproperly clothed, having only one blanket, no overcoats, and light cottonunderwear.8 Overcrowding of troopships was considered by the SurgeonGeneral as the most menacing insanitary condition then existing with referenceto the spread of influenza. Under date of October 1, the attention of the WarDepartment was invited to this condition, and request made that the overcrowdingof transports be immediately relieved.7 It was recommended that theauthorized capacity be reduced at least one-half.a
It may be said in passing that the severe outbreaks of influenza andpneumonia and the heavy mortality therefrom on troop ships were not due, exceptin part, to their sanitary conditions per se. This was generally good, save forovercrowding. Yet overcrowding and lack of sufficient hospital space, medicalpersonnel, and supplies undoubtedly increased the percentage of pneumoniacomplications, and also the case mortality from that disease. But it should beemphasized that the epidemic would have appeared among these troops had theyremained in camps in the United States, and it is safe to say the fatality wouldhave been nearly the same as occurred aboard transports. In later troopmovements, after the peak of the epidemic had been passed in the majority ofArmy camps, recommendation was made that only commands which had passed throughthe epidemic be selected for shipment overseas; 9 that those who hadactually had the disease could now be transported abroad with safety; and thosewho had not suffered from the disease might be assumed to be immune to futureattack if they had lived in a station which had passed through a severeoutbreak. As a result of this policy, shipments made later than October 15 wereaccomplished with very little influenza and pneumonia among those en route.
Early in the pandemic (September 28, 1918), before the disease had actuallyappeared in the majority of Army camps, a review was submitted to the Chief ofStaff by the Surgeon General, together with appropriate recommendations.10
_____a Consult Chap. XVIII of this section for details concerning thecapacity of troop ships.
351
The action of the War Department on the recommendations was prompt andefficacious. A telegram was sent to commanding generals of all camps, embodyingthe substance of the Surgeon General's letter.11 The effect ofthese instructions was to secure the fullest possible cooperation and support onthe part of commanding officers for camp surgeons, commanding officers of basehospitals, and others responsible for the local management of the epidemic.Special inspectors from the Surgeon General's Office visited the majority ofthe camps during the height of the outbreak, and not a single report wasreceived indicating that the line of the Army had not given the MedicalDepartment all assistance and support that it was possible for it to render.
The correspondence forming the basis of the statements made in the foregoingparagraphs, together with some other letters, telegrams, and cablegrams bearingon the influenza pandemic, is considered to be of so much historical interestand importance that it is quoted here in full.
SEPTEMBER 16, 1918.
Memorandum for the Surgeon General:
The Chief of Staff directs that the memorandum of the Director of MilitaryIntelligence, dated September 16, 1918, herewith, relative to influenza andpneumonia among the troops of the American Expeditionary force at Archangel, bereferred to you to note and return, with such comment as you may desire to make.
FULTON Q. C. GARDNER,
Lieutenant Colonel, General Staff, Secretary.
SEPTEMBER 16, 1918.
Memorandum for the Chief of Staff:
Subject: American Expeditionary Force, Archangel.
1. The following telephone message was received this morning from Mr.Harrison of the Department of State:
Ambassador Francis, Archangel, dated September 12. Epidemic Spanish influenzabroke out on three transports conveying American troops. Were 5 days fromArchangel. Men not acclimated. Many cases developed into pneumonia, and 24deaths have resulted. Speert thinks infection under control. Out of about 250afflicted there will possibly be a few more deaths. Coolidge leavestonight for America direct via Canada.
M. CHURCHILL,
Brigadier General, General Staff,
Director, Military Intelligence.
SEPTEMBER 19, 1918.
Memorandum for the Chief of Staff:
This office is without information as to the organizations composing theAmerican Expeditionary Forces at Archangel, and the port from which the commandsembarked, and is, therefore, unable to comment intelligently on the source ofthe infection. It is understood that influenza has been widespread among ourtroops in France, and it is presumed that the epidemic had its origin on theother side. The conditions appear to be serious, and it is hoped that amplemedical personnel and hospital supplies and equipment are available with theseforces to properly handle the situation. This office is without information withrespect to the above data.
Influenza is now epidemic in many camps on the Atlantic seaboard, includingCamps Devens, Upton, Dix, and Lee. A few cases have appeared at Camps Mills,Merritt, and Stuart. If movements of troops overseas continue withoutinterruption, influenza may be expected to break out on our troop ships, whichunder present conditions of overcrowding may be expected to result in thousandsof cases of the disease, with many deaths, and thus duplicate on a larger scalethe experience of troop ships bound for Archangel. The probability of a similaroutbreak on troop ships en route to France must be foreseen and considered inconnection with movements of troops during the continuance of this epidemic.
352
The military situation may demand that troops move without interruption, andthis office recognizes that military necessity must govern in the last analysis.However, if the situation will permit, it is recommended that organizationsknown to be infected, or recently exposed to the disease, be not permitted toembark for overseas service until the disease has run its course within theorganization, or until it is considered comparatively safe from danger ofinfection.
CHARLES RICHARD,
Brigadier General, Medical Corps, N. A.,
Acting Surgeon General, U. S. Army.
SEPTEMBER 25, 1918.
Memorandum for the Acting Surgeon General:
1. There is transmitted herewith for your information, a copy of thememorandum for the Chief of Staff from the Acting Surgeon General, datedSeptember 19, 1918, relative to the matter of the embarking for overseas oftroops known to be infected with, or recently exposed to, influenza.
2. Attention is invited to the action of the Chief of Staff as indicated bythe following notation:
The recommendation of the Acting Surgeon General on last paragraph of hisletter herewith is approved. If carried out, there will be no reduction of menembarked.
MARCH, C. of S.
3. Copy of this paper has been referred to the Director of Purchase, Storage,and Traffic for action as indicated in the notation above referred to,
FULTON Q. C. GARDNER,
Lieutenant Colonel, G. S., Secretary.
SEPTEMBER 25, 1918.
DEPARTMENT SURGEON, WESTERN DEPARTMENT,
San Francisco, Calif.
It is desired all camps and posts in your department report daily by wiredirect to this office number new cases influenza comma pneumonia and deathsperiod If no new cases appear no report required.
RICHARD, Acting Surgeon General.
Same telegram to all departments and to independent stations.
[Night letter]
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 contactsbut movements of officers and men not contacts will be effected promptly asordered period.
Details of all movements from your camp to other camps will be arranged withcommanding officers thereat period Make no movements until commanding officersof camps to which men are to be sent advise you their camps not quarantined andthey are ready to receive men period 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.
War Department telegraph desk:
Please send same telegram to: Commanding general, Eastern Department,Governors Island, N. Y.; commanding general, Southeastern Department,Charleston, S. C.; commanding general, Southern Department, Fort Sam Houston,Tex.; commanding general, Central Department, Chicago, Ill.; commanding general,Western Department, San Francisco, Calif.; commanding officer, North AtlanticCoast Artillery district, Boston, Mass.; commanding officer, Middle AtlanticCoast Artillery district, Fort Totten, N. Y.; commanding officer, South AtlanticCoast Artillery district, Charleston, S. C.; commanding officer, South PacificCoast Artillery district, San Francisco, Calif.; commanding officer, NorthPacific Coast Artillery district, Seattle, Wash.
ADJUTANT GENERAL
353
[First indorsement]
WAR DEPARTMENT, A. G. O.,
September 30, 1918.
To the Surgeon General, who will inform all under his control.
By order of the Secretary of War:
C. M. THEILE, Adjutant General.
SEPTEMBER 25, 1918.
From: The Acting Surgeon General of the Army.
To The Adjutant General of the Army.
Subject: Influenza epidemic.
1. A Most serious situation exists at Camp Devens, Mass., due to the outbreakof epidemic influenza in that camp, followed in many cases by pneumonia whichhas been, and is, extremely fatal, More than 10,000 cases of influenza have beenreported up to date, with 776 cases of pneumonia. One hundred and forty-twodeaths have occurred since September 19, the greatest number in any one daybeing 63 on September 23. The strength of command is approximately 45,000.Hospital facilities are entirely inadequate, and many barracks have been turnedover for extemporized hospitals. Influenza appears to be on the decline, butpneumonia is increasing. Additional medical officers and nurses and supplieshave been sent so far as available, but the situation remains grave and manymore fatalities are expected before the epidemic has run its course.
2. During the continuance of this epidemic new men should not be sent to CampDevens nor should men be sent away from that camp. New men will almost surelycontract the disease and add to the already heavy burden of the camp in caringfor them. In transferring men from Camp Devens at present a virulent form of thedisease will almost surely be conveyed to other stations.
3. It is understood that 500 registrants are scheduled to go to Camp Devenson September 25, and 3,000 registrants about October 7. It is recommended thatorders be modified, if possible, either to send these registrants elsewhere, orto detain them at their homes until these epidemics have subsided.
4. Similar conditions are reported from Camp Dix, N. J., though less seriousthan at Camp Devens, Twenty-five deaths from pneumonia occurred at Camp Dix onSeptember 23. If military necessities will permit, similar action is recommendedwith respect to sending new men to Camp Dix, or sending men from that camp,during the continuance of the epidemic.
CHARLES RICHARD,
Brigadier, Medical Corps,
Acting Surgeon General, U. S. Army.
SEPTEMBER 26, 1918.
From: the Acting Surgeon General of the Army.
To: The Chief of Staff.
Subject: Epidemic influenza.
1. Epidemic influenza, which is prevailing extensively in many camps andcantonments in the United States, has become a very serious menace andthreatens, not only to retard the military program, but to exact a heavy toll inhuman life, before the disease has run its course throughout the country. Thedanger in this disease lies in the frequency of pneumonia occurring as acomplication, which under the conditions of existing density of population inour camps and cantonments has a high incidence and mortality.
2. The experience at Camp Devens, Mass., may be instanced as what may befairly expected to occur at other large cantonments in the United States. Thedisease in epidemic form appeared first in camps and stations along the Atlanticseaboard. From the knowledge of previous epidemics, it may be expected to travelwestward and involve successively military stations in̓ its course. CampDevens, with a strength of approximately 45,000 men, has reported over 12,000cases of influenza. The first cases were reported on September 12. The number ofnew cases increased each day up to September 20 when 1,543 new cases werereported, and the disease curve reached its highest point, since which date adaily
354
decline in the number of new cases has occurred, 271 new cases being reportedon September 25. Twelve hundred and ninety cases of pneumonia have been reportedsince September 19, with 287 deaths at this camp alone since September 19 up toand including September 25. The greatest number of deaths in any one day was 83on September 25. While influenza itself is on the decline, pneumonia has beenincreasing up to and including September 24, when 342 new cases were reportedfor that day alone. On September 25, 309 new cases of pneumonia were reported,which may indicate that the height of the curve for pneumonia in the presentepidemic at this camp has been reached. An increasing daily death toll may beexpected at this camp until the pneumonia admissions curve shows a permanentdecline.
3. Camp Devens is fairly representative of the 16 large cantonments. With fewexceptions, they are densely populated from a sanitary point of view, acondition which tends to increase the chance for "contact" infection,the tendency to complicating pneumonias, and the virulence and mortality of thedisease. Hospital facilities are entirely inadequate to meet such heavy suddendemands, and the majority of cases must be treated in barracks. Medical andnursing personnel available in each cantonment can not properly handle thesituation without outside help.
4. The deaths at Camp Devens from influenza and its complications willprobably exceed 500. Multiply this number by 16 (the number of similarcantonments), and assuming that the other camps have a similar experience, it isseen that the loss in men in all 16 cantonments may conceivably reach 8,000 or10,000. This takes no account of the many large tent camps and the numerouspermanent military stations. The noneffective loss and delays in training andmovements of troops must also be considered in connection with this epidemic.
5. The disease is now prevailing in 10 of the 16 large cantonments, at theport of embarkation, Hoboken, N. J., and two of the tent camps in the South. Theproblem is, therefore, no longer local. Recommendation was made to The AdjutantGeneral in a recent communication that no drafted men be sent to Camps Devensand Dix during the continuance of the epidemic. Although the disease can not becompletely excluded from the camps, at least its progress can be controlled, itsspread limited, complications and fatalities lessened by proper restrictivemeasures, the chief of which are restriction of communication to and frominfected camps and adjacent infected communities (quarantine), relief andprevention of overcrowding in camps, and adequate provision for the proper careof influenza patients to prevent occurrence of the highly fatal complicatingpneumonias.
6. The new men brought to an infected camp are almost certain to contract thedisease in their first days in camp and add to the already heavy burden of thecamp in caring for them. Under conditions existing in a home the danger ofhaving pneumonia superimnposed upon influenza is much less than is the case indensely crowded cantonments. It is believed, therefore, that registrants shouldhave influenza in their own homes, if they must contract it, where mothers orsisters can care for them, rather than come to a camp already overcrowded andovertaxed to have the disease under much less favorable surroundings and withgreater chances for complicating pneumonias and deaths. Bringing new men intocamp under such circumstances would be destructive to morale at the very startof the soldiers̓ career. It is believed that aside from the humanitarianaspect, the economic gain in the number of lives saved by retaining registrantsdue to be called for service in the near future in their home communities untilthe epidemic has run its course or is under control, justifies immediate actionlooking to stopping the movement of registrants to camps and cantonments, or thetransfer of men from infected to uninfected camps and stations during thepresent emergency.
7. It is recommended, therefore, that-(a) All draft calls of registrantsdestined for severely infected camps in the immediate future be canceled. Thelist of severely infected camps is herewith appended. The duration of the needfor such cancellation can not now be estimated. (b) Transfer of militarypersonnel from one camp or station to another be reduced to the minimum requiredby urgent military necessities, especially restricting military movements oftroops from an infected to an uninfected camp or station, or vice versa.
CHAS. RICHARD,
Brigadier-General, Medical Corps,
Acting Surgeon General, U. S. Army.
355
BASE HOSPITAL,
Camp Devens, Mass., September 25, 1918.
From: Medical Board from the Surgeon General's Office.
To: The Commanding General, Camp Devens, Mass.
Subject: Statements and recommendations regarding the epidemic of influenza.
1. That no accession of troops be received at Camp Devens until the presentepidemic of influenza wholly subsides.
2. That no troops be sent from this to other camps until the epidemic hasdisappeared.
3. That as soon as the epidemic disappears the population of this camp bereduced to the number for which quarters have been provided, by sending 10,000troops elsewhere, or that the quarters be enlarged to properly accommodate thenumber here. This recommendation is founded upon the fact that this camp isovercrowded and was overcrowded to this extent before the epidemic appeared.
4. That immediately the quarters be expanded by proper tentage sufficient toprovide 50 square feet per man.
5. That all nonmilitary assemblies be discontinued during the prevalence ofthe epidemic.
6. That visitors to the camp be restricted to the friends of those who areseriously ill.
7. That no convalescents be returned to duty, except on certificate of theproper medical officer.
8. That the services of experts be secured by arrangement with the campsurgeon and the commanding officer of the hospital, to determine as far aspossible the nature of this epidemic and the best procedures in its control.
9. That additional hospital space be secured by the erection of hospitaltents to a sufficient extent to secure for each patient 100 square feet of floorspace.
10. That during the epidemic every occupied bed in hospital and barracks becubicled.
11. That mess tables be so arranged, either that all shall sit on one side ofthe table, or that the occupants of the two sides of the table be separated byscreens suspended above the middle of the table.
12. That instructions be given all men in the Medical Enlisted Corps and allsergeants in the organizations as to the manner of spread and the proceduresdesirable in the elimination of the spray-borne diseases.
13. That the Surgeon General be requested to supply the base hospital with 20medical officers, in addition to those already requested.
14. That the Surgeon General be requested to furnish the base hospital with200 more nurses than those already promised by the Surgeon General. Pending thearrival of nurses sent by the Surgeon General, the commanding officer of thehospital should be authorized to employ as many nurses as are needed, or as hecan obtain, in accordance with Army Regulations 1476.
15. That the commanding general give the camp surgeon verbal orders to assignfor temporary duty in medical detachment at base hospital, such number ofenlisted men as may be available.
16. That the camp surgeon be authorized to purchase in the open market suchproperty as can not be obtained through military channels, and is needed toproperly equip the hospital for the number of patients contained therein.
17. There are evidences furnished by a decrease in the number reported sick,and in admittances to hospital, that the epidemic has reached its height, andwill soon begin to decline. In all probability the number of deaths willcontinue to be large for some days.
18. We desire to express our high appreciation of the skill, energy, anddevotion shown by both medical and line officers in the handling of thisepidemic which came so unexpectedly and so overwhemingly on the camp. Specialapproval is deserved by the camp surgeon, commanding officer of the hospital,the epidemiologist, and their assistants.
VICTOR C. VAUGHAN,
Colonel, M. C., U. S. A.
WILLIAM H. WELCH,
Colonel, M. C., U. S. A.
RUFUS I. COLE.
356
[First indorsementl
WAR DEPARTMENT, S. G. O., September 27, 1918.
TO THE ADJUTANT GENERAL OF THE ARMY.
1. The within statements and recommendations made to the commanding general,Camp Devens, Mass., by Cols. Victor C. Vaughan and Wm. H. Welch, M. C., U. S.A., and Contract Surg. Rufus Cole, M. C., U. S. A., are concurred in.
2. The recommendations in paragraphs 1 and 2 have already been made to youroffice in letter dated September 25. Recommendations 4, 5, 6, 7, 8, 11, 12, and15 are matters of local administration and have probably already been compliedwith so far as possible. The recommendations in paragraphs 8, 10, 13, 14, and 16have been or will be given necessary action by this office.
3. The recommendation in paragraph 3 is most important. Camp Devens has beenovercrowded during the entire summer, as have practically all the largercantonments. Repeated recommendation has been made that every man in barracks beallowed 50 square feet of floor space; and where overcrowding has been found,recommendation has been made Ihat additional construction be provided on thisbasis. The recommendation in paragraph 3 that 10,000 troops now at Camp Devensbe sent elsewhere as soon as the present epidemic has subsided, is concurred in.It is not considered safe at the present time to transfer these men from aninfected to a noninfected camp.
4. Tentage should be sent to Camp Devens in such quantities as will properlymeet the requirements for additional hospital space and relieve presentovercrowding in barracks.
CHARLES RICHARD,
Brigadier General, Medical Corps,
Acting Surgeon General, U. S. Army.
[Second indorsement]
WAR DEPARTMENT, A. G. O., October 1, 1918.
TO THE SURGEON GENERAL.
Action has already been taken in connection with the recommendations inparagraphs 1 and 2 on the strength of your letter dated September 25.
The draft of 3,000 men who were to go to Camp Devens on October 7 has beensuspended. Steps are being taken to send other troops away from Camp Devens assoon as the quarantine is lifted.
Additional tentage needed will be shipped at once.
By order of the Secretary of War:
PAUL GIDDINGS, Adjutant General.
SEPTEMBER 27, 1918.
From: The Acting Surgeon General of the Army.
To: The camp surgeon, Camp Devens, Mass.
Subject: Overcrowding, Camp Devens, Mass.
1. Your telegram, September 26, is acknowledged. Wire has just been sent yousaying that orders for the October 7 draftees had been canceled.
2. Recommendation has been made to The Adjutant General that no more men besent to Camp Devens until the present epidemic subsides; further, that as soonas the epidemic has subsided the 10,000 men now at Camp Devens in excess of theaccommodations be transferred to another station, and that no furtherovercrowding be permitted.
3. With reference to the 500 colored draftees, it is hoped that you will beable to segregate them from the infected command and, if possible, prevent theinfection reaching them. Recommendation had been made that orders for thesecolored men be canceled, but the recommendation was made too late to secure thedesired action, as the machinery for sending them to Camp Devens was already inmotion and they could not be stopped. If overcrowding recurs, it should be notedon monthly sanitary reports that it may be brought to the attention of the WarDepartment.
By direction of the Acting Surgeon General:
D. C. HOWARD,
Colonel, Medical Corps.
357
WAR DEPARTMENT,
OFFICE OF THE SURGEON GENERAL,
Washington, September 28, 1918,
From: The Acting Surgeon General of the Army.
To: The Chief of Staff.
Subject: Influenza in camps.
1. The present influenza epidemic among troops in the United States hasassumed serious proportions; and, as the disease extends to other camps, thenoneffectiveness and mortality may be expected to materially increase. Everypossible measure must be taken in all camps and stations, infected as well asnoninfected, to prepare for handling epidemics of this disease, to restrict itsravages, and reduce the mortality therefrom. With this end in view, it isrecommended that instructions be sent all commanding officers substantially asfollows:
2. Influenza is a "crowd" disease. Epidemics of the disease will bemore extensive and the complications more frequent and serious in directproportion to the degree of overcrowding in camps. Where housing facilities ortentage are inadequate to allow for each man in camp a minimum of 50 square,feet of floor space in barracks or tents, immediate steps will be taken toremove a part of the command and place them in camp under canvas, if no othermeans are available for relieving overcrowding. If the camp is not infected, thenumber of men in camp in excess of the number for which accommodations areavailable based on the minimum of 50 square feet per man, may be reported to TheAdjutant General with a view to their transfer to another camp or station whichis noninfected and where accommodations may be available.
3. The prevention of overcrowding of influenza patients in hospitals orbarracks extemporized as hospitals is of the greatest importance. For eachinfluenza patient under treatment the minimum of 100 square feet of floor spaceis required; furthermore, each patient must be kept and treated in a cubicleduring the continuance of the disease, Hospital facilities will be entirelyinadequate as soon as the disease assumes epidemic proportions. Early provisionmust be made to completely vacate barrack buildings, preferably near the basehospital, which in the presence of an epidemic will be required as extemporizedhospitals. Ample provision in bed capacity must be made in advance, asadmissions will frequently number well over 1,000 daily during a well-developedepidemic. The treatment in regimental infirmaries or in parts of barracksoccupied by well men of a disease as contagious as influenza should not bepermitted. Barrack buildings used as temporary hospitals ordinarily will beadministered by the hospital staff as an adjunct to the main hospital.
4. Temporary details of commissioned and enlisted personnel, including cooksand kitchen helpers, from the line may be necessary to assist the medicalofficers in handling the situation. Additional medical officers and nurses willbe supplied from the Surgeon General's Office so far as they are availableupon proper request. Unskilled workers must come from an extemporized personneldetailed from the line or other camp source to supplement the trained personnelon duty at the hospital. Sufficient trained Medical Department enlisted men arenot available for transfer.
5. It is recommended that a synopsis of these instructions, if approved, betransmitted by wire to all camp and cantonment commanders, department andindependent station commanders. The element of time is of vital importance.Delay in sending out these instructions by mail in the view of this office wouldnot be justified in the present emergency.
CHARLES RICHARD,
Brigadier General, Medical Corps,
Acting Surgeon General, U. S. Army.
[First indorsement]
WAR DEPARTMENT, A. G. O., September 30, 1918.
TO THE SURGEON GENERAL.
With the information that a synopsis of paragraphs 2, 3, and 4 has been wiredto the commanding officers of all camps, cantonments, ports of embarkation,independent stations, and departments.
By order of the Secretary of War
C. M. THIELE, Adjutant General.
358
[Night letter]
SEPTEMBER 28, 1918.
COMMANDING GENERAL,
Camp Fremont, Calif.
Following regarding influenza is for information and guidance periodInstructions therein will be complied with without delay period
Influenza is a crowd disease period Epidemics more extensive andcomplications more frequent and serious according to degree of overcrowdingperiod Where housing facilities or tentage are inadequate to allow for each mana minimum space of fifty square feet of floor space in barracks or tents,immediate steps will be taken to remove a part of men and place them in campunder canvas if no other means are available for relieving overcrowding periodExtreme care must be taken in moving men from barracks into camp under canvasduring inclement weather and when men are provided with insufficient clothingand bedding to protect them against serious consequences period. If camp notinfected comma number of men in camp in excess of number for whichaccommodations are available at rate of fifty square feet per man may bereported to Adjutant General with a view to transfer elsewhere period
Prevention of overcrowding of influenza patients in hospitals or extemporizedhospitals of greatest importance period For each patient under treatment commaminimum of one hundred square feet of floor space required and each patient mustbe kept and treated in cubicle during continuance of the disease period Earlyprovision must be made to completely vacate barrack buildings comma preferablynear base hospitals comma when required as extemporized hospitals in thepresence of an epidemic period Treatment in regimental infirmaries or parts ofbuildings occupied by well men comma of influenza should not be permitted periodBarrack buildings used as temporary hospitals will be administered by hospitalstaff as adjuncts to main hospital period
Temporary details of commissioned and enlisted personnel comma includingcooks and kitchen police from line may be necessary to assist medical officersin handling the situation period Additional medical officers and nurses will besupplied from the Surgeon General's Office as available upon proper requestperiod Unskilled workers must come from personnel detailed from line or othercamp sources period Sufficient trained medical department enlisted men notavailable for transfer.
HARRIS.
War Department Telegraph Desk:
Please send same telegram to the following commanding generals:
* * * * * * *
SEPTEMBER 30, 1918.
From: The Acting Surgeon General of the Army.
To: The Adjutant General of the Army.
Subject: Epidemic of influenza.
1. On account of the spread of epidemic influenza, unprecedented demands arebeing made on the department for commissioned personnel. Many of these demandsare in excess of the need and more than can be supplied. In order that dueeconomy may be practiced and the personnel equally distributed, it isrecommended that the following telegram be sent to commanding generals of allcamps:
During present epidemic of influenza it is essential that medical personnelbe utilized in most economical manner, Retain minimum number of medical officerson duty with organizations and assign all others to care of sick in hospital.All requests for additional officers for camp or hospital will be made throughcamp commander. If officers are asked for duty in hospitals in excess of 1officer to each 35 bed patients, including all administrative, laboratory, andother officers on duty with the hospital, specific explanation of necessityshould be made.
For the Acting Surgeon General:
R. B. MILLER,
Colonel, Medical Corps, U. S. A.
359
WAR DEPARTMENT,
OFFICE OF THE SURGEON GENERAL,
Washington, October 1, 1918,
From: The Acting Surgeon General of the Army.
To: The Chief of Staff.
Subject: Overcrowding of troop ships.
1. Attention is invited to the following quotation from a cablegram fromheadquarters, S. O. S., A. E. F., dated September 25:
American troops joining A. E. F. through French ports thoroughly infectedwith influenza and large percentage of these cases develop pneumonia. Influenzasevere type epidemic throughout France and in A. E. F. complicated by septicrapidly fatal type of pneumonia. Resources of Medical Department in personneland hospital accommodations strained to limit by epidemic in view of greatshortage of medical equipment, personnel, and transportation. Urgentlyrecommended personnel, equipment, and supplies now due A. E. F. on medicalpersonnel and tonnage allotments be shipped as rapidly as possible. Exceptionalrequests for trained nurses to assist in handling this situation will follow assoon as proper estimates of number needed can be made. Further recommend closecamp segregation without leaves or furloughs of one week for troops prior totheir embarkation and more liberal allowance of hospital space for isolation ofpneumonia cases on transports. Two vessels entered port September 24 with 425hospital cases, of which approximately 170 were pneumonia.
2. From the above it is evident that a serious situation exists in the A. E.F. with reference to influenza and pneumonia. If infected troops continue toarrive in France it will add greatly to the burden already heavy of caring forsick and noneffectives with the present shortage of medical personnel andequipment.
3. Uncomplicated influenza is not often fatal. The danger lies in acomplicating pneumonia, the fatality of which is heavy. Overcrowding in campsand hospitals increases the percentage of pneumonia cases during epidemics ofinfluenza. The danger of overcrowing troop ships is even greater. Troop shipshave been greatly overcrowded during the past summer. If the same degree ofovercrowding is continued while influenza is so generally prevalent in theUnited States, transports arriving in France may be expected to havewell-developed pneumonia epidemics aboard with many fatalities during thevoyage. It can not be said with safety that any particular command is absolutelyfree from infection at the time of embarking while the disease is so widespreadin this country.
4. The recommendations in the above-quoted cablegram that commands be held inquarantine for one week prior to embarkation and that more liberal allowance ofhospital space for isolation of pneumonia cases be provided are concurred in.There may be difficulties in carrying out these measures in some instances, butthe principles should be approved and followed in practice so far as possible.It is advisable that troop movements overseas be restricted to actual immediatenecessities until the epidemic of influenza from this side of the water hassubsided.
5. It is recommended further that the overcrowding of troopships beimmediately relieved, covering such shipments as may be imperative during thepresent epidemic. It is believed that the present authorized capacity oftroopships should be reduced at least one-half for the present and it is sorecommended.
CHARLES RICHARD,
Brigadier General, Medical Corps,
Acting Surgeon General, U. S. Army.
[First indorsement]
WAR DEPARTMENT, A. G. O., October 5, 1918.
TO THE SURGEON GENERAL.
Returned.
In view of the instructions which have already issued from the War Departmenton the subject of physical examinations and inspections prior to departure fromcamps and prior to embarkation, your recommendation for a reduction in thetransport capacity to 50 per cent, and that troops be held in quarantine for oneweek prior to embarkation, is disapproved.
By order of the Secretary of War:
PAUL GIDDINGS, Adjutant General.
360
[First indorsement]
WAR DEPARTMENT, S. G. O., October 5, 1918.
TO THE ADJUTANT GENERAL OF THE ARMY.
1. Forwarded, inviting attention to letter from this office dated October 1,copy inclosed.
2. While influenza is so widespread throughout the country, it is impossiblefor medical officers to state with any degree of safety that any particularcommand is free from infection, or that it may safely embark on troopships foroverseas service. It may be assumed that all commands at ports of embarkationare infected or have been exposed to the disease. It is recommended, therefore,that all troop movements overseas be suspended for the present, except such asare demanded by urgent military necessity. Similarly, movements to and fromcamps in thi country should be restricted to absolute necessities.
CHARLES RICHARD,
Brigadier General, Medical Corps,
Acting Surgeon General, U. S. Army.
[Night letter]
OCTOBER 8, 1918.
COMMANDING OFFICER,
Camp Fremont, Palo Alto, Calif.
In order to prevent the spread of influenza through civil communities, thecommanding officers of camps, posts, and stations, not quarantined, but in whichinfluenza is prevalent, will suspend all individual furloughs for enlisted menand leaves of absence to officers, except where exceptional circumstances ofgreat weight render such furlough very necessary.
HARRIS.
Sent to all stations.
[Third indorsement]
WAR DEPARTMENT, S. G. O., October 10, 1918.
To the CHIEF OF EMBARKATION SERVICE,
Purchase, Storage, and Traffic Division, General Staff.
1. Returned. The suggestions of the surgeon, port of embarkation, NewportNews, are concurred in for such troop movements as are imperative during theprevalence of the present epidemic. Recommendation was made by this office toThe Adjutant General, in indorsement, October 5, that "all troop movementsoverseas be suspended for the present, except such as are demanded by urgentmilitary necessities." However, several camps have now passed the peak oftile epidemic wave, and it is believed if the suggestion is approved of shippingonly men who have already had the disease, and are therefore presumably immune,that such shipments may be resumed at an early date with safety.
2. It is believed to be desirable at the present stage of wide-spreadepidemic now sweeping through our camps that shipments be made of individual menwho have actually had the disease rather than shipments of entire organizationsin which is certain to be many nonimmunes. It is true that usually no more than40 per cent of the population of a given community contracts the disease. At thepresent time, there is no camp in the United States in which 40 per cent of thecommand has contracted the disease, If the percentage of infection of a commandis to be taken as a guide in this matter, it is believed that 40 per cent willprove altogether too high. Camp Devens, for instance, has now had a total of13,000 cases with a command of something over 45,000 men. Camp Devens was firstinfected, and the disease has practically run its course there. The degree ofinfection at Camp Devens is about 30 per cent of the command, and the epidemicis practically over.
3. Individual men who have recently had the disease may be safely sent at thepresent time, If it is imperative to send organizations intact, it will, ofcourse, be safer to send a command in which the disease has run its course,rather than one in which the disease has not yet appeared, and it is sorecommended.
CHARLES RICHARD,
Brigadier General, Medical Corps,
Acting Surgeon General, U. S. Army.
361
DETROIT, Mich., October 17, 1918.
SURGEON GENERAL, U. S. ARMY,
Washington, D. C.
The following telegram has been sent to the commanding officer of all Armyand Navy camps in the Middle Western and Southern States: Investigation showsthat a great many men are daily arriving in Detroit from military establishmentsand that a majority of them are on furlough, many convalescent after influenzaperiod Specific instances are at hand where men have been stricken withinfluenza on their way to this city and after coming here have infected peoplewith a virulent type of the disease period Detroit has one hundred fiftythousand men working on war contracts period Liberty motor and aircraftproduction depend upon this city and men in these industries must be protectedperiod It has been decided to-day to establish a quarantine against all militaryencampments Army and Navy this quarantine will go into effect Saturday thenineteenth period Will you kindly issue orders that no men will be allowed tocome to Detroit from your camp period Exceptional cases where men are onnecessary military business having a statement from a superior officer and whoare in good health will be considered.
J. W. INCHES,
Commissioner of Health.
[First indorsement]
WAR DEPARTMENT, S. G. O., October 18, 1918.
TO THE ADJUTANT GENERAL OF THE ARMY.
1. Forwarded, for his information. No action appears necessary.
For the Acting Surgeon General:
D. C. HOWARD,
Colonel, Medical Corps.
[Third indorsement]
WAR DEPARTMENT, S. G. O., October 18, 1918.
To THE ADJUTANT GENERAL OF THE ARMY.
1. Returned. Influenza is now prevailing in all camps and cantonments in theUnited States. This disease will probably continue for several months.
2. It is recommended that five men only be permitted to occupy a singlepyramidal tent during the present fall and winter. This will give each man 50square feet of floor space, which is absolutely essential to preventovercrowding. It is recommended that decision to this effect be communicated toall commanding officers, without delay, for their information and guidance.
For the Acting Surgeon General:
D. C. HOWARD,
Colonel, Medical Corps.
FORT SAM HOUSTON, TEX., October 12, 1918.
SURGEON GENERAL, U. S. ARMY, Washington.
No. 1066. Following telegram received by department commander:"Washington, D. C., October 3, 1918, Commanding General, SouthernDepartment, Fort Sam Houston, Tex. Reference movements of men to and from campsand stations at this time all possible precautions will be taken againsttransfer of any influenza contacts but movements of officers and men notcontacts will be effected promptly as ordered. Details of all movements fromcamps or stations to other camps or stations will be arranged with commandingofficers there to make no movements until commanding officers of camps orstations to which men are to be sent advise you their camps or stations notquarantined and they are ready to receive men. All movements which may besuspended due to quarantine will be effected as soon as conditions will permit.Harris." Following telegram received October 9, "Washington, D. C.,Commanding General, Southern Department, Fort Sam Houston, Tex. You will effectas directed all transfers ordered by this office of men from S. A. T. C. unitsin your Department regardless of quarantine from influenza at their school or atdestination to which ordered provided that you will send only men who are notill at time of departure. Direct that all men sent be warmly clothed. AdviseCommanding Officers at destination as to men who go from schools quarantined forinfluenza. Harris." Influenza epidemic particularly
362
severe in S. A. T. C. stations this department. Believe if movements ofstudents are carried out now serious cases may develop on trains causing unduesuffering, possibly deaths and criticism medical administration. Request youtake this up with proper authority depart. ment commander approves this wire.
CLAYTON
To be sent in broken code:
OCTOBER 15, 1918.
COMMANDING GENERAL, Camp Wadsworth, S. C.
During present epidemic, following instructions govern: When an organizationhas been ordered to a port of embarkation, you will send to that port, as soonas notified by the port commander of that port, all men in that organization whoare physically fit for overseas service who are well at the time and who havenot been in contact with an influenza case for four days. All organizations whoare within ten per cent of their authorized strength and fulfill these healthconditions will be reported at once.
HARRIS,
S. O. S. No. 186. SEPTEMBER 26.
THE ADJUTANT GENERAL.
* * * * * * *
Paragraph 2. For the Chief of Staff. There are a great number of cases ofsevere influenza and pneumonia and consequently many deaths among troopsrecently arriving in France. On investigation it developed that troops arearriving improperly clothed, having only one blanket, no overcoats, and lightcotton underwear. This is exceedingly dangerous at this season of the year. Inaddition to 3 blankets called for by S 99, paragraph 1, it is imperative thattroops be provided with overcoats and winter underwear.
* * * * * * *
HARBORD,
No. 1744.
To THE ADJUTANT GENERAL.H. A. E. F., October3.
Paragraph 1. For the Chief of Staff and Surgeon General.
* * * * * * *
Subparagraph A. Reference 5 178, paragraph 1 B. Influenzaexists in epidemic form amongst our troops in many localities in Franceaccompanied by many serious cases of pneumonia. Request coming * * * allquarters for additional members of the Army Nurse Corps. In all probabilityconditions will not improve but will grow worse during the winter, Request 1,500members of Army Nurse Corps, item M 1181 W, be sent to France as an emergencyrequirement at the earliest practicable date for duty at camp hospitals and tomake up shortage. Cancel an equal number of Medical Corps replacements requestedfor October and November.
* * * * * * *
PERSHING.
S. O. S. 248. Confidential. OCTOBER 9.
THE ADJUTANT GENERAL, (For the Chief of Staff and Embarkation.)
Investigation by inspector general of condition on Louisville,recently arrived at Brest, shows cause of epidemic of influenza pneumonia tohave been overcrowding, poor ventilation, filth, and insufficient covering, eachman having but one blanket. Bunk capacity of Louisville is about 3,000and there were 3,300 passengers on board, Statement of ship's surgeon was thatinfluenza was brought on board by a naval draft which he endeavored withoutsuccess to have removed before sailing. Surgeon further stated that ship'scaptain and executive officer were never present at daily routine inspection ofship's compartments and that the Louisville was dirty during entire trip. Therewere 500 cases of influenza on the Louisville, 32 deaths on the voyageand 18 after arrival.
Report of inspector general on the Vale shows spread of epidemic wasdue to overcrowding and lack of covering, each man having but one blanket. Bunkcapacity of transport is 1,600, and there were 2,600 on board, There were 500cases of influenza on the Vale, 80 of which developed into pneumonia; 31deaths on the voyage and 14 after arrival.
HARBORD.
363
S. O. S. No. 246. Confidential.
TO THE ADJUTANT GENERAL, Washington.
OCTOBER 8.
(For Chief of Staff and Surgeon General.)
At noon October 7 there were 1,541 influenza and 1,062 pneumonia cases atBrest, with total of 77 deaths. On Leviathan, which arrived there samedate 3 p. m., there were 571 cases influenza, 134 pneumonia, and 67 deathsduring the voyage. Convoy arriving St. Nazaire October 6 with 24,488 officersand men had 4,147 sick during voyage, 1,357 needing hospitalization on arrival,and had * * * deaths from pneumonia during the voyage. Presume all ships arebeing disinfected there before return trip and that quarantine recommended isbeing enforced. Am informed that statement of shortage in medical personnel andmaterial is being cabled you from commander in chief to-day. The need for thesethings is urgent and can not be too strongly stated.
HARBORD.
OCTOBER 9, 1918.
From: The Acting Surgeon General, U. S. Army.
To: The Adjutant General of the Army.
Subject: Remedial measures to prevent transferring influenza to France,
1. With reference to the attached cable of October 7, signed by Harbord, noreply to which has been made by this office, attention is invited to theattached recommendation to the Chief of Staff, dated October 1, 1918, withreference to remedial measures and first indorsement to A. G. O., October 5,1918, disapproving said recommendations.
For the Acting Surgeon General:
D. C. HOWARD,
Colonel, Medical Corps.
2 incls. (Attached was letter from Acting Surgeon General, dated October 1,1917, already quoted.)
H. A. E. F. October 8.
No. 1766,
THE ADJUTANT GENERAL, Washington.
* * * * * * *
Paragraph 7.
Subparagraph B. Request information as to when personnel now due will beshipped; as to present status of influenza and pneumonia at embarkation ports,and practicability of your acting upon our recommendations in cable S 178. Alsoas to whether you are prepared to ship and in what amounts, as exceptionalsupply polyvalent pneumococcus lipovaccine over and above our present request.
* * * * * * *
PERSHING.
S. O. S. No. 261. Confidential.
THE ADJUTANT GENERAL. OCTOBER11.
(For the Chief of Staff and Surgeon General.)
Leviathan arrived October 7. Deaths en route, 85; 6 more moribund, 366pneumonias, 597 influenza in ship's hospital on arrival. One per cent of thetotal strength of convoy arriving Liverpool October 8 died of pneumonia at sea.Deaths expected from cases sent to hospital on arrival will raise totalmortalities to 2 per cent of this convoy.
HARBORD.
No. 1785, Confidential.
H. A. E. F., October 12.
TO THE ADJUTANT GENERAL, Washington.
Paragraph 1. For the Chief of Staff and Surgeon General. Inadequatehospitalization facilities becoming more critical. In order to enable us to carefor serious sickness and battle casualties it is absolutely imperative that the1 base hospital and 31 evacuation hospitals,
364
due September 30, and 14 base hospitals, due in October, should be sentimmediately and that their nurses and equipment should be sent with them, or,when possible, in advance. Forty-six base hospitals have arrived since Junewithout equipment, which later on did not become available for many weeks. Thereare 15 base hospitals now here without their quota of nurses. We have reachedthe limit of what we can do without necessary Medical Department personnel andequipment. Situation so serious that it merits immediate attention andexhaustion of every possible effort to get this material and personnel to us atonce.
PERSHING.
S. O. S. 329. Confidential.
TOURS, October 23,
TO THE ADJUTANT GENERAL.
Paragraph 1. For Chief of Staff and Surgeon General. Convoy 49 arrivedLiverpool October 17, strength 21,000. Influenza and pneumonia 606, measles 20,mumps 26. Deaths on voyage 88 from pneumonia.
Subparagraph A. Convoy 50 arrived Liverpool October 19; strength 4,236.Influenza and pneumonia 94 cases, 59 deaths.
HARBORD.
S. O. S. No. 340. Confidential.
OCTOBER 24.
To THE ADJUTANT GENERAL.
(For the Chief of Staff and Surgeon General.)
Seven transports arrived Brest October 20; strength, 12,821. Deaths en route,47; cases influenza, 314; pneumonia, 88 sick on arrival. Three transportsarrived Brest October 21; strength, 6,474; deaths en route, 10; cases influenza,101; pneumonia, 24 on arrival.
HARBORD.
S. O. S. No. 357,
H. S. O. S., October 26.
To THE ADJUTANT GENERAL.
Paragraph 1. For Chief of Staff. Convoys just arrived England show markedimprovement health conditions due to efficacious preventive measures taken inUnited States.
* * * * * * *
HARBORD.
S. O. S. No. 362, Confidential.
LONDON, October 27.
TO THE ADJUTANT GENERAL.
(For the Chief of Staff.)
Marked improvement from 3 base ports in condition of troopsarriving on 17 transports past 24 hours. Total arriving, 28,898; influenza andpneumonia on voyage, 149; deaths from pneumonia on voyage, 2.
HARBORD,
S. O. S. 375. Confidential.
TOURS, October 29,
To THE ADJUTANT GENERAL.
(For the Chief of Staff and Surgeon General.)
Convoy Antigone, 12 transports arriving LiverpoolOctober 25, strength 19,154; cases pneumonia and influenza registers; deaths,pneumonia, 2; others sick, mumps, 80; measles, 33; chicken pox, 3. Transport Olympicarrived Southampton October 25; strength~ 5,430; influenza, 34; pneumonia,2; no deaths. Mouth and nose masks worn day and nigh~. One per cent of iodine inalbolene used as sprays. Three transports arrived Brest October 25; strength,4,215; influenza, 26; pneumonia, 3; no deaths.
HARBORD.
365
REPORTS OF SANITARY INSPECTIONS DURING THE INFLUENZA EPIDEMIC
While sanitary inspectors from the office of the Surgeon General madefrequent routine visits to all important camps during the World War, wheninfluenza began to assume a serious aspect, special inspections in addition wereordered at most stations in the East and Middle West, partly by regular membersof the inspection service and partly by officers borrowed for the purpose fromother divisions of the Surgeon General's Office. At these inspections it wascontemplated that the visiting sanitary inspector obtain first-hand informationregarding the situation for the Surgeon General's Office and offer to thelocal authorities such advice as appeared necessary in respect to the control ofthe disease and the care of the sick. The presence of inspectors and theirrecommendations served to steady morale and to convey the impression thateverything possible was being done by the central authorities. In general, itwas found that the difficult situation was being well handled in the camps.
One of the first of the special inspections was made on September 25, 1918,2at Camp Devens by a board of medical officers from the Office of the SurgeonGeneral. The recommendations made by this board were referred by the SurgeonGeneral to The Adjutant General for appropriate action on September 27,as shownin the above quoted correspondence on the subject of influenza.
The report of an inspection regarding the influenza situation at Camp Dix,made on September 28, 1918,12 was considered to be representative ofconditions existing in other military commands. Therefore, it was thought thatknowledge of the steps taken by the local authorities, and of therecommendations offered by the inspecting officer, might prove useful to thecamp surgeons at other stations, particularly those at which the epidemic wasjust commencing. Consequently, copies of this inspection report were sent allthe more important camps, posts, and aviation fields, together with theprefacing remarks shown in the memorandum below. This report is quoted in fullas giving a vivid picture of the situation in a camp which was one of thelargest in this country and which was among the most seriously afflicted.12
WAR DEPARTMENT,
OFFICE OF THE SURGEON GENERAL,
Washington, September 30, 1918.
Memorandum for all camp surgeons, surgeons of recruit depots and independentstations, department surgeons, and officer in charge of Air Service divisions:
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 shouldcon s:ult 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.
By direction of the Acting Surgeon General:
D.C. HOWARD,
Colonel, Medical Corps.
366
REPORT OF INSPECTION IN RELATION TO EPIDEMIC OF INFLUENZA ANDPNEUMONIA AT _____.
MADE SEPTEMBER 28, 1918
By Colonel ______, M. C.
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 allowances, so that over 50 square feet is provided eachman. In the depot brigade from 12,000 to 15,000 men are kept under canvas, 5 mento 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 out doors 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 out doorspractically 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 "DustexGlutten," 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 hasbeen in force some days, except that relatives of severely ill are admitted andvisit 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 exchanges 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 for new cases and see that men areproperly cared for, Medical officers visit all barracks at least twice a day.
7. Throughout the camp a part of each barrack, generally one room, has 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.
367
11. Two thousand negroes who arrived at the camp from civil life between twoand 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"quarters" cases, referred to in paragraph 7 above, were not reportedto the Surgeon General, so the actual number of influenza cases was in excess ofthe figures reported to the Surgeon General. On September 16 the reports of thebase hospital show no cases of influenza, 51 cases of pneumonia, and no deaths,On September 27 there were 536 cases of pneumonia in the base hospital and 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, almostexclusively from pneumonia.
The daily admissions for influenza and pneumonia sinceSeptember 16 are as follows (the 970 cases on September 18 represent anaccumulation of three days. The first known cases was on the 16th):
14. To supplement the base hospital, a group of 18 companybarracks, fortunately empty, were set aside and fitted up as an"annex" base hospital, being administered by the base hospital. Thisgroup of buildings was three-fourths mile from the base hospital proper. Theannex had been in operation three days at date of my arrival and, consideringthe suddenness of the organization, it was in excellent condition. Quartermastercots were used and the rooms supplied on the bases of a bed for each 100 squarefeet of floor space. In some rooms the beds were too close together around thewalls and the central space was empty. This will be corrected at once. Thecapacity of the annex was 1,040 beds. On day of my visit another adjacent groupof barracks, with a capacity of 1,000 beds (on basis of 100 square feet perbed), was being vacated and the occupants placed under canvas.
The annex was equipped with straw mattresses and the soldiers̓own blankets. Medical Department sheets, some pillows, pillow cases, and pajamaswere provided. There was one female nurse on duty, and more were to come onarrival of nurses now en route. Messes were run in some of the buildings andwere shortly to be started in more. "Ambulant cases"- that is,influenzas whose temperatures had been normal 24 to 48 hours-went out of theirparticular building to the nearest mess for meals. No men with temperatures wereallowed to go out to the lavatories. No cubicles had been installed. Allattendants were masked. Part of the medical personnel was drawn from the campphysical examining board. A portion of the 186 enlisted men on duty weresoldiers from the line who had some previous experience
368
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 setaside for hospital purposes and was run by the four field hospitals of thedivision. This hospital had accommodations for 700 patients. The conditions herewere not quite as good as in the annex. No sheets, pillow cases, or pajamas wereprovided. Coughing cases were neither masked nor screened. There was noovercrowding. Female nurses are to be sent here as soon as available.
16. The base hospital was in excellent condition and appearedto be meeting the situation in a most creditable manner. At time of visit therewere 2,800 cases at the base hospital proper, but 300 of these were venerealcases which had been placed in tents, and 400 others were to be transferred tothe new part of the annex that afternoon. There was only slight crowding at dateof visit and that should be entirely obviated when the 400 are moved out. Thecorridors were not used for sick at all. The porches were occupied by beds andare provided with rolling canvas curtains to keep out rain. All pnuemonia casesin wards were cubicled, but not those on porches, though the beds were too closetogether. Patients were arranged heads and feet alternating. Masking ofattendants throughout the hospital was most thoroughly enforced. Ventilation ofentire hospital was ample. Straw mattresses and quartermaster beds were used toa considerable extent. All influenza patients are fed in their own wards. Theyare not cubiclcd because of lack of sheets.
17. There was one ward full of sick female nurses, of whom 30were said to have pneumonia. There were 51 on sick report. One nurse and onedietitian have died. One medical officer and one dental officer also have died.
18. There were over 100 bodies in the morgue and adjacentbuilding used as an extemporized morgue. Relays of men were embalming, washing,and dressing the dead. The supply of coffins was adequate. The order andcleanliness of the morgue buildings was not entirely satisfactory. Only threeautopsies have been done, as commanding general disapproves. The commandingofficer did not know that the authority for doing autopsies had been placed inhis hands, The three autopsies showed bronchopneumonia.
19. There is no serious shortage of supplies. At the outsetthe camp surgeon directed the camp supply office to purchase anything necessary.
20. Thirty medical officers are en route or arriving at thecamp, and it is thought this number will be sufficient, except that twoadditional laboratory men arc needed at once, there being only two on duty, oneof whom is a chemist. Ninety-four nurses are ordered to the hospital, of whomthirty have arrived. This number is not sufficient. One hundred additionalenlisted men, Medical Department, arrived last night, and the number appearssufficient at present, in view of the men detailed from the camp.
21. The type of pneumonia was reported to be about one-halfpneumococcus and one-half streptococcus (not hemolytic), in both instancesusually associated with influenza bacillus. Six cases of empyema have developedthus far. The colored men appear to be suffering less from the influenza andpneumonia epidemic than are the whites. Influenza cases are being kept seven toeight days in hospital. The rule is to keep them in till temperature has beennormal four days.
22. Numerous circulars relative to prevention of influenzaand its complications have been issued by the camp authorities. These are verycomplete and satisfactory. The whole situation has been well handled. The onlyserious defect has been the retention of mild cases in quarters, but this willshortly be changed and perhaps was necessary at the outset, owing to thesuddenness of the onset.
23. Report and recommendations made to commanding general:
SEPTEMBER 28, 1918.
From: Colonel , M. C.
To: The commanding general, Camp
Subject: Sanitary inspection.
1. With reference to the epidemic of influenza and pneumoniaat this camp, it is my opinion that the situation is being handled in agenerally satisfactory manner, in so far as conditions will permit. Thefollowing recommendations are made with a view to improving certain details ofthe work, and it is understood that, in some respects, the procedures recom-
369
mended are already contemplated by the camp authorities orunder way, but not yet completed, on account of lack of time or lack ofmaterial. Such recommendations as follow are probably not arranged in the mostlogical manner because of limited time in which to prepare this letter.
2. It is recommended:
(a) That no soldiers who have been afflicted with influenzabe returned to duty until at least 10 days after the temperature has becomenormal.
(b) That, in caring for influenza patients, all theprovisions in regard to the care of measles which were prescribed in memorandumS. G. O., January 1, 1918, be carried out, At least 100 square feet of floorspace should be provided for all uncomplicated influenza cases with a view topreventing the onset of pneumonia. This is considered even more important thanproviding the same space for cases which have already acquired pneumonia. Allcases of influenza should be screened from each other as rapidly as possible,using cheesecloth if sheets are not available.
(c) That, as far as possible, no cases of mild influenza betreated in barracks which are in part occupied by healthy soldiers. Toaccomplish this purpose it is recommended that additional barracks, if possible,be set apart exclusively for the care of such cases and be administered as anannex to the hospital in the same way as the present annex is administered.
(d) That, both in barracks and in tents, the cubicle systembe adopted for all healthy men by the use of the shelter tent, supported at onecorner of the bed by a stick or hung from the ceiling by a wire. This was beingdone in some barracks visited.
(e) That mess tables be so arranged that the men shall siteither on one side of the table alone or else the occupants of the two sides ofthe table be separated by a screen of cheesecloth suspended above the middle ofthe table.
(f) That the present quarantine of the camp against thesurrounding country and of the surrounding country against the camp be continuedexcept as regards the entry and exit of the friends and relatives of theseriously ill.
(g) That, as soon as the epidemic disappears, the populationof the camp be reduced to the number for which quarters have been provided, onthe basis of 50 square feet of floor space per man, or else that the quarters besufficiently amplified to provide accommodations for the number here.
(h) That female nurses be provided for the barracks used as ahospital annex and in the barracks used as a hospital by the field hospitalcompanies as soon as they are available.
(i) That, if possible, improvised corridors covered withcanvas be provided to connect the lavatories with the barracks which are beingused for hospital purposes.
(j) That steps be taken to prevent men from crowding togetherin post exchanges and also about the stoves when they are in barracks.
(k) That the laying of the dust in the camp be expedited asmuch as possible.
(1) That the greatest care he taken in the disinfecting ofthermometers used for taking temperatures in the barracks.
(m) That all the patients in the infirmary annex to the tentarea in the depot brigade be masked or cubicled.
(n) That the providing of pieces of newspapers under the spitcups in the barracks used as wards be enforced.
(o) That messes be started as soon as possible in all thebarracks used as wards in order to save convalescents from the necessity ofgoing outdoors.
(p) That sheets and pillow slips be provided for the sick inthe barracks run as a hospital by the sanitary train.
(q) That greater care be taken to maintain order andcleanliness in the buildings which are now being used for the temporary shelterof the dead at the base hospital.
(r) That cases of pneumonia and influenza on porches at thehospital be cubicled as well as those in the wards.
24. Recommendations to Surgeon General:
(a) That 30 additional nurses be sent at once.
(b) That two additional officers for the laboratory servicebe sent at once.
(Both these matters have been taken up personally with theproper divisions, and are being adjusted).
370
The following extracts from reports of sanitary inspectorsthrow light on the situation at many of the other camps during the influenzaepidemic and indicate certain of the difficulties under which the personnellabored.3 It should be noted that only faults are mentioned; this isthe usual practice in such reports.
Base Hospital, Camp Cody, N. Mex.,March 22, 1918.-Gowns, caps, and masks not habitually worn by officers,nurses, and attendants in the influenza wards. No paper napkins and bags in use.
Debarkation Hospital No. 3, New YorkCity, December 28, 1918.-Cubicles not used in influenza and pneumoniawards. Attendants not isolated.
General Hospital No. 14, Fort Oglethorpe,Ga., May 8, 1918.-Different types of pneumonia not separated. Cases ofempyema after operations are placed in surgical wards with clean cases.
Letterman General Hospital, SanFrancisco, Calif., September 28, 1918.-Pneumonia cases not cubicled;attendants not isolated; floors in measles ward not mopped up with adisinfectant.
Camp Grant, Ill., October 7, 1918.-Followingrecommendations made concerning the influenza epidemic: Convalescents dischargedfrom the hospital to be kept at the battalion infirmary for five days beforegoing to their company. That not more than five men be quartered in eachpyramidal tent (now contain six men). That a cheesecloth or gauze screen be hungdown the center of each mess table to separate the men on each side. That asheet of paper be placed on tile floor beneath each sputum cup.
Camp Gordon, Ga., September 13, 1918.-Manyeases of influenza being cared for in the regimental infirmaries, due to crowdedcondition of the base hospital.
CampGordon, Ga., October 12, 1918.-Following recommendations made during theinfluenza epidemic: That closer supervision of the isolation barracks bemaintained by the commanding officer, base hospital. That additional nurses bedetailed for night duty at the isolation barracks. That all post exchanges beclosed. That number of men sleeping in tents be reduced from seven to five.
Camp Hancock, Ga., October 15, 1918.-Casesof influenza which are not seriously ill are treated in tent infirmaries, Nocubicles are used; flies are numerous and there is overcrowding in some groups.These defects were corrected on recommendation of the inspector from the SurgeonGeneral's Office. No attempts made to boil mess dishes throughout the camp.
Camp Humphreys, Va., October 3, 1918.-Inthe colored camp mild cases of influenza were being treated in portable framebuildings holding 14 patients each. These were unscreened and flies verynumerous. In the base hospital the pneumonia cases were not entirely segregatedfrom uncomplicated influenzas. In only one organization in camp were cubiclesbeing used in barracks. No particular effort made to prevent men fromcongregating during the influenza epidemic.
Camp Lee, Va., October 4, 1918.-Followingrecommendations made by the special sanitary inspector regarding the influenzaepidemic: (1) That all organizations be inspected daily to detect sick men; (2)that out-door drills be continued in good weather, modifying so as to eliminateanything strenuous; (3) that screens made of cheesecloth be used down the centerof each mess table; (4) that companies boil their dishes; (5) that gasmasks be thoroughly disinfected after use.
Camp Lee, Va., January 6, 1919.-Inthe barracks at the remount station the cubicle system was not in use as percamp order.
Camp MacArthur, Tex., October 27, 1918.-Throughoutthe entire influenza epidemic the troops were not quarantined against theoutside communities, nor were those outside quarantined against the troops. Alsono orders were issued preventing the congregation of troops in mess halls,exchanges, theaters, etc., inside the camp. Both of the above measures wererecommended by the camp surgeon, but not followed by the camp commander.
Base Hospital, Camp MacArthur, Tex.,October 28, 1918.-Memorandum, S. G. 0.,, January 1, 1918, not compliedwith in all respects. Paper bags and paper napkins not supplied; insufficientfloor and air space for pneumonia and influenza cases.
371
Camp Meade, Md., March 14, 1918.-Owingto crowded conditions at the base hospital, many cases variously diagnosed ascoryza pharyngitis, laryngitis, and influenza are being treated at theinfirmaries.
Camp Meade, Md., October 8, 1918.-Thefollowing recommendations made concerning the handling of, the influenzaepidemic: (1) That all dishes be boiled; (2) that all floors in barracks used ashospitals and in latrines be disinfected at least once a week; (3) that all messtables be provided with screening hung through the center; (4) that all floorsbe oiled; (5) that temporary buildings be constructed at once for use asmorgues.
Hospital, Fort Monroe, Va., October 20,1918.-There is failure to completely comply with memorandum, S. G. O.,January 1, 1918. Masks were tried and discarded. Cubicles not used; papernapkins and bags not used.
Aviation Mechanics School, St. Paul,Minn., October 8, 1918.-No typing of pneumonia done during the influenzaepidemic.
Camp Hancock, Ga., October 15, 1918.-OnSeptember 29 and 30 approximately 2,800 troops arrived from Camp Grant, Ill,They were two days en route from Rockford, Ill., to Augusta. Seven hundred ofthese men were admitted directly from the train to the base hospital withinfluenza, the next day 500 more were sent to the hospital. Since that time thetotal number admitted has been approximately 2,000. Amongst these there havebeen 143 deaths to date. The infection in these men was most virulent. Over halfof the deaths in this camp were from these men. Laboratory reports indicate thatthey had a staphylococcus infection.
Camp Humphreys, Va., October 3, 1918.-OnOctober 3 there were 314 cases of influenza in hospital and 2,183 in infirmaries(barracks specially set aside for this). The cases had not been evenlydistributed through the command. The incidence here, as at Camp Dix, was muchhigher than among the white men. The number of whites was about three andone-half times the number of blacks, but the white had had 11 times as muchinfluenza. Both here and at Camp Dix the negroes were all in tents and the whitemostly in barracks.
REFERENCES
(1) Report from Base Hospital at Camp Devens, relative to influenzapneumonia, and respiratory diseases. On file, S. G. O., 710 D.
(2) Report of a medical board from the Surgeon General̓s Office,September 25, 1918, to the Commanding General, Camp Devens, Mass. Subject:Statements and recommendations regarding the epidemic of influenza. On file, S.G. O., 710 (Camp Devens).
(3) Letter from the Surgeon General, September 25, 1918, to The AdjutantGeneral. Subject: Influenza epidemic. On file, S. G. O., 710 (Influenza).
(4) Second indorsement War Dept., A. G. 0., October 1, 1918, to the SurgeonGeneral. On file, S. G. O., 710 (Influenza).
(5) Telegram from The Adjutant General, September 20, 1918, to CommandingGenerals all departments reference movements of troops to and from camps. Onfile, S. G. O ., 710 (Influenza).
(6) Letter from the Acting Surgeon General, September 26, 1918, to the Chiefof Staff. Subject: Epidemic influenza. On file, S. G. O., 710 (Influenza).
(7) Cablegram from Hq. A. E. F., September 25, 1918, reference arrival ofAmerican troops at French ports with influenza and pneumonia, quoted in letterfrom the acting Surgeon General, October 1, 1918 to the Chief of Staff. Subject:Overcrowding of troopships. On file, S. G. O., 573.2.
(8) Cablegram from Hq. A. E. F., September 27, 1918. (S. O. S. No. 186September 26, 1918, Par. 2). On file, S. G. O., 710 (Influenza).
(9) Third indorsement W. P., S. G. O., October 10, 1918, to Chief ofEmbarkation Service, P. S. and T. Div., Gen. Staff. On file, S. G. O., 710(Influenza).
(10) Letter from the Acting Surgeon General, September 28, 1918, to the Chiefof Staff. Subject: Influenza in camps. On file, S. G. O., 710 (Influenza).
(11) Night letter from The Adjutant General, September 28, 1918, toCommanding Generals 13 camps. On file, S. G. O., 710 (Influenza).
(12) Mimeograph letter from the Surgeon General, September 30, 1918, tosurgeons of all camps, recruit depots and independent stations. Subject: Method,etc., to be used, in combating the influenza epidemic.. On file, S. G. O.,Mimeograph (C-47).
