History

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

Circular No. 1, 1917

HEADQUARTERS AMERICANEXPEDITIONARY FORCES,
CHIEF SURGEON'SOFFICE

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

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

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

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

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

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

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

DIPHTHERIA AND MENINGITIS

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

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

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

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

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

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

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

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

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

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

904

Circular No. 2.

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

Circular No. 2.

HEADQUARTERS AMERICANEXPEDITIONARY FORCES,
OFFICE OF THE CHIEFSURGEON,
France, November 9, 1917.?

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

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

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

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

3. The professional authority of directors, assistantdirectors, and consultants, within their respective divisions, will berecognized by all concerned and duly respected and observed, it being fullyunderstood that this authority does not in any way include administrativecontrol.

4. The directors, each for his particular division, willbe immediately responsible to the chief surgeon, A. E. F., for the workperformed in these various divisions. In general, they will direct andcoordinate the professional service of all sanitary formations and hospitalsso that there will be a continuity of treatment along lines of recognizedapproved practice, from the front to the rear, in each professional division.

They will also act as consultants and advisors, and, whennecessary in the interest of the service, they will change professionalprocedure or inaugurate new methods.

5. In order to carry out these plans, the professionalservice of base hospitals and general hospitals, and other hospitals asfar as practicable, will hereafter be subdivided into eight sections, asfollows:

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

The commanding officer of each hospital will organizehis hospital as indicated, assigning a suitable officer to duty in chargeof each section. He will assign an adequate number of assistants to eachsection as far as it may be practicable. In making these assignments theprofessional qualifications of an individual in a particular specialtywill receive due consideration. The chiefs of sections will report directto the commanding officer, to whom they will be responsible, each for thesatisfactory operation of his particular section.

By command of General Pershing:

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

J. G. HARBORD,Chiefof Staff.

905

Circular No. 3.

HEADQUARTERS AMERICANEXPEDITIONARYFORCES,
OFFICE OF THE CHIEFSURGEON,
November 24, 1917.

The following instructions are issued for the guidanceof all medical officers:

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

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

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

4. In this connection attention is called to paragraph4, General Orders, No. 34, Headquarters A. E. F. No uncomplicated casesof venereal disease will be sent to base hospitals.

By command of General Pershing:

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

Approved:

J. G. HARBORD,Chief of Staff.

Circular No. 4.

HEADQUARTERS, AMERICANEXPEDITIONARY FORCES,
OFFICE OF THE CHIEFSURGEON,
France, December 22, 1917.

The following instructions relative to charges for certainclasses of dental work requiring precious metals and other expensive materialsnot furnished by the Government are issued for the guidance of all concerned.

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

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

3. List of charges:

Gold fillings:
Simple	$2.00
Compound	$2.50-3.50
Gold inlays:
Simple	$3.00-3.50
Compound	$4.00-5.00
Gold shell crowns (gold bridgedummies):
Bicuspids-
Swaged cusps	$5.00
Solid cast cusps	$6.00
Molars-
Swaged cusps	$6.00-7.00
Solid cast cusps	$7.00-8.00
Gold-porcelain crowns	$5.00
(Richmond, Goslee, Steele, or Ash facings, and bridgedummies)
Porcelain crowns, with cast gold base	$3.00
Bridges: Charges to be based uponforegoing figures covering components, i. e., abutment crowns, inlay anchorages,and dummies, plus a charge for consolidation not to exceed $1 for eachinterproximal space soldered.

By command of General Pershing:

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

Approved:

J. G. HARBORD, Chiefof Staff.

906

Circular No. 5.

HEADQUARTERS, AMERICANEXPEDITIONARYFORCES,
OFFICE OF THE CHIEFSURGEON,
France, January 15, 1918.

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

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

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

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

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

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

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

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

(e) Keep careful records of all cases examined.

(f) Make such reports to the chief surgeons ofdivisions as they require and to make monthly reports of their operationsto the director of psychiatry, bringing especially to his attention anymatters likely to increase the efficiency of this part of the medical workof the American Expeditionary Forces.

By command of General Pershing:

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

Approved:

J. G. HARBORD,Chiefof Staff.

Circular No. 6.

GENERAL HEADQUARTERS,AMERICAN EXPEDITIONARYFORCES,
OFFICE OF THE CHIEFSURGEON,
France, January 28, 1918.

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

(a) Immediately after the receipt of a wound ofwhatever character, if a battle casualty, preferably at the regimentalaid station.

907

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

(c) During operations performed under conditionsof unsatisfactory asepsis, e. g., emergency operations, operations forhemorrhoids, or when there has been contamination from the contents ofthe large intestine.

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

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

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

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

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

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

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

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

Circular No. 7.

GENERAL HEADQUARTERS,AMERICAN EXPEDITIONARYFORCES,
OFFICE OF THE CHIEFSURGEON,
France, January 28, 1918.

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

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

3. All accountable officers of Medical Department unitscoming under chief surgeons of divisions will at once invoice upon Form28, M. D., all property of whatever nature for which they are accountable,to their respective divisional medical supply officers. Under the supervisionof the chief surgeons of divisions this property will be issued and heldupon memorandum receipt, Form 28, M. D., so modified as to meet this need.

4. The medical supply officer of each division will prepare,after this transfer has been completed, accurate final returns upon Forms17, 17a, 17b, and 17c, in duplicate, of all equipment, property, and suppliesfor which he may then be accountable. The upper certificate upon Form 17cwill be used by the officer completing the final return, the lower form,as modified, by the officer making final inventory. One copy will be retainedand one copy forwarded to the chief surgeon, line of communications.

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

908

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

6. Accountable officers of Medical Department units, notunder chief surgeons of divisions, will proceed as per instructions containedin paragraph 4 above, and subparagraphs 1 and 2, paragraph 1, General OrderNo. 74, above quoted. These final returns will be made in duplicate andone copy retained by the accountable officer and one forwarded to the chiefsurgeon, line of communications.

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

8. Requisitions for all property listed upon tables ofsupply will be made for divisional units in quadruplicate, and in all othercases in triplicate upon Forms 33, 35, or 36, M. D. In each case one copywill be retained and the others forwarded for action. Requisitions forblank forms will be made as in the past upon Form 37 and for all organizationsbut one copy forwarded for action.

9. All equipment, property, and supplies needed for useof divisional units will be requisitioned for by the divisional medicalsupply officer, and his requisitions will be forwarded to the chief surgeonof that division for his action. The chief surgeons of divisions will forwardall approved requisitions, or those approved as modified, except for transportationas noted in paragraph 11, direct to the officer in charge of the issuingdepot. The same disposition will be made of requisitions from organizationsother than divisional, and with the same exception. The chief surgeon,line of communications, will publish from time to time detailed instructionsrelative to the exact depot to which requisitions from the various unitsshould be sent. These instructions will also contain a statement of policyas regards "articles due."

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

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

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

13. The public vouchers referred to above will be madein duplicate and accompanied by the proper forms. In cases where the purchasehas been made under the supervision or authority of a divisional chiefsurgeon, the vouchers will be sent to that office for visa and approvalafter which they will be sent direct to the proper disbursing officer forpayment. The papers referring to transactions not falling normally withinthe province of divisional chief surgeons will be forwarded to the chiefsurgeon, line of communications, for final action.

14. The chief surgeons of divisions may authorize ordinaryand emergency expenditures of public funds for their own department inamounts not to exceed $100. All such expenditures so authorized will bereported to this office monthly upon a consolidated list showing the largergroups and not each individual item.

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

909

MODIFIED FORMC,MEDICALDEPARTMENT

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

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

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

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

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

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

Circular No. 8.

GENERAL HEADQUARTERS,AMERICAN EXPEDITIONARYFORCES,
OFFICE OF THE CHIEFSURGEON,
France, February 4, 1918.

The following information is published for the guidanceof all concerned:

* * * * * * *

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

2. These men were not furnished with rations when theyleft the hospital; and as very few of them had any money, the large majoritywent without anything to eat from 6.10 a. m. to about 8 p. m. No notificationwas sent to the authorities at _____ from Hospital No. ____ to expect thesemen, and when they arrived, about 8 p. m., there was therefore no provisionfor taking care of them until they could be forwarded to their respectiveorganizations.

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

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

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

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

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

910

Circular No. 9.

GENERAL HEADQUARTERS,AMERICAN EXPEDITIONARYFORCES,
OFFICE OF THE CHIEFSURGEON,
France, February 7, 1918.

The following memorandum has been issued by the SurgeonGeneral, and as far as it is applicable will be observed by all concernedin the American Expeditionary Forces:

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

Reports of inspectors indicate lack of uniformity in thecare and isolation of infectious disease in hospitals, and in many instancesthe steps taken are reported to be insufficient to prevent possible spreadof infection and development of complications. The following procedureshould be followed whenever local conditions permit. When any or all ofthe necessary medical department material is lacking, requisition shouldbe made by telegraph for the needed articles, and referring to this memorandumas authority. Such additional precautions should be taken as are deemedadvisable by the commanding officer of the hospital.

1. Meningitis.-Strict isolation should be instituted.Male attendants should be segregated and not allowed to eat or sleep withthe sanitary detachment. The same steps should be carried out with femalenurses as far as possible. When on duty in wards all female nurses, maleattendants, and medical officers should wear operating gowns, caps, andgauze masks over nose and mouth. The hands should be thoroughly washedand disinfected after coming off duty and before leaving the ward. Culturesshould be taken every fourth day from medical officers, nurses, and maleattendants on duty in meningitis wards, and no such nurse or attendantshould be assigned to other duty until a negative culture is obtained.Bedding, clothing, etc., of patients and gowns and caps of attendants shouldbe thoroughly disinfected by steam or chemicals before going to the laundry.Nasal and oral discharges of patients should be disinfected or burned.Dishes, etc., for bringing food should be sterilized before being returnedto the general kitchen. Meningitis convalescents and carriers will notbe returned to duty until after three consecutive negative cultures takenat intervals of from 3 to 6 days. Meningitis carriers should not be segregatedin the same room with men sick with meningitis, but in a suitable segregationward, camp, or barrack.

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

3. Measles.-An allowance of at least 1,000 cubicfeet per patient should be provided in wards or barracks used for treatingmeasles patients. Wires should be arranged across measles wards and sheets,or newspapers, hung over these in such a way as to form a screen betweeneach two patients; or some other suitable screening arrangement shouldbe provided. This is with a view to preventing spread of pneumonia by dropletinfection during coughing. Patients convalescent from measles should beretained in hospital, or in a well-warmed convalescent barrack, for atleast 10 days after the temperature has permanently returned to normal.Medical officers, nurses, and male attendants in measles wards will weargowns, caps, and masks. Nasal discharges and sputum of patients will bedisinfected. Oral cleanliness should receive special attention. Attendantswho have had measles should be selected, if possible, for duty in measleswards. 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 thermometersand other utensils as they pass from patient to patient. Wards should bekept warm. A urinary examination should be made before discharge from hospital.

Patients developing pneumonia should immediately be removedfrom the measles wards. They should not be placed in the same wardswith primary lobar pneumonia.

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

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

Patients should not be released from quarantine untilnasal, aural, glandular, or other abnormal discharges have ceased, andall open sores have healed, nor earlier than six weeks after the onsetof the disease under any circumstances. A urinary examination should bemade before discharge from hospital.

6. Smallpox patients should be handled with thesame precautions as meningitis, and in addition all attendants, and othersin the vicinity, and all contacts should be revacci-

911

nated. Smallpox may safely be treated in a room in theisolation ward if these precautions are observed.

7. Where the hospital facilities are insufficient to providetreatment for measles and scarlet fever patients for the periods aboveprescribed, request should be made for the setting aside of the necessarybarracks or tentage for use as convalescent hospitals. Special attentionshould be given to keeping such convalescent quarters well warmed, andadditional stoves should be installed if necessary. Warm and convenientlylocated lavatories are essential. Patients in the acute stage of measlesand scarlet fever should use commodes.

8. Enlisted attendants in wards for infectious diseasesshould wear white cotton coats and trousers, which should be changed twicea week. These garments are on hand in depots, and should be required forat once by the local quartermaster.

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

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

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

12. The above precautions in regard to measles are prescribedprimarily to diminish the incidence of the very fatal post-measles pneumoniawhich has reached alarming proportions in some camps. There has been widespreadfailure to appreciate the seriousness of measles under existing camp conditions.

13. Immediately on receipt of this memorandum, the commandingofficer of a hospital will hold a conference with such of his assistantsas are concerned with the handling of infectious diseases, and will arrangefor the carrying out of the details as far as local conditions will permit.Report of action taken will be made to this office.

* * * * * * *

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

Circular No. 10.

AMERICAN EXPEDITIONARYFORCES,
OFFICE OF THE CHIEFSURGEON,
France, March 4, 1918.

1. Allowance for soldiers sick in hospital.-Paragraph1212, Army Regulations, has been amended so as to provide for commutationof rations for soldiers sick in hospital and members of the Army NurseCorps at the rate of 60 cents a day at all stations where purchases ofsubsistence supplies from Quartermaster Department are possible, and atthe rate of 75 cents a day at stations where purchases must be made inopen market-effective February 16, 1918.

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

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

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

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

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

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

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

   Name and allsurnames ----------------------------------------------------------------------------------------------------------------------------
   Nationality--------------------------------------------------------------------------------------------------------------------------------------------
   Place of birth-----------------------------------------------------------------------------------------------------------------------------------------
   Date of birth------------------------------------------------------------------------------------------------------------------------------------------
   Address (actuallodging; not business address) -------------------------------------------------------------------------------------------
   Last employment-----------------------------------------------------------------------------------------------------------------------------------
   Name and nationalityof father -----------------------------------------------------------------------------------------------------------------
Name and nationality ofmother ----------------------------------------------------------------------------------------------------------------
   References(3) ---------------------------------------------------------------------------------------------------------------------------------------

4. Use of medical supplies.-Medical officers areurged to effect every possible economy in medical supplies of all kinds,and to give careful consideration to every requisition, bearing in mindthe problems which confront the supply division. Every item should be consideredfrom the standpoint of its relation to the success of our Army and notalone from its convenience and desirability under peace conditions.

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

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

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

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

But the needs of the medical department are only a partof the great needs of our Army, and the fact that the requirements forthe sick are given precedence over a great many other supplies should makeus insistent that the privilege is not abused. Every item saved will notinsure the only future supply of the essential articles, but will aid materiallyin the success of the Army, whose interests we serve.

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

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

7. Ordre de transport.-The following, from CircularNo. 9, office of the chief quartermaster, general headquarters, A. E. F.,is repeated:

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1. The proper disposition of the pink and yellow foldsof the ordre de transport does not seem to be clearly understood by manyshipping and receiving officers, and, pending issuance of new forms, whichare designed especially for use by the American Expeditionary Forces, officersshould strictly observe the following instructions in the use of the Frenchforms.

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

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

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

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

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

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

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

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

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

Circular No. 11.

HEADQUARTERS, AMERICANEXPEDITIONARYFORCES,
OFFICE OF THE CHIEFSURGEON,
France, March 4, 1918.
The following instructions are issued for the guidanceof all medical officers:

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

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

3. To insure to the man not only the proper treatmentfor this type of injury, but the proper supervision until he is as fullyrestored as possible, necessitates some form of radial control that makesit impossible for a man to be overlooked in inevitable transfers, fromservice to service, or hospital to hospital.

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

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

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

Officers attached to other divisions may operate uponand treat such conditions, but the division of orthopedic surgery, throughits director, will be held responsible for the character of the treatmentand for the final results.

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

5. To carry out the instructions of this circular, thedirector of the division of orthopedic surgery will arrange so that representativesof his division will see all cases of the nature described, to determinewhether or not their management is proceeding satisfactorily so as to obtainthe best possible results. These representatives will report to the commandingofficers of the hospitals in which such patients are being treated andtheir services as consultants will be freely utilized; any recommendationmade by them as to change of treatment, transfer to some other professionalservice, or hospital, will ordinarily, if the military situation permits,receive favorable consideration.

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

By command of General Pershing:

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

Approved:
J. G. HARBORD,Chiefof Staff.

Circular No. 12.

AMERICAN EXPEDITIONARYFORCES,
HEADQUARTERS, SERVICESOF SUPPLY,
OFFICE OF THE CHIEFSURGEON,
France, March 6, 1918.

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

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

3. The copy returned to the organization will serve bothas an invoice and as a packing list, and those two forms heretofore furnishedorganizations will no longer be prepared. Upon receipt of the marked copyfrom the depot, the organization making the requisition will erase allarticles on the corresponding retained copy except those shown on the copyfrom the depot as having been shipped (showing the amounts shipped in anyarticle cut) and will then forward the copy so marked to the chief of thedivision of accounting and finance, Medical Department, headquarters, Servicesof Supply, direct, acknowledging receipt across its face.

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

915

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

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

6. Articles not in stock or not expected within a reasonabletime will not be due listed and should therefore be again requisitionedfor, but not until the lapse of a sufficient interval to warrant expectationof their receipt from the States. Articles not on hand, but expected withina reasonable time, will be due listed and will be furnished upon receiptwithout further requisition.

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

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

All boxes will be marked with the number given the requisitionat the depot, followed by the number of packages in the shipment, thus:25-48 would mean that the shipment was made on requisition No. 25 and that48 packages were shipped. The copy of the requisition or due list returnedby the depot to the consignee would carry the number 25.

9. Attention is again called to the very great importanceof conserving medical supplies in every possible way. It must be rememberedthat supplies are obtainable only with the very greatest difficulty, andevery unnecessary expenditure is both hurtful to the country and to theindividual soldiers, who by such unnecessary expenditure are deprived oftheir legitimate due. Frequent inspection of storerooms and the closestscrutiny of all expenditures is enjoined upon all commanding officers andsurgeons.

Hospital fund statements.-These statements forthe month of April and thereafter, for all organizations of the AmericanExpeditionary Forces in France, will be rendered upon the basis of theamount received, expended, etc., in francs-the rate of exchangeemployed being set forth if conversion from dollars and cents to francshas been necessary. Any loss resultant from this conversion will be shownas an expenditure by expenditure vouchers.

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

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

Circular No. 13.

GENERAL HEADQUARTERS,AMERICAN EXPEDITIONARYFORCES,
OFFICE OF THE CHIEFSURGEON,
France, March 11, 1918.

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

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

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

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

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Circular No. 14.

FRANCE, March 13, 1918.

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

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

3. The urgent necessity of close inspection frequentlyrepeated for skin parasites of all kinds is in this connection again broughtto the attention of all medical officers.

Office circular No. 15.

OFFICE OF THE CHIEFSURGEON,
AMERICAN EXPEDITIONARYFORCES,
HEADQUARTERS, SERVICESOF SUPPLY,
France, March 25, 1918.

OFFICE REGULATIONS, CORRESPONDENCE PRACTICE, ETC.

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

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

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

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

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

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

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

8. Telegrams will proceed through the regular correspondencechannels of the office except that an identifying number will be assignedand a brief record made in the mail room as prescribed by Services of Supplycircular.

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

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

11. Cablegrams to the United States will be dictated directto the official cable clerk. This clerk can be reached at any time in roomNo. 20.

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

917

will replenish the supply of ink in the several officesas the need arises. Informal requests, verbally or in writing, for otheroffice supplies should be made upon the issuing clerk during the hoursmentioned.

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

It has been decided to designate the senior staff officerof each division as "division adjutant," "division inspector," "divisionordnance officer" "division signal officer," "division veterinarian," insteadof "inspector general," "judge advocate," "chief quartermaster," "chiefsurgeon," "chief ordnance officer."

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

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

Circular No. 16.

AMERICAN EXPEDITIONARYFORCES,
HEADQUARTERS, SERVICESOF SUPPLY,
OFFICE OF THE CHIEFSURGEON,
France, March 28, 1918.

I

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

1. * * * It is requested that whatever steps are necessarybe taken to carry out the plans laid down in the Manual of the MedicalDepartment, which provide that pathological specimens of military interestbe forwarded through regular channels to the Army Medical Museum accompaniedby complete histories.

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

To Medical Department personnel: 1. The Assistant Auditorfor the War Department has stated that he sees no objection to quartermasterspaying civilian employees of the Medical Department from quartermasterfunds, provided the civilian employees payable from Medical Departmentfunds are vouchered on separate rolls, and the Medical Department appropriationto which chargeable is clearly shown thereon, and that such rolls are enteredon the abstract of disbursements under the same medical appropriation asis shown on the voucher. Under this decision, it is possible for quartermastersat all base hospitals to make the necessary payments to all civilian employeesof the Medical Department on the approval of the pay roll by the commandingofficer of the hospital, which action the commanding officer is authorizedto take.

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

2. Recent arrangements with the French central authorityprovide that notifications of property shortages occurring in officialshipments should be made immediately upon the discovery of the shortageof the local chef de gare of the railroad company concerned. It is, ofcourse, necessary that immediate action should be taken upon the receiptof a shipment

918

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

3. Commutation for allied patients in hospital.-Thecommutation for patients of this class has now been determined to be 60cents a day, where commissary privileges are available and 75 cents a day,where such is not the case. Under these conditions, it will not be necessaryto draw the additional 20 cents from the Red Cross, as heretofore authorized.This change becomes effective from April 1, 1918, and after that date the60 cents allowed will be drawn as the entire compensation to the hospitalfund for both officer and soldier patients of the allied armies.

III

1. The attention of all medical officers commanding hospitalsand Medical Department detachments is called to the importance of carryingout closely all the details of military administration required by existingregulations, orders, and customs of the service, to the end that theircommands may at all times be ready to pass with credit the inspection ofsuperior officers.

2. Cases of neglect or slackness in carrying out ordinarymeasures of discipline, administration, and sanitation having been broughtto the notice of the chief surgeon special emphasis is here given to thefollowing points: Discipline and administration-the reveille and checkroll calls are to be invariably observed in every hospital and detachment;the weekly formation and inspection of the detachment must never be omittedand military drill for all available men of the Medical Department willbe held as often and to as great an extent as circumstances permit, withthe object that every soldier may present a well-poised, alert, and soldierlyappearance.

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

3. Sanitation.-Details of sanitation for the maintenanceof a clean hospital are only to be carried out properly by frequent andpatient instruction to subordinates, by officers and noncommissioned officersresponsible for the care of the wards, mess rooms, kitchens, and otherparts of the hospital.

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

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

Cleanliness and order will render even a primitive andextemporized hospital attractive, but slovenliness and disorder will spoilthe efficiency of the best-equipped institution. To utilize to the utmostadvantage the often imperfect buildings and equipment which war conditionsimpose, is the ideal to be striven for and this ideal is only to be approachedby unremitting attention to the small details of discipline, management,and sanitation.

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

Circular No. 17.

AMERICAN EXPEDITIONARYFORCES,
HEADQUARTERS, SERVICESOF SUPPLY,
OFFICE OF THE CHIEFSURGEON,
France, April 2, 1918.

INSTRUCTION CONCERNING AUTOPSIES

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

919

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

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

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

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

5. Weights and measurements should be indicated by themetric system.

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

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

8. When necessary to perfect the diagnosis, tissues formicroscopic examination should be removed and preserved in 10 per centformal or other suitable fixative.

9. Gross specimens suitable for museum purposes are tobe removed and preserved in 10 per cent formal. Such specimens are to besent to the central Medical Department laboratory, A. E. F., as soon aspossible, for eventual transference to the Army Medical Museum. Each specimenmust have attached an identification tag with name and organization ofpatient, date, diagnosis of specimen, and name of sender. In case specialtags for this purpose are not available, an ordinary label protected bydipping in melted paraffin may be used. For further details as to handlinggross specimens, see supplement to section 135, Manual of the Medical Department.

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

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

Circular No. 18.

AMERICAN EXPEDITIONARYFORCES,
HEADQUARTERS, SERVICESOF SUPPLY,
OFFICE OF THE CHIEFSURGEON,
France, April 3, 1918.

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

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

(b) To supply such patients as are admitted withoutproper gas defense equipment, requisitions should be made on the properofficers for a reserve supply of masks, based on 20 per cent of the maximumbed capacity.

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

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

920

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

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

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

Circular No. 19.

AMERICAN EXPEDITIONARYFORCES,
OFFICE OF THE CHIEFSURGEON, SERVICESOF SUPPLY,
France, April 4, 1918.

1. Accountable office for Medical Department transportation.-Thereseems to be some misunderstanding by organizations in the different sectionsregarding the accountable office for Medical Department transportationin France.

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

Motor ambulances and motor cycles with and without sidecar are Medical Department transportation; touring cars and trucks areQuartermaster Department property, and memorandum receipts for the lattershould not be sent to M. S. D. No. 3.

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

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

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

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

Circular No. 20.

AMERICAN EXPEDITIONARYFORCES,
OFFICE OF THE CHIEFSURGEON,SERVICESOF SUPPLY,
France, April 12, 1918.

1. White clothing for hospital attendants.-So muchof paragraph 8, Circular No. 9, office chief surgeon, A. E. F., February7, 1918, as provides for the wearing of white cotton coats and trousersby enlisted attendants in wards is changed to provide for the wearing ofblue dungarees under the conditions named. Requisitions on the QuartermasterDepartment for clothing to be worn on ward duty will specify the blue dungaree,instead of white clothing. The Quartermaster Corps has made provisionfor the supply of white clothing for cooks; and requisitions may specifythis class of clothing for this class of personnel.

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

921

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

3. Manual, sick and wounded reports.-A manual dealingwith the sick and wounded reports and returns for the American ExpeditionaryForces, and with the methods of preparing the same, will be issued shortlyfrom the office of the chief surgeon, A. E. F., Services of Supply.

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

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

Sufficient copies to supply all incoming medical officerswill be sent to surgeons of ports of debarkation, who will be responsiblefor their distribution.

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

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

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

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

Circular No. 21.

APRIL 13, 1918

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

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

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

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

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

(2) Sera, therapeutic and prophylactic:

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

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

922

these products will be kept on hand only at the laboratoriesmentioned below. It is not contemplated that a supply greater than a reasonableamount to meet actual emergencies be kept on hand in other Medical Departmentunits.

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

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

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

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

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

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

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

3. Hereafter, biological products will be obtained fromthe commanding officer of the nearest designated distributing center bytelephonic or telegraphic request. In emergency, deliveries will be madeby motor-cycle courier whenever necessary and feasible. In instances wheretravel by train would be in the interest of economy and would not resultin delay in delivery, the commanding officers of the laboratories designatedabove are authorized to dispatch couriers by train to make the deliveries.

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

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

6. Requests for special biological products will be madedirectly to the director of laboratories, A. E. F., A. P. O. No. 721, indicatingthe necessity for their use. The director of laboratories and the commandingofficers of laboratories designated as distributing centers are authorizedto modify requisitions whenever the demands are manifestly in excess ofactual requirements or when the biological products requisitioned for areof such a nature as to require careful laboratory control in their administrationand it is definitely known that such laboratory facilities are not available.

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

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

Circular No. 22.

AMERICAN EXPEDITIONARYFORCES,
OFFICE OF THE CHIEFSURGEON, SERVICESOF SUPPLY,
France, April 17, 1918.

1. The attention of all medical officers is again calledto the extreme importance of bodily cleanliness and freedom from verminthroughout the troops of the American Expeditionary Forces. The followingnotes are furnished for the information and guidance of all concerned:

Scabies and lousiness, with their resulting inflammationsand scratch infections of the skin; also trench fever, due to lice, bidfair to cause more ineffectiveness than any other disease or disease groupin the American Expeditionary Forces.

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

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

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

Sanitary reports from our own divisions, and from numerousscattered organizations in France, indicate that infestation with liceand scabies is widespread, in some large commands as many as 75 per centof the men being infested.

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

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

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

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

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

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

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

Prevention of general infestation of men and their clothingcan be assured by the discovery of early cases, through careful inspectionand accurate diagnosis, and the instant removal of the patients and theirpossessions from barracks or billets, to avoid the general infestationof quarters. All men should be questioned as to itching of the skin, andno complaint considered too trivial to investigate.

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

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

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

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

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

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Circular No. 23.

FRANCE, April 22, 1918.

1. Payment of civilian employees by quartermaster.-Wheneverpayment of civilian employees is made by the quartermaster under the methodlaid down in paragraph 1, section 2, Circular No. 16, this office, a truecopy of the roll as paid will be sent to this office, through the sectionsurgeon, by the commanding officer of the hospital concerned.

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

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

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

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

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

Circular No. 24.
AMERICAN EXPEDITIONARYFORCES,
France, April 23, 1918.

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

GENERAL
In dealing with these cases, there should be borne inmind their chronicity, the probability of recurrences or acute episodesin constitutional disorders, and the bearing which abnormal mental stateshave upon questions of responsibility. The special mental stresses of modernwarfare and the fact that the safety of many soldiers often depends uponthe conduct of one of their number should be given due weight in consideringthe fitness of men with mental or nervous diseases for service at the front.At the same time the importance of utilizing, in any safe and suitableway, the services of men partially incapacitated should not be overlooked.The essential question for boards to decide is usually whether, takingall the facts into consideration, the individual before them will be anasset or a liability to the Expeditionary Forces. Whenever possible a psychiatristor a neurologist should act as one member of a board passing upon mentalcases.

925

PSYCHOSES (INSANITY, MENTAL ALIENATION, MENTAL DISEASES)

All officers and enlisted men in whom frank psychosesexist should be marked "D" and returned to the United States as soon asthis can be done without injury or endangering their chances of recovery.It will often be advantageous to hold these cases in the psychiatric departmentsof base hospitals at base ports until acute and severe manifestations havepassed or, in cases of an especially favorable type, until recovery hastaken place, but it should not be made the practice to provide extendedtreatment in hospitals of the American Expeditionary Forces.

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

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

CONSTITUTIONAL PSYCHOPATHIC STATES
In making recommendations as to the disposition of soldiersfound to have constitutional psychopathic states, the considerations mentionedunder the preceding heading should govern. It should be remembered thatmany individuals with volitional defects are amenable to military control.Conditions which should usually indicate the wisdom of returning thesecases to the United States are marked emotional instability, sexual psychopathies(homo-sexuality, etc.), paranoid trends, and specific criminalistic traits.These cases should be classed "D." Excessive fear or timorousness shouldprevent return to duty at the front. For military reasons it is especiallyundesirable, however, to return such cases to the United States. They shouldbe recommended for duty in labor organizations and marked "C."

EPILEPSY
Epileptics should be classed as "D," the only possibleexceptions to this rule being individuals in robust physical health whohave attacks of moderate severity at long intervals and those in whom treatmenthas had this result.

In making the diagnosis of epilepsy the fact should beborne in mind that attacks are likely to be less frequent in the favorableenvironment of the hospital while observation is being carried on thanin the organizations from which patients are received. Great weight shouldbe given to a well-authenticated history of epileptic seizures, especiallywhen witnessed by medical officers or other persons who can give a clearaccount of their character. While the possibility of malingering shouldnot be overlooked, it should be remembered that attacks similar to thosein epilepsy are much more frequently psychoneurotic in their nature thanfeigned. The high prevalence of epilepsy among soldiers should be remembered.

DRUG ADDICTION AND ALCHOLISM
These conditions are essentially curable. Inebriates anddrug addicts should not be recommended for return to the United Stateswith a view to their discharge until they have failed to respond to adequatetreatment. Then, their disposition should depend upon the type of personalitypresented, the effects of alcohol or drugs in physical deterioration ordamage to the central nervous system, and the conditions to which theywill be exposed when they are returned to duty. It will often be foundthat these cases do better at the front than in duty at the rear.

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PSYCHONEUROSES (HYSTERIA, NEURASTHENIA, PSYCHASTHENIA)

These conditions must be dealt with as disorders amenableto treatment under proper conditions. Individuals who fail to benefit fromsuch treatment in the special hospital which has been provided, eitherbecause of severe defects in make-up or on account of previous mismanagement,should be returned to the United States for continued treatment unlessit seems likely that good results can be obtained from their assignmentto duty at the rear. A very large proportion of the severe neuroses seenin war are of the "situation type," rather than psychoneurotic manifestationsin persons who have had many previous episodes of the same kind in civillife.

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

Circular No. 25.
AMERICAN EXPEDITIONARYFORCES,
France, May 5, 1918.

ORGANIZATION OF PROFESSIONAL SERVICES, MEDICAL DEPARTMENT,A. E. F.

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

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

In order to utilize the professional services of the specialistsof the Medical Department, A. E. F., in a manner which will best facilitatecomplete coordination between forces from front to rear, the followinginstructions are issued:

Director of professional services.-The directorof professional services, under the hospitalization division of the officeof the chief surgeon, will supervise the professional activities of theMedical Department, A. E. F., and coordinate the work of the consultantsand specialists of the Medical Department.

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

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

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

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

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

927

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

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

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

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

The senior divisional consultant will also coordinatethe activities of the professional personnel in his divisions in a mannerthat will be conducive to high surgical standards, and elimination or reassignmentto other duties of those who fall below the requirements. He will spareno effort to promote professional harmony and unity of treatment in thedivisional formations.

Senior divisional medical consultants.-The seniordivisional medical consultant will, by frequent inspections, satisfy himselfthat the various classes of patients suffering from medical disabilitiesare receiving the best and most advanced treatment possible. He will reportfrom time to time to the chief medical consultant, A. E. F., the resultsof his inspections, and make suggestions looking toward the perfectionof the medical services of the American Expeditionary Forces.

Divisional surgical consultants.-The divisionalsurgical consultant will, under the senior divisional surgical consultant,supervise the immediate surgical activities of operating teams within hisdivision. During mobile or semimobile warfare, when established evacuationhospitals are absent, the operative work, in formations for nontransportablecases, will be handled, when practicable, by surgical teams functioningunder the supervision of the senior divisional surgical consultant, orhis assistant.

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

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

The division surgeon will supply the necessary hospitalfacilities, supplies, and personnel other than those forming teams. Hewill spare no effort in technical cooperation which may promote harmonyof action between the professional services with the fighting forces, fromthe front to the rear.

Division specialists.-One orthopedic surgeon, oneurologist, and one neuropsychiatrist will be appointed from the divisionsanitary personnel, and, under the direction of the divisional chief surgeon,they will perform the duties pertaining to their several specialties, inaddition to the other duties of medical officers which may be requiredof them by the exigencies of the service.

928

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

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

ORGANIZATION OF BASE AND GENERAL HOSPITALS

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

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

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

ARMY

Senior consultant, surgery, A.E. F.:	Senior consultant, medicine, A.E. F.:
1 general surgery.	1 general medicine.
1 orthopedic surgery.	1 neuropsychiatry.
1 urology and dermatology.	1 formations, equivalent to an army corps.
1 eye.	2 consultants (assistants to division senior consultants).
1 ear, nose, and throat.	(Others as required.)
1 neurological surgery.
1 maxillofacial surgery.
1 Roentgenology.
1 research.
1 formations, equivalent to an army corps
4 consultants (assistants to division senior consultants).

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(Army corps)

DIVISION
Specialists: Each tactical division
(A part of division sanitary personnel, Tables ofOrganization)
Surgery:	Medicine:
1 orthopedic surgery.	1 neuropsychiatrist.
1 urology.	1 neuropsychiatrist.
HOSPITAL CENTERS
Consultants, medicine (each hospitalcenter, Services of Supply):	Consultants, surgery (each hospitalcenter, Services of Supply):
1 general medicine.	1 general surgery.
1 neuropsychiatry.	1 orthopedic surgery.
(Others as required)	1 urology and dermatology.
	1 eye.
	1 neurological surgery.
	1 ear, nose, and throat.
	1 maxillo-facial surgery.
	1 Roentgenology.
SERVICES OF SUPPLY
Specialists: Each base hospital
(Part of unit personnel)
Surgery (as needed):	Medicine (as needed):
General surgery.	General medicine.
Orthopedic surgery.	Psychiatry.
Urology and dermatology.	(Others as required.)
Neurological surgery.
Eye.
Ear, nose, and throat.
Roentgenology.
Maxillo-facial surgery.

Circular No. 26.

AMERICAN EXPEDITIONARYFORCES,
France, May 4, 1918.

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

2. Shipments to Medical Department repair shop No.1.-In connection with paragraph 2, Circular No. 23, this office, April22, 1918, it is directed that when typewriters or surgical instrumentsare sent to Medical Department repair shop No. 1, an order for transportor the number of the order be mailed to the officer in charge to facilitatethe receipt of such articles from railroad station. When organizationshave sufficient typewriters needing minor repairs to warrant the sendingof a typewriter repair man with a portable outfit to make these repairs,a request will be made directly to the officer in charge of the shop.

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

930

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

4. Requisitions for laboratory and X-ray supplies.-Ithas become apparent that the director of laboratories and the directorof Roentgenology, in order to maintain proper supervision over the technicalservices, must visa all requisitions for those services. Hereafter allrequisitions for laboratory supplies and for X-ray supplies, includingboth articles listed on the supply table and articles not so listed, willbe made separately and forwarded as follows:

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

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

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

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

6. Requisitions upon the Red Cross.-Hereafter requisitionsupon the Red Cross will be honored at the Red Cross depots after approvalby the following officers:

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

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

7. Purchase of food supplies locally to be chargedagainst hospital fund.-Due to the fact that local French authoritiesare not authorized to receive payment for supplies purchased from themthe United States Government is receiving bills from the French Governmentfor food supplies purchased by United States Army hospitals. Commandingofficers should bear in mind that there will be ultimately a charge againstthe hospital fund and should keep accurate track of all such purchasesand the cost thereof and should consider the same an outstanding chargeagainst the hospital fund, reserving a sufficient balance to enable promptreimbursement to the fund from which these bills are paid.

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

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

NOTE.-CircularNo. 25 has been delayed and will be issued later.

931

Circular No. 27.

AMERICAN EXPEDITIONARYFORCES,
France, May 13, 1918.

1. Administration of messes-Function of dietitian.-Thereports of medical inspectors and officers of the food and nutrition sectionshow that the administration of messes is, as a rule, the least efficientand satisfactory part of hospital administration. The defects noted area monotonous and ill-balanced dietary, poor service, and lack of cleanlinessin the kitchen and the kitchen personnel. These inspections show that commandingofficers have not made proper use of the agency which is especially intendedto correct these defects, that is to make proper use of the dietitianswho have been assigned to the base hospitals, to use their expert knowledgefor the correction of these defects, and to exercise the constant vigilanceand attention to detail which is necessary for successful mess administration.

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

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

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

(1) Clean the inside of the bag thoroughly.

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

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

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

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

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

(7) Report any difficulties to the medical officer.

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

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

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

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

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

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

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6. Visiting places for convalescent officers.-Commandingofficers of hospitals are notified that the persons whose names and addressesare given below have expressed a willingness to receive in their homesas guests, free of all expenses, convalescent officers to the limit ofthe accommodations. Commanding officers should exercise judgment in theselection of cases which will be received on their recommendation, andshould not send any who are not fully able to look after themselves orrequire hospital treatment. There is, however, a Red Cross physician inthe town of Cannes who can give treatment in the case of emergency. Beforesending an officer to either place the commanding officer should ascertainby telegraph whether it is convenient for the host to receive him. Thechief surgeon's office should be notified by mail of each case in whichan officer has availed himself of this hospitality, and given the nameand organization of the officer, and the date.

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

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

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

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

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

Circular No. 28.

AMERICAN EXPEDITIONARYFORCES,
France, May 15, 1918.

Subject: Sick and wounded reports for the American ExpeditionaryForces.

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

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

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

(AMENDMENT TOSECTION XVI (ALLIEDPATIENTS IN A. E. F. HOSPITALS)

FRENCH PATIENTS

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

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

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

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

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

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

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

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

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

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

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

3. For the purposes of reporting sick and wounded underthe new system, all medical organizations which do not habitually holdpatients for more than three days will be considered as without hospitalizationfacilities.
COMPLETENESS OFDATA

1. Whenever a patient is received by a base hospital withoutfield medical card or data sufficient to completely fill one in, stepswill be taken to obtain the necessary data, and the patient will be helda reasonable time in the hospital until the lacking information is receivedand the card and envelope made out. Whenever this is done, statement ofthe fact will be made on the back of the card, reference being made toit by an asterisk (*).

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

PROCURING OF FORMS

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

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

2. All previous instructions at variance with this circularare revoked.

934

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

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

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

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

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

Circular No. 29:
AMERICAN EXPEDITIONARYFORCES,
France, May 21, 1918.

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

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

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

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

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

The senior consultant, orthopedic surgery, will, underthe chief consultant, surgical services, make such recommendations relativeto treatment of "injuries and diseases of the bones and joints, other thanthose of the head, as well as the injuries or diseases (other than nervelesions) of the structures involved in joint functions," as will insureearly restoration of functions, shorten convalescence, and hasten returnto active military duty.

He will also supervise the subdivisions of surgery, pertainingto bones and joints, in a manner which will permit the complete surgicalharmony necessary for cooperation in treatment of these cases by eithergeneral or orthopedic surgeons, in formations from front to rear. To insurea minimum loss of function to the parts involved, uniform cooperation mustbe maintained by the chief consultant, surgical services, during both earlytreatment and all stages of convalescence.

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

935

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

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

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

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

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

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

These standard spectacles are of nickel, steel, roundglass, and any combination of lens can be supplied or repairs made on shortnotice.

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

It will also repair any optical instruments used in hospitals.

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

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

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

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

(c) The historical data need not be voluminousnor trivial, but should be sufficiently complete so that from them in connectionwith the regular official and clinical records of the organization a reportto date of its activities can at any time be made. The historical records,if not already begun, will be initiated without delay and written up fromthe beginning of the activities of the organization or command in connectionwith the present war and they will be maintained by careful notation ofall matters of historical interest involving the organization.

3. Replacement of X-ray tubes.-Broken X-ray tubeswill be sent to the repair shop, Paris, by messenger, who will carry backthe replacement tube. Unless urgent, two or more tubes should be sent atone time. If the travel involved requires an order from the commandinggeneral, Services of Supply, a request for such should be made to theseheadquarters.

4. Travel orders and classification of patients dischargedfrom hospital under General Order 41, general headquarters, 1918.-Ordersdirecting the travel of patients discharged to duty from Services of Supplyhospitals should in each instance indicate the classification to whichthe man belongs under General Order 41, general headquarters. In the caseof men of B and C classes, copies of reports of disability boards on theprescribed form should be attached to travel orders.

936

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

5. Admission of officers and soldiers to Services ofSupply hospitals.-The attention of commanding officers of Servicesof Supply hospitals is called to the following extract of General Order46, general headquarters, the provisions of which have been disregardedin number of instances. Prompt rendition of the required report is enjoined:

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

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

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

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

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

Circular No. 31
FRANCE, May 23, 1918.

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

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

2. The following translation of extracts from Circular684 Ci/7, Sous-Secretaire d'Etat du Service de Sante, of April 6, 1918,are published for the information and guidance of medical officers:
AMERICAN SOLDIERS IN FRENCH SANITARY FORMATIONS
The French sanitary formations must keep only Americansick and wounded who can not be evacuated without inconvenience. Consequently,as soon as an American patient is susceptible of being evacuated, he willbe evacuated to the nearest American hospital without other formality thana previous understanding with the chief surgeon of that hospital.

If, for any reason, the transfer of the patient necessitatesthe presence of nurses, the surgeon of the American hospital should berequested to send one or two nurses to insure the transfer in satisfactoryconditions.

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

French soldiers hospitalized in American sanitary formationswill be evacuated to the nearest French hospital as soon as their transfercan be made without risk.

The evacuation of the sick and wounded will take placewithout any other formality than a previous understanding with the medicinchef of the French hospital, who will furnish one or several nurses ifnecessary.

All medico-surgical documents will follow the patientunder closed envelope.

937

AMERICAN SOLDIERS DEAD IN FRENCH HOSPITALS

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

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

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

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

(b) Hospitals of the zone of the interior (includesregional hospitals of the army zone).-The personal property will beturned over to the commanding officer of the nearest French hospital, permanentmilitary hospital, or complementary hospital, who will look after the settlement.

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

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

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

Numbers {Ofthe present form.
{Of the parcel.

From^a------------------------------------------------------------------------------------------------------------------------------------------------------------------
Address ----------------------------------------------------------------------------------------------------------------------------------------------------------------
Name of the soldier --------------------------------------------------------------------------------------------------------------------------------------------------
Surnames^b-------------------------------------------------------------------------------------------------------------------------------------------------------------
Regiment ---------------------------------------------------------------------------------------------------------------------------------------------------------------
Rank ------------------------------------------------------------------------------------Class ------------------------------------------------------------------------
Place of enlistment ---------------------------------------------------------------------------------------------------------------------------------------------------
Number of enlistment -----------------------------------------------------------------------------------------------------------------------------------------------
Died at -------------------------------------------------------------------------------------------------------------------------------------------------------------------
On the -------------------------------------------------------------------------------------------------------------------------------------------------------------------
Address of family ----------------------------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------

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

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

938

EVACUATION OF BRITISH PATIENTS

3. British patients in American hospitals fit to travelshould be evacuated to Paris. The office of the assistant director medicalservices, British Expeditionary Force, No. 6, Rue Capucines, Paris, shouldbe given 24 hours' notice by telegraph of date and hour of arrival of patients.Patients should be evacuated by express train and should be routed so asnot to arrive in Paris late at night.

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

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

AMERICAN EXPEDITIONARYFORCES,
France, June 7, 1918.

Circular No. 32.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

939

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

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

18. Don't forget that cases of gas poisoning with markedcyanosis are benefited by oxygen inhalations, which in order to be efficientshould be given continuously. The oxygen to be administered either by maskor introduced into the posterior nares by means of a small rubber catheterconnected with the oxygen tank through a double tube in a bottle half filledwith water.

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

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

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

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

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

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

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

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

27. Don't forget that vomiting and stomach trouble whichpersist after mustard gas poisoning is usually functional, especially whenoccurring some months later.

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

29. Don't forget that pulmonary cases following mustardgas poisoning are the most important. They entail prolonged absence frommilitary duty and may simulate pulmonary tuberculosis so closely that itwill be difficult to decide, in some cases, whether tuberculosis existsor not.

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

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

Circular No. 33.

AMERICAN EXPEDITIONARYFORCES,
France, June 12, 1918.

1. Hospitalization and evacuation of cases of pulmonarytuberculosis and suspected pulmonary tuberculosis.-(a) Collectingand observation centers have been established at the hospitals indicatedbelow for cases of pulmonary tuberculosis and suspected pulmonary tuberculosiswhich may occur in the American Expeditionary Forces.

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

940

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

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

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

3. Travel orders to individuals or units forwardedto the advance section.-The following instructions of the commanderin chief, A. E. F., are published for the information and guidance of medicalofficers:

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

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

All such individuals or detachments should be furnishedwith rations to include two days' travel beyond the time of their expectedarrival at the regulating station.

By order of the commander in chief.

4. Etiquette of visits to French hospitals.-Correspondencerecently received from the French Service de Sante indicates that in certaincases medical officers of the American Expeditionary Forces have visitedAmerican patients in French hospitals without first calling on the medecinchef of the hospital to get his permission.

It is a military principle which governs in all armies,to which the French attach much importance, that an officer should notgo into any military organization for the purpose of inspecting withoutfirst calling on the commanding officer of that organization to get hispermission. It is very desirable when the visit is one of inspection, andnot merely a personal visit to individual patients, that the medecin chefor an officer designated by him should accompany the American medical officers.This is an important matter of military administration, as well as militarycourtesy, which all medical officers should be careful to observe.

5. Method of requisitioning fuel.-The attentionof commanding officers of hospitals is invited to the provisions of GeneralOrder 19, Services of Supply, 1918, which order makes certain changes inthe method of requisitioning fuel. The chief quartermaster advises that,as far as possible, supplies of fuel for hospitals for winter use be securedand stocked during the summer. It is especially desired that emergencyrequisitions for fuel be reduced to a minimum. Proper anticipation of thedemand for wood is fully as essential as that for coal.

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

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

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

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

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

941

sidered as without hospitalization facilities. All unitswhich care for patients for a period longer than three days will be consideredas hospitals regardless of official designation. All units in the sectionsof the Services of Supply falling under the latter class, but which arenot officially designated as hospitals, will be instructed by the sectionsurgeon to begin reporting as hospitals and to make requisition on medicalsupply depot No. 3 for necessary forms. Requisitions for Form No. 1, M.D., A. E. F., will be filled as soon as supply is available. Section surgeonswill notify this office of all such units in their sections.

M. W. IRELAND,

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

Circular No. 34.

AMERICAN EXPEDITIONARYFORCES,
OFFICE OF THE CHIEFSURGEON,
France, June 12, 1918.

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

SHORT RÉSUMÉOF THE SYMPTOMS ANDTREATMENT OF POISONINGBY IRRITANTGASES^a
The gases which have been met with most commonly up tothe present time may be divided schematically into three classes:

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

(2) Vesicants, the prime effect of which is exercisedupon the skin conjunctivitæ and upper air passages (dichlorethylsulphide-mustard gas or Yperite).

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

Gas may be liberated from cylinders in clouds, a methodnot now commonly employed or from shells.

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

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

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

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

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

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

In patients who recover, the odema fluid is absorbed withina few days; in some cases signs of bronchitis or broncho-pneumonia, dueto a secondary infection, persist for some time but in most cases the lungreturns to a condition which is normal except for the presence of somedisruptive emphysema. In consequence, however, of the odema of the lungsduring the early stage, deficient oxygenation of the blood occurs, unlessprevented by the administration of oxygen. The deficient oxygenation givesrise to widespread temporary injury in the various systems---------------------.

2. Vesicants.-The only one hitherto employed isdichlorethyl sulphide, an oily liquid used in shells, and scattered fromthem to the ground, where it slowly evaporates. This not only attacks thosein the immediate vicinity of the shell burst, but may affect those whomay walk over the contaminated ground later. The fluid may be spatteredalso on clothing, shell casings, rifles, etc., and may thus become effectivethrough direct contamination of the skin.

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

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

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

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

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

(iii) Burns (12 hours). Widespread erythema with localvesication occurs, going on to definite burns. Thecommonest sites are the axillæ, genitals, and back, but no area maybeexempt. The affected surfaces frequently develop very marked pigmentation.Deep burns sometimes occur when the liquid itselfcomes into contact with the clothes or skin.

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

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

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

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

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

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

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

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

(b) Warmth: Warmth is important. Cold and shiveringmean an increased production of CO₂and an increased demand for oxygen. The clothes must be removed at the earliestmoment, for they hold gas and may be dangerous not only to the patient but tothose about him; warm covering must however, be provided.

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

(d) Bleeding: In patients who are cyanotic and showengorgement of the venous system, bleeding is indicated. By venesection wecombat-

(1) Oedema of the lungs.

(2) The condensation of the blood; for with the abstractionof the polycyth?mic blood, fluid is drawn from the lungs and the tissues, andthe circulatory medium becomes less viscous.

(3) The overburdening of the right heart.

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

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

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

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

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

Never bleed these patients. Bleed only those with venouscongestion.

Rest, warmth, and oxygen are the mainstays of treatment.Atropine and adrenaline are contraindicated. These drugs place and increasedstrain on the heart. It is best to abstain from intravenous salt solutioninjections. The fluid introduced puts an extra burden on the heart, is soonabsorbed into the tissues, and may increase the pulmonary odema. In gravecardiac weakness, preparations of camphor or caffeine may be givenhypodermically, and digitalis may be indicated, according to the nature of case.

Relapses-In any patient who has had pulmonary odemait may, within the first few days, recur on slight exertion or even withoutapparent cause, and if there have been any definite symptoms of odema of thelungs the patient should be kept in bed for a week.

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

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

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

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

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pulmonary odema and symptoms similar to those observed inthe suffocative cases may occur; moreover, the patient may have had a doubleexposure to different sorts of gas. All the precautions, therefore, abovementioned should be observed at the outset, but other special steps must betaken.

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

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

After removal, the clothes should be sterilized in wet steamfor 30 minutes; in dry heat for 15 minutes; exposed to the air for 15 minutes.This may be carried out in the Thresh sterilizer, and may have to be repeatedtwice, although two or even one treatment may be efficacious. While waiting forsterilization, have the clothes placed outside the quarters, in the open. Allwho handle the clothes must be protected by respirators and special oiledclothing and gloves.

Removal of the poison from the skin.-The patientshould be thoroughly bathed in a warm room in soap and water at the earliestpossible moment. Areas which have been specially exposed may first be coveredfor a few minutes by a paste of 25 to 50 per cent chloride of lime in water andthen washed with warm water. Bathing with 0.05 per cent permanganate ofpotassium is said to be useful.

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

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

Blisters should be carefully attended to. The contents of thevesicles are poisonous and irritating to the surrounding skin; the blistersshould, therefore, be opened carefully and the contents taken up with absorbentcotton, which should promptly be burned. Interdigital areas should be washedcarefully daily, powdered and bandaged.

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

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

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

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

The mouth should be rinsed with alkaline washes and gargles.

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

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

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

945

sleep with dreams, paroxysms of coughing, and even asthmalikeattacks. These patients are often polycyth?mic. Nervous manifestationsunassociated with apparent organic lesion are common.

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

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

Zinci sulphatis	0.065-0.13 (gr. I-II)
Acidi borici	3.75 (3T)
Aqu?	30 (3T)

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

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

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

Attention to these details may save a considerable wastage ofmen.

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

Circular No.35.AMERICAN EXPEDITIONARYFORCES,
France, June 13, 1918.

THEMANAGEMENT OF MENTALDISEASES AND NEUROSESIN THE AMERICANEXPEDITIONARY FORCES

Absence of the auxiliary civil facilities that simplify themanagement of mental cases in the Army in home territory, and the extraordinaryincidence of functional nervous diseases in all armies in the present war, havemade it necessary to provide special facilities and methods of procedure in theAmerican Expeditionary Forces. These disorders, by their very nature, interferewith the morale and efficiency of troops in war. Their proper management in thehospitals and organizations in which they first come to notice and their wisedisposition and reclassification subsequently will not only increase militaryefficiency, but in the case of war neuroses, will tend to diminish to aconsiderable extent their incidence.

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

(a) Provisions for prompt diagnosis and early care.-Tacticaldivisions: Each tactical division in the American Expeditionary Forces and inthe United States is provided with a psychiatrist whose duty it is, under thedirection of the division surgeon, to examine all mental cases coming toattention in the division and to make recommendations for their evacuation orother disposition. The psychiatrists will be detailed from the division sanitarypersonnel. Their specific duties are defined in Circular No. 5, chief surgeon'soffice, A. E. F.

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

946

quents brought to their attention, especially those in whomself-inflicted wounds or malingering is suspected. Except under exceptionalcircumstances, no cases of this kind will be evacuated to the rear untilexamined by the division psychiatrists. In the case of prisoners accused ofcrimes, the maximum punishment of which is death, the division psychiatristshould, whenever practicable, have the assistance of a consultant in psychiatry.

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

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

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

It is very important that mental cases be accompanied byrecords in which the circumstances under which their condition came to noticeare fully stated. It is obvious that, without such information, the medicalofficers who have the responsibility of dealing with these cases will often havedifficulty in arriving at a diagnosis or in making suitable recommendations fortheir disposition.

Base hospitals in the advance section will transfer to thiscollecting station all mental cases except those which can readily be retaineduntil sent for by the psychiatric department of one of the base hospitals at abase port, and those in whom complications or other reasons render a transferundesirable. Effort will be made to provide all base hospitals with severalnurses or enlisted men of the Medical Department who have had experience in thecare of mental cases. With such attendants it will be unnecessary to placeguards in observation or mental wards. Commanding officers will protect thesecases from the ridicule to which they are sometimes subjected even in hospitals.

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

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

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

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

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

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

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

(c) Transportation.-The neuropsychiatricdepartment at Base Hospital No. 116 will send for patients to other basehospitals in the advance section, Services of Supply, and to tactical divisionsand training areas as provided in Paragraph I (b) of this circular. Theneuropsychiatric departments of base hospital centers to be established in theintermediate section, Services of Supply, will send for patients in the samemanner.

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

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

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

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

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

II. FUNCTIONAL NERVOUS DISEASES AND CONCUSSION CASES

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

For this reason a special hospital for these cases, BaseHospital No. 117, has been established, and an ambulance service has beenprovided in connection with this hospital by which cases can be receiveddirectly from tactical divisions at the front. At this hospital the resourcesfound most useful in the British and French special hospitals for these casesare employed. Success in their treatment depends very largely upon the attitudeof medical officers generally toward the special problems in diagnosis andmanagement which they present. For this reason regimental medical officersshould guard against making an unfavorable prognosis even in cases presentingsevere symptoms.

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(b) Treatment.-Tactical divisions: The adviceof the division psychiatrists should be utilized to the fullest extent in theearly treatment of these cases in division sanitary organizations and in theselection of cases for evacuation to hospitals in the Services of Supply. Itwill be found advisable, whenever practicable, to receive such cases in specialwards in one field hospital and to evacuate cases to hospitals in the Servicesof Supply only upon the recommendation of the division psychiatrist. Thisofficer will advise with regimental medical officers regarding the management ofnervous manifestations when they first come to attention at the front.

Hospitals in the Services of Supply in France: It is expectedthat a very large proportion of these cases will be admitted directly from theirorganizations to Base Hospital No. 117 and that relatively few, unlesscomplicated by wounds, gassing, or other conditions, will be received in otherbase hospitals. Other base hospitals will promptly transfer suitable cases toBase Hospital No. 117 except in these instances in which it is thought that theycan return directly to duty and those in which the outlook seems so unfavorable,from constitutional neuropathic tendencies or other factors, that theirreclassification is probable. Cases in which there is some doubt as to whetheran organic or functional disorder is present should be transferred to BaseHospital No. 117. No cases having wounds requiring much surgical attentionshould be sent to Base Hospital No. 117. All cases in which there is doubt as tothe best disposition should be brought to the attention of the consultant inneuropsychiatry for the hospital.

Hospitals in the Services of Supply in England: A specialhospital for war neuroses will be provided in England which will be organizedand conducted upon the same lines and will perform the same functions as BaseHospital No. 117. American soldiers serving with British organizations will betransferred to this hospital from the British clearing hospital for these casesor from other hospitals in England.

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

(c) Disability boards for functional nervousdiseases and concussion cases.-Disability boards for these cases will beconvened at Base Hospital No. 117, neuropsychiatric departments of base hospitalcenters, and psychiatric departments of base hospitals at base ports. No otherdisability boards should pass upon these cases.

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

Circular No. 36.

AMERICAN EXPEDITIONARYFORCES,
France, June 11, 1918.

Subject: Promotion in the Medical Reserve Corps.

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

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

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

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

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

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

4. In order to accumulate the data for the determination ofthese factors in each case, it will be necessary to have commanding officers andsenior medical officers furnish recommendations in the case of officers of theMedical Reserve Corps serving under them. An individual report upon a separatesheet of paper should be given in the case of each officer, whether considereddeserving of promotion or not, except those under the draft age of 31 years.Officers under the draft age will not be promoted except in special cases wherethe officer has rendered unusually distinguished service and has been more thana year on active duty. This report should in each case give the followinginformation:

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

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

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

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

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

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

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

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

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

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

(c) Is the officer, on account of professionalignorance, indolence, bad habits, or moral delinquency of any sort, undesirablefor the military service? In this case, as full a statement as is practicableshould be made of all the facts throwing light upon the shortcomings of theofficer, in order that he may be brought before a board for the determination ofhis fitness for the service. Any available evidence in the form ofcorrespondence or documents which is available should be forwarded in suchcases.

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

Circular No. 37.

AMERICAN EXPEDITIONARYFORCES,
France, June 22, 1918.

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

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

3. Billets or shelter tents.-The attention ofcommanding officers of ambulance companies, field hospitals, and other mobilemedical units is invited to the fact that Medical Department soldiers attachedto these units should be sheltered in the same way as other soldiers at thefront, namely, by billets or shelter tents, it not being practicable to issuetentage for the shelter of soldiers at the front. Commanding officers of theabove-named organizations will therefore turn in to the nearest quartermasterdepot the large pyramidal tents issued to ambulance organizations and fieldhospitals for the use of enlisted personnel, and such wall tents as are issuedfor the use of officers not entitled to tentage in the field.

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

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

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

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

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

5. Orders involving travel of over 10 persons.-Whenorders, involving travel of over 10 persons, are received by the commandingofficer of a base hospital or other sanitary formations of the Services ofSupply, he should at once notify the railroad transportation officer at hisstation and should not comply with the order until notified by the railroadtransportation officer that a schedule has been arranged.

If no railroad transportation officer is at the point wherethe movement originates, details of the movement should be wired to the troopbureau of the transportation department at these headquarters, with request thatproper arrangements be made.

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

951

overlooked. It must be borne in mind that a neglected orimproperly treated slight wound may have serious consequences and causeprolonged hospitalization. Slightly wounded men form the greatest military assetamong all those admitted to hospitals, in that their early return to duty can belooked for if properly treated. The tendency in some hospitals is to delegatethe care and treatment of slightly wounded men to the medical officers young inexperience and skill in surgery.

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

7. Telegraphic and mail communications.-Allcommunications, both telegraphic and mail, intended for the chief surgeon, A. E.F., should be addressed to the chief surgeon, A. E. F., Services of Supply, andnot general headquarters.

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

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

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

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

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

Circular No. 38.

AMERICAN EXPEDITIONARYFORCES,
France, July 1, 1918.

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

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

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

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

952

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

3. Disposition of sick and wounded of AmericanExpeditionary Forces on duty with British Expeditionary Force.-In accordancewith agreement of May 6, 1918, between the British War Office andrepresentatives of the American Expeditionary Forces, sick and wounded ofAmerican Expeditionary Force troops on duty with the British Expeditionary Forceare to be evacuated into British Expeditionary Force hospitals. As far aspracticable, this evacuation will be into hospitals staffed by American sanitaryunits.

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

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

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

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

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

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

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

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

953

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

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

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

(a) For the information and guidance of surgeons ofbase sections, surgeons on transports, liners, and hospital ships, disabilityboards at hospitals at base ports will classify all mental cases destined fortransfer to the United States into the following groups, making entry on boardproceedings in each case: "Close supervision"; "ordinarysupervision"; "no special supervision."

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

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

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

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

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

7. Letter from the Surgeon General of the Army.-Thefollowing letter from the Surgeon General of the Army is quoted for the guidanceof the medical officers of the American Expeditionary Forces, and theinformation called for will be entered on the sick and wounded card wheneverknown:

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

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

Also broncho-pneumonia should, if practicable, be reportedas:
  Broncho-pneumonia, pneumococcus, type 1.
  Broncho-pneumonia, pneumococcus, type 2.
  Broncho-pneumonia, pneumococcus, type 3.
  Broncho-pneumonia, pneumococcus, type 4.
  Broncho-pneumonia, pneumococcus, type unclassified.
  Broncho-pneumonia, streptococcus, h?molyticus.
  Broncho-pneumonia, streptococcus, other types.
  Broncho-pneumonia, streptococcus, unclassified.
  Broncho-pneumonia, other organisms, unclassified.

954

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

GENERAL HEADQUARTERS,
AMERICAN EXPEDITIONARYFORCES.

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

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

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

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

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

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

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

3. The policy with regard to promotion of officers in theDental Reserve Corps shall be the same as that outlined above for the officersof the Medical Reserve Corps. The chief surgeon is authorized to forward at onceany recommendations for promotions which he believes should be made for thepurpose of rectifying inequalities in grade due to mistakes in originalappointments.

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

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

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

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

Circular No. 39.

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

1. The following menus for hospital light diets are sent outas suggestions for the guidance of mess officers. They are based upon a seriesprepared for use in a base hospital in the United States which proved byexperience to work satisfactorily at that place. The

955

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

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

3. In preparing menus from Table 2 it should be borne in mindthat the total number of calories for each diet should be between 2,000 and2,500. "Cup" has the same significance in all tables.

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

NOTE.-In these menus "cup" means approximatelyone-half pint of material prepared ready to serve. The "slices ofbread" refer to those of the 1-pound loaf or to the half slices of thelarge Army loaf.

SUNDAY	Calories
Breakfast:	Calories
1 orange, or equivalent in fresh fruit	75
1 cup cornmeal mush with sugar and milk	200
2 slices bread with butter	175
1 cup coffee, half milk	200
	650
Dinner:
Chicken fricassee, medium service	150
1 baked potato, medium size	150
2 slices bread with butter	175
1 cup tapioca pudding	250
1 cup cocoa, half milk	240
	965
Supper:
1 soft-boiled egg	80
1 cup Farina with sugar and milk	250
? cup stewed peaches	250
2 slices bread with butter	175
1 cup coffee	---
	755
Total:	2,370
MONDAY
Breakfast:
²/3 cup stewed prunes	250
1 cup oatmeal with sugar and milk	200
2 slices bread with butter	175
1 cup coffee, half milk	200
	825
Dinner:
1 cup chicken soup	100
2 soda crackers	50
1 poached egg	80
? baked sweet potato	150
1 cup jelly	200
1 cup coffee	---
	580
Supper:
1 cup custard	300
1 cup rice with milk and sugar	200
? cup stewed apricots	250
2 slices bread with butter	175
	925
Total:	2,330
TUESDAY
Breakfast:
1 baked apple	200
1 cup Farina with sugar and milk	200
2 slices bread with butter	175
1 cup coffee, half milk	200
	775
Dinner:
1 cup creamed chipped beef	200
2 slices bread with butter	175
? cup ice cream	225
1 cup cocoa, half milk	240
	840
Supper:
1 poached egg on toast	125
1 cup hominy with sugar and milk	250
2 slices bread with butter	175
? cup stewed pears	125
	675
Total:	2,290
WEDNESDAY
Breakfast:
2 slices pineapple	200
1 cup oatmeal with milk and sugar	200
2 slices buttered toast	175
1 cup coffee, half milk	200
	775
Dinner:
Chicken fricassee, medium service	150
1 medium baked potato	150
2 slices bread with butter	175
1 cup bread pudding	250
1 cup cocoa, half milk	240
	965
Supper:
1 soft-boiled egg	80
1 cup rice with milk and sugar	200
2 slices bread with butter	175
1 orange	75
	530
Total	2,270
THURSDAY
Breakfast:
²/3 cup stewed prunes	230
1 cup hominy with milk and sugar	250
2 rolls with butter	175
1 cup coffee
	655
Dinner:
1 cup chicken broth with croutons	100
1 egg as omelet	80
? baked sweet potato	150
1 cup Farina pudding	250
1 cup coffee
	755
Supper:
1 cup tomato spaghetti	100
2 slices bread with butter	175
2 slices pineapple	200
1 cup cocoa, half milk	240
	715
Total:	2,125
FRIDAY
Breakfast:
1 orange, or equivalent in fresh fruit	75
1 cup oatmeal with milk and sugar	200
2 slices buttered toast	175
1 cup coffee, half milk	200
	650
Dinner:
1 cup creamed codfish	200
2 soda biscuits	50
2 slices bread with butter	175
1 cup tapioca pudding	250
1 cup cocoa, half milk	240
	915
Supper:
1 soft-boiled egg	80
1 cup Farina with milk and sugar	200
2 slices buttered toast	175
? cup stewed peaches	250
	705
Total:	2,270
SATURDAY
Breakfast:
1 baked apple	200
1 cup Farina with sugar and milk	200
2 rolls with butter	175
1 cup coffee, half milk	200
	775
Dinner:
1 egg as omelet	80
1 medium baked potato	150
1 cup creamed carrots	100
2 slices bread with butter	175
1 cup junket	150
1 cup cocoa, half milk	240
	895
Supper:
1 poached egg on toast	125
1 cup corn meal mush with milk and sugar	200
2 slices buttered toast	175
²/3 cup apple sauce	150
	650
Total:	2,320

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

BREAKFAST
Take one				Take one			Take one	Take one
DINNER
	Take one¹	Take one	Take one²	Take one	Take one³	Take one		Take one
SUPPER
Take one	Take one marked "S"			Take one			Take one	Take one
Cereals	Meats and meat substitutes	Vegetables		Bread and butter	Soups	Desserts	Fruits	Drinks
Cereals	Meats and meat substitutes	High starch	Green	Bread and butter	Soups	Desserts	Fruits	Drinks
Rice. Oatmeal. Farina. Hominy.	Eggs (S). Chicken. Fish. Beef or mutton. Chipped beef. Macaroni and spaghetti with tomatoes serves for both meat and vegetables (S).	Baked white potatoes. Baked sweet potatoes.	Spinach. Lettuce. Tomatoes. Carrots. Green peas.	Liberty. Rye. White. Graham. Whole wheat. Toast. Rolls. Crackers.⁴	Beef soup. Beef broth. Chicken soup. Chicken broth. Noodle. Vegetable.⁵ Barley. Chowder. Boullion.	Custard. Ice cream. Gelatine jellies. Puddings. Farina. Tapioca. Cornstarch. Rice. Fruit bread.	Raw: Apple. Orange. Baked apple. Canned or stewed, fresh: Apples. Cherries. Peaches. Pears. Plums. Dried, stewed.⁶ Apples. Apricots. Peaches. Prunes.	Milk. Coffee. Cocoa. Tea.

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

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

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

	Calories
Cereals:
1 cup of cereal with milk and sugar	200
1 egg	80
Meats:
1 cup creamed chipped beef or 1 cup creamed codfish	200
1 cup creamed chicken	400
Beef, mutton, or chicken, small service	100
Vegetables:
1 cup tomato macaroni	100
1 medium potato, white	100
1 medium potato, sweet	200
1 cup tomato, canned spinach, or lettuce	50
1 cup creamed carrots	100
1 cup creamed peas	225
Bread, 1 slice, or 1 roll, or ? slice of Army loaf	50
Butter, 1 service (40 to pound)	85
Soups:
1 cup thin soup	50
1 cup thick soup	100-200
Desserts:
1 cup custard	300
1 cup ice cream	300
1 cup gelatine jelly	200
1 cup pudding	250
Fruits, raw:
1 apple, large	100
1 orange, large	100
Baked, 1 apple, large, with sugar	200
Canned or stewed fresh fruit:
1 cup apple sauce	250
3 large halves apricots with juice	100
1 slice pineapple with juice	100
3 halves pears with juice	100
1 cup cherries (stewed)	100
1 cup stewed dried fruit	400
Drinks:
1 pint milk	800
1 cup cocoa	240
1 cup coffee, half milk	200

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

Circular No. 40.

AMERICAN EXPEDITIONARYFORCES,
France, July 20, 1918.

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

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

3. This division is charged with the following generalduties:

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

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

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

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

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

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

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

(h) Distribution and replenishment of transportablelaboratory equipment.

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

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

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

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

(d) Advisory supervision of all activities looking tothe control of transmissible diseases including direct liaison with divisionsurgeon.

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

(f) Experimental investigation of suggestedprophylactic methods for the prevention of infectious diseases andrecommendations relative to their general adoption.

(g) Collection of epidemiological data on infectiousdiseases.

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

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

(b) Investigating Army food requirements andconsumption.

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

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

4. The laboratories for the American Expeditionary Forceswill be of two general types-stationary and transportable. The stationarylaboratories will include the central Medical Department laboratory, baselaboratories for the sections of the Services of Supply and for selecteddistricts where necessary, Army laboratories where necessary, base hospitallaboratories for individual base hospitals, base laboratories for base hospitalcenters, and laboratories for camp hospitals.

Transportable laboratories will be organized for evacuationand mobile hospitals and for divisions. Their equipment will consist ofstandardized expandable units in chests, and their personnel will be speciallytrained for the duties which they will perform.

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

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

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

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Circular No. 41.

AMERICAN EXPEDITIONARYFORCES,
France, July 22, 1918.

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

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

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

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

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

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

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

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

6. Clinical records.-Clinical records, temperaturecharts, and other detailed descriptions of treatment will not be forwarded withmonthly report of sick and wounded, by any hospital. They are hospital recordsand will be retained as such.

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

PERSHING,AMEXFORCE:

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

MC CAIN.

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

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

10. Requisitions for antigas clothing and gas masks.-Theseitems have been included in some requisitions for medical supplies made uponadvance medical supply depot No. 1.

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

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

In arriving at the required numbers of each of thesearticles, commanding officers must continually bear in mind the exceedingdifficulty with which all articles of this nature are secured, also thelikelihood of extreme scarcity of fuel during the coming winter. In thisconnection, stoves should be so located as to reduce the number of pipes andelbows necessary to a minimum.

12. Expenditures.-Vouchers submitted for purchasesmade under the authority of paragraph 4, Circular No. 15, office of chiefsurgeon, line of communications, which reads as follows: "The commandingofficer of each base hospital is authorized to expend from Medical Departmentfunds a sum not to exceed $100 per month for the purchase of equipment andsupplies properly chargeable under regulations against such funds," willbear the signature of the commanding officer of the hospital either as acertifying officer or as the approving officer.

This allowance will be confined to the emergency purchase ofarticles on the supply table and in amounts sufficient only to bridge over theperiod pending the receipt of supplies from the depot. Supplies furnished byother departments will not be purchased, as such are not properly chargeableagainst Medical Department appropriations. Authority to purchase items whichhave been erased from the medical supply table or of any item in an amount inexcess of the immediate needs must be approved either by this office or thesection surgeon.

The reserve of medical supplies is now such that requisitionsbased upon future requirements can be filled, and many emergency purchases orrequisitions can now be taken as evidence of poor administration of the supplydepartment of the hospital.

13. Papers for publication.-The attention of allmedical officers is called to the following memorandum which has been receivedfrom the Surgeon General. Papers for publication should be sent through theoffice of the chief surgeon:

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

"1. Attention of medical officers is directed to theprovisions of paragraph 423, M. M. D. Medical officers will not publishprofessional papers requiring reference to official records or to experiencegained in the discharge of their duties without the previous authority of theSurgeon General.

"2. Numerous scientific papers written by officers ofthe Medical Department have recently appeared in the medical press withoutspecific authority from this office. This practice will be discontinued, and theabove regulations will be strictly complied with.

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

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

Circular No. 42:

AMERICAN EXPEDITIONARYFORCES,
France, July 27, 1918.
COLLECTION OF MUSEUM MATERIAL FOR MEDICALEDUCATION AND RESEARCH

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

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

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

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

4. Use in American Expeditionary Forces.-Collectedmaterial required for investigation in the American Expeditionary Forces will beshipped as early and as directly as possible to the groups of officersconducting the investigations in such manner and quantity as they may requestthrough the director of laboratories, A. E. F. After serving the needs of theimmediate investigation, this material, if still of value, will be preserved foruse elsewhere.

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

5. Concentration points.-All other collected materialwill be shipped without unnecessary delay directly to concentration points asfollows:

(a) To the central Medical Department laboratory fromall hospitals in the southeastern portion of the zone of advance and from otherhospitals to which the central Medical Department laboratory is most readilyaccessible.

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

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

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

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

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

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

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

7. Pathologic specimens.-All pathologic specimenssuggested in paragraph 2 from both operations and autopsies should be preservedas follows:

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

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

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

These materials may be requisitioned.

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

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

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

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

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

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

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

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

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Army Regulations authorize transportation of all museummaterial by the Quartermaster Corps. Packages of specimens weighing 7 pounds orless should be directed on a penalty envelope marked official and delivered toan American post office of the military postal express service, withexplanations of their character and the importance of their prompt delivery toprevent spoiling.

9. Bacteria.-Army Regulations provide that cultures ofall pathogenic bacteria isolated in the American Expeditionary Forces shall besent to the central Medical Department laboratory for confirmatoryidentification. The museum supply will therefore be drawn from the centralMedical Department laboratory.

10. Microscopic slides.-Microscopic slides containingdata which can not readily be duplicated in other material sent from the samesource should be sent to the appropriate concentration point.

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

12. Missiles.-For the psychic effect, a missileremoved from the body of a wounded soldier may be given to him if he wishes tokeep it. However, he may be induced to relinquish his claim when the scientificvalue of the comparative study of such missiles and their preservation in amuseum is explained to him. The place and character of all missiles inamputation material should at least be accurately described and, if possible,sketched. All missiles and foreign bodies removed at autopsies should becarefully preserved, if possible in situ, with the pathological specimen. Whenit is necessary to remove them, their location and wound effects should beminutely described, the description, if possible, being accompanied byphotographs or sketches.

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

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

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

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

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

18. Photographs.-General Order No. 78, generalheadquarters, A. E. F., May 25, 1918, amends previous orders as follows:"The Medical Department, A. E. F., is charged with technical photographyconnected with the recording of photographic processes of surgical andpathological matters." For the proper discharge of this duty each hospitalunit should have on its personnel, either in the laboratory or Roentgenographicdepartment, at least one man capable of taking good technical photographs ofmedical subjects. A standard laboratory photographic outfit should berequisitioned by each base hospital not already

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

In addition, the following expendable materials may berequisitioned:

Plates, Lumiere orthochromatique:
Series C, 13 by 18cm.
Series C, 5 by 7inches.
Series C, 4 by 5inches.
Plates, Lumiere ordinaire, slow series C, 3?by 4 inches.
Plates, Lumiere, autochrome, for colorphotography, 3? by 4 inches.
Printing paper, glossy:
Soft, 5 by 7 inches.
Soft, 4 by 5 inches.
Medium, 5 by 7inches.
Medium, 4 by 5inches.
Hard, 5 by 7 inches.
Hard, 4 by 5 inches.
Lantern slide covers, clear glass, 3? by 4inches.
Lantern slide gummed binding strips, 100 inpackage.
Lantern slide gummed labels, 100 in package,1 by 10 cm.
Metol, or substitute therefor, 1 ouncebottles.
Hydroquinone,?-pound bottle.
Metachinone,concentrated for Lumiere autochrome plates, 125-c. c. bottle.
Potassium bromide,xls 10 grams in bottle.
Sodium carbonate,bulk.
Sodium bichromate, 1ounce bottles.
Sodium hyposulphite,bulk.
Sodium sulphite,bulk.
Acid, acetic, 1-poundbottles.
Acid, sulphuric,?-pound in ggs. bottle.
Alumen, ?-poundbottle.
Alumen, chrome,1-pound bottles.
Ammonia, 1-poundbottles.
Plate varnish,Lumiere gum damar, 50 c. c. in bottle.
Autochrome colorscreens, 2-inch.
Autochrome colorscreens, holders.
"Virida"paper for dark-room light for autochromes, 6 sheets in set.

Photographic records should be made of interesting lesions,particularly in the fields noted in paragraph 2, and of those things of medical,surgical, or pathological interest in the hospital which may be of value forteaching, research, or for their historical connection. Copies of these shouldbe forwarded by mail or courier to the central Medical Department laboratory,(museum unit), A. P. O. 721, as soon as made, and the negatives reserved forsubsequent shipment to the most accessible concentration point.

19. Radiographs.-Radiographs, especially those inseries or illustrating wound conditions of their treatment which may be of valuefor teaching, should be copied in prints or lantern slides which should beforwarded by mail or courier with full data to the central Medical Departmentlaboratory (museum unit), A. P. O. 721.

20. Original publication.-All pathological specimens,casts, models, paintings, drawings, photographs, radiograms, etc., should beaccompanied by the name of the medical officer collecting them, and of themedical officer, if any specifically interested in their subject matter. This isimportant, not only for the occasional necessity for retracing them back totheir origin for additional data, but also that the privilege of originalpublication of the data by the officer with whom they originated may berespected.

21. Supplies.-All requisitions for supplies will beprepared and forwarded by medical supply officer of the hospital unit.Requisitions for laboratory supplies only will be made

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in quadruplicate, one copy being retained and three copiesforwarded to the director of the division of laboratories and infectiousdiseases, office of the chief surgeon, A. P. O. 721, and it is desired that asfar as possible requisitions be timed so as to permit shipment thereupon to beincluded in larger shipments from supply depots on ordinary requisitions. Thesespecial requisitions, therefore, should be sent approximately 10 days prior tolarger requisitions contemplated, and should bear notation that shipment shouldbe held pending the receipt of requisition of general supplies.

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

Circular No. 43:

AMERICAN EXPEDITIONARYFORCES,
August 1, 1918.

1. Recommendations for promotions in the Medical ReserveCorps.-The attention of commanding officers of hospitals and other seniormedical officers is invited to the fact that the form on the back of Circular 36should not be used for the recommendation of majors, M. R. C., because suchpromotions take these officers out of the Medical Reserve Corps and into theNational Army. Promotions of this sort must necessarily be limited to a smallclass of specially capable officers, occupying positions of unusualadministrative or professional importance. Such recommendations should, whenmade, be in the form of a special report giving with great fullness all thereasons for the promotion. They should not be made at the request of the officerinterested, or except when such promotions are obviously to the interest of theservice. The blank form with Circular 36 should be used, therefore, only forcaptains and for lieutenants about the age of 31 who are class A men.

The responsibility rests with officers making recommendationsto see to it that elderly men who have no administrative capacity, and nounusual professional accomplishments which would fit them for the grade ofmajor-in other words, men who belong to class B- are not recommended forpromotion as class A men. Lieutenants within the draft age should only berecommended for promotion in unusual and exceptional circumstances, where theindividual has received a military decoration, or wound, or is a man of veryunusual professional ability and occupying a position of such importance as tomake his promotion of obvious advantage to the service.

2. Returning men to duty with 20th Engineers.-Attentionof all medical officers is invited to the fact that the 20th Engineers is alarge regiment and the companies are designated by battalions. It is thereforenecessary to always state the battalion number in connection with the companyletter whenever men from this regiment are returned to duty.

3. Messengers.-Under authority granted by thecommanding general, Services of Supply, in the future when requisitions forX-ray tubes are made on any medical supply depot, the organization making therequisition will, upon receipt of notification that the tubes are available,send the necessary number of messengers to the medical supply depot in questionfor the purpose of carrying back the tubes. Two tubes will be all that one mancan handle.

4. Repair of typewriters.-The question of the repairof typewriters has been taken over by the Quartermaster Department. Hereafterall typewriters needing repair should be shipped to the typewriter repair shop,Tours, notification of the fact of shipment being made to the commanding officerthereof. Upon completion of repairs, machines will be returned to the medicalunits who forwarded them.

5. Convalescent homes.-Arrangements have been madewith the American Red Cross that nurses for whom a period of change is desiredfor convalescence after illness may be sent to the "American Red Crossconvalescent home and vacation hotel," at Le Croisie, near St. Nazaire,during the summer months instead of to Cannes as formerly.

It should be understood that in order to take advantage ofthis arrangement authority should be requested from the chief surgeon, A. E. F.,to send the nurse or nurses to this convalescent home on a status of absent sickfor convalescence with a statement as to the physical condition which requiresthis change. Nurses for whom this authority has been

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granted should not be placed on a status of sick leave, noauthority being granted for sick leave to nurses.

It is not the intention to send nurses to the convalescenthomes whose physical condition is such that they are in need of nursing care.Only those who are fully able to care for themselves should be sent.

6. Charge for subsistence of civilians sick in hospital.-Changes,Army Regulations No. 69, provide that the charge of subsistence of civilianpatients in hospital on the footing of enlisted men will be an amount equal tothe commutation rate prescribed for enlisted patients plus 10 cents a day.

7. Prompt evacuation of class D patients.-Attention isdirected to the policy of this office with respect to the disposition of allclass D patients. It is not intended to hold patients for prolonged periods ofobservation and study who are clearly destined to fall within this class, nomatter how much professional interest they excite.

Such cases should be placed before disability boards promptlyfor classification, and as soon as they are able to travel by ordinary trainthey should be sent to Base Hospital No. 8, at Savenay, with a view to theirtransfer to the United States. If not able to bear travel upon ordinary trains,all such patients should be sent on the hospital train which will be routedregularly to collect such cases as are able to bear the journey to the UnitedStates.

Therefore, as soon as a patient is classified as of class Dhe should be considered as destined for transfer to the United States, since theintention is to evacuate to the United States all mutilated and disabled men fortreatment, reconstruction, reeducation, and final disposition. The necessity forthis policy lies in the fact that the hospitalization program in the AmericanExpeditionary Forces is based upon a definite priority schedule of building andof housing material, and also of tonnage space for medical supplies on shipsfrom home ports, in direct ratio to the number of troops in France. Thehospitalization program in the United States also contemplates the reception ofa constant stream of evacuables from the zone of operations.

8. Biological products.-The following biologicalproducts have been selected by the chief veterinarian as all that are necessaryfor the American Expeditionary Forces. Supply depots and base laboratories willcarry these only in stock:

(a) Serumantitetanic.
(b) Serumantistreptococcic.
(c) Malleinintradermal.

9. Authority to authorize expenditures and approvevouchers on Medical Department funds.-Authority to authorize expendituresand to approve vouchers for purchases properly chargeable against MedicalDepartment funds, in sums not to exceed $250, is granted to the commandingofficers of all hospital centers and to the chief surgeons of armies.

The authority to authorize expenditures and to approvevouchers for purchases properly chargeable against Medical Department funds, insums not to exceed $100, is hereby granted to chief surgeons of army corps.

10. Hospital trains.-When the commanding officer of ahospital is informed of the arrival of a train of patients for his hospital hewill send an experienced medical officer and a sufficient number of enlisted mento unload patients from the train. This work is not to be done by the trainpersonnel except in emergency.

Commanding officers of base hospitals are authorized to issueexpendable medical and surgical supplies to the commanding officer of hospitaltrains, taking the memorandum receipt of the commanding officer of the train asa voucher for property return.

11. Mail.-It has been reported to the chief surgeon'soffice that some medical officers on duty in wards where there are mental casesare in doubt as to their power to prevent the mailing of letters from mentalcases of an obscene or abusive nature, or letters on trivial subjects, toprominent persons. Commanding officers of hospitals should regulate this matterand see that letters of this character are not placed in the mails.

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

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Circular No. 44.

AMERICAN EXPEDITIONARYFORCES,
August 3, 1918.

1. System of evacuation of wounded.-The followingreport of the system of evacuation of the wounded adopted by the regimentalsurgeon, -th Infantry, is published for the information of regimental surgeons:

1. I made a reconnaissance the night of June -th of all roadsand paths between P----- road and B----- farm, including a personalreconnaissance of B----- , N-----, Bois la' M----- roads, etc., for suitableroutes for ambulances; especial attention was given to safety of ambulances,speed and comfort of wounded, and avoidance of traffic congestion.

2. Outline the following system as the result of this study,which was very successfully followed during and after the attack:

On June -th, 1918, an advance station was organized atM-----, including 3 medical officers, 8 Hospital Corps men, and 20 litterbearers. Ample supplies were stored in the dugout in which this station waslocated. At T----- farm another dressing station was established, with 3 medicalofficers, 8 Hospital Corps men, and 15 litter bearers, with reserve supply oflitter bearers and corps men and medical supplies always available forforwarding to any point where added assistance might be needed. An advancestation of the -d Infantry was located at B-----. Their evacuation and operationof the station was under my supervision. One surgeon, one sergeant, and oneprivate went forward from M----- with the assaulting waves, and they establisheda dressing station at V-----. The stretcher bearers worked for this station, andthe prompt need with which first aid was given at the forward stationundoubtedly saved a large number of lives. At La N----- farm an advance medicalsupply depot was established and a reserve ambulance station. This was in thehands of 1 medical officer and 1 noncommissioned officer in charge of ambulanceand medical supplies. The regimental infirmary included the regimental surgeonand 3 assistants, with 5 medical officers in reserve to be forwarded to thepoint of greatest need, and was located at B----- farm.

3. Thirty-five ambulances were in service for the evacuationof wounded from the battalion aid station through the regimental infirmary toField Hospital No. -. At the time of our assault there were 2 ambulances inwaiting at M----- station, 2 at B-----, and 2 at T----- farm. Four ambulanceswere at the intermediate station at La N----- farm. As soon as a loadedambulance going to the rear passed La N----- farm, the noncommissioned officerstationed there sent an empty ambulance forward to replace it; in this way therewere always two, and no more than two, ambulances at each battalion aid station.As soon as the loaded ambulance reached B----- farm, another empty ambulance wassent forward to replace the ambulance at the intermediate station at La N-----farm. This system cut down congestion on the roads and enabled us to haveambulances always available and secured the greatest efficiency in the use ofeach ambulance.

4. Under the system of evacuation outlined, many wounded hadreached the field hospital at B----- within one hour after the first assaultingwaves had left their lines of departure. When the -d Infantry dressing stationwas demolished by artillery, killing one medical officer and wounding another,it was possible to replace them by two of the medical officers held in reservefor this purpose within 15 minutes after the accident and before there was anyaccumulation of wounded at the station.

Hospital Corps men held in reserve were forwarded to each ofthe battalion stations as they were needed, and when the pressure relaxed theyreturned to the reserve station. This arrangement allowed an elasticity whichkept wounded from congregating at any station and kept a steady, constant streamof evacuations to the rear. It enabled us to evacuate the major part ofapproximately ----- cases before midnight. At 3.30 a. m., excepting stragglingcases, there were no wounded in any of the dressing stations or in theregimental infirmary, all having been sent to the rear.

The cases handled included about ----- Americans, about----- each of French and Germans, each of which received hot drinks andadditional medical aid at the regimental infirmary before being sent to thefield hospital at B----- . I left the regimental infirmary before being sent tothe field hospital at B-----. I left the regimental infirmary in care of aMedical Reserve Corps captain and in a motor cycle side car made the rounds ofthe forward stations, apportioning the reserve surgeons and litter bearersaccording to the need of the stations at that time, and supervised theforwarding of medical supplies as they were needed.

2. Shortage of personnel.-Because of the shortage ofMedical Department personnel trained in the care of mental cases, it is directedthat commanding officers of all base and evacuation hospitals or other MedicalDepartment units forward to this office the names of any nurses or men who havehad such training and who are not at present performing such duties.

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3. Prisoners of war.-As soon as prisoners of war whohave been under treatment in a United States Army hospital are ready to beevacuated to the C. P. W. E., the commanding officer of the hospital shouldnotify the provost marshal general, who will send the necessary guard to escortthem to the C. P. W. E. In order to economize on the number of escorts sent tothe hospitals, these prisoners of war should be evacuated from the hospital ingroups of five or more.

4. Lipo vaccines.-The following letter from theSurgeon General is quoted for your information:

I beg to inform you that the Army Medical School is nowpractically ready to begin furnishing triple lipo vaccine in place of tripletyphoid saline vaccine. The lipo vaccine has the great advantage over the salineof being administered in a single dose. The oil permits this, since itdiminishes the rapidity of absorption, and a large dose can be administered,which is absorbed gradually over a long period. It is expected in the course ofa few months to stop the manufacture of the saline vaccine altogether. Thequantity of machinery apparatus, necessary to this change in the method ofmanufacture is delaying the output for a short time only. So far this month, 30liters have been issued, and we will soon be in position to issue not less than150 liters per month.

After the typhoid vaccine is well on the way a similar oilvaccine will be made to be used against pneumonia, dysentery, cholera, plague,and perhaps streptococcus infections.

5. Medical war diaries.-Beginning with July 1, 1918,and in connection with medical histories of camps, depot brigades, and basehospitals recently filed in the Surgeon General's office, it is directed thatmedical war diaries be kept henceforth in these stations until the close of thewar. These diaries shall be regarded as the literary property of the division ofmedical and surgical history of the war, Surgeon General's office, and must beentirely disassociated from the ordinary military and medical records of campsand base hospitals.

Attention is called to the fact that these records are to beregarded as stationary; i. e., the medical records of the division surgeon of amobilized division must not be confused with the permanent medical historyrecords of the camp or other stations in which the division has temporarily beenquartered or through which it passes. The latter records must remain in thestation until the end of the war as the ultimate property of the SurgeonGeneral's office, and should not be removed by any outgoing division surgeon.

It is requested, however, that each outgoing camp or divisionsurgeon transmit to this office (division of medical and surgical history) acarbon of his own individual contribution to the war medical diary up to thetime of his departure from the station.

Medical war diaries of camps and base hospitals shall be madeup of brief but circumstantial entries of any events in the history of thesestations which have influenced their sanitary status; e. g., outbreaks ofepidemic diseases of major or minor importance, fires or other accidents,important changes in personnel, medical administration, sanitation, newtherapeutic measures and sanitary devices introduced, new construction whetherby enlargement of existing buildings or erection of new buildings, incidence ofunusual diseases or complications of disease, unusual surgical cases andoperations performed, or any other feature of like interest.

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

Circular No. 45.

AMERICAN EXPEDITIONARYFORCES,
France, August 13, 1918

I. Circular No. 6 is amended to read as follows:

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

(a) Immediately after the receiptof a wound of whatever nature or severity.
(b) Upon the recognition of so-calledtrench foot, with or without skin abrasions.
(c) In cases of frost bite.
(d) During operations performed underconditions of unsatisfactory asepsis; e. g., emergency operations, operationsfor hemorrhoids, fistul?, or any conditions where fecal contamination is apossibility.

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(e) During secondary operationsnecessary in the course of the treatment of wounds received seven or more dayspreviously.

(f) Following the manipulationsincident to the reduction of compound fractures or dislocations, after theremoval of adherent drains, or any other procedure resulting in a seriousdisturbance of the healing processes in a wound seven or more days old.

2. One prophylactic dose of 1,000 units of tetanus antitoxinwill be given to all wounded whatever the nature or severity of the wound, aspromptly as possible after the infliction of the wound if a battle casualty,preferably at the battalion aid station. This dose should be givensubcutaneously preferably over the lower abdomen. A second dose of 1,000 unitswill be given in every case after an interval of seven days.

3. In severe injuries where prolonged suppurative processespersist, especially when fecal contamination of the wound per rectum or throughintestinal fistul? is present and when much tissue necrosis occurs, three oreven four doses may be indicated. The attending medical officer must bear thisin mind and exercise judgment accordingly in the individual case.

4. There is no objection to the use of 1,500 units for theinitial and the second prophylactic doses, but doses of 1,000 units each affordsufficient protection. (NOTE.-Tetanusantitoxin from the United States usually contains 1,500 units to the dose.)

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

6. All injections, with amounts and dates, signed by theofficer administering them, will be entered on patient's field medical card, bythe letters A. T. S. followed by the date and hour. In the case of the freshlywounded the letter T should be marked plainly upon the patient's forehead withan indelible pencil.

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

8. Medical officers who are thus compelled to administer A.T. S., because of the failure of any medical officer or officers previouslyresponsible for this administration to carry out the above instructions, mustmake an immediate report of such ommissions to the chief surgeon, A. E. F.,through the director of general surgery, with sufficient data to establish thetime and circumstances of the omission.

II. Patients dying on hospital trains.-Commandingofficers of base hospitals will receive from hospital trains the remains of anypatients dying en route, and will arrange for their burial and render thenecessary reports called for by existing orders.

III. Civilian employees for hospital centers.-Authorityis hereby granted to commanding officers of hospital centers to authorize theemployment of such civilian employees as may be necessary for the administrationof the base hospitals under their command. The employment of these civiliansmust be in accordance with existing regulations; and attention is invited toBulletin No. 14, headquarters, line of communications, February 13, 1918, andGeneral Order No. 7, headquarters, services of supply, March 11, 1918.

IV. Address of director of professional service.-Attentionof all medical officers is invited to the fact that the address of the directorof professional service is A. P. O. 706, and that of the consultants is A. P. O.731. Considerable mail is coming to this office for these services and addressedto post office 717. These cause a delay and unnecessary work in this office.

V. Transportation of wounded in trucks.-Trucks can beused to great advantage for transportation of wounded where the distances arenot too great. Twelve litter cases can be carried in a 3-ton truck. In loading,3 litters are first placed transversely in the upper tier, with handles restingon the edges of the sideboards of the truck box; then 3 longitudinally in thebed of the wagon; then 3 more transversely in the upper tier; and finally 3 moreon the floor of the truck longitudinally. The tailboard of the truck remainsopen. The stirrups of the 3 rear litters in the lower tier fit into the openingbetween the body of the truck and the tailboard. In order to keep the rearpatients from rolling out, one open litter is placed on edge at the back of thetruck, with its lower handles resting on the side-

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boards and the upper handles supported by the rear bow of thetruck. It requires 12 minutes for 4 men to load 12 patients. Where there is abank beside the road, it can be conveniently used for loading the upper tier.

VI. Promotion and demotion of enlisted men, MedicalDepartment.-The commanding officers of hospital centers are authorized topromote and demote enlisted men of the Medical Department between the grades ofprivate and sergeant, first class, inclusive. They will sign warrants "forthe chief surgeon" for men promoted under this authority. The number of menpromoted will not exceed the percentages authorized by law. Recommendations forpromotions of soldiers of the Medical Department to the grade of master hospitalsergeant and hospital sergeant will be forwarded to this office for approval.

VII. Visits of French ladies to American wounded.-Authorityhas been granted the Association of French Homes (Foyers Francais) to issue toladies who are members of that society permits which will entitle them to visitAmerican wounded in military hospitals of the American Expeditionary Forces. Thesociety has been informed, however, that these visits can, as a rule, be onlymade during the regular visiting hours prescribed by the commanding officer ofthe hospital or hospital center.

VIII. Anthrax.-The following letter from the SurgeonGeneral, of July 6, 1918, is quoted for your information:

1. I am directed by the Surgeon General to inform you thatthe number of cases of anthrax being reported to this office is sufficient toattract attention at this time. Anthrax, so far as reported, has withoutexception appeared on the face or neck, and shaving brushes have fallen undersuspicion, and in some cases anthrax organisms have been isolated from them. Forthis reason, it is necessary that each case of anthrax coming to your attentionbe examined critically; that the man's shaving brush, talcum powder, and othershaving accessories be obtained; that the organism be sought for with greatthoroughness. For the purpose of testing brushes, it is recommended thatinoculations of bristles from the brush be made into rabbits, guinea pigs, andrats; nothing short of this may give conclusive results. Report should be madeto this office of each case, giving the clinical history, the etiology, theresults of the examination of supposedly infected material. The shaving brush orother article from which the anthrax bacillus may be isolated must also beforwarded to this office, with full information as to its source, name of themaker, and other data to facilitate its identification.

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

Circular No. 46.

AMERICAN EXPEDITIONARYFORCES,
France, August 16, 1918.

1. Upon the recommendation of the chief consultant insurgery, and with the approval of the director of professional services, thefollowing instructions are published for the information and guidance of allconcerned:
INSTRUCTIONS CONCERNING THE TREATMENT INORTHOPEDIC CONDITIONS, INCLUDING FRACTURES AND JOINT INJURIES

2. The work of the division of orthopedic surgery in themedical organization of the Army divides itself quite clearly into two parts,one having to do with the preparation of the men for the expected combat, andthe other assisting in their recovery if wounded. The first endeavors to seethat they are so trained that there will be the greatest possible vigor for thecombat, and that physical defects which might have rendered them ineffective arecorrected. The second has to do with the treatment of the men if injured, sothat there will be the least possible ultimate crippling or interference withfunction. The first has to do with saving men for service who would otherwise bedischarged as physically unfit and also, as the result of careful training,increasing the number of days that should be expected of the men for activeduty. The second has to do with the saving for service of men who but for suchwork might not have lived, or, had they lived, been so crippled as to be of nouse to the Army.

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3. Without such methods of treatment available for thoseneeding such care in the precombat or training period, large numbers of men willbe lost for active duty, as the ordinary medical measures can only givetemporary relief.

4. Without such methods in cases of combat or other injurythere will be much unnecessary loss of function and much of the acute surgicaltreatment will be purposeless.

5. In each of the large hospital centers, a base hospitalwith special personnel and equipment for caring for such cases will beinstalled, while in the detached base hospitals special services will beestablished so that there will be the least possible transferring of cases fromone hospital to another.

6. Consultants in orthopedic surgery will be assigned togroups of hospitals, whose function it will be to keep in touch with theorthopedic work of the given group. These consultants should be freely used bythe staff of the respective hospitals and can be reached through the commandingofficers of hospital centers.

7. To best accomplish the purposes of the division and tomake the services of its members available the following instructions willgovern:
AMPUTATIONS

8. Cases of amputation of either extremity will be assignedas soon as possible to the orthopedic service for the needed special treatment.A guillotine amputation, for instance, without other injuries, can usually bemoved without risk in one week, and with suitable measures rapid closure of thewound is usually possible so that the artificial leg can be fitted and the manget about without crutches many times in from four to five weeks from the timeof injury. It is desirable that transfer to the orthopedic service take place asearly as possible before contractures have taken place so that the temporaryartificial limb, in case that is desirable, can be most favorably fitted and themuscles used to the best advantage.

TENDON INJURIES OR INFLAMMATIONS

9. The cases of injury to the tendons or inflammation in orabout the tendons should be assigned as soon as the primary wound healing iswell established, or as soon as the acute inflammatory reaction has subsided tothe orthopedic service. Early transfer to these special services is important inorder that the treatment having to do with the full restoration of function inthe part that has been injured or inflamed may be established at the earliestpossible moment and before adhesions have formed or become organized.
FLAT FEET, WEAK FEET, OR PRONATED FEET

10. Cases of flat, weak, or pronated feet associated withpain, swelling, or inflammation, when admitted to a hospital should be assignedto the orthopedic service. As soon as the acute symptoms have passed, the casesshould be transferred to the nearest convalescent camp. From here, in keepingwith the degree of difficulty, the cases should be transferred for full duty orto the orthopedic training camp, depot division, for training to fully overcomethe weakness, or for noncombat duty under class C classification.

11. No cases of uncomplicated flat foot should be exemptedfrom service or recommended for transfer to the United States, as all can bemade useful for military service.

SPINAL STRAINS, WEAK BACKS, CHRONIC BACKACHES

12. The cases of weak, painful, or lame backs, or of sprainof the spinal or sacro-iliac joints, should be assigned to the orthopedicservice. From here they should be transferred to the nearest convalescent campas soon as the acute symptoms have passed, and from there, after a reasonabletime, they should be transferred either for full duty or for noncombat dutyunder class C classification.
GENERAL BAD POSTURE

13. Cases of general bad posture, which is commonlyassociated with lack of vitality or general endurance as well as being part ofthe condition leading to weak feet and weak backs, should be sent for trainingin the orthopedic training camp, depot division.

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FRACTURES

14. For all cases of fracture of bones other than of the heador face, or of extensive muscle injuries, it is of the utmost importance thatproper splints be applied at the earliest possible moment so that the transferof the patients to the hospital in which treatment is to be given, is associatedwith the least possible damage to the tissue adjacent to the injured bone. TheThomas leg splint, the hinged half-ring splint, the Thomas hinged arm splint(Murray modification), the Cabot posterior splint, and the ladder splinting arethe appliances most needed for such work.

15. In case the fracture is compound, the wound treatment atthe evacuation or other hospitals should follow the principles outlined by thechief consultant of surgical services.

16. After the primary wound treatment has been given, thesecases should be transferred to the orthopedic service, in which the mostapproved methods for the early restoration of function to the injured part willbe available. An effort should be made to transfer the cases to such services,wherever possible, within a week or 10 days of the time of injury, this beingthe most favorable time as regards bone repair. All fracture cases which, forany reason, can not or should not be transferred to one of the services asindicated above, should be reported to the senior consultant in orthopedicsurgery, or to the orthopedic consultant of the special area.

17. Simple fractures should not be converted into openfractures except under very exceptional conditions or after consultation withone of the orthopedic consultants. A result which may not be as perfectanatomically as might have been obtained by open operation may, nevertheless, befunctionally good. This is so commonly the case that the risk of infection,which is greater under the war conditions than in civil life, should be avoidedwhenever possible.
JOINT INJURIES

18. All injuries of the joints should be protected with thesame care for transport to the hospital in which the treatment is to be given ashas been indicated for fractures. Suitable splints should be appliedimmediately, and the standardized list of splints of the Army provides typesthat will meet all the needs.

19. In case the injury is associated with open wounds, theprinciples of the wound treatment are those which have been laid down by thechief consultant of general surgery.

20. Since in all such injuries ultimate function of the jointis the chief requisite, treatment having for its purpose the restoration offunction should be instituted as soon as possible, and for this purpose it isdesirable that cases of such injury be transferred, as soon as the primary woundtreatment has been given, to the orthopedic service. It is important that suchtransfer be made before unnecessary adhesions have formed so that therestoration of function can be obtained with the least possible loss of time. Inall such functional restoration it should be clearly understood that whilemotion is to be encouraged at the earliest possible moment, it should consistentirely of active motions performed by the patient, in which case the reflexmuscular contraction will protect the joint from undue injury. All passivemotion should be avoided.

21. Operations upon the joints that are not emergency incharacter should not be performed until after consultation with one of theconsultants in orthopedic surgery.
TRANSFER TO UNITED STATES

22. It will be the policy to send to the United States, assoon as transportable, all cases that are of class D type, or cases in whichprolonged treatment will be required for restoration to duty.

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

Circular No. 47.

AMERICAN EXPEDITIONARYFORCES,
August 28, 1918.

I. The following memorandum from general headquarters,American Expeditionary Forces, is published for the information of all medicalofficers concerned. Strict observance of the instructions that only class A men,fit for immediate combat duty, be sent to replacement battalions is enjoined:

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1. Complaints are reaching these headquarters that hospitalsare sending men to replacement battalions who are not fit for class A orimmediate combat duty. The commanding general of the First Corps reports thismatter to these headquarters and is advised in substance as per the telegrambeing sent out to-day:

"Following furnished for your information and guidance.Commanding general, First Corps, recently forwarded these headquarters complaintthat men other than class A were sometimes being sent to replacement battalions,and requested authority to send all class B, C, D men to depot division fordisposal. Our indorsement August 19 approved this request, with statement mensent to replacement battalion must be class A, fit for immediate assignment tocombat duty, and was never contemplated that class B, C, D men be sent thosebattalions. Chief surgeon has been directed to circulate this information tomedical officers concerned.

"MOSELEY."

II. Discharge of civilian patients from hospitals.-Ina recent case a civilian employee of the Army was admitted to hospital as asoldier, was transferred to another hospital as such, and upon discharge fromthe hospital for duty was issued the uniform of an American soldier. He waslater arrested on the charge of illegally wearing the uniform. Commandingofficers of hospitals should take every possible precaution in issuing uniformsto patients being discharged from hospital that they are only given to thoseentitled to wear them.

III. Appliances.-Requisitions for all appliances whichrequire heat or power should show in the column "Remarks" whether gasor electricity is available; and, if the latter, the type of current, voltage,and cycle will be designated. This applies in particular to X-ray, dental, andlaboratory equipment.

IV. Prolonged active hospital treatment.-Patients haverecently been evacuated from the front to Services of Supply hospitals "Forcontinuation of antisyphilitic treatment." General orders and circularsissued on this subject provide that "Only cases presenting complicationsindicating the necessity of prolonged active hospital treatment will betransferred back from the regimental lines." In this connection, attentionof all medical officers is called to paragraph 5, section 1, General Order 34,general headquarters, 1917, and paragraph 5, Circular 15, office of chiefsurgeon, 1917.

V. To registrars of all hospitals.-The copies of Form22, A. G. O., received in this office are in many cases so illegible as to beunavailable for use. Unless better copies are sent, it will be necessary in alarge proportion of the reports to require that new sets be made out andforwarded. To obviate this necessity it is suggested that first and third, orsecond and third, copies of the original impressions be forwarded to thisoffice.

VI. Evacuating officers and soldiers from hospitals.-Therehave been frequent complaints that orders governing the evacuation of officersand soldiers from hospitals were not being complied with. Commanding officers ofhospital centers and hospitals are charged with the duty of seeing that all theofficers of their command concerned with the evacuation of patients fromhospitals are thoroughly familiar with the orders governing this subject. Inthis connection attention is called to section 7, General Orders 111, generalheadquarters 1918; section 2, General Orders 11, Services of Supply, 1918;section 1, General Orders 41, general headquarters, 1918; and Circular Letter6-A, office of chief surgeon, 1918.

VII. Records to accompany patients on evacuation fromhospitals.-1. Attention of all medical officers is called to theinstructions on the field cards, which state that these cards are to be securelyfastened to the patient's clothing. These instructions are not being carriedout, and as a result patients and their cards are becoming separated and thereis a great confusion of records. In some cases when patients are being evacuatedby hospital trains the field cards are turned over in bulk to the traincommanders. This method of transfer of field cards is not authorized, and traincommanders are hereby instructed not to accept field cards in this manner.

2. Many patients are being received at hospitals in baseports for evacuation to the United States without adequate records of previouscondition. Attention is called to the requirements of General Orders 41, generalheadquarters, 1918; section 1, paragraph 8; and to the Manual of Sick andWounded Reports, sections 6 and 7, and section 9, paragraph 12.

3. In making report, disability boards will use card Form No.25, statistical section, A. G. O.

VIII. Personal property of patients.-It has beenreported that articles of value have been turned in, without receipt, by greatnumbers of wounded soldiers at field, evacuation,

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and other hospitals and that on their being evacuated toother hospitals these articles have not been returned to them. Commandingofficers of hospitals should give this matter their attention and endeavor tosee that personal property belonging to their patients accompanies them uponevacuation.

IX. Fire protection.-The following suggestion is madeto this office by the bureau of fire protection:

In hospitals where different types of construction have beenused, commanding officers should keep in mind in making assignments of patientsto wards that on account of difficulties of evacuation in case of fire the moreserious bed patients should, whenever practicable, be placed in less inflammablewards.

X. Ordnance equipment.-Commanding officers ofhospitals in and adjacent to Paris are informed that all ordnance equipment,with the exception of guns and ammunition, should be shipped to the Americansalvage depot, St. Pierre des Corps. All firearms and ammunition should beshipped to the advance ordnance depot No. 1, at Is-sur-Tille. Guns should besecurely packed in boxes or tied together and well wrapped so that they mayarrive in as good condition as possible. All salvaged clothing which is notrequired can be turned in to the American salvage depot, 110 Boulevard deHospital, Paris.

XI. Requisitions for X-ray supplies.-A Roentgenologisthas been attached to intermediate medical supply depot No. 3 for the purpose ofacting upon requisitions for X-ray supplies. Hereafter requisitions for X-raysupplies will be listed separately as heretofore but will be sent direct to theintermediate medical supply depot No. 3, A. P. O. No. 737.

XII. Emergency medical teams.-The medical teamsheretofore known as "gas teams," or "shock teams," will beknown in the future as "emergency medical teams." They are to be usedin emergencies for the medical care of the wounded (especially chest wounds) andfor those suffering from surgical shock as well as gas.

XIII. Front-line packages.-It is directed thatcommanding officers of Services of Supply hospitals stop the practice of makingrequisitions for the "front-line packages" prepared by the Red Cross.There dressings are expensive and not specially suited to regular hospital work.They are intended for use at the front only.

XIV. Rest rooms for nurses.-The building of Red Crossamusement rooms and rest rooms for nurses has unfortunately been much delayed atmany base hospitals on account of the demand for more beds for patients and thenecessity for using all available material and labor to provide the additionalroom needed for the sick and wounded.

M. W. IRELAND,
Major General, M. C., Chief Surgeon.

Circular No. 48:
AMERICAN EXPEDITIONARYFORCES,
September 9, 1918.

I. Official relations between medical and veterinarypersonnel.-(1) The veterinary service of the American Expeditionary Forcesis by special order now placed under the authority of the chief surgeon, and theVeterinary Corps will in the future function under Special Regulation 70, datedWashington, December 15, 1917.

This special regulation is not to be interpreted as placingindividual veterinary officers or veterinary organizations under the authorityof medical officers. On the other hand, it is to be interpreted as placing alldetachments of veterinary personnel in an independent status with reference toother Medical Department personnel.

The senior veterinary officer of any organization or station,therefore, would bear the same relationship to the commanding officer thereof asdoes the senior medical officer, and, as a detachment commander, he has the sameresponsibility for the care, instruction, and discipline of his men.

(2) Senior veterinary officers are not to be considered asassistants or subordinates to corresponding medical officers. It is notcontemplated that correspondence, reports, or returns emanating from orpertaining to the Veterinary Corps will pass through the office of medicalofficers as part of the routine channel of communication.

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(3) Requisitions for veterinary supplies will be forwarded asfollows: (a) Organizations with divisions through division veterinarian,and upon his approval, in the manner as laid down by General Order 44. (b)Officers commanding veterinary hospitals and other independent units direct toproper supply depot.

(4) Although the independence of action outlined herein isexpected to govern official relations between the medical and veterinaryservices, it should not be forgotten that the activities of both are in contactat several points and that frequently occasion arises when the medical officer,by reason of longer service and broader experience, can be of materialassistance to the veterinary officer. This is particularly true as regards army,corps, and division surgeons and veterinarians.

Senior medical officers will therefore cooperate withveterinarians and assist them by counsel and advice in the handling of dutiesnewer to many of them. While the veterinarian should welcome such assistance, heshould at the same time cultivate independence and authority in his departmentand avoid submitting himself to such supervisory action as would tend to destroyhis initiative and sense of responsibility.

II. Telegraphic reports.-Commanding officers ofhospitals in making telegraphic reports to the British authorities of deaths ofBritish officers and soldiers should indicate in the report the number or nameof the hospital from which the report is being made.

III. Inspection.-It has been brought to the attentionof this office that isolated detachments connected with divisions, and with theServices of Supply, sometimes fail to undergo the regular inspections forvenereal disease. The attention of all responsible medical officers is called tothis oversight.

IV. Treatment of Y. M. C. A. personnel.-Therequirements of Circular 37, paragraph 8 calling for reports to be submitted toY. M. C. A. headquarters for Y. M. C. A. personnel treated in AmericanExpeditionary Forces medical formations are not being observed. In many casesdiagnoses are not given or anything indicating the condition of the patient ondischarge from hospital. These reports should be addressed to medical section,Y. M. C. A. headquarters, No. 12 Rue D 'Aguesseau, Paris, which change ofaddress will be noted.

V. Rating of enlisted men.-Commanding officers ofhospital centers are authorized to rate enlisted men under paragraph 1420?,Army Regulations. Report of any ratings made under this authority will beforwarded to this office.

VI. Carrel-Dakin tubing.-There is great difficulty inmeeting the needs for Carrel Dakin tubing. Every effort must, therefore, be madeto conserve the supply. The commanding officers of hospitals will give suchinstructions as to insure that the tubing after use will be cleansed andsterlized and again used, and that all received at the hospital in excess of theneeds of the hospital will, after cleaning and sterilization, be returned to thenearest supply depot.

VII. Nurses.-Any member of the Army Nurse Corps whomarries while on active service in France will be returned immediately to theUnited States for duty and will not be discharged in France. Report of themarriage of any nurse will be immediately reported to this office by the propercommanding officer.

VIII. Ordnance equipment.-Decision has been renderedthat mess equipment and canteens should be issued to patients upon dischargefrom hospitals, whether patients are to go to replacement organizations or toconvalescent camps. The commanding officers of hospitals are instructed tomaintain a sufficient supply of this ordnance equipment to issue to patientsupon discharge.

IX. Reports of issues of ordnance to patients dischargedfrom hospital.-Circular letter No. 6-A, from this office, requiring thatordnance property issued to patients leaving hospitals be dropped on a monthlyabstract of issues showing the quantity of each kind of article issued duringthe month and giving the names of the soldiers to whom such uniform equipmenthas been issued, is with the consent of the chief ordnance officer amended sothat the names of the soldiers to whom these articles are issued will not berequired.

X. Conservation of supplies.-The necessity for theutmost economy in all surgical dressings and supplies is obvious. Not only thelimitations imposed by the tonnage situation, but the enormous increase in theburden thrown upon the manufacturer, makes this essential. Gauze and bandagesshould be repeatedly washed and sterilized. Rubber gloves should be

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cleaned and tested. Wastage in catgut should be avoided byinsistence upon an economical method of tying. Ether should be conserved. Onlyby the cooperation by the entire surgical staff of each hospital can the desiredconservation of supplies be brought about, and the importance of this subjectshould be repeatedy impressed upon all concerned. The Surgeon General reportssome most satisfactory results in the United States through efforts atconservation and suggests the following method:

While the varying equipments of different hospitals maymodify the method used for the reclamation of gauze and bandages, the followingmethod is suggested: Each surgical ward and dressing room should be equippedwith two galvanized-iron buckets with a cover, lined by a paper bag in one ofwhich should be put all blood-stained and slightly soiled dressings; in theother, pus-stained dressings. These buckets should be taken twice daily-oftener,if necessary-to the room where dressings are washed. If no laundry equipment, orlaundry machinery, is available, the gauze and bandages can be washed by hand,using heavy rubber gloves for this purpose. Previous to washing, the slightlystained and blood-stained dressings should be soaked for 12 hours in cold watercontaining one-tenth per cent of chloride of lime; the pus-stained dressings ina solution containing one-tenth of 1 per cent chloride of lime and one-half of 1per cent washing soda. If washed by hand, these dressings should be boiled forat least one hour. When laundry machinery is available, or in the largerhospitals which are now being furnished with equipment for the reclamation ofre-use knitted gauze, ordinary gauze and bandages may also be reclaimed. Thegauze and bandages should be put in mesh bags, soaked for 12 hours as directedabove, boiled for 1 hour, transferred to the washing machine, and, if a rotarytumbler is available, can be dried in the bags in this tumbler. If this is notavailable, gauze and bandages can be passed through a wringer and hung on linesto dry. After drying dressings should be sorted, folded, put in packages, andsterilized in the ordinary way for 30 minutes at 15 to 30 pounds pressure, ontwo successive days. Careful bacteriological tests should be made from time totime to test its sterility.

M. W. IRELAND,
Major General, M. C., Chief Surgeon.

Circular No. 49.

AMERICAN EXPEDITIONARYFORCES,
September 18, 1918.

I. Preparation of gum-salt solution.-Prepared solutionof gum-salt for intravenous infusion in cases of hemorrhage and shock will belimited to field, mobile, evacuation, and advanced base hospitals reallyfunctioning as evacuation hospitals, where, during active periods bloodtransfusion may be impossible of accomplishment. Such hospitals may obtaingum-salt solution from the nearest Army medical dump or from the central MedicalDepartment laboratory. The solution is issued in 500 c. c. automatic stopperedbottles, 12 bottles to a case. Both cases and bottles are obtained with greatdifficulty, and empty bottles and cases must be returned in order to receivereplenishments.

In base hospitals, generally, blood transfusion should be theprocedure of election and intravenous infusion of gum-salt solution resorted toonly in emergency. The small stock of gum-salt solution necessary to meet thoseemergencies should be prepared locally, by each base hospital for its own use.Directions for the preparation of the solution may be obtained from the directorof laboratories, A. P. O. 721.

In order that all the acacia that is available may beconserved for use in the preparation of gum-salt solution, its issue from supplydepots for dispensary use is interdicted.

Requisitions for acacia in small quantities, not to exceed 5pounds in the instance of base hospitals, will be honored, provided thenotation: "For preparation of gum-salt solution" is entered oppositethis item in the column of remarks.

II. Transfusion sets.-On several occasionsrequisitions for transfusion sets have been received from base hospitals withthe explanation that the transfusion set formerly on hand had been taken to anadvanced field, evacuation, or mobile hospital by some member of the staff ondetached service with a "shock team."

The impression has been gathered, apparently, thattransfusion sets issued to individuals, upon completing the course inresuscitation at the central Medical Department laboratory, were for theirpersonal use. This impression is erroneous, as each set was destined for use inthe hospital to which the individual returned, and should have been turned overto the supply officer of the hospital.

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All transfusion sets now in the possession of individualswill be turned in to the supply officer of the hospital to which they arepermanently attached. Transfusion sets have been issued to advanced hospitals,and reserve supplies have been placed in Army medical dumps. These supplies areadequate for the use of "shock teams" serving temporarily at advancedhospitals.

III. "Shock teams."-It is directed thatemergency medical teams ("shock teams"), when once formed, be leftintact by commanding officers of Medical Department units unless specificauthority to change personnel of these teams is obtained from the office of thechief surgeon or from the director of professional services.

IV. Purchase of foodstuffs.-The following letter fromgeneral headquarters is quoted for the information of all concerned:

We are in receipt of information from the French mission,general headquarters, A. E. F., stating that in certain localities Americantroops are offering prices for foodstuffs in excess of the prices fixed by theFrench authorities. This practice is obviously bad in whatever way considered.

Please take necessary steps to have the troops under yourcommand pay no more for their open-market purchases of foodstuffs than the pricefixed and published by the French authorities.

V. Coast Artillery casuals.-All Coast Artillerycasuals discharged from hospitals as of class A shall be sent to Angers.

VI. Epidemic disease.-The attention of surgeons of allorganizations and commanding officers of all Medical Department units is againcalled to the necessity for prompt report to the local French civil and militaryauthorities of all cases of epidemic disease. This report should give the nameand organization of patient.

VII. Clinical records.-It is desired that the clinicalrecords of patients treated in Services of Supply hospitals be as complete ascircumstances will permit. Form 55, Medical Department, will be used for thispurpose. Form 55-A will be made out for all patients, but only such other partsof Form 55 will be used as are of interest or value in the individual case. Theclinical record for completed cases will be filed in the hospital in which thecase is completed. When patients are transferred from one Services of Supplyhospital to another, Form 55 will be placed in the envelope with the fieldmedical card.

VIII. Construction at base hospitals and hospital centers.-Manycases have occurred recently where patients were evacuated from one hospital toanother without sufficient rations. In travel of this sort there are many andunexpected delays. In addition to the cooked rations issued for the expectedlength of the journey, a reserve of cooked or travel rations for at least 36hours over and above ordinary schedule time should be issued for each patient.The number of such travel rations issued can be noted on the travel order andpatients required to turn in rations unused on arrival.

IX. Reports.-Circular No. 28, section on alliedpatients in American Expeditionary Forces' hospitals, is modified to read asfollows:

"PAR. 2.When French military patients are admitted to, discharged from, or die in,American military hospitals in the French zone of the armies, notification ofthe fact will be sent within 24 hours, on Form 52, Medical Department, toAmerican statistical section, 10 Rue St. Anne, Paris."

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

X. Patients to be examined by board of officers.-It isdesired that in the future no patients be transferred from hospital, either toduty or convalescent camp, without having been examined by a board of medicalofficers. In most cases disability boards already appointed can act upon allsuch cases. Where the time of disability boards is fully occupied with class Dcases, a board, to consist of the chief of service and ward surgeon, can actupon cases going to duty or convalescent camp. Complete physical examinationwill not usually be required in such cases, and no formal record of theproceedings of the board other than a note by the senior member on the patient'sclinical record.

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XI. Hospital fund.-In view of the fact thatirregularities in the hospital fund of a base hospital have been discovered, thefollowing recommendations have been made by the officers conducting theinvestigation will be carried out in all base hospitals:

The commanding officer of each base hospital in the AmericanExpeditionary Forces will appoint an auditing committee for the hospital fund,with instructions to make a careful examination of the hospital fund accountsfrom the time of the establishment of the hospital in France, with a view todetermine if funds due from all sources have been collected and accounted for,and also to take necessary steps to see that the fund is carefully andmethodically audited each month hereafter.

A cash book will be kept by the custodian of the hospitalfund in every hospital in such manner as to show the daily receipts andexpenditures from the hospital fund.

Patients who are charged board in hospitals should, if theyare not able to pay their mess bills, sign an acknowledgment showing theirindebtedness. The accounts of pay patients should be checked against the dailylists of patients received and discharged so as to show that the full amountsdue are paid.

Arrangements will be made to secure the services of skilledaccountants who will from time to time be sent to base hospitals to investigatetheir hospital fund accounts.

M. W. IRELAND,
Major General, M. C., Chief Surgeon.

Circular No. 50:

AMERICAN EXPEDITIONARYFORCES,
October 4, 1918.

I. (1) Instructions regarding hospitalization andevacuation of patients with disease or injury of the eye, ear, nose, throat, andmaxillo-facial region.-In general, the policy as regards hospitalization andevacuation of these cases is as follows:

(a) Simple cases should, whenever possible, beretained for treatment with their organization or be treated in near-by camp,field, or evacuation hospital.

(b) Cases not suitable to be retained withorganizations but which will be fit for return to duty in the AmericanExpeditionary Forces within a reasonable time should be transferred to thenearest camp or base hospital.

(c) Cases which are permanently unfit for duty in theAmerican Expeditionary Forces, or which will require prolonged treatment torender them fit for duty, should be classified as "D" and evacuated assoon as safely transportable to the United States. Class D cases, in whichhealing might be materially retarded by delay or interruption of treatmentincident to evacuation to the United States, or which have unsightly wounds ofthe face or neck that could be materially helped within a reasonable time,should be retained for primary treatment in the American Expeditionary Forces.

The treatment of cases retained in France must involve theleast possible amount of transportation from one hospital to another, andfacilities will be provided in each hospital center and in the larger basehospitals not connected with hospital centers for the treatment of this class ofcases. Base Hospital No. 115, located at Vichy, has more elaborate equipment forthis class of cases.

Consultants in the different specialities will be located atcertain hospitals, whose services can be called upon by neighboring hospitals.Addresses where these consultants can be reached will be published from time totime.

(2) Ophthalmic cases.-Routine refractions and visionexaminations for troops should be done in the nearest hospital serving thesetroops. Ophthalmic cases which require more elaborate treatment than can begiven in isolated camp or base hospitals and which do not come within theprovisions of paragraph 1 (c) above, should be transferred to the nearesthospital center, or upon recommendation of the local or senior consultant inophthalmology be transferred to Base Hospital No. 115, Vichy.

(3) Ear, nose, and throat cases.-Cases of disease orinjury of the ear, nose, or throat which require more elaborate treatment thancan be given in isolated camp or base hospitals and which do not come within theprovisions of paragraph 1 (c) above, should be trans-

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ferred to the nearest hospital center, or, uponrecommendation of the local or senior consultant in oto-laryngology, betransferred to Base Hospital No. 116, Vichy.

(4) Maxillo-facial cases.-Cases evacuated to the Parisdistrict will be treated at the American Red Cross Military Hospital No. 1.Other cases that can not be treated in the hospital in which they are situatedmay, on request of the local or senior consultant in maxillo-facial surgery, beevacuated to a base hospital or hospital center where there is a maxillo-facialservice, or to Base Hospital No. 115, Vichy.

Maxillo-facial cases requiring only occasional surgical ordental supervision may be sent from the base hospitals to convalescent camps toawait further examination or operation.

No maxillo-facial case should be evacuated to the UnitedStates until the patient can open his mouth sufficiently and has the pharyngealmuscle control necessary to obviate the danger of aspiration during seasickness.

Cases that have been recently repaired should be retained inhospital until the sutured wound is safely healed.

II. British soldiers in American hospitals.-Pursuantto recommendation from the British authorities, the following instructions willgovern visits of relatives to dangerously ill British soldiers in Americanhospitals:

(a) In all cases requests for relatives to visitBritish soldiers dangerously ill in American hospitals should be sent to the A.D. M. S., Paris, and not direct to the relative of the patient.

(b) When the American hospital is located outside ofParis or its near vicinity request should be made to the A. D. M. S., Paris, andat the same time there should be a statement as to whether suitableaccommodations for the relatives of the soldier exist at the place where theAmerican hospital is situated. In those cases where it is not possible toaccommodate relatives it is not proposed to make arrangements for the relativeto visit.

III. Evacuation of orthopedic cases.-Some confusionhas resulted from apparent conflict of instructions in Circular Letter A-1 andCircular 46, Office of Chief Surgeon. All instructions regarding evacuation ofthis class of cases, issued prior to Circular 46, are revoked.

IV. Pail collection system.-Reports have been receivedat this office that in certain of the hospitals where the pail collection systemis used, urine and other human excreta has been dumped into the sewer system.Attention of all responsible officers is called to the fact that where the pailsystem is used the sewer system is provided for sink waste only and that thereis no purification system adequate to care for human excreta. Steps should betaken at once to prevent a recurrence of this faulty method of using the sewersystem.

V. Ordnance property.-The following information,received from the chief ordnance officer, is repeated for all concerned:

It has come to the attention of this office that the"pouch for small articles, model 1916," which is furnished the MedicalDepartment by the Ordnance Department, has been incorrectly called "pouchfor adhesive tape and foot powder." The supply division of the OrdnanceDepartment has been notified to discontinue the use of this name, "pouchfor adhesive tape and foot powder."

VI. Reports.-The following revisions in the Manual ofSick and Wounded Reports for the American Expeditionary Forces, revision ofSeptember 15, will be noted, effective October 1:

Section IX, paragraph 11 (p. 9), sentence "Casestransferred to convalescent camps will be considered completed as far as therecords are concerned," is revoked.

Section XXI, paragraph 2 (p. 51), is revoked.

In the future all convalescent camps will report as do basehospitals carrying patients on sick report. Hospitals will not consider thatcases are completed when the patients are transferred to convalescent camps.

VII. Promotions.-Since the issue of Circular 36, ofthis office, explaining the general principles of the system of promotion byroster in the Medical Department, two very important orders have appeared which,while not upsetting this scheme, have modified it to a certain extent. The firstof these was Bulletin 59, general headquarters, dated August 16, which abolisheddistinctions between the Regular Army, National Army, National Guard, andReserve Corps, merging all of these in the United States Army. It also announcesthat the principle of selection will govern for promotions.

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General Order 162, general headquarters, dated September 24,gives the rules under which promotions are made and states that they will betemporary appointments made by the commander in chief, pending approval by theWar Department.

The general effect of these orders is to give greaterimportance to the factor of special qualifications in determining the rosternumber. The value of this factor is determined by the chief surgeon and is basedupon the reports received of the officer in the "Report of character ofservices and qualifications" on the form published in connection withCircular 36 (known as C. S. and Q. report). General Order 24 has been revoked,and at least half of the data required thereby have been eliminated. If the FormC. S. and Q. is accurately made out, it furnishes all the data necessary.Attention is, however, invited to the importance of its being signed, with dateand station, by the officer making the report. Attention is also called to thefact that a statement of the physical condition is required which, however, neednot be the elaborate report upon the prescribed form heretofore required. Therequirement is simply:

(d) A certificate that the officer has been examinedby a medical officer and found physically fit to perform the duties of the gradeto which he is recommended for promotion will be forwarded with therecommendation.

If an officer is temporarily disabled by wounds or sickness,a careful statement of the nature of the disability and the length of time whichit will probably prevent him from performing his duty should be given, with astatement that the officer is with the exception of the disability notedphysically fit to perform the duties of the grade to which he is recommended.

M. W. IRELAND,
Major General, M. C., Chief Surgeon.

Circular No. 51:

AMERICAN EXPEDITIONARYFORCES,
October 12, 1918.

PNEUMONIA, ITS PREVENTION AND MANAGEMENT

THE PREVENTION OF PNEUMONIA

The present epidemic of respiratory infection in the AmericanExpeditionary Forces is largely influenzal in character, with a rather highincidence of secondary pneumonia due usually to pneumococci or streptococci andoccasionally to influenza bacilli and possibly to meningococci. The mortalityhas been in the neighborhood of 30 per cent. As primary pneumonia is likely toincrease with the advent of colder weather, medical officers are reminded thatthe prevalence of pneumonia, as well as of other respiratory infections, inarmies in the field depends particularly upon:

(1) Overcrowding.
(2) Exposure to wet and cold.
(3) Fatigue, whether induced by overwork, along journey, loss of sleep, or nervous exhaustion from worry.

Crowding forces the occupants in barracks or billets intoclose personal contact, and the greatest danger from it in relation to theoccurrence and spread of respiratory infections is obviously in the increasedopportunity furnished for droplet infection of the healthy inmates from thosewho already harbor pathogenic micro-organisms in their noses or throats.

In epidemics of pneumonia or of influenza, the disease isundoubtedly usually spread from man to man through the secretions or dischargesfrom the mouth, nose, or other parts of the respiratory tract, and an individualwho harbors virulent pneumoccoci or streptococci or influenza bacilli isobviously very likely to infect his cosleepers by coughing or sneezing, or evenspeaking loudly in close proximity to them.

In the present epidemic, the great majority of the cases ofpneumonia are secondary to influenza-the natural resistance of the individualhaving been first broken down by this disease, secondary infection of therespiratory tract with pneumococci or streptococci has occurred.

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In Panama, where climatic conditions were not severe,pneumonia was prevalent, particularly on account of overcrowding, and the samewas found to be true among the workers in the South African mines. Preventionconsisted particularly in scattering the individuals and giving them separatedwellings in place of barracks.

Overcrowding.-In relation to overcrowding, Medical WarManual No. 1, for 1917, authorized by the Secretary of War under the supervisionof the Surgeon General and Council of National Defense, states that wheneverpossible the floor space per enlisted man should be 80 square feet, affording960 cubic feet, and should never be less than 10 by 6 feet, or 60 square feet,which with a ceiling 12 feet high would afford 720 cubic feet. This manualfurther states that should an epidemic occur and should the soldiers beovercrowded, it may be assumed axiomatically that the epidemic can not bechecked by other sanitary measures alone, but must be combined with measures torelieve the overcrowding. Owing to the shortage of lumber and materials, it wasthought necessary in the American Expeditionary Forces to reduce the space perman to 1 linear foot, or 20 square feet-one-third of the minimum amountrecommended. The order directs that bunks shall be 2 feet 8 inches wide by 6feet 6 inches, double tier, in sets of four, 2 feet 8 inches apart, giving 1linear foot of Adrian barracks per man. It is hoped that conditions will soon besuch that this allowance may be increased. In the meantime, an effort must bemade to prevent droplet infection by other means between the men sleeping sideby side in barracks. A board partition 2 feet high may be built between the twoadjoining bunks. Until this is done, wires may be run 2 feet above the bunks andthe shelter tents suspended upon them between the adjoining bunks. Similarprecautions should be taken in billets and tents. This is a more practicalarrangement than placing the head to the feet of the adjacent sleeper. In caseswhere the overcrowding is excessive and the weather fine, the advisability ofbivouacing the men in the open air under shelter tents, or other canvas, shouldbe considered. If this is done, additional blankets obviously should besupplied. Relief from the dangers of overcrowding should be the first importantconsideration in connection with the checking of the present epidemic. Distancebetween beds is the important factor, not cubic space, in the prevention of thespreading of pneumonia infections. Crowding in recreation rooms at cinematographentertainments, etc., should at present time be prevented as much as possible.

Wet and cold.-Wet and cold are also importantpredisposing factors in pneumonia epidemics. A lowered condition of vitalityfrom cold favors particulary the development of such infectious diseases aspneumonia and influenza, by lowering the resistance of the bronchial andpulmonary tissues to infection. Experiments suggest that infections with thesediseases are favored by cold and chilling through the stimulation of the mucousglands with resulting closure of the small bronchioles with plugs of mucus. Itis well known that the functions of the leucocytes are disturbed by cold, and itseems likely that phagocytosis may play an important r?le in connection withthe mechanism of immunity in pneumonia, and that immunity is in this diseaseparticularly related to the functions of the leucocytes. The movements andphagocytic action of the leucocytes occur most favorably at about thetemperature of the normal body. Exposure of the skin to cold and wet leads tochilling of the leucocytes during their repeated passage through the skincapillaries, which may diminish their functional activity, and thus lowerresistance to a point at which infection may occur. It should be borne in mindthat cold wet feet produce a general reaction of the body and not only a localone, and that this condition also predisposes to infection. Cold and wet haveless unfavorable action when accompanied by energetic muscular exercises, if acondition of fatigue is not reached. Additional efforts should be made toprovide for the prompt removal and drying of the wet clothing of the soldier,and additional blankets at night must be insisted upon.

Fatigue.-It should be borne in mind that fatigueinduced by overwork and also by lack of sleep and worry in connection with wetand cold has been one reason for the excessive mortality from pneumonia inarmies in the field. It is well known that normal resistance to infection may bebroken down by fatigue.

Early detection.-Greater attention should be paid bymedical officers to the early discovery of cases of colds, cases of influenza,and other respiratory infections, and to prompt isolation and treatment of suchcases. Carriers undoubtedly play an important r?le in disseminating pneumococci,streptococci, and influenza bacilli as well as meningococci.

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Warning against spitting.-Men should be specificallyinstructed at this time against expectorating in quarters, and the danger ofsneezing and coughing and of speaking in close proximity to the face explained.

THE MANAGEMENT OF PNEUMONIA

1. Pneumonia, especially as it occurs among troops, and as itis now present in the American Expeditionary Forces, must be regarded as ahighly contagious disease, and it must be managed with the same precautions asare taken in the care of other contagious diseases.

2. The epidemics of influenza now prevalent in many widelyseparated parts of France have at least one point in common; i. e., theoccurrence of pneumonia as an incidence of the disease, a complication, or asequel. The pneumonia is usually of a patchy type, different slightly in itscharacteristics in different regions, but characterized by rapid progress, greatrespiratory distress, frequency of early collapse, and high mortality. Thecausative organism may not always be the same; pneumococcus, streptococcus, andthe influenza bacilli and occasionally the meningococcus all seem to contributetheir share.

3. Early isolation and hospitalization of pneumonia as wellas of influenza and similar respiratory infections will do much to prevent thespread of the disease and lower the mortality. Cases should be hospitalized,when possible in medical formations where they may remain until recovery, eventhough the initial trip by ambulance may be somewhat lengthened. Cases ofpneumonia in the earliest stages withstand transportation fairly well, but laterin the disease after they are hospitalized, they are greatly injured by moving.Numerous cases of respiratory infections have been evacuated by train or bymotor, to arrive at their destination some hours later in profound collapse, todie within a very short time. Moving a case of pneumonia to make room for abattle casualty may kill the pneumonia patient and not aid the wounded, and thepractice should not be tolerated.

4. Isolation or segregation should be practiced in all casesof respiratory infection and such isolation should start in the field. Uponarrival at the hospital the cases of respiratory infection should be received inwards devoted to the observation of cases with respiratory infection; or if itis possible to make an absolute diagnosis on admission to the hospital, the casemay be sent directly to the ward designated to receive cases suffering from thatparticular type of infection. The observation ward for respiratory diseasesshould be cubicled, a sheet or other partition being placed between adjacentbeds. It is desirable that an accurate diagnosis be made as soon as possible ofcases in this ward so that they may be transferred immediately to those wardsdesignated to receive cases suffering from the different types of respiratoryinfection. All cases of uncomplicated influenza should be isolated in separatewards as rigidly as if they were cases of measles, and all beds should becubicled. No cases of pneumonia should be sent to these wards, and should apatient with influenza develop pneumonia he should be immediately removed to apneumonia ward. Cases of pneumonia should be segregated in wards set aside forthis purpose. These wards should be cubicled. The reason why such rigidisolation and employment of the cubicled system is imperative is due to the factthat, first, cases of influenza are highly susceptible to pneumonia and may beinfected with great readiness by a pneumonia patient in the near proximity, and,secondly, that the lobular type of pneumonia may be caused by several varietiesof organisms, and should a patient with a pneumococcal pneumonia be placed nextto one with a streptococcus pneumonia either one or both patients might readilycontract a double infection. The course of the disease in such double infectionsis much more serious and the mortality much higher than in single infections.Cross infections will, therefore, be less common and the mortality reduced bycubicle isolation for all respiratory infections. The practice of receivingrespiratory infections of unknown origin in wards with other medical or surgicalcases is reprehensible and is responsible for many fatal cases of pneumonia inindividuals who might otherwise have been returned to duty within a short time.Cubicle isolation may most readily be carried out by screening with sheets. Thiscan be done by posts and the use of wire and can be adapted for tents as well asfor wards. It is only necessary that the screen should reach midway between thefoot and head of the bed, halfway between the bed and the floor, and 2? to 3feet above the level of the patient. It is, however, highly important that thescreen should extend several inches beyond the head of the bed.

984

5. Protection of medical officers, nurses, and personnel withgowns and fresh and clean gauze masks is important, both to prevent spread ofinfection among them and to prevent their transmitting infection to others.Attendants should be examined with the view to finding carriers: When found,these should be disinfected. Masking of all individuals who come in contact withcases of respiratory infection and fever, except in case of extreme urgency, andthen only with precautions to prevent the transmission of the disease to others.Patients should be masked while being moved.

6. Special attention must be paid to all cases of respiratoryinfection, with fever with relation to the development of signs of pneumonia. Itis often impossible at the outset to distinguish between cases of influenza,without consolidation, and actual pneumonia. All cases, with fever and withsymptoms referable to the respiratory tract, must be viewed with suspicion andhospitalized, and the physical signs must be carefully watched.

7. Bacteriological examination in order to determine theinfecting organism is important, not only from the standpoint of specifictherapy, but also to facilitate the management of cases of different etiology.It must be remembered that pneumonia is really a group of diseases, with certaincommon signs and symptoms. The promiscuous mingling of cases of pneumonia,without determination of the infecting organism, is as harmful as the minglingof measles, scarlet fever, and smallpox.

8. Specific therapy, when possible, is advisable. This willat present be limited to cases of pneumonia due to pneumococcus, type 1. Theindiscriminate use of serum, without proper type determination, is ill-advised,not only on account of the fact that it subjects the patient to unnecessaryinconvenience, discomfort, and possibly danger, but on account of the fact thatserum is scarce, and must be saved for the cases in which it is actuallyindicated. The polyvalent serum may be used in type 1 cases, as its titer forthe type 1 organism is as high as that of the monovalent type 1 serum. The useof polyvalent serum in cases other than those due to pneumococcus, type 1, isnot advised.

9. General treatment should be directed toward sustaining thepatient and guarding against collapse. Under no circumstances should a patientwith pneumonia, or suspected of having pneumonia, be allowed to walk, and afterhe is put to bed he should not be permitted to sit up for any reason whatsoever.He must be kept warm, but must be assured a continuous supply of fresh air.Fluids should be given freely from the start, and the patient should be inducedto take them frequently and in considerable amounts. Sponge baths should be usedto combat high temperatures.

10. Early cyanosis and collapse are characteristic of thepresent form of pneumonia. Treatment aimed to prevent and to combat circulatoryfailure should be instituted promptly on making the diagnosis of pneumonia. Theearly use of digitalis has been shown to reduce mortality, and is advised. Itmay be given in the form of a standard tincture, of which a total amount of 30c. c. (1 fluid ounce) should usually be given. The following schedule may befollowed.

If seen on the first or second day:

Day of digitalis therapy	1	2	3	4	5	6	7	8	9
Total amount of standard tincture to be given in divided doses on the days indicated	5	5	0	5	5	0	0	5	5
Minims	lxxv	lxxv	---	lxxv	lxxv	---	---	lxxv	lxxv

If seen on the third day, or later:

Day of digitalis therapy	1	2	3	4	5	6	7
Total amount of standard tincture to be given in divided doses (c.c.)	10	10	0	5	0	0	5
Minims	cl	cl	---	lxxv	---	---	lxxv

The hospitals should supply themselves with a standardtincture of digitalis. Do not use pills which are insoluble. Other stimulants,notably citrated caffeine and camphorated oil, may be used by hypodermicinjection when collapse occurs or is imminent. The use of strychine has not beenshown to be of value.

985

11. Morphine is of great value to control severe coughing, torelieve the pain of pleuritis, and to secure rest for the patient. It should beused without hesitation. For the troublesome tympanites that frequently occur,turpentine stupes, given while a small catheter is inserted in the rectum, areof value.

12. Most careful attention must be paid to the physicalsigns, particularly with relation to spread of the consolidation and to fluid inthe chest. When the physical signs suggest fluid exploratory puncture, themicroscopic and bacteriological examination of the fluid obtained should beperformed promptly. Exploratory respiration is a simple procedure, with littledanger or discomfort to the patient. Local anesthesia may be induced by freezingor by intracutaneous and subcutaneous injection of cocaine or novocaine. Whenclear or even slight turbid fluid is obtained, even when the infecting organismsare demonstrated in the fluid, treatment by repeated aspiration with the Potainaspirator is followed by the best results. When purulent fluid is found, or incases where fluid previously clear becomes purulent, operation is advised, withpostoperative measures necessary to insure free drainage.

13. Convalescence must be managed with care, both as to thecondition of the patient and as to his transmitting the disease to others.Development of pleural exudate late in the disease, or during convalescence, isnot uncommon, and frequent physical examination must not be neglected. Relapseor spread may also occur after the temperature has been normal for several days,and the patient should not be permitted to sit up or move about until 7 to 10days have elapsed. During this period isolation should be practiced as duringthe acute stage of the disease. The use of mildly antiseptic solutions in themouth and nasal passages is of value in reducing the number of carriers.Patients should not be allowed to mingle with other patients, and should not beevacuated until all signs of infection of the respiratory tract havedisappeared.

14. Recovery and return to duty will be slow. The finalstages of recovery will best be provided for in convalescent camps. No patientwho has had pneumonia should be evacuated to a convalescent camp until histemperature has been normal for at least two weeks, and in cases where theinfection has been severe or prolonged this period will be materially increased.The patient should be free from cough and other physical signs should be normal.

WALTER D. MCCAW,
Colonel, Medical Corps, Chief Surgeon.

Circular No. 52.

AMERICAN EXPEDITIONARYFORCES,
October 22, 1918.

I. Recommendations for appointments.-The followingparagraphs of a letter, adjutant general's office, is quoted:

1. With reference to the cases of * * * and * * * action hasbeen taken to withdraw the recommendation contained in courier letters fromthese headquarters to The Adjutant General of the Army, that these men beappointed as officers in the United States Army.

2. Chiefs of staff departments and other services areexpected to take the necessary steps to insure that only persons fully qualifiedare recommended by them for appointment, and it is desired that greater care beexercised in the future that recommendations from the office of the chiefsurgeon conform to the above requirements.

II. X-ray therapy.-The following hospitals aredesignated as being the only ones qualified, at present, to administer X-raytherapy: Base Hospitals Nos. 15, 28, 32, 20, 18, 9, 6, American Red CrossMilitary Hospital No. 1.

When it becomes necessary to administer X-ray therapy, eitherbecause it is immediately indicated or in the event that a patient requiring itneed not be evacuated to the United States, and he is in some other hospital, hewill be transferred to one of the above-designated hospitals.

III. Base Hospital No. 8.-Hospital trains anddetachments of patients hitherto ordered to Base Hospital No. 8 will hereafterbe directed to report to the commanding officer hospital center, Savenay.

IV. List of B and C class personnel.-The commandingofficer of each Medical Department unit will forward to this office, with theleast practicable delay, a nominal list, showing all B and C class personnel,with branch of service, now on duty with his unit, with statement of the numberreturned to duty reclassified as class A.

986

Attention is invited to the fact that paragraph 5, section 1,General Order No. 41, c. s., requires reexamination of all class B officers andsoldiers at least every two months. This order is apparently not being compliedwith.

V. Soldiers qualified as opticians.-The commandingofficer of each Medical Department unit will report by mail to this office, withthe least practicable delay, the names of all Medical Department soldiersbelonging to his command who are qualified as opticians.

VI. Telegrams to be numbered serially.-The adjutantgeneral informs this office that telegrams are frequently received from basehospitals, especially at hospital centers, in which the particular unit sendingthe telegram can not be identified. In order to avoid this, each base hospitalshould number its telegrams serially and state immediately after the serialnumber the numerical designation, as, for example, the first telegram of BaseHospital No. 25 under this system, would begin "1 BH 25 Allerey."

This would not be necessary, however, where the commandingofficer of a hospital center preferred to send all telegrams through his officeand signed with his name. Only one serial list for the center would be kept insuch case, and the telegrams would begin, "1 HC Allerey."

VII. Nurses' names.-Commanding officers of all medicalunits to which nurses are attached will, if they have not already furnished thisinformation, forward to this office the name in full of all nurses of theRegular Army Corps, and the places from which they were assigned, as given inoriginal letters of appointment. Special attention will be given to the correctspelling of the names of nurses and places.

VIII. Change of station of nurses.-When making achange of station, either for temporary or permanent duty, the letter ofappointment of the nurse, with the required information as to pay, etc.,indorsed thereon, should be carried by her and delivered to the commandingofficer or chief nurse at her new station. Failure to carry out this procedurein the past has caused difficulties in the matter of the pay of the nurse.

In order to avoid delay in the receipt of baggage, nurses whoare traveling under orders should be instructed to give it their personalattention when changing trains.

IX. Amendment to Circular No. 45.-Paragraph 8, SectionI, Circular 45, office of chief surgeon, c. s., is amended to read:

Medical officers, who are compelled to administer antitetanusserum by reason of the failure of medical officers through whom the patient haspassed to administer the same, will make immediate report of said failure, withsufficient data to establish the circumstances of the omission, directly to thesurgeon of the division from which the case came, or in case the patient belongsto a higher or separate organization to the senior medical officer of thatorganization.

X. Requisitions for medical supplies.-Allorganizations in base section No. 1, other than base hospitals and hospitalcenter depots, will submit their requisitions for medical supplies to thesurgeon, base section No. 1, A. P. O. No. 701, and will hereafter submit nonedirect to intermediate medical supply depot No. 3, Cosne.

Upon the approval of the section surgeon, the requisitionswill be sent to the medical supply depot, base section No. 1, for issue.

XI. Address of American statistical section.-Theaddress of the American statistical section, to which reports of French militarypatients hospitalized in American military hospitals in the French zone of thearmies are sent, has been changed from No. 10 Rue Saint Anne, Paris, to No. 7Rue Tilsitt, Paris. Hereafter all American Expeditionary Forces hospitals in theFrench zone of the armies will send reports to the latter address.

XII. Identification tags.-The removal ofidentification tags from the persons of patients during the process ofevacuating them from the front, especially from groups of patients who have beenbathed as an antigas measure or as a routine to admission to hospital, hascaused the erroneous return of soldiers' identification tags to others. In onerecent instance a soldier's tags were erroneously placed on another whosubsequently died and was buried and reported as dead under the name of theformer. This one mistake gave rise to much needless grief and administrativedifficulties.

The removal of identification tags as a routine while bathingpatients either, as an antigas measure or on admission to hospitals, isprohibited. When for any reason, other than the above, it becomes necessary toremove a soldier's identification tags the utmost care will be exercised inpreventing the possibility of their being placed on another.

987

XIII. Base Hospital No. 66.-Base Hospital No. 66 ishereby detached from hospital center, Bazoilles, and will operate as a basehospital directly under the chief surgeon, A. E. F.

WALTER D. MCCAW,
Colonel, Medical Corps, Chief Surgeon.

Circular No. 53:

AMERICAN EXPEDITIONARYFORCES,
October 29, 1918.

I. The following extract from assistant chief of staff, G-4,is published for information of all concerned:

1. A serious situation has arisen with regard to thetelegraph and telephone systems of the American Expeditionary Forces, andattention is directed to the necessity of exercising the most rigid economy intheir use, particularly the long-distance telephone service. During the pastthree months, the use of the long-distance telephone service has increased 70per cent, and during the same period it has been possible, through the moststrenuous efforts, to increase the telephone and telegraph services only 25 percent. Until recently, there has been a margin of safety in the facilities, butthis has now been entirely absorbed by the tremendous increase in the number oftelegrams and long-distance telephone calls. If this increase continues, a veryserious congestion will soon result.

2. It is not desired to issue any hard and fast rules torestrict the use of the long-distance telephone and telegraph. It is believed,however, that a reading of paragraph 1 above explains fully the presentsituation, and the necessity of some action to reduce the number oflong-distance telephone calls and telegrams sent. It is desired that thisreduction be made by the chiefs of the services, themselves.

3. The following means of communication are now available,and are arranged in the order in which they should be used:

(a) Mail.
(b) Courier and messenger service.
(c) Telegraph.
(d) Long-distance telephone service.

4. It is desired that each chief of a service prepare and putinto operation at once a system which will reduce the number of long-distancetelephone calls and telegrams in use by his service. It is desired that amemorandum be sent to this office (G-4), giving an outline of the system devisedand the means adopted for its execution.

It is desired that every effort be made to use the mail,courier, and messenger service wherever possible among the Medical Departmentunits, and it is thought that, except in immediate emergency, any message whichcan be delivered within 24 hours should be sent by this service rather than bytelegraph or telephone. There will be certain exceptions to this rule, such asthe weekly report on Form 211, which must be consolidated in one office and thenforwarded on to another office for consolidation, thereby consuming three daysfor delivery to this office instead of one. In cases such as this the telegraphwill be used.

II. Daily and weekly telegraphic bed report.-Withregard to daily telegraphic bed report from base hospitals and the weeklytelegraphic bed report from camp hospitals, constancy with reference topersonnel should now be eliminated. This refers to item E. Hereafter item E willbe designated to indicate the total number of beds which can be utilized in theevent of emergency, consideration being given to bed space in tentage, halls,and corridors of the hospitals.

III. Unloading of freight cars.-The French railwaysare taxed to their utmost to meet the demands made upon them. Facility oftransport is vital to the American Expeditionary Forces. Reports have been madethat cars containing medical supplies have been delayed at destination pendingunloading.

It is desired that all Medical Department organizationshaving to do with such supplies take the necessary steps to prevent the leastdelay in the unloading and release of cars. Orders require that this be donewithin 24 hours.

IV. Commissions in the Sanitary Corps.-With referenceto Bulletin No. 30, c. s., these headquarters, the attention of all medicalofficers is invited to the fact that the Medical Department, within the next fewmonths, will have urgent need of large numbers of well-qualified soldiers atpresent in the Medical Department who may be suitable for commission in theSanitary Corps. It is desired that, before recommending a soldier for commissionin another department, the commanding officer of a Medical Department unitsatisfy himself that the soldier recommended is better fitted for commission insome other branch of the service than in the Sanitary Corps.

988

V. Nurses.-With reference to paragraph 7, Circular 48,the policy outlined therein has been changed and following adopted:

"Nurses marrying in France will be sent to base sectionNo. 3 for duty, and no leave to visit France will be allowed after they shallhave reported in England."

VI. Vocational education.-There is somemisunderstanding among disabled soldiers affecting the matters of vocationaleducation. It is important that erroneous ideas be corrected, and medicalofficers are urged to set the men straight. The terms of the following lettershould be understood and communicated to disabled soldiers by medical officersand the facts in the letter should be placed on the bulletin board in eachhospital.

Subject: The vocational rehabilitation act (Smith-Sears Act)to provide vocational education for disabled persons discharged from themilitary or naval forces.

Question 1. What is the vocational rehabilitation act?

Answer. It is an act of Congress appropriating the funds andproviding the means for giving every disabled person discharged from themilitary or naval forces a vocational education free.

Question 2. Who is entitled to a vocational education underthe provision of this act?

Answer. Every war-disabled person whose physical disabilityentitles him to any compensation under the regulations of the Bureau of War RiskInsurance.

Question 3. Will the person who elects to secure vocationaltraining under the provision of this act receive a monthly compensation duringthe period of time he is pursuing his vocational training?

Answer. Yes. He will receive a monthly compensation equal tothe amount of his monthly pay for the last month of his active service, or theamount of his monthly compensation allowed by the Bureau of War Risk Insurance,whichever amount is the greater. His family will receive the family allowance inthe same manner as if he were an enlisted man.

Question 4. Will the fact that he has secured a vocationaleducation, and thereby increased his earning power, in any way change the amountof compensation he should receive from the Bureau of War Risk Insurance?

Answer. No. The compensation he will receive from the Bureauof War Risk Insurance is calculated on the basis of his physical disability andnot on the basis of his economic efficiency. A vocational education will notlower his compensation from the war risk insurance.

Question 5. Under whose supervision and administration willthe vocational training be given?

Answer. The Federal Board for Vocational Education, ofWashington.

Question 6. What types of vocational education will theFederal Board for Vocational Education provide for these men?

Answer. Training for every vocation will be provided. Anyvocation in the fields of industrial, commercial, agricultural, technical, andprofessional education is open for him. His past vocational experience, hisphysical disabilities, his own desires and aptitudes will determine the vocationhe elects, in which to take his training. He will be given scientificinformation concerning the economic advantages of the different vocations bytechnical experts.

Question 7. Where will the training be given?

Answer. In the vocational and technical schools, colleges,and universities of the United States. All courses will be under the supervisionof the Federal Board for Vocational Education.

(Signed)EDWIN L. HOLTON,
Special agent, Federal Board for Vocational Education.

VII. Change in paragraph II, Circular No. 52, office ofchief surgeon.

The list of hospitals designated in Paragraph II, Circular52, office of chief surgeon, October 22, 1916, as being the only ones qualified,at present, to administer X-ray therapy, has been changed as follows: Basehospitals Nos. 6, 7, 9, 15, 20, 28, 30, 32, 38, 115, 116, Mars hospital center,American Red Cross Military Hospital No. 1.

WALTER D. MCCAW,
Colonel, Medical Corps, Chief Surgeon.

Circular No. 54.

AMERICAN EXPEDITIONARYFORCES,
November 9, 1918.

I. Data necessary for promotion.-Attention is calledto the requirement of General Order 162, A. E. F., 1918, that a statement of thecurrent physical condition of an officer shall be made as an accompaniment toany request or recommendation for promotion. This is mandatory, and if thecertification is not made it must involve annoying delay to everyone concerned.

989

Papers covering promotions must be acted on by superior localmedical authority prior to submission to this office.

Recommendations for promotion of officers of the SanitaryCorps will be made on the blank for character of service and qualifications, asin the case of medical, dental, and veterinary officers. The only citation whichrequires omission in this blank is the fourth, which specified the medicalschool from which graduated. However, should the officer be a graduate of a highschool, college, or university, the citation may be made under this paragraph.

II. Travel orders.-Complaint has been made thathospitals evacuating patients to other hospitals have failed to furnishattendants accompanying them with sufficient copies of travel orders to getcommutation of rations and return transportation. In order to avoid unnecessaryduplication of work at the hospital where these patients are received, hospitalswill furnish attendants the necessary copies of orders for commutation andreturn transportation.

III. Claims for damages to French property.-Claimsmade for damages to French property have been erroneously paid out of hospitalfund. Such payments are not to be made in the future, either out of hospitalfund or out of Medical Department appropriations.

In this connection, attention is invited to section 4,paragraph E, General Orders, No. 50, general headquarters, A. E. F., dated March30, 1918, which establishes a renting, requisition, and claims service for theAmerican Expeditionary Forces and outlines procedure for handling damage claims;and attention is also invited to section 4, General Orders, No. 78, generalheadquarters, A. E. F., dated May 25, 1918, which quotes an act of Congressappropriating specific sums for the payment of such damages.

IV. Middle initial or number to be given in reports.-Attentionis invited to the following letter from the chief paymaster, United StatesMarines. Care will be taken to follow the instructions as requested in thisletter:

1. Numerous cases have arisen in which we are unable todistinguish certain men on account of no middle initial being given in yourreports to this office of men returning to the United States on account ofdisability.

2. It is requested that whenever possible the middle initialbe given, or in the absence of such information that the man's number be given.Whenever it is impossible to give either the number or the initial, it isrequested that the company organization be designated instead of regimentalorganization.

V. Property of French soldiers.-The chief of theFrench mission states that the provisions of Circular 31, office chief surgeon,May 23, 1918, regarding the personal property of French soldiers who die inAmerican hospitals, are not being carried out. The attention of all MedicalDepartment organizations is called to this circular, and the directionscontained therein will be carefully and strictly followed in the future.

VI. Religion of patient to be entered on field medicalcard.-Attention is invited to paragraph 8, Circular 41, office chiefsurgeon, July 22, 1918, which provides that, as soon as practicable, thereligion of every patient admitted to a hospital ward will be ascertained by theward medical officer and appropriate entry thereon made on the patient's fieldmedical card. These instructions will be carefully followed, as it has beenreported that this is very often neglected.

VII. Reporting of French military patients.-Theattention of all commanding officers of American hospitals in the zone of theinterior is again directed to instructions governing the reporting of Frenchmilitary patients to the Franco-American section of the region and not to theAmerican statistical section, No. 7 Rue Tilsitt, Paris.

VIII. Nurses and civilians.-In many cases the numberof nurses and civilians assigned to duty have not been entered on weeklystrength return of hospitals. In future, care will be exercised to have thesereturns complete in every respect.

IX. Nurses' uniform.-The uniform of all nurses,including the cap, must conform in all respects to that of the Army Nurse Corps.The use of the Red Cross cap will be discontinued by the reserve nurses ofthe Army Nurse Corps.

X. Sick leave for nurses, Army Nurse Corps.-Bulletin43, War Department, July 22, 1918, states that nurses shall be entitled to sickleave with pay not exceeding 30 days in any one calendar year in cases ofillness or injury incurred in the line of duty. Nurses while so absent areentitled to commutation of rations at rate fixed by Army Regulations. When

990

sent to convalescent homes or hotels provided by the AmericanRed Cross, nurses will be charged for subsistence at the same rate as will bepaid to them by the Government as commutation of rations.

XI. Original papers on the surgery of the war.-Theeditor of The Military Surgeon is anxious to secure original papers on thesurgery of the war, especially reports on regional surgeries. Medical officersof the American Expeditionary Forces are requested, when forwarding papers tothis office for publication in the United States, to state if they wish them tobe published in The Military Surgeon. This will also apply to professionalpapers other than surgical.

XII. Requisitions for medical supplies.-Allorganizations in base section No. 2, other than base hospitals and hospitalcenter depots, will submit their requisitions for medical supplies to thesurgeon, base section No. 2, A. P. O. No. 705, and will hereafter submit nonedirect to intermediate medical supply depot No. 3, Cosne.

Upon the approval of the section surgeon, the requisitionswill be sent to the medical supply depot, base section No. 2, for issue.

XIII. Applications for transfer.-In order thatapplications for transfer from one branch of the service to another, forwardedby officers and soldiers while sick in hospital, may be acted uponintelligently, the following information will be indorsed upon all suchapplications forwarded to higher authority for action:

(a) Whether the applicant is a patient; and if so,

(b) The nature of his disability, whether wounds orsickness, with a brief description thereof.

(d) The class in which he will probably be dischargedfrom the hospital.

XIV. Alphabetical list of officers on duty in the office ofthe chief surgeon showing rank, department, and telephone number:

Officer	Rank	Department	Telephone No.	Officer	Rank	Department	Telephone No.
McCaw, Walter D.	Colonel	Chief surgeon	549	Brown, John D.	First lieutenant	Dental	256
Glennan, James D.	Brigadier general	Hospital	51-1	Calder, J. W.	.do.	Transportation	50-2
Winter, Francis A.	Colonel	Assistant chief surgeon	57	Douglas, Malcolm C.	.do.	.do.	50-2
Fife, James D.	.do.	Hospital	55-1	Evans, John E.	.do.	Hospital	51-2
Fisher, Henry C.	.do.	Inspection	57	Emerson, Bertrand, jr.	.do.	Supply	257-2
Oliver, Robert T.	.do.	Dental	50-1	Fenton, William J.	.do.	Det.	448-2
Shaw, Henry A.	.do.	Sanitation	57-1	Foster, Elliott O.	.do.	Finance and accounting	538-1
Whitcomb, Clement C.	.do.	Supply	261-2	Goodyear, Russell W.	.do.	.do.	538-1
Aitken, John J.	Lieutenant colonel	Veterinary	252-1	Hanford, Harry C.	.do.	Hospital	51-2
Clarke, Howard	.do.	Transportation	256-1	Mael, Jesse H.	.do.	Personnel	253-1
Culler, Robert M.	.do.	.do.	256-1	Mannix, Daniel E.	.do.	.do.	246-2
Harmon, Daniel W.	.do.	Sick and wounded.	524-1	Mims, Martin D.	.do.	Hospital	51-2
Johnson, Thomas H.	.do.	Hospital	468-1	Mueller, Frederick W.	.do.	.do.	55-1
McDiarmid, Norman L.	.do.	Supply	257-1	Murray, Joseph E.	.do.	Transportation	256-2
Shepard, John L.	.do.	Hospital	569-1	Ross, Frank A.	.do.	Sick and wounded	524-1
Thearle, William H.	.do.	Personnel	253-1	Yohe, Edward L.	.do.	Dental	256
Welles, Edward M., jr.	.do.	.do.	253-1	Russell, George E.	.do.	Hospital	51-2
White, David S.	.do.	Veterinary	252-1	Rich, Harold	.do.	.do.	51-2
Weed, Frank W.	.do.	Hospital	569-1	de Grange, Garrett S., jr.	.do.	.do.	51-2
Bemis, Harold E.	Major	Veterinary	252-1	Skelly, Patrick J.	.do.	Sick and wounded	524-1
Dickson, Robert A.	.do.	Administration	255	Engel, William E.	.do.	Records	59-1
Emerson, Haven	.do.	Sanitation	59-2	Bibby, Henry L.	Captain	Prom	448-1
Fielden, John S.C., jr.	.do.	Supply	257-2	Delafield, Robert H.	Second lieutenant	Sick and wounded	524-1
Rice, William S.	.do.	Dental	50-1	Duffield, Thomas J.	.do.	Sanitation	59-2
Williams, Linsly R.	.do.	Sanitation	59-2	Powell, George E.	.do.	Veterinary	533
Thompson, Richard K.	Captain	Dental	50-1	McComb, Robert P.	.do.	.do.	533
Whitcomb, Walter D.	.do.	Finance and accounting.	538	Proctor, Arthur W.	.do.	Supply	261-2
Barney, James E.	First lieutenant.	Transportation	50-2	Scott, Ernest E.	.do.	Hospital	269-1
Berry, Eugene J.	.do.	Finance and accounting	538	Benett, Lowell	Second lieutenant	Reference library	---
Bolton, Ray	.do.	Veterinary	533	Bissonette, Geo. A.	.do.	Transportation	50-2
				Nelson, Arthur E.	.do.	Sick and wounded	524-1

WALTER D. MCCAW,
Colonel, Medical Corps, Chief Surgeon.

991

Circular No. 55:
AMERICAN EXPEDITIONARYFORCES,
December 12, 1918.

DISTRIBUTION OF MEDICAL SUPPLIES IN THE AMERICANEXPEDITIONARY FORCES OUTLINING LINES OF SUPPLY AND DECENTRALIZATION OF BOTHREQUISITIONS AND SUPPLIES

I. The following outline of medical supply departmentactivities from front to rear will obtain in the future operations of thisdepartment.

(a) Divisional medical supply dumps.-On a basisof one to each division.

Activities: To supply divisional troops and to stock onlysuch items as are needed by combat divisions. Items of stock carried to beidentical in all divisional supply dumps the amount of each item to be carriedand controlled by a maximum stock list.

(b) Army park medical supply dumps.-On a basisof one to each army corps.

Activities: To supply divisional medical supply dumps and inemergency to surrounding medical units. Stock items to be the same as thosecarried by divisional medical supply dumps. The amount of stock to be carried onitems to be based on the number of combat divisions concerned in the sectorsupplied.

Activities: To supply army park medical supply dumps,evacuation hospitals, field hospitals, ambulance companies, mobile hospitals,mobile surgical units, veterinary field units, and such other units as speciallydesignated. Stock items to be carried should meet all the requirements of theunits concerned and should also be based on a maximum stock list.

(d) Services of Supply medical supply depots.-Numberprescribed by the chief surgeon, A. E. F.

Activities: To supply army medical supply depots anddesignated Services of Supply medical units. The stock in these Services ofSupply depots in advance positions to fully cover all the items carried at armymedical supply depots, as well as the surrounding Services of Supply medicalunits.

(e) Controlled stores.-Includes all medicalsupplies in storage at base ports or other designated Services of Supply depots,the issues from which are under the direct control of the chief surgeon, A. E.F.

Activities: To furnish supplies to all depots and initialequipment to new units being installed.

(f) Medical supply depots at hospital centers.-Numberprescribed by the chief surgeon A. E. F.

Activities: To furnish supplies to the hospitals of the groupconcerned to any other units specially designated by the chief surgeon, A. E. F.Hospital centers not having depots should consolidate requisitions and forwardsame direct to the chief surgeon, A. E. F., A. P. O. 717.

Depot control.-While the chief surgeon, A. E. F.,controls all activities of the Medical Department, the immediate control of thearmy dumps and army medical supply depots is vested in the chief surgeon of thearmy concerned. The immediate control of all other medical supply depots beingunder the chief surgeon, A. E. F.

II. Decentralization of requisitions.-Hereafter allrequisitions, except those specially exempted below originating in the Servicesof Supply will be acted upon by the chief surgeon of the section concerned, whowill modify the requisition and forward same to designated depot for issue.

This modification will be final and any question theretoshould be taken up by the depot concerned with the surgeon of the sectionapproving the requisition.

Exceptions.-Requisitions from medical supply depotsand medical supply depots at hospital centers and for initial equipment ofmedical units will be sent direct to the office of the chief surgeon, A. E. F.,A. P. O. 717, for his action.

Requisitions for laboratory supplies, except from medicalsupply depots, will be sent direct to the director, central laboratory, A. P. O.721, Dijon, for his action; same will then be forwarded to the designated depot.

992

Requisitions for X-ray supplies covering initial equipment-i.e., base hospital X-ray outfits, portable X-ray outfits and bedside units-willbe forwarded to technical consultant, Roentgenology, A. P. O. 702.

X-ray supplies such as plates, chemicals, etc., will beincluded in requisitions for medical supplies and referred to the sectionsurgeon, but they must appear under separate heading, X-ray supplies.

Requisitions for veterinary supplies follow the course ofmedical requisitions except for initial equipment of units, which will beforwarded to the chief surgeon, A. E. F., direct.

Requisitions for dental supplies follow the course of medicalrequisitions except for initial equipment of base hospitals; i. e., base dentaloutfits, which will be sent direct to chief surgeon, A. E. F.

III. Pending the installation of additional depots, thefollowing sections will be supplied by medical supply depots as follows:

Base section 1, 4, 5, by base medical supply depot No. 1, St.Nazaire.

Base sections 2, 6, 7, by base medical supply depot No. 2,Bordeaux.

Intermediate section and Paris district by intermediatemedical supply depot No. 3, Cosne.

Advance section, Services of Supply, by advance medicalsupply depot No. 1, Is-sur-Tille.

Surgeons of sections will take the necessary steps to notifythe unit now in their sections and new units arriving as to the proper channelsfor medical supply requisitions as above outlined.

IV. This circular does not modify the method of handlingrequisitions in combat sectors.

WALTER D. MCCAW,
Colonel, Medical Corps, Chief Surgeon.

Circular No. 56.

AMERICAN EXPEDITIONARYFORCES,
November 19, 1918.

I. Made-up surgical dressings.-Because of the immenseamount of devoted labor given by the women of America, through the American RedCross, there is now available in France a sufficient supply of made-up surgicaldressings to warrant the issue to and use in all hospitals of these prepareddressings.

It is desired therefore that requisitions be submitted forthese dressings and that requisitions for gauze, plain, be consequently reduced.These dressings are of two classes:

First, already sterilized.-The supply of this type islimited, and issue will be made to field and evacuation hospitals, and theyshould be used only in times of stress or where opportunities for sterilizationare inadequate. Requisitions for these dressings should call for "Dressingsfor evacuation hospital use, sterilized."

In ordinary times dressings of the following type should beused:

Second, prepared and wrapped ready for sterilization butnot sterile.-These supplies are stocked in all medical supply depots anddumps and in Red Cross storehouses. They should ordinarily be obtained from themedical supply depot by original requisitions. Case lots should be asked for.For the initial stock, requisition should be submitted to this office. Theattached list approximates 10 carloads, and requisition may be submitted in theform of a request for 10 carloads, or a specified portion thereof. (In this casethe shipment will be prorated.) Subsequent requisitions should call for caselots of dressings needed:

993-994

10-carload lot of assorted surgical dressings

[To be used as basis for requisitions by medical supplydepots, A. E. F.]

	Number of cases	Dressings
Dressings used as:
Sponges-
Gauze wipes-
2 by 2	10	200,000
4 by 4	23	207,000
Gauze finger sponges	8	128,000
Gauze squares, 9 by 9	2	72,000
Folded gauze strips	10	45,000
		652,000
Compresses-
Sterile dressing pads, 8 by 4	20	120,000
Gauze compresses-
4 by 4	20	127,000
9 by 9	20	66,000
		313,000
Packing and padding-
Gauze rolls, 5 yards by 4?	12	4,200
Gauze rolls, 3 yards by 4?	20	25,000
Laparatomy pads-
12 by 12	2	1,300
6 by 6	1	1,000
4 by 16	2	1,400
		32,900
Absorbent-
U. D. pads, type 1-
Cotton, 8 by 12	40	22,000
Oakum, 8 by 12	12	4,680
U. D. pads, type 1-
Cotton, 14 by 20	40	8,000
Oakum, 14 by 20	15	2,250
U. D. pads type 1, cotton, 12 by 24	80	14,400
Split irrigating pads, 21 by 16	10	1,000
		52,330
Bed pads-
U. D. pads, type 2-
11? by 18	40	10,800
18 by 23	60	6,000
		16,800
Drains-Gauze packing, 2 by 1 yard, ? by 1 yard	5	10,000
Body bandages:
Abdomen-
Many-tailed bandages, 48 by 12	6	4,800
Abdominal bandages-
Muslin, 48 by 18	8	4,000
Flannel, 52 by 12	4	1,000
Scultetus, flannel	10	4,000
		13,800
Perineal, T bandages, 53 by 7	5	3,500
Head and chin, four-tailed bandages, 36 by 8	3	3,000
Arm and various slings	25	12,500
Eyes-
Double-eye bandages	4	2,000
Single-eye bandages	2	1,000
		3,000
Pneumonia jackets	14	1,400
Accessories used with splints:
Supports-
Support slings-
No. 1, 8 by 21	2	3,200
No. 2, 5? by 16	2	5,000
No. 3, 7 by 23	1	1,400
Rubber cloth support slings (wooden ends), 8 by 24	?	250
Canvas support slings (wooden ends), 8 by 24	?	250
Canvas swathes, 18 by 22	?	100
Straps and buckles-
1? by 4 yards	1	4,000
1? by 2 yards	1	2,400
Heel rings	1	630
		17,230
For traction-
Anklets	---	500
Elbow traction bands	1	1,000
Traction bands, flannel, 10 by 5, 16 by 7, 23 by 7	3	5,000
Adhesive plaster	10	500
Shot bags^a	1	22,000
Canvas weight bags	1	1,820
		28,820
Accessories used with plaster:
Sheet wading, 5-inch	30	4,500
Crinoline-
5-inch	10	10,000
Bolts	2	---
Felt, 100 yards	1	---
Canvas hammocks, 20 by 42	1	290
		14,890
Bandages:
Gauze bandages, 3 inches by 5 yards	15	37,500
Muslin bandages, bias-
3-inch	2	1,200
4-inch	2	1,200
5-inch	1	600
6-inch	4	3,200
Muslin bandages, straights-
5 by 5	8	8,000
4 by 5	6	4,800
5 by 5	1	600
Flannel bandages, straights-
3 by 5	3	3,000
4 by 5	2	1,600
Jackinette, 500 yards	1	61,700

^aIn stock, but not being replaced.

II. Reconstruction aides.-Reconstruction aides arecivil employees under contract with the Surgeon General. They are subject to theorders of the commanding officer of the units to which assigned and will beunder the direct charge of the chief nurse. They are entitled to such pay andemoluments as are set forth in contracts.

Their especial function is to carry out the instructions ofthe medical staff in the rehabilitation of wounded in methods of physical andoccupational therapy.

When assigned to duty at hospitals they are subject to thesame regulations which govern nurses, and when their services are not requiredin their special work they may be temporarily assigned to duty as nurses' aides.

The necessary reports will be made by the chief nurse andforwarded through regular channels.

III. Expendable property.-The following articles ofmedical property will be considered expendable property: Crutches, canes, andsplints of all kinds.

To expedite the evacuation of patients, commanding officersof hospitals and hospital trains are authorized to exchange bath robes(convalescents' gowns), blankets, liters, pajama coats, and pajama trousers on anumerical basis except where it is found to be more practicable to transfer theproperty by exchange of invoices and receipts.

WALTER D. MCCAW,
Colonel, Medical Corps, Chief Surgeon.

Circular No. 57.
AMERICAN EXPEDITIONARYFORCES,
November 20, 1918.

I. Duties of professional consultants.-(1) The dutiesof the professional consultants will be to supervise the clinical work of theAmerican Expeditionary Forces. They will be assigned to hospital centers,districts, armies, army corps, and divisions, as the necessity demands, onrecommendation of the chief consultant of their respective services, by theproper military authority.

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(2) In order that the individual consultant may perform hisduties effectively, he will make frequent visits to the hospitals or othermedical organizations in his territory, as may be required. He shall spend somuch time in each hospital as in his judgment may be necessary in order toacquaint himself thoroughly with the character and quality of the work donetherein.

(3) It is the duty of the consultant to supervise theprofessional work, as to his department, of the organization or organizations towhich he is assigned. He will give advice, instruction, and actualdemonstrations as to the best and most efficacious methods of treatment in orderthat the work of his department may conform to the recognized and acceptedstandards of the best civil and military practice.

He will make recommendations to the commanding officer as tothe ability and professional fitness of individual medical officers of hisdepartment. The commanding officer will take the necessary steps to carry therecommendations of the consultant into effect. A copy of the recommendations ofthe consultant will be forwarded to the senior consultant for his information.In case of difference of opinion between the commanding officer and theconsultant, the decision rests with the commanding officer on whom, in allmilitary organizations, the ultimate responsibility rests. This does notinterdict the right of appeal to higher military authority.

(4) In order that the supervision and direction of theclinical care of the sick and wounded may be consistent throughout, consultantswill recommend to commanding officers of hospitals in their respective areas thenames of those suitable for appointment as chiefs of clinical services andspecialists in those hospitals.

(5) Consultants will render regular monthly reports of theiractivities. These reports will embody the nature of the clinical work of theorganizations in their jurisdiction, the character and quality of the work, andfitness of individual medical officers in their departments. These reports willbe submitted to the senior consultant, through the commanding officer of thehospital center, or in base hospitals operating separately, the commandingofficer of the hospital, or through the surgeon of the unit to which they areassigned.

(6) The commanding officers of units in the district assignedto a consultant will afford proper and necessary facilities to the consultant inthe performance of his duties.

(7) The consultant will report to the commanding officerimmediately on his arrival at, and before his departure from, any unit which iswithin the sphere of this action.

II. Assignment of personnel.-Commanding officers ofhospital centers may make such changes of assignment of personnel on duty withunits belonging to their centers as may be necessary or desirable. Thisauthority will not be construed to cover personnel belonging to units, such asfield hospitals or ambulance company which are not permanently assigned to thecenter. All changes of assignment made under this authority will be promptlyreported to this office.

III. Class B men.-Men of class B held at hospitals inaccordance with telegraphic instructions, chief surgeon's office, October 25,1918, will be held as classified men, after disability boards have acted uponthem, and not as patients.

IV. Artificial eyes.-Four centers have beenestablished where men requiring artificial eyes can best have them fitted. BaseHospital No. 115 at Vichy is the principal center. The others are base opticalunit, Medical Department repair shop, Paris; Base Hospital No. 8, Savenay; andBase Hospital No. 29, London. Cases requiring plastics on the eyelids or orbitprior to the fitting of an artificial eye should be routed to Base Hospital No.113 if practical. Such cases appearing in Paris may be sent to American RedCross Military Hospitals Nos. 1 or 2.

V. Trachoma.-Cases of trachoma which occur among thetroops can be treated in the base hospitals, but precautions should be taken toprevent any danger of spread of the disease. Special care of towels andhandkerchiefs is most necessary. Severe cases likely to require long treatmentwith resulting impairment of vision should be classified "D" androuted accordingly.

VI. Civilian employees.-(l) Supplementing paragraph 3,Circular No. 45, chief surgeon's office, dated August 13, 1918, commandingofficers of hospital centers are directed to report to the office of the chiefsurgeon (F. and A. Division), all authorities for the employ-

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ment of civilians granted by them to date to commandingofficers of base hospitals under their command, and also to forward to the sameoffice copies of all similar authorities hereinafter granted by them. Attentionof commanding officers of hospital centers is invited to section 3, paragraph 2,General Order No. 32, general headquarters, A. E. F., dated February 13, 1918,and also to section 5, General Order No. 131, general headquarters, A. E. F.,dated August 7, 1918, which regulates employment of civilian personnel.

(2) Supplementing section 2, paragraph 1, Circular 16, chiefsurgeon's office, dated March 28, 1918, and section 1, Circular 23, chiefsurgeon's office, dated April 22, 1918, commanding officers of hospitals andother units functioning as such, are directed to have payment of civilians,whenever possible, made from the hospital fund and reimbursement to such fundsecured in the method provided in section 2, paragraph 1, Circular No. 16, chiefsurgeon's office. Payment of civilians should be made by Quartermaster Corpsdisbursing officers only when sufficient balance is not on hand in the hospitalfund. Whenever civilians are paid from the hospital fund, the original pay roll,properly signed and executed, with memorandum voucher attached, should be sentto the disbursing officer, Medical Department, office chief surgeon, A. P. O.717, for reimbursement by one check drawn to the order of the hospital fund.These original rolls should bear the following properly
signed certificates:

(a) I certify that I have witnessed the payment ofthis roll and that the amount paid each employee was such as is set oppositetheir respective names.

------------------------------------------------------------
Signature.

(b) I hereby certify that payment of this roll wasmade from hospital fund, Base Hospital No. -------, and hereby request that saidhospital fund be reimbursed the amount of francs -----------------.

--------------------------------------------------------------
Custodian, Hospital Fund.

VII. Surgical instruments.-Any surplus instrumentsheld by medical units will be turned in at once to the instrument repair shop,11 ter Rue de La Revolte, Paris, France.

The same procedure will obtain where medical units arediscontinued. All instruments shipped in compliance with the above instructionwill be properly invoiced to commanding officer of the instrument repair shop.

VIII. Paragraph 3, Circular 28, office of chief surgeon, c.s., is amended by substituting the following:

When French and allied military patients are admitted to,discharged from, or die in, American military hospitals in the French zone ofthe interior, notification of the fact will be sent within 24 hours to theFranco-American section of the region (Service de Sante), on Form 52, which willcontain: Surname, Christian name, regiment, serial number, place of enlistment(if possible), nationality, date of admission, source of admission, nature ofwound or disease, and, if in line of duty, complications, mode and date ofdischarge, or date of death and place of burial, name of hospital in whichpatient is being treated.

IX. Patients remaining in hospital December 31, 1918.-Aremaining card, Form 52, will be made out for each patient in hospital onDecember 31. It will be identical with Form 52 as used for completed casesexcept that in space 16, "Disposition," the entry "Remaining inhospital" will be made, and in space 17, "Date of disposition,"the entry "December 31, 1918," will appear.

A nominal check list of these will be made with the word"Supplemental" appearing on the form at the top. The sheet, togetherwith the cards, will be submitted with the regular monthly report for December.

WALTER D. MCCAW,
Colonel, Medical Corps, Chief Surgeon.

Circular No. 58:
AMERICAN EXPEDITIONARYFORCES,
December 2, 1918.

I. Collection of museum material for medical education andresearch (supplement to Circular No. 42).-The cessation of hostilities makesnecessary the following additional directions concerning the collection,preservation, and shipment of specimens for the Army Medical Museum:

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PAR. 2. Scope.-Sinceopportunity is past for obtaining pathologic material showing recent warinjuries, efforts will now be made to obtain material showing such injuries inall stages of healing. Serial graphic records by photographs and drawings willbe made of typical or otherwise interesting cases. Amputated and resectedmaterial will be preserved. Also all lesions from war injuries in cases comingto autopsy. It is believed such specimens will be of inestimable value in thestudy of the treatment of wounds, gas burns, trench foot, etc.

PAR. 7. Pathologicspecimens.-(a) To prevent overhardening during long delays which mayoccur in transporting specimens to the United States, all gross pathologicspecimens, after short preliminary fixation in Kaiserling No. 1, if not carriedthrough the entire Kaiserling process, will be placed in fresh Kaiserling No. 1,which contains only 10 per cent of formalin.

PAR. 8. Shipment.-Toavoid loss during long delays in transit in France, when possible specimens willbe shipped by motor transport to concentration points. (See par. 5, Circular42.) If rail transport must be used, pathologic specimens will be well paddedwith waste absorbent cotton, moss dressing, or paper, packed closely in kegs,barrels, or casks, which will then be headed and filled with half-strengthKaiserling No. 1 and shipped by "Grand Vitesse." Where large numbersof specimens have been collected and capable packers are not available,application for assistance will be made to the director of laboratories, A. E.F. (museum unit), A. P. O. 721.

PAR. 18. Photographs.-Byauthority first and fourth indorsements, O. C. S. ²⁰⁰/2065C. S. O., the Medical Department, through the Signal Corps, now has fullauthority to make photographs of subjects pertaining to the Medical Department.Commanding officers of hospitals will take immediate steps to procurephotographs for illustrating the history of their organizations.

II. Proceeds from sale of garbage.-(l) Decision of thejudge advocate states that proceeds from the sale of kitchen refuse at hospitalsbelongs to the hospital funds of the organizations.

(2) Commanding officers are therefore instructed to makecontracts locally for the sale of same, and place proceeds therefrom in thehospital funds.

(3) If proceeds previously received have been turned over tothe Quartermaster Corps, effort should be made by commanding officers ofhospitals to secure refund, either from the local disbursing quartermaster or bysending claims with all details to this office (F. and A. Division).

III. Camphor.-Due to the difficulty of obtainingcamphor, it is desired that every effort be made to conserve it.

IV. Return of buildings occupied for hospital purposes.-Noagreement should be made between commanding officers of hospitals and localFrench authorities for the return of buildings occupied for hospital purposes,as this office has been repeatedly informed by the French central authoritiesthat local authorities are not competent to act on the premises. This transfershould be only done after receiving directions from the chief surgeon of theAmerican Expeditionary Forces in the case of base hospitals, and the sectionsurgeons of the Services of Supply in the case of camp hospitals.

It has been reported to this office that a number of basehospitals have evacuated patients who should not have been moved, with a view todemobilizing the hospitals.

Action such as this will not facilitate the departure ofMedical Department units to the United States, but will in fact retard it.Greater care than ever must be exercised in treatment and evacuation ofpatients. This office will make proper recommendation, when the time arrives, asto ordering the units to the United States.

V. Medical Department property.-All officersaccountable for Medical Department property who are carrying Red Cross propertyon their returns are instructed to drop this property from their returns, makinga certificate to this effect to the chief surgeon, F. and A. Division, givingthe number of the voucher on which the property was dropped.

Although there is no formal accountability for Red Crossproperty (see par. 3, Circular 3, B. G. and L. O. C., August 28, 1917),responsibility, however, for this class of property rests with the commandingofficers of hospitals and other organizations who should be prepared at alltimes to give and account of the use to which this property has been put.

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VI. Medical journals and books.-Standard medicaljournals and books are available in the medical supply depots and the medicalresearch and intelligence department of the Red Cross, Hotel Regina, Paris.Application for such books should be made through the usual channels. Basehospitals will be supplied from the Army stock, and camp and evacuationhospitals from the Red Cross stock. If nonstandard books are not available inone stock, request will be referred, if approved, to the other.

The medical research and intelligence department of the RedCross, Hotel Regina, Paris, will be glad to review the literature on any specialsubject in which a medical officer is interested, and to furnish him an abstractof the results. Correspondence may be made direct.

VII. Repairs or installation of X-ray apparatus.-Incase of repairs needing the attention of an X-ray officer of the Sanitary Corpsthe commanding officer of the hospital should wire the office of the technicalconsultant in Roentgenology, A. P. O. 702, who will direct the proper officer tomake the repair. A brief, explicit statement of repair needed will expediteservice.

In case of portable or bedside transformer, wire the aboveoffice for a replacement and send damaged part to medical repair shop No. 1,X-ray division, 11 Bis Avenue de la Revolte, Neuilly, Paris.

No officer for the installation of new equipment will be sentunless the telegram to the above office states that machine is on hand and thatcurrent is available.

VIII. Personnel available for transfer.-Commandingofficers of Medical Department units and detachments will report, by mail, tothis office on the 15th and the last day of each month the names of anyofficers, nurses, or men who can be spared for return to the United States orfor duty elsewhere in the American Expeditionary Forces.

IX. The following information will be furnished thisoffice, when units are sailing for the United States:

The immediate commanding officer of each medical departmentformation will make a final return showing all members of the Medical Departmentpresent for duty with his organization, on date of departure to the UnitedStates.

Division surgeons will make a separate return of all membersof the Medical Department serving in their divisions and not included on otherreturns.

Separate return will be made of all personnel, present forduty, in the following order: Officers of the Medical Corps; officers of theDental Corps; officers of the Veterinary Corps; all to be listed alphabeticallyaccording to grade.

Separate return will be made of all enlisted personnel,present for duty, alphabetically according to grade, the soldier's serialnumber, name, and rank will be recorded in the following manner:

Serial No.: 14278
Surname: Brown,
Christian name: William E.
Rank:

Separate return will be made of all civilian employees andmembers of the Army Nurse Corps.

The return will be prepared on letter or cap paper(typewritten). The return will then be forwarded to the chief surgeon, A. E. F.,through the base surgeon, who will take such memoranda therefrom as he mayrequire, and will without delay transmit it by informal indorsement to thisoffice.

X. Sick leave of absence.-In granting sick leaves ofabsence under paragraph 2, General Order 7, Services of Supply, c. s.,attention of all commanding officers is invited to paragraph 9, General Order 6,General Headquarters, c. s. In this connection, Paris is in the French zone ofthe armies, and leave should never be granted to visit Paris except in veryexceptional cases.

XI. Travel orders.-Reports have been received at thisoffice that the commanding officers of base hospitals, in sending men to depotdivisions and casual camps, are not complying with the requirements of GeneralOrder 111, General Headquarters, c. s. In order that there may be no mistake,the travel orders of officers and soldiers evacuated from hospital not only asof classes B and C, but also of class A, will state clearly the classificationto which the officer or man belongs. Especial attention will be given the factthat sufficient

999

number of orders must accompany each group in order that thecommanding officer of the depot division or casual camp may have the properrecords immediately on receipt of a man or group of men.

WALTER D. MCCAW,
Colonel Medical Corps, Chief Surgeon.

Circular No. 59:
AMERICAN EXPEDITIONARYFORCES,
December 9, 1918.

I. PNEUMOCOCCUS LIPO-VACCINE

1. The following directions for vaccination against lobarpneumonia and for making the necessary records are published for the informationand guidance of medical officers of the American Expeditionary Forces.

2. Each cubic centimeter of the pneumococcus lipo-vaccinecontains 15,000 million pneumococci of Type I and 15,000 million of Type II. Onstanding in the cold, some of the fats may separate and cause a precipitate.This will disappear on standing a short time at room temperature.

3. A single dose of 1 c. c. of this vaccine is sufficient. Itis especially important that it be given subcutaneously, not intravenously,intramuscularly, or under the fascia. In order to insure this, you will pick upa fold of skin and inject into the subcutaneous tissue of that fold. Practicallyall the severe reactions that have been reported have been due to neglect ofthis precaution. The deep injection of this vaccine may lead to fat embolism anddefeats the object of the inoculation.

4. No person should be vaccinated who is not perfectlyhealthy and free from fever. The temperature will be taken before vaccination isbegun and, in doubtful cases, the urine should be examined; if fever or anyother symptoms of illness are present, the procedure should be postponed. Thisprecaution is necessary to avoid vaccinating men who may be in the incubationstage of a fever. Neither beer nor alcohol in any form should be drunk on theday of treatment. It is advisable to give the vaccine about 4 o'clock in theafternoon, and the men should be required to remain in quarters for 24 hoursafter the injection.

5. A sick and wounded card is to be made out for each personvaccinated, giving the type of vaccine employed, batch number for itsidentification, and the dosage. This card is to be marked "For vaccinationrecord only" and sent direct to the office of the chief surgeon, A.E. F., A. P. O. 717. Enter on the service record, date, type, and dose ofvaccination.

6. The pneumococcus lipo-vaccine may be obtained byrequisition from base laboratories in accordance with paragraph 10, MemorandumNo. 21, office chief surgeon, division of laboratories and infectious diseases,September 18, 1918.

7. Vaccination against lobar pneumonia is not compulsory, andthe use of pneumococcus lipo-vaccine in the American Expeditionary Forces mustbe made only with the consent of the patient.

II. TYPHOID LIPO-VACCINE

1. The following information is furnished for the guidance ofthe medical officers of the American Expeditionary Forces.

2. As rapidly as the supply of triple lipo-vaccine isincreased it will be sent in filling requisitions for triple typhoid salinevaccine. Requisitions should be made to the nearest base laboratory inaccordance with paragraph 10, Memorandum No. 21, office of chief surgeon,division of laboratories and infectious diseases, September 18, 1918.

3. Triple typhoid lipo-vaccine contains in each cubiccentimeter 2,500 million Bacillus typhosus, 2,500 million Bacillusparatyphosus A; and 2,500 million Bacillus paratyphosus B. Onstanding in the cold some of the fats may separate and cause a precipitate. Thiswill disappear on standing a short time at room temperature.

4. A single dose (not three) of 1 c. c. of the lipo-vaccineis sufficient. It is especially important that this vaccine be givensubcutaneously and not intravenously, intramuscularly,

1000

or under the fascia. To insure this, a fold of skin is pickedup and the injection made into the subcutaneous tissue of that fold. Practicallyall the severe reactions that have been reported have been due to neglect ofthis precaution. The deep injection of the lipo-vaccine defeats the object ofits use and in addition may lead to fat embolism.

5. The precautions to be taken regarding the absence oftemperature or disease are the same as are given for the typhoid vaccine inCircular No. 16, War Department, office of the Surgeon General, March 20, 1916.It is advisable to give the vaccine about 4 o'clock in the afternoon, and theman should be required to remain in quarters for 24 hours.

6. After the injection, the record of the vaccine should bekept on Form No. 81, that form being modified by writing "Lipo" after"Triple vaccine," and by striking out "First" in the"Dose" column, and by striking out all columns in the"Second" and "Third" doses. The batch number of the vaccineshould always be entered on the card.

WALTER D. MCCAW,
Colonel, Medical Corps, Chief Surgeon.

Circular No. 60.

AMERICAN EXPEDITIONARYFORCES,
CHIEF SURGEON'SOFFICE, SERVICESOF SUPPLY,
December 16, 1918.

DIPHTHERIA AND DIPHTHERIA CARRIERS IN THE ARMY
I. Bacillus diphtheri?.-(a) True diphtheriabacilli when freshly isolated and examined in young cultures (24 hours onLoeffler's blood serum) have fairly typical morphology and staining reactionswhich usually serve to differentiate them from other organisms.

(b) Their positive identification may be made uponmorphology and staining reactions plus cultural characteristics.

(c) B. diphtheri? may be divided into twogroups-virulent and avirulent-which are indistinguishable from each othermorphologically, tinctorially, and culturally, but may be positivelydifferentiated by guinea-pig inoculation.

(d) Practically speaking, an avirulent strain ofdiphtheria bacilli never acquires virulence, and a virulent strain retains itsvirulence with great tenacity.

II. Etiology.-Clinical diphtheria is produced only byvirulent diphtheria bacilli.

III. Diphtheria bacillus carriers.-(a) Singlethroat cultures from healthy individuals of various ages reveal B.diphtheri? in 1 per cent to 30 per cent. The average incidence appears tobe 3 to 4 per cent.

(b) Among the bacillus carriers the per cent ofcarriers with virulent bacilli varies greatly, but is commonly found to be 10 to15 per cent of carriers.

(c) The carrier stage may be temporary or chronic.Sometimes diphtheria bacilli disappear from the throat of a carrier within a fewdays after they find lodgment there; in other cases they persist for weeks,months, or even years.

(d) If daily cultures are taken from the throats ofchronic carriers, very interesting and instructive results may be obtained; (1)Positive cultures may be obtained for a number of consecutive days extendingperhaps over weeks. (2) A majority of the cultures may be positive, withoccasional negatives interspersed among the positives. (3) A majority of thecultures may be negative, with occasional positive cultures. (4) A carrier whohas been giving regularly positive cultures for a number of days may showirregular results for a time and then give entirely negative cultures for anumber of successive cultures, to be followed still later by regularly positivecultures, and this condition of affairs may repeat itself many times. (5) Thegrowth of diphtheria bacilli is not confined to the surface of the mucousmembrane; colonies have been demonstrated in the depths of the tonsillar tissue,and the condition described under (4) above is probably to be explained by thesuccessive coming to the surface of these deep colonies as the superficiallayers of the tonsils are gradually exfoliated. (6) Virulent and avirulentbacilli
are rarely, if ever, found in the throat of a carrier at thesame time.

1001

IV. Sterilization of carriers.-To free carriers ofvirulent diphtheria, a great number of methods have been tried. The only onewhich has met with any considerable degree of success in chronic carriers hasbeen tonsillectomy. This will not prove universally successful, as in some casesthe nidus may be elsewhere than in the tonsils, as, for example, in theaccessory sinuses.

V. The r?le of carriers in the spread of diphtheria.-Ther?le of carriers who have not been in close contact with an active clinicalcase of diphtheria in the spread of diphtheria does not seem to be important.This is obvious when it is recalled that 85 to 90 per cent of all carriersharbor only nonvirulent bacilli, and that infection does not readily occur fromthe remaining 10 to 15 per cent who constitute a possible source of infectionfor susceptible individuals.

VI. The detection of carriers.-A single throat culturefrom any large number of people would probably reveal less than half the actualnumber of carriers present. Two cultures, taken with an interval of a week ortwo between, would probably reveal twice the number of carriers found on asingle culturing. If six or seven cultures were taken with an interval of a weekor two between cultures, the number of carriers remaining undiscovered wouldprobably be very small. Nasal cultures might show a few additional carriers, butvery few.

Isolation of healthy carriers is impracticable because (1) ofthe labor involved in detecting all the carriers. (2) If all the carriers amongany large group of persons were detected, their number would be too great. (3)The only method of sterilizing chronic carriers (tonsillectomy) that has metwith much success could hardly be recommended as a routine procedure, andwithout this many of them will remain carriers indefinitely. (4) They do notconstitute a menace serious enough to justify any of the above procedures. (5)Finally, if for any reason an attempt is made to detect and isolate carriers,virulence tests should be performed and the carriers of avirulent organismsshould be disregarded.

VII. The diphtheria patient.-While the healthy carrierof even virulent diphtheria bacilli does not constitute a serious danger topersons in contact with him, the same can not be said of the individualsuffering from clinical diphtheria. The disease is readily transmissible, bothby direct contact and by moist discharges from the nose and mouth. Strictisolation of all cases should be carried out and thorough disinfection of allclothing, bedding, and other articles that have been used by the patientsubsequent to his infection. It is possible that persons who have recentlybecome carriers by contact with a diphtheria patient may be a greater source ofdanger in the spread of the disease than the ordinary healthy carrier who hasnot been recently in contact with the disease; therefore, all those who are inintimate contact with a person at the time of, or just prior to, his developmentof diphtheria should be isolated until the incubation period of the disease haspassed or until they can be shown to be free from the infection by at least twonegative throat cultures. All nurses and orderlies in attendance upon cases
of diphtheria should be isolated during the whole of the timethat they are in charge of such patients and for a period thereafter equal tothe incubation period of the disease, or until they are shown free from theinfection by at least three successive negative throat cultures at intervals ofthree days.

VIII. The incubation period.-The incubation period ofdiphtheria is from 2 to 5 days, oftenest 2 days, and under experimentalconditions has been found to be short as 24 hours.

IX. Treatment with diphtheria antitoxin.- Diphtheriaantitoxin given in adequate doses sufficiently early in the diseases will effecta prompt cure in practically 100 per cent of cases. There should be no mortalitywhere antitoxin is given within 24 hours of the development of symptoms. Foradults weighing 90 pounds or over, the amount of antitoxin required in thetreatment of cases is as follows: Mild cases, 3,000 to 5,000 units; moderate,5,000 to 10,000 units; severe,^d 10,000 to 20,000 units;malignant, 20,000 to 40,000 units.

Cases of laryngeal diphtheria, moderate cases seen late atthe time of the first injection, and cases of diphtheria occurring as acomplication of the exanthemata should be classified and treated as"severe" cases.

In all cases a single dose of the proper amount, as indicatedin the schedule, is recommended.

^dWhen given intravenously, one-half the amounts stated.

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It is recommended that the methods of administration be asfollows:

Mild cases, subcutaneous or intramuscular.
Moderate cases, intramuscular orsubcutaneous.
Severe cases, intramuscular or subcutaneousor intravenous.
Malignant cases, intravenous or intramuscular.

Some point on the surface of the body should be chosen forthe injection, as where there is an abundance of subcutaneous cellulartissue-the abdomen or infrascapular region. Before the remedy is administered,the skin should be sterilized at the point of injection with tincture of iodineor other disinfectant. The syringe should be thoroughly sterilized. It is betternot to employ massage over the point of injection.

THE EARLY ADMINISTRATION OF ANTITOXIN

The earlier the remedy is administered the more certain andrapid is the effect. In cases of any severity where diphtheria is suspected, itis far better to administer the remedy at once, making a culture at the sametime, than to delay the treatment until a diagnosis has been made bybacteriologic examination. The first injection should be large enough to controlthe disease. One large dose given early is far more efficacious than the sameamount in divided doses. Severe cases and those in which the administration ofantitoxin has been delayed, or cases which are progressive because of aninsufficient first dose, should receive a large intravenous injection wheneverfeasible. In this way the full value of antitoxin is obtained at once, whereasthe absorption from the subcutaneous injection is so slow that many hours mustelapse before any great amount of antitoxin has found its way into the generalcirculation. It must be warmed to the body temperature and given very gradually.

X. Anaphylaxis.-While it must be admitted thatanaphylactic shock may follow the administration of diphtheria antitoxin serumand that this danger is slightly greater when the serum is given by theintravenous route than when given subcutaneously or intramuscularly, instancesof serious consequences from therapeutic use of diphtheria antitoxin are so rarethat there is no justification in withholding antitoxin in clinical diphtheria.Desensitization may with advantage be attempted in cases of known sensitivenessto horse serum.

XI. Immunity.-(a) Natural immunity: Experiencehas shown that approximately 50 per cent of mankind are naturally immune againstdiphtheria. This immunity is due to the presence, naturally, of a small amountof diphtheria antitoxin circulating in the blood. This immunity once establishedapparently lasts throughout life. The Schick test: The presence of natural orartificial immunity may be determined by the Schick test. This test consists inthe intradermal injection of a small amount of diphtheria toxin; if antitoxin ispresent (natural immunity) the toxin injected will be neutralized and noreaction will follow. If no antitoxin is present (as in a susceptibleindividual) the toxin will give rise to an inflammatory reaction at the site ofinoculation, a positive reaction. Technique of the Schick test. The testconsists in the intracutaneous injection of one-fiftieth M. L. D. diphtheriatoxin in volume of 0.1 c. c. The M. L. D. (minimum lethal dose) of toxin is thatamount which will kill a 250-gram guinea pig in 4 to 5 days. For the injection,a 1 c. c. hypodermic syringe with very small sharp needle is necessary, and the
injection may conveniently be made into the skin of forearm.

(b) Susceptibility.-It seems highly probablethat people who give a negative Schick test may be exposed freely to diphtheriawithout danger of their contracting the disease, while persons giving a positiveSchick test so exposed are likely to contract the disease.

(c) Active immunization.-Susceptibleindividuals may be actively immunized against diphtheria by the injection oftoxin-antitoxin mixtures, and such immunity is probably fairly lasting, in someinstances persisting throughout life.

(d) Passive immunization.-Susceptibleindividuals may be passively immunized against diphtheria by the injection ofantitoxin. Such immunity reaches its maximum degree immediately, if theantitoxin is injected intravenously, and after about 48 hours followingsubcutaneous injection. Passive immunity following the usual prophylactic doseof 1,000 units of antitoxin gives the individual a temporary immunity againstnatural infection, but the immunity is transitory, diminishing rapidly andusually lost in ten days or

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two weeks. Rarely persons may retain some demonstrable degreeof immunity as long as three weeks. Subsequent use of antitoxin for passiveimmunity in the same individual develops even a briefer protection.

(e) Prophylactic use of antitoxin.-Experiencehas abundantly demonstrated the almost absolute power of a prophylacticinjection of antitoxin in preventing the development of diphtheria in personswho have been exposed to the disease. It probably has no effect in preventingthe lodgment and growth of bacilli in the throats of such persons, and it isconceivable that the bacilli which have lodged in the throats of such personsmight persist and give rise to the disease after the transient immunityconferred by the antitoxin has disappeared. That this frequently happens is notborne out by experience. It is evident, however, from what has been said aboutnatural immunity, that in approximately 50 per cent of persons there is no needof giving prophylactic injections of antitoxin, since this proportion of humansare naturally immune. If prophylactic injections are to be given, it is worthwhile to perform a preliminary Schick test and give antitoxin only to those whoare thus shown to be susceptible by a positive reaction.

XII. Prevention of spread of diphtheria.-Undoubtedlythe most important measure in preventing the spread of diphtheria is the promptrecognition of cases as soon as they develop, and effective isolation of them.It is undoubtedly true that many cases are not immediately recognized and thatthey give rise to a spread of the disease among their associates.

At a time when diphtheria is prevalent, frequent throatinspections should be made of all individuals exposed, or who may have beenexposed, and any person having a throat that looks at all suspicious should beisolated and regarded as having diphtheria until negative cultures prove thatthe suspicion is unfounded. This measure alone, if efficiently carried out, willprobably serve to prevent any spread of the disease.

XIII. A typical case of diphtheria.-It should be bornein mind that not infrequently cases of diphtheria occur in which the typicalappearance of the throat is lacking, and the symptoms may be so mild that theymay be overlooked. The pharynx in these cases may present a beefy redappearance, with perhaps a few pinhead-sized patches, and the symptoms consistin little more than a feeling of malaise on the part of the patient. Thethermometer will usually reveal a slight elevation of temperature, and it isthese cases that may escape isolation and by freely mingling with theirassociates give rise to a spread of the disease.

XIV. Wholesale measures in dealing with epidemicsillogical and valueless.-There are certain measures that have become so wellestablished in dealing with epidemics of diphtheria that to question them issure to arouse the antagonism of those whose ideas have become fixed bytradition. These are the wholesale taking of throat cultures and theprophylactic administration of antitoxin. A knowledge of the practicallimitations of application of wholesale culturing to organizations or groupsamong which diphtheria has appeared, and the poverty of actual results indetecting the insignificant incidence of carriers of virulent B. diphtheri?,should suffice to forbid the practice. Similarly, the uselessness ofadministering diphtheria antitoxin to insusceptibles and the temporary characterof the protection given to susceptibles by passive diphtheria immunization willserve to put an end to the routine use of diphtheria antitoxin without Schickreaction control for
prophylactic purposes in an organization where diptheria hasappeared.

XV. Selective immunization.-We may next consider theadvisability of determining the susceptible individuals, either in a camp oramong those who presumably have been most exposed to the danger of infection,and of giving prophylactic doses of antitoxin to those of persons or of applyingother precautionary measures to them. The susceptible individuals may bediscovered by means of the Schick test. The results may be known at the end of48 hours. If a camp of 5,000 men be tested, 25 per cent, or 1,250, may be foundsusceptible, and these are the only ones who run any risk of developingdiphtheria and to whom the prophylactic injection of antitoxin could be of anyuse.

If the Schick test is applied to a small group (those whohave been more intimately exposed to the disease), one will have to deal with aproportionately smaller number of individuals.

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XVI. Principles for management of diphtheria outbreak.-Inall preventive measures the two main objects to be accomplished should be keptclearly in mind: (I) the protection of the individual; (II) the protection ofthe community. We should also keep clearly in mind what we consider constitutesthe danger to the individual and what, to the community.

I. The danger to the individual is that he may developdiphtheria.

II. The danger to the community, as usually considered, isthat diphtheria may be spread by: (a) Diphtheria bacillus carriers; (b)the failure properly to isolate recognized cases of diphtheria; (c)contact with persons who are in the incubation period of the disease; (d)unrecognized cases of diphtheria with which healthy persons are allowed to comein free contact.

I. The danger to the individual that he may developdiphtheria.-Among adults there is a 75 per cent factor of safety to startwith, represented by natural immunity. This is further increased by the chancethat of the 25 per cent of susceptible adults exposed to diphtheria not all ofthem will have diphtheria bacilli implanted in throats-a chance, however, thatfor the sake of safety we will not consider. Of any group of individuals exposedto diphtheria, the susceptible ones may be determined by the Schick reaction. Itis obviously unnecessary to give a prophylactic dose of antitoxin to any but thesusceptible persons. The time necessary to determine the result of the Schickreaction is 48 hours and during this period all the contacts should be kept inisolation. The incubation period of the disease is given at "from two tofive days, most often two," so that by the time the result of the Schicktest is known most of those who are going to develop the disease willalready have manifested signs of symptoms. The Schick test has therefore beenunnecessary. Antitoxin given in the first 24 hours of the disease is curative inpractically 100 per cent of cases. Therefore, if isolation and observation onlyof the contact is employed without the prophylactic use of antitoxin or theSchick test, the occasional individual who develops the disease under theconditions has lost little if anything, and the large majority of contacts haveexperienced no inconvenience other than a very short isolation.

II. Danger to community.-(a) From carriers:There is no danger from the carrier of nonvirulent bacilli, and the danger fromthe ordinary healthy carriers of virulent bacilli is so slight that it does notseem practical to take any measures against it.

(b) The necessity of carefully isolating allrecognized cases of diphtheria is so universally acknowledged and practicallycarried out that no further discussion of this point seems necessary.

(c) That persons in the incubation period of thedisease constitute a distinct danger is certain, and the prompt isolation ofpersons who are in contact with diphtheria cases is an important measure.Fortunately the short incubation period of the disease makes necessary only avery brief isolation. If these contacts are isolated and a daily observationmade of their throats and symptoms, no other measures are necessary unlesssuspicious symptoms arise. In such cases cultures should be made and antitoxingiven according to the nature of the developments.

(d) Unrecognized cases of diphtheria: It is probablethat these cases are the most potent agents in giving rise to the spread of thedisease. At a time when diphtheria is prevalent, the most important measure,other than the isolation and treatment of the recognized cases of diphtheria, isthe search for the mild cases which might otherwise escape detection. Dailyinspection of throats, with an inquiry as to symptoms, will serve to discoverall suspicious cases. If these are isolated as they are discovered, a culturetaken, and in sufficiently suggestive cases antitoxin given, no serious spreadof the disease need be feared. The taking of cultures may be limited in thesecases, and to the routine procedure covered by Army orders for the discharge ofpatients convalescent from diphtheria and to those who have been in attendanceon diphtheria.

The Schick reaction may be of value in eliminating 75 percent of the individuals constituting any group as naturally immune and thereforeunnecessary to be kept under observation as possible subjects of diphtheria. Itmay further be of use in selecting naturally immune persons to serve asattendants on diphtheria patients, and, finally, if active immunization againstdiphtheria should be undertaken, it will discover those persons who stand inneed of immunization.

WALTER D. MCCAW,
Colonel, Medical Corps, Chief Surgeon.

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Circular No. 61:

AMERICAN EXPEDITIONARYFORCES,
OFFICE OF THE CHIEFSURGEON, SERVICESOF SUPPLY,
December 18, 1918.

I. The following salient points are noticed in a recentreport, based on actual observations, of the nutritional officer, chiefsurgeon's office:
MESS SERVICE TO PATIENTS
1. Mess lines of soldiers are to be avoided if possible. Twosystems of avoiding this are in operation in American Expeditionary Forcehospitals:

First. Tickets with different times for presentation at themess hall are issued to the various groups of men.

Second. Patients are conducted by noncommissioned officers tothe mess hall in squads.

In either case the men must be checked to see that theirnumber corresponds with that called for by the diet slips. Patients in pajamasand slippers must not be allowed in lines and exposed to the weather.
DIETITIANS
2. Attention is again directed to Circular 27, office of chiefsurgeon, c. s., which has evidently not been carefully read. Dietitians are notcooks. Their duties may be defined as follows:

(a) The dietitian.-It is her duty to preparemenus for all patients in the hospital. She is to see that the food is properlyprepared and served. She should see that the menus are served as written.

(b) She should be present in the kitchens during thepreparation of meals. However, during the service she should divide her timebetween the wards and mess hall in such a way that she may know whether the foodis being properly served throughout the hospital. She, or her assistant, isresponsible for the issuing of the food to the wards. She should also report tothe commanding officer defects of service found in the wards, that these may becorrected through proper channels. Defects of preparation or service found inthe mess hall or kitchen should be reported to the mess officer.

(c) She is directly responsible for the preparation ofspecial diets and for special items or modification of the three listed diets.She should, however, be supplied with sufficient help to relieve her from allthe details of preparation of these items. It is her duty to advise with theheads of the services, ward surgeons, or nurses, as may be necessary, to insurethe patients getting food that is adapted to their needs, while at the same timethe kitchen may be relieved of preparing unnecessary specials.

3. In the absence of regularly qualified dietitians, Circular39, office of chief surgeon, c. s., should prove invaluable, attentionparticularly being invited to Table II, page 4. Two corrections, as follows, areto be made in Table III: (1) the caloric value of a pint of milk is about 300calories; (2) one cup of coffee, half milk, contains about 150 calories.

CHIEF MESS OFFICER
4. Large centers should include a chief mess officer as a partof the administrative personnel for the center. Among others, his duties shouldinclude the following for the entire center:

(a) Purchaser and distributor of articles of mess.

(b) Inspection of all messes.

(d) The organization of schools for cooks, bakers, andmess sergeants.

(e) Acting, for a short term, as hospital mess officerin any unit in the center where the regular mess officer is temporarilyincapacitated.

Where an officer running one of the hospital messes in acenter has acted as purchaser for the center, the results have proven entirelyunsatisfactory. One hospital gets fed; the others go without.

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II. Long-distance telephone calls.-A report from thechief signal officer shows that long-distance telephone calls originated by theMedical Corps were in November, 21.7 per cent more numerous than the average forthe previous three months. Attention is called to Circular No. 53, and it isdirected that long-distance calls be not made for communications of a trivialnature.

III. Nurses to pay their own expenses.-Commandingofficers will direct the attention of all nurses to the fact that when passingthrough Paris under orders they must pay their own expenses and requestreimbursement later from the quartermaster and must not call upon the Red Crossfor lodging. The Red Cross up to the present time has had arrangements with theContinental Hotel in Paris to take nurses as guests and render the bill to theRed Cross. The Red Cross has notified this office that this arrangement will bediscontinued immediately.

IV. Medical supplies.-In case of shortages of medicalsupplies received, General Order No. 57, headquarters Services of Supply,November 21, 1918, will be consulted and the procedure therein outlinedfollowed.

V. The instrument repair shop.-The instrument repairshop is now located at Parc des Princes, Porte St. Cloud, Paris.

VI. Medical Department property of organizations changingstation.-Officers accountable for Medical Department property are directed,upon change of station of their organization, to submit to this office, byletter, a brief report showing the status of their Medical Department property,what disposition has been made thereof, under what authority, etc.

VII. Salvage medical field supplies.-Salvage medicalfield supplies will be shipped to officer in charge, medical supply depot,Montierchaume, Indre, properly invoiced.

VIII. Disposal of records of hospitals.-(l) Theattention of all hospital commanders is called to Circular 73, War Department,November 18, 1918, which prescribes methods for the disposal of the records oforganizations which are being disbanded.

(2) In addition, it is directed that each hospital upon finalclosing of its work as an organization in the American Expeditionary Forces,shall send its final report of sick and wounded, including (a) finalreport of sick and wounded for the period since last report, per Section XI,Manual Sick and Wounded Department, A. E. F., dated September 15, 1918; (b)retained file of copies of Forms 22, 647, and 648; (c) retained registerindex cards Form 52, to the office of the chief surgeon, A. E. F., Tours, in thepersonal charge of the registrar and such personnel as he may deem necessary inaddition. After examination of these records and the making of the necessarycorrections in them the registrar will be given a clearance receipt.

(3) In the case of medical units (infirmaries, etc.) otherthan hospitals, which function as hospitals and are required to render sick andwounded reports, the final report and records may be forwarded in charge of aresponsible soldier, preferably one who has had to do with the preparation ofthe records and reports.

(4) Such records as are to be sent to Washington inaccordance with Circular 73 may be sent by postal express. Such records,relating to Medical Department work or personnel, as Circular 73 designates tobe left at camp headquarters should instead be sent to the office of the chiefsurgeon, to be kept until checked against by Washington.

(5) The supply of Circular 73 is limited, but as soon assufficient quantities are received they will be distributed.

IX. Property.-Medical officers accountable forproperty, when returning to the United States, should report their departure byletter to this office (finance and accounting division). Statement of propertycharged against them will be forwarded to the office of the surgeon general forsettlement. In case transfer of property is made to another accountable officerin the same unit, clearance of departing officer's accountability will beexpedited if the officer before his departure submits a final return to thisoffice (finance and accounting division). If a unit is disbanded and propertyturned into salvage or supply depots, transfer should be made in the usualmanner. When vouchers covering above are forwarded to this office, certificatethat all property has been disposed of should accompany the last voucher. Inthis case also clearance of departing officer's accountability will be expeditedif he submits before his departure final return to this office (finance andaccounting division). Medical Department officers responsible for but notaccountable for property should clear their responsibility to
accountable officer before their departure.

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X. Lice.-A recent inspection of patientsreceived from base hospitals at classification camps shows that 12 per cent areinfested with lice. This appears due to the fact that pubic and axillary hairsare not carefully inspected for presence of nits.

In future, in addition to usual manner of disinfestation, thepubic and axillary hairs will be clipped.

XI. Advance medical supply depot No. 2.-Advancemedical supply depot No. 2 has been established by the Services of Supply atTreves, Germany, to furnish medical supplies to armies and all other medicalunits in Germany.

WALTER D. MCCAW,
Colonel, Medical Corps, Chief Surgeon.

Circular No. 62.
AMERICAN EXPEDITIONARYFORCES,
CHIEF SURGEON'SOFFICE, SERVICESOF SUPPLY,
December 23, 1918.

EPIDEMIC CEREBRO-SPINAL MENINGITIS (CEREBRO-SPINALFEVER)
The following bulletin is published to amplify and modify theinstructions relative to the handling of epidemic cerebro-spinal meningitisheretofore issued from this office, more particularly those incorporated in thebulletin on transmissible diseases and the use of therapeutic sera.

Clinical manifestations.-The early signs and symptomsof cerebro-spinal fever are those common to many other acute infections.Headache is almost always present. Vomiting is often an early manifestation.Fever is almost invariably present. Constipation is a fairly constant symptom.The pulse is relatively slow in relation to the temperature. Changed mentalactivity, varying from a slightly increased delay in cerebation, marked apathy,drowsiness to restlessness or even violent delirium, is generally present. Apetechial rash about the shoulders, arms, and pelvis occurs in about a fifth ofthe cases. When such manifestations as these are present, cerebro-spinal fevershould be considered in the differential diagnosis, and, in case of doubt, ablood culture should be taken and the advisability of spinal puncture weighed.

More characteristic manifestations include stiffness of theneck, tending to increase upon continued movement of the examination, retractionof the head, sluggishness and inequality of the pupils, stiffening of thehamstring muscles (Kernig's sign), incontinence or retention of urine, andsudden deafness, total or partial. Such manifestations, unless adequatelyexplained as due to a cause other than meningitis, are imperative indicationsfor spinal puncture.

Specific diagnosis.-Diagnosisdepends upon the recognition of the meningococcus in the fluids derived from thepatient. Meningitis, with all its clinical manifestations, may be caused by anyone of several other organisms without the meningococcus being present. Suchforms of meningitis do not possess the epidemic tendencies of the meningococcusmeningitis, a fact which renders their bacteriological differentiation veryimportant.

For diagnostic purposes the meningococcus is sought in thenasopharynx, in the circulating blood, and in the cerebro-spinal fluid. Inspecimens from the nasopharynx many other bacteria are likely to be met with. Inthe circulating blood and in the spinal fluid the bacteriology is ordinarilysimple.

Cerebrospinal fluid is obtained by lumbar puncture in themedian line between the fourth and fifth lumbar vertebr?. This point is on aline joining the summits of the iliac crests. The fluid should be collected in aseries of sterile tubes. The normal fluid is water clear and contains less than10 leukocytes per cubic millimeter. In meningitis the fluid is usually, but notalways, under increased pressure and more or less turbid, and the number ofleukocytes is greatly increased. Cultures should be made at once by spreading adrop of the fluid over the surface of a suitable medium in a Petri dish.Gordon's trypsin agar^e to which has

^eGordon's trypsin agarmay be obtained from the central Medical Department laboratory or from thenearest base laboratory.

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been added ether-laked blood is recommended, but glucose agarmixed with blood or with laked blood may be used. A portion of the fluid shouldbe mixed with an equal volume of plain broth and incubated, and a portion shouldbe incubated without the addition of any other medium. All media should beincubated before use, should be warm when inoculated, and kept at 37?thereafter. The sediment should be smeared on slides, stained with Wright's orLeishman's stain, and examined with the oil immersion objective, observing thenumerical relations of red blood cells, various types of white cells, morphologyand position of the bacteria present. A second smear should be stained by Gram'smethod. The presence of Gram-negative intracellular diplococci in the spinalfluid warrants a provisional diagnosis of meningococcus meningitis.Identification of the organism in cultures will be considered subsequently.

If clinical diagnosis of cerebrospinal fever has been made, adose of polyvalent antimeningococcus serum should be given at once through thesame needle that is used for obtaining the specimen of spinal fluid, withoutwaiting for the bacteriological report. The prompt introduction of this firstdose of serum is of utmost importance to the patient. It is best run in bygravity, very slowly, 2 c. c. per minute, the total dose being 15 to 40 c. c.,or two-thirds of the volume of fluid removed.

Blood culture may give positive results in cerebrospinalfever before clinical manifestations of meningitis are evident, especially infulminant cases. At least three agar plates and two broth cultures should bemade with a total quanity of 10 c. c. of blood. Gram-negative diplococciappearing in pure culture in these media warrant a tentative diagnosis ofcerebrospinal fever. The final identification of the organism will besubsequently considered.

Cultures from the naso-pharynx give positive results in thelarge majority of cases of cerebrospinal fever but, on account of the admixtureof other micro-organisms in the specimen, material from this region is lesssuited for rapid diagnosis of the active case of meningitis than is thecerebrospinal fluid. However, may individuals are infected with meningococcus inthe upper respiratory passages without the infection extending to the bloodstream or to the meninges. Such individuals may show no clinical evidence of theinfection. Their detection, segregation, and treatment constitutes an importantpart of the procedure for restricting the spread of cerebrospinal fever. As ageneral rule the examination of the naso-pharynx for meningococci should beresorted to only in active or convalescent patients and in persons who have beenvery closely associated with such patients. General surveys of entire regimentsor brigades by this method in a search for carriers are, as a rule, unwarranted.

The specimen should be obtained from the mucous membrane ofthe naso-pharynx without contamination from the mouth or palate, because thepresence of saliva and of the normal buccal or pharyngeal bacteria interfereswith the subsequent detection of meningococci in the specimen. A considerabledegree of technical skill is essential in getting the specimen. In some cases aprotected swab (West swab) will be of service. The material from the naso-pharynxshould be placed at once on the surface of h?moglobin agar plates and keptwarm. It may be spread at once or after a brief interval, if more convenient.The medium is prepared by mixing ether-laked blood with Gordon's trypsin agar.Rabbit's blood or human blood (10 c. c.) may be used, laked by the addition ofether (5 c. c.) and distilled water (90) and added (1:50) to the melted agar,previously cooled to 45? C. The mixed medium is then poured into Petri dishes,allowed to harden, and warmed to 37? before use. After inoculation the platesare kept warm until transferred to the incubater at 37? C.

Identification of the meningococcus.-Gram-negativediplococci found in cultures from the cerebro-spinal fluid or from thecirculating blood should be subcultured to trypsin agar without bloodenrichment, for testing against specific agglutinating sera. Colonies ofGram-negative diplococci found on the plates inoculated with pharyngeal mucusrequire more critical scrutiny because other Gram-negative cocci are frequentlymet with on such plates. The colonies should be examined after 16 to 24 hoursincubation, first with the naked eye and then with a lens magnifying about 10diameters. The meningococcus colony presents a glistening appearance and has abluish-gray tint by reflected light (black background). It is transparent,colorless, or very slightly yellow, by transmitted light. Its margin is

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smooth and circular. The lenticular character of the colonyallows an inverted image of window bars or other objects to be seen by lookingthrough it. The colony less than 24 hours old shows no internal markings.

Suspicious colonies, whether derived from cerebrospinalfluid, circulating blood, or pharyngeal mucous membrane, should be transplantedto trypsin agar without h?moglobin enrichment. On the next day these culturesare examined by Gram's stain and then subjected to agglutination with specificserum. For this purpose the growth is suspended in salt solution, thoroughlyshaken, and heated in a water bath at 65? C. for 30 minutes to kill thebacteria and destroy the autolysin. To prepare the suspension of suitableconcentration for the tests, one measures out 0.1 c. c. into a clear test tube12 mm. in diameter. A measured amount of salt solution or of clear water is thenrun in from a burette or graduated pipette until the diluted suspension is justperceptibly turbid, read by daylight, in comparison with a control tube of thediluent. This end-point concentration is assumed to represent approximately100,000,000 cocci per cubic centimeter. One then calculates the approximateconcentration of the original suspension and the volume to which it must bediluted in order to obtain a suspension of approximately 2,000,000,000 cocci percubic centimeter. Salt solution, together with sufficient 5 per cent carbolicacid to furnish 0.5 per cent of this preservative in the final volume, is thenadded up to this volume and the whole thoroughly mixed. Such a suspension,heated, diluted, and phenolated, may be kept for several months.

For the agglutination test the specific sera to be employedare prepared in 1 to 100 dilutions and at the same time normal control sera ofhorse in 1 to 25 and 1 to 50 and of rabbit in 1 to 25 dilution. Equal volumes ofthe bacterial suspension and of the dilute serum are mixed ineach instance in a series of tubes so that thefinal serum dilutions are 1 to 200 for the immune sera and 1 to 50 and 1 to 100for the control normal horse serum and 1 to 50 for the normal rabbit control.All the tubes are plugged with colon or corks and immersed in a water bath at55? C. for 16 hours. Under these conditions a true meningococcus shouldnot be agglutinated in the normal control sera, but should be completelyagglutinated by one of the specific type sera and by the polyvalent immuneserum. Micrococcus flavus will be agglutinated in the normal control as well asthe others. For critical investigations it is well to employ agglutinating seraof each type in graded dilutions as well as polyvalent serum, and to control theactivity of each diluted serum by running it against a known standard-typesuspension at the same time that the unknown cocci arebeing tested. When a large number of cultures have to be tested under fieldconditions one will often employ only polyvalent diagnostic serum and the normalserum control.

The supply of meningococcus type sera available in theAmerican Expeditionary Forces is somewhat uncertain. Three sources of supply arebeing utilized and the sera supplied may be from any one of these. They aredesignated as follows:

I Rockefeller Institute meningococcus diagnostic type sera	II Pasteur Institute meningococcus diagnostic type sera	III Gordon meningococcus diagnostic type sera
Normal meningococcus.	Type A.	Type I.
Intermediate A.	Type B.	Type II.
Intermediate B.	Type C.	Type III.
Parameningococcus.	Type D.	Type IV.
Polyvalent.	Normal horse serum control.	Normal rabbit serum control.

The mutual relationships of the recognized types in thesedifferent classifications are still somewhat uncertain.

Serum treatment.-Aseptic technic is essential. Theserum should have a temperature of about 40? C. when injected. At the firstspinal puncture, when indicated, polyvalent antimeningococcus serum should beinjected at a rate not to exceed 2 c. c. per minute. The amount introducedshould be about two-thirds of the volume of spinal fluid withdrawn. Followingthe injection, the patient should lie with his head somewhat below the level ofthe buttocks to favor the diffusion of the heavier serum to the head.Immediately afterward, especially in severe cases, 50 to 100 c. c. of the serumshould be very slowly introduced

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intravenously, not faster than 1 c. c. per minute for thefirst 10 minutes, but at a gradually increasing rate after that if no untowardsymtoms appear.

In severe cases the spinal puncture should be repeated twiceat intervals of 8 to 12 hours, giving a further intraspinal injection of serumeach time. After that the interval may be lengthened to 24 hours. Even inpatients who show most marked improvement after the first injection, a secondpuncture after 24 hours, with injection of serum, should always be performed.The character of the spinal fluid withdrawn, in conjunction with the clinicalsigns, is a guide for continuing or stopping the intraspinal treatment.Repetition of intravenous injection is usually necessary also.

Anaphylaxis.-Serious intoxication from injection ofhorse serum is not likely to occur after intraspinal injection. It may occurwhen intravenous injection is done and, for this reason, the first part of theserum should always be introduced very slowly and the injection interrupted atthe first sign of distress. Hypersensitiveness to horse serum is often presentin persons who have previously been injected with serum, but it exists also inother persons.

To avoid the dangers of hypersensitiveness, 1 c. c. of theserum may be injected subcutaneously, followed after an hour by the slowintravenous injection of the full dose. Where time permits, one may first give asubcutaneous injection of 0.5 c. c. of serum diluted with 0.5
c. c. of salt solution, followed after 5 minutes by a secondsubcutaneous dose of 1 c. c. of serum, and 15 minutes later by a thirdsubcutaneous dose of 5 c. c. of serum. One hour later the intravenous injectionof the full dose should be begun. Injections should always be made slowly, withcareful attention to the patient's condition, and the serum should be warm wheninjected.

Fear of anaphylaxis should never prevent the use of serumwhen indicated. Careful technic and slow administration will go far to avoidserious accidents of this nature.

Contacts.-Military experience has shown that a singlecase of cerebrospinal fever, isolated and properly cared for as soon as thedisease is recognized, is ordinarily not followed by subsequent cases in hisimmediate associates. Those who have been immediately associated with thepatient, especially at mess and in sleeping quarters, should be segregated inroomy, light, and clean quarters and eat at a separate mess for a period of twoweeks, at the end of which period they may be returned to their properorganization, in the event that no other cases have developed. When, however,more than one case has appeared in a given small group of men, the immediateassociates require not only segregation but also bacteriological examination andtreatment.

The amount of time devoted to the examination of contactswill have to depend upon the circumstances, such as the extent and character ofthe epidemic, the number of contacts to be handled, and the amount of trainedhelp available for the purpose. It is not well to make a pretense of elaboratesurveys of contacts when the danger is not considered sufficient to warrantemploying the necessary personnel actually to do the work in an efficientmanner.

According to available facilities, the pharyngeal culture maybe taken only once, or a duplicate set may be made on the following day. In anycase the men should be segregated before the examinations are begun, and whenpossible those with coughs and colds should be segregated apart from the others.Separate, clean, airy, and light quarters under strict quarantine should beprovided for them. Their treatment as carriers should begin directly after thedesired number of specimens has been obtained for bacteriological examination.In addition to general hygienic measures such as cleanliness, good food,properly regulated work, play, and rest, the local antiseptic treatment of theupper respiratory passages may with advantage be tried. Various medicaments maybe used. Dichloramine-T in chlorcosane, administered by atomizer, is aconvenient agent with which to begin. This antiseptic treatment may prevent tosome extent the spread of the infection to previously uninfected men who may bein company with actual carriers while awaiting the result of the laboratoryexamination.

As soon as a negative result has been reached in these firstlaboratory examinations, the particular man may be released to his organization.In this way the number of men held in segregation can be very much reducedwithin two days. Suspicious or positive laboratory results warrant retaining therespective individuals in segregation for further observation.

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After six days the antiseptic treatment of the positive casesshould be discontinued for 24 hours before new cultures are taken, after whichthe treatment may again be continued. At the end of another week the treatmentshould be stopped for 24 hours before the third bacteriological examination. Thetreatment may then again be continued until the laboratory reports have beenreceived. All men found negative at these two examinations should be returned totheir organizations. The remaining men should be transferred to a segregationbarracks or available hospital formation for treatment as chronic carriers.

General hygienic measures.-In any command in which anoutbreak of cerebrospinal fever has developed, general measures should beinstituted at once to improve the living conditions and prevent the spread ofrespiratory infections among the men. Overcrowding in billets and barracksshould be relieved by placing part of the men in tents. Those with coughs andcolds should be quartered apart from the others. Distance between heads ofadjacent sleepers should be increased by head to foot arrangement of bunks, orthe bunks should be separated by wooden partitions or by shelter halves so hungas to separate the sleepers.

Sleeping quarters should be fully ventilated day and night,and blankets, mattresses, and clothing should be aired and exposed to sunlightdaily, weather permitting.

A special place for drying clothing should be provided, andclothing, wet or dry, should not be allowed at the head of the bunk.

Dust in quarters should be avoided by cleanliness and bydampening dirt floors with a disinfecting solution.

All personal equipment-mess kits, pipes, clothing, towels,toilet articles-must be used only by a single individual, and all mess equipmentwashed and rinsed in boiling water after use.

The entire command should be examined daily, preferably inthe afternoon, to detect beginning illness. Lounging in quarters during the dayshould be avoided, and sick should be hospitalized at once. Pillows should beprohibited unless they have been properly disinfected before being issued to newtroops.

Careless coughing and sneezing should be prohibited andpromiscuous spitting promptly and severely penalized. Gauze masks, not less thaneight thicknesses, or the combat gas masks, may be worn during cleaningoperations involving exposure to dust. The former should be immersed in boilingwater after use.

WALTER D. MCCAW,
Colonel, Medical Corps, Chief Surgeon.

Circular No. 63.
AMERICAN EXPEDITIONARYFORCES,
OFFICE OF THE CHIEFSURGEON, SERVICESOF SUPPLY,
December 30, 1918.

I. Roentgenograms.-Directions for selection andshipping of Roentgenograms for the Army Medical Museum, Washington, D. C.:

The commanding officer of each base or camp hospital in theAmerican Expeditionary Forces will have all Roentgenograms on file in hishospital examined by the hospital Roentgenologist with a view to selecting thosesuitable for preservation in the Army Medical Museum. In hospital centers orgroups the work should be done under the direction of the consultingRoentgenologist for the group.

The following directions will be observed:

1. Discard all technically imperfect plates unless of unusualinterest.

2. Discard all normal or negative plates.

3. In selecting plates, emphasis should not be placed uponthe bizarre or unusual. It should be kept in mind that this collection ofRoentgenograms is to be used especially for teaching purposes.

4. Gastro-intestinal and genito-urinary plates are notdesired unless related to war trauma.

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5. Plates especially desired are those of good technicalquality illustrating all war wounds and diseases of the chest.

6. Each plate or film should be plainly marked with the date,patient's name, number, and organization.

7. Each plate or film will be accompanied by the clinicalhistory; autopsy records, if any; personal observations by the Roentgenologist;and all other data throwing light on the case.

8. Plates should be packed with great care, having in mindthe special liability to breakage in overseas shipment. The plates should beplaced face to face in pasteboard boxes and then in wooden cases well protectedwith excelsior, paper, or straw. Each box will be marked in both French andEnglish to denote the fragile nature of its contents.

9. Films should be packed in tin cases and sealed.

10. Each box should be numbered and addressed to the ArmyMedical Museum, Washington, D. C., via -------------------------- (port).

11. When shipment is made, Col. Joseph E. Siler, centrallaboratory, Dijon, will be notified of the fact giving the number of the Frenchordre de transport, number of car in which shipped, and the name of the port towhich shipped.

12. The senior consultant in Roentgenology will be notifiedby letter when shipment is made, giving the number of plates and films shipped,the ordre de transport number, and number of the car.

13. Any additional advice needed may be obtained by letter tothe senior consultant in Roentgenology, headquarters medical and surgicalconsultants, A. P. O. 731.

II. Epidemic disease.-Pursuant to request of theFrench Service de Sante, the chief surgeon directs that the surgeons of allorganizations and commanding officers of medical units promptly notify the localFrench military and civil authorities upon the appearance in their organizationof any epidemic disease.

Attention is called to the general neglect by medicalofficers, particularly those of hospital formations, base, camp, and field, ofthe requirement that they shall notify the local French military and civilauthorities (the m?decin chief de place and the mair? or prefet) of all casesof communicable diseases as soon as diagnosed or admitted to their organization.The letter from the chief surgeon, line of communications, of January 28, 1918,is quoted, and compliance will be expected.

It is of considerable importance that every case of any ofthe diseases specified in Section XII, Sick and Wounded Reports, be reported tothe French authorities at the same time that it is reported to the chiefsurgeon, A. E. F.

III. Vacancies in permanent Medical Corps.-The SurgeonGeneral writes as follows to the chief surgeon, A. E. F.:

There is, at present, a large number of vacancies in thepermanent Medical Corps of the Army, and it is desired to take advantage of thepresent conditions to fill them with desirable men-preferably with those whohave had some military service in the present war.

It is therefore requested that you give careful considerationto the selection of suitable officers and that you make a special effort tointerest medical officers who have demonstrated their ability and fitness.

The attention of all medical officers who may be consideringentry into the regular corps is called to the fact that rank therein dates fromentry, and, if they should decide that they wish to remain in the Armypermanently, each week of delay may mean loss of rank which would affect themduring their entire service.

IV. Commutation value of the ration.-This office hasbeen advised by the chief quartermaster that the commutation value of the rationhas been fixed at $0.58 for the months of January, February, and March, 1919.Amounts collected by hospitals from local quartermasters should therefore be$0.68 or $0.83, according to whether or not commissary privleges are available.

V. Clothing for army nurses.-The chief quartermasteradvises that he has now in stock hats, overcoats, Norfolk suits, gray warduniforms, raincoats, shoes, rubbers, silk and cotton waists, and that thosearticles of clothing are for free issue to all Army nurses whose pay does notexceed $75 per month. Commanding officers of base hospitals and hospital cen-

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ters will consolidate the requisitions submitted by thevarious members of their unit, and submit same direct to the office of the chiefquartermaster, care being taken to furnish exact sizes of shoes and othergarments desired.

Requisitions will be restricted to actual requirements only.All requisitions must be approved by chief nurses, who will assure themselves ofthe actual need of articles requested.

Sales to nurses whose pay exceeds $75 per month will be madeat cost prices as follows:

Shoes	$6.31
Silk waists	$5.22
Overcoats	$27.86
Norfolk suits	$30.00
Raincoats	$5.60
Hats	$3.17
Uniforms, gray, ward	$3.00
Waists, cotton	$ .73

VI. Paragraph 229, Manual for the Medical Department, 1916,is changed, as follows:

229. Upon the discharge from the hospital of patientspermanently disabled, they may retain the appliances then in their use which arenecessary for their comfort and safety; and the accountable officer will dropthe same from his next return of medical property, submitting a certificateexplaining the circumstances as a voucher for so doing, to which will beappended the patient's receipt for the appliance.

VII. General office supplies.-Attention is invited toGeneral Order 50, headquarters, Services of Supply, transferring the procurementand distribution of standard office supplies, heretofore issued by the MedicalDepartment, to the chief quartermaster. The following items are excepted fromthe provisions of this order, and will be required for as heretofore by MedicalDepartment units:

Books, prescription, paragraph 240.
Binders, loose-leaf, for medical history of post.
Files, Shannon, for clinical history.
Labels, for dispensary sets.
Labels, for vials.
Labels, poison, assorted.
Pads, prescription.

Requisition for office supplies (stationery, office furniture,etc.) will in the future be made on the Quartermaster Department by all MedicalDepartment units.

VIII. Baggage of patients.-Commanding officers of allbase, camp, and evacuation hospitals will notify the central baggage office, A.P. O. 713, Gievres, of the respective departure for the United States of sickand wounded, under their care, and of the location of their baggage,as well as a list of all patients who have already been evacuated.This information will greatly assist the baggage service in getting baggage toits owner before the owner departs for the United States.

IX. Publications.-The War Department desires completefiles of all publications made by different organizations in the AmericanExpeditionary Forces.

Complete files, whenever possible, will be forwarded to J.Terquom, Paris agent for the Library of Congress, No. 19 Rue Scribe, Paris. Thisoffice will be notified whenever files of a publication are forwarded to Paris.

X. Proper papers to accompany men evacuated from basehospitals.-Reports are being received that base hospitals are careless inforwarding men to base ports for evacuation to the United States without properpapers. The greatest care must be exercised by all base hospitals evacuatingpatients to base ports to see that all papers are complete, with proper numberof copies of each paper, especially those relating to disability boards andorders directing travel. These points have been covered many times, and itappears that they are not being followed in a conscientious and painstakingmanner.

XI. Broken splints.-Instructions previously issued,directing the shipment to splint repair shop, Dijon, of broken splints, arehereby revoked. In view of the fact that this shop has been discontinued, thesesplints will in the future be turned in to the nearest medical supply issuedepot.

WALTER D. MCCAW,
Colonel, Medical Corps, Chief Surgeon.

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Circular No. 64:

AMERICAN EXPEDITIONARYFORCES,
OFFICE OF THE CHIEFSURGEON, SERVICESOF SUPPLY,
January 7, 1918.

I. Hospital fund.-(1) Organizations returning to theUnited States: All medical organizations in the American Expeditionary Forceswhich are under order to return, or which in the future receive orders toreturn, to the United States as a unit shall, as long before their departure asis practicable, close out their accounts, and send in a complete report to thisoffice (finance and accounting division) of the condition of the hospital fund,giving in detail any accounts which remain unpaid or amounts due to the fundwhich remain uncollected, together with the number of enlisted personnel in theunit. Instructions will be issued by this office as to what portion of the fundmay be retained by the organization. The balance, if any, will be forwarded tothis office, to be credited to the United States Army hospital fund; checks ornegotiable papers being made payable to "trustee, United States Armyhospital fund." The final account will be audited by the hospital council,and the proceedings shown in the face of the statement.

(2) Organizations disbanding: Any organization which disbandsor for any other reason ceases to exist as a unit will submit, after audit bythe hospital council, a final statement on Form 49, M. D., showing theproceedings of the council, properly signed on the face of the statement, andturn in all funds to this office to be credited to the United States Armyhospital fund; checks or negotiable papers being made payable to "trustee,United States Army hospital fund." Upon receipt and acceptance of the finalstatement the custodian will be cleared of all accountability for the funds ofhis organization.

(3) Transfer of funds: No organization under orders todisband or return to the United States shall transfer funds to any organizationwithout authority from this office.

(4) Disposal of funds: Custodians of funds will be heldresponsible for the improper disbursement of the funds for purchases of articleswhich are not proper expenditures from the hospital fund.

(5) Transfer of fund: Any officer who is custodian of a fundand who is transferred from his organization, or for any other reason is to beabsent for a period of more than l0 days, will submit a final statement on Form49, M. D., showing the following properly signed certificates:

I certify that to the best of my knowledge the following is acomplete and accurate statement of all outstanding debts and obligations payablefrom this fund, and to have transferred to my successor--------------------------------------- , the sum of --------------------------,being the balance on hand this date of the hospital fund of----------------------------------------------------------------------------------------------------.

I certify to have received the sum of---------------------------------, from------------------------------------------------------------------------------------------------
being the balance on hand this date of hospital fund of-----------------------------------------------------------------------------------------------------------.

Until the final statement bearing the above properly signedcertificates is received, the present custodian will be held responsible for thefunds of his organization.

II. Purchase of medical supplies.-All purchases ofmedical supplies in Paris will be made through the office of the medicalpurchases, room 507, Elysee Palace Hotel, in that city, when same are properlyauthorized.

The practice of obtaining medical supplies from the FrenchGovernment through local Service de Sante formations, and having same voucheredto the Medical Supply Department, United States Army, payment to be made onconsolidated bill by a medical disbursing officer, will be discontinued at once.

Authority for purchases must be obtained before purchase ismade from the chief surgeon, A. E. F., except on purchases covered by Circular15, paragraph 4, office of the chief surgeon, dated December 15, 1917, whichapplies to detached base hospitals, and Circular 43, paragraph 9, dated August1, 1918.

Hereafter a copy of the authority for purchase will accompanythe voucher; this in addition to the usual notation of authority on the face ofthe voucher. Copy of Form No. 12 accompanying the voucher will have enteredthereon the property voucher number of the accountable officer.

III. History and clinical records.-Reports have beenreceived in this office that proper histories and clinical records, includinglaboratory and X-ray blanks, are not being

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forwarded with patients evacuated to the United States. Suchhistory and clinical record as may be necessary for the proper care andunderstanding of the case must accompany each patient upon his evacuation.

IV. Operations.-It has been evident for some time thata large number of operations are being performed that are not absolutelynecessary. In this connection attention is called to Circular 37, office ofchief surgeon, June 22, 1918, with special reference to paragraph 4 thereof.

V. Leather jerkins available for issue to Army nurses.-Leatherjerkins are now available for issue to Army nurses. Requisition therefor shouldbe made upon the local quartermaster, approved by the chief nurse of the unit,stating that the nature of the nurse's duty requires the jerkin.

VI. Returning class A patients to duty.-In returningclass A patients to duty with organizations, men must be equipped with thefollowing: 2 blankets, 1 overcoat, 1 blouse, 1 pair breeches, 1 suit ofunderwear, 2 pairs socks, 1 pair shoes, 1 overseas cap, 1 mess kit, toiletarticles. Requisitions will be made immediately on the Quartermaster Departmentand Ordnance Department to carry these instructions into effect.

Before returning men direct to organizations, theorganization commander will be telegraphed as to ability to receive them.

VII. Y. M. C. A. patients in military hospitals.-Y. M.C. A. secretaries and workers who are patients in military hospitals for woundsor any other cause will, when able to travel, be sent to the Paris headquartersof the Y. M. C. A., where adequate arrangements are made for their future careand transportation.

VIII. Vaccination against typhoid and paratyphoid fevers.-Typhoidfever has been recognized in several different organizations in the AmericanExpeditionary Forces, especially those recently engaged in active militaryoperations. Medical officers should be on the alert to detect this disease earlyin its course. Typhoid and paratyphoid fever should be considered in thedifferential diagnosis of all obscure pyrexias. Early blood culture is advised.

Triple typhoid lipo-vaccine is available for immunization ofthe men of those organizations in which outbreaks of these fevers have appeared.Whenever as many as two cases occur in the same company, within a period of onemonth, the vaccination of the entire company is advised. If scattered casesamounting to one-half of 1 per cent of the strength of the organization occur ina battalion or a regiment, within a period of one month, immediate inoculationof the entire organization with lipo-vaccine should be undertaken. Only one doseof this vaccine is required. It must be injected into the subcutaneous areolartissue. The precautions and contraindications are the same as for the salinevaccine previously employed. In this connection your attention is invited toCircular 59, this office.

IX. Lice.-Reports still continue that patients areevacuated from base hospitals who are lousy. This reflects not only upon thecleanliness of the hospital but the care and administration as well. Commandingofficers will take proper steps to see that every patient is carefully examinedand when found infested with lice will have effective treatment for theireradication.

X. Convalescent home for nurses at Antibes, near Cannes.-TheAmerican Red Cross has opened another convalescent home for nurses at Antibes,near Cannes. Eighty nurses can be cared for after January 6 and a maximum of 200about January 15. All convalescent nurses should go to Antibes, and arrangementsshould be made before they leave their stations to secure reservations at Paris.Many convalescent nurses are reported to have arrived at Cannes physicallyexhausted on account of difficulty in securing accommodations on board thetrain.

Commanding officers of Medical Department formations will inthe future forward to this office a carbon copy of their daily reports on FormsNos. 647 and 648, A. G. O.

XI. Neuropsychiatrists.-The senior consultant inneuropsychiatry recommends, and this office approves, the retention ofneuropsychiatrists in tactical divisions. In at least one case, the divisionneuropsychiatrist has been relieved from duty with the division because noallowance was made for his assignment to the division by tables of organization.This difficulty could easily be obviated by assigning him to the Sanitary Train.

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XII. Quartermaster personnel.-Upon the abandonment ofhospitalization from various places, commanding officers concerned areinstructed that all Quartermaster Corps personnel, not pertaining to statutoryunits, as they become surplus will be sent to the Quartermaster casual depot,Camp Clayton, Chateau-du Loir (Sarthe), and the chief quartermaster notified ofaction taken.

WALTER D. MCCAW,
Colonel, Medical Corps, Chief Surgeon.

Circular No. 65.
AMERICAN EXPEDITIONARY FORCES,
OFFICE OF THE CHIEF SURGEON, SERVICES OF SUPPLY,
January 15, 1919.

I. Monthly reports, sick and wounded.-The followingcircular letter, Surgeon General's office, November 14, 1918, is quoted for theinformation of all:

1. All responsible medical officers are urgently requested toprepare and forward as soon as practicable after the close of the calendar yearall the monthly reports of sick and wounded for the year.

2. It is recognized that in large hospitals, and particularlyduring extensive epidemics, that it is impossible to prepare and forward thereport within five days as required by the N. M. D. Certainly, however, itshould be possible to prepare and forward the reports some time during thesucceeding months. In many instances reports are several months delinquent.Requests for information are being constantly received from other Governmentagencies for information which it is difficult or impossible to furnish for thisreason. It was impossible to begin the final tabulation of the statistics forthe year 1917 until the 1st of May of the year 1918 because so many reports weredelinquent. Even after the 1st of May, 1918, a good many reports for the year1917 were received.

3. Reports for the year 1918 must be forwarded to this officenot later than January 31, 1919.

II. Salvage of supplies belonging to the British andFrench medical services.-(1) All supplies received in salvage belonging tothe British medical supply service should be shipped to ordnance officer,Graville, Le Havre.

(2) All medical supplies received in salvage belonging to theService de Sante medical service should be disposed of as follows: A listcovering the property in question in each "region" should be sent tothe "directeur du Service de Sante" of the region concerned, who willissue instructions covering its disposition.

III. Registrars.-The attention of all registrars iscalled to typographical error in Manual of Sick and Wounded Reports for theAmerican Expeditionary Forces. In Section XI, paragraph 1, line 6, theparentheses should read "(See Sec. VI, par. 7, and Sec. VIII)."

In the monthly sick and wounded report the cases transferredto the United States differ in no way from cases completed in other mannerexcept that the field medical envelopes and contents accompany the patientinstead of being forwarded as a part of the report.

IV. Gas for an?sthesia.-Hereafter nitrous oxide gasand oxygen will be furnished by medical supply depots only. Empty nitrous oxidetanks will be shipped to American Red Cross nitrous oxide plant, Montereau(Seine-et-Marne), and empty oxygen tanks to the nearest medical supply depot.

V. Nurses.-(1) Incidents have occurred where Armynurses traveling under orders changing station, and nurses suffering fromphysical disability traveling between hospitals or to base ports for return tothe United States, have encountered great difficulties and discomforts atrailroad stations, in boarding trains, in securing seats, in changing cars, andat places of arrival, and have occasionally had to spend the night in railroadstations.

(2) Hereafter it will be the duty of commanding officers ofhospitals or other units forwarding nurses to see that seats are obtained andthat nurses and their baggage are put aboard trains, and, after a study of thetime-tables and changes, to telegraph the commanding officer of any hospital atplaces where changes of trains are made, or at places of destination, or tosurgeons of base sections in the case of nurses arriving at base ports, givingthe number of nurses, the time of arrival, and destination.

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(3) It will be the duty of any medical officer receiving thismessage to have some one meet the train, arrange for transportation, assistancewith baggage, place to remain at hospitals or other suitable quarters overnightwhen necessary, to notify the medical officer at the next place where assistanceis desired, and to give any help that may be required.

VI. General Order No. 1, c. s., headquarters, Services ofSupply.-The attention of all commanding officers of Medical Department unitsis invited to General Order No. 1, c. s., headquarters, Services of Supply.

VII. Special articles of clothing not issued generally.-Thecommanding general, Services of Supply, directs that commanding officers of allhospitals handle special articles of clothing not issued generally to allenlisted men in such a manner that they will be returned to their originalowners in a serviceable condition upon their discharge from the hospital.

VIII. Neuropsychiatric patients.-In the future noneuropsychiatric patients will be transferred to Base Hospital No. 117, LaFauche (Haute Marne). This hospital is in the process of being closed andabandoned.

IX. Improper classification of patients in hospital.-Manyreports, general and specific, are being received regarding improperclassification of patients in hospital. Men have been returned to duty as classA before their wounds were properly healed and when dressings have beennecessary. It is imperative that greater care and attention be given to theproper classification of patients in hospital. Commanding officers will, eitherpersonally or by delegation of a thoroughly reliable medical officer,supervise this work. The reports received reflect seriously upon the care andattention given by classification boards to the patients in hospital.

X. Baggage department.-Regarding the establishment ofa baggage department and the handling of baggage of patients in hospital,attention of commanding officers of all hospitals is invited to Bulletin 48,headquarters, Services of Supply, December 3, 1918, and General Orders, No. 62,December 5, 1918, headquarters, Services of Supply.

XI. Typhoid fever and paratyphoid fever.-All medicalofficers, and especially those in charge of hospitals, and particularly those onduty in medical wards of hospitals, are advised to note carefully and followprecisely the precautions with regard to the handling, diagnosis, and releaseafter convalescence of cases of suspected or diagnosed typhoid and paratyphoidfevers, as given in sections 184 and 185, of Article III, of the Manual of theMedical Department:

184. Early detection of all cases of typhoid fever isnecessary, especially those of mild or ambulant type, and of all typhoidcarriers or excretors. Undetermined fevers should be regarded with suspicion andhandled like typhoid until that disease is excluded. Specimens of blood fromsuspected cases should be sent promptly to the nearest laboratory for diagnosis.

185. No patient convalescent from typhoid should be releasedfrom isolation until three successive examinations of his stools and urine,collected at six-day intervals, have shown him to be free from typhoid bacilli.

XII. Commanding officers of hospitals to notify commandingofficers of organizations.-In view of the present prevalence of typhoidfever in the American Expeditionary Forces, it is directed that commandingofficers of hospitals notify by telegraph the commanding officers oforganizations from which the patient has been admitted, as soon as a case oftyphoid or paratyphoid fever has been suspected or diagnosed. This report willbe sent at the same time as, and in addition to, the telegraphic report sent tothe office of the chief surgeon, in compliance with Section XII of the Sick andWounded Reports.

XIII. Professional reports.-The office of the directorin charge of professional services has been closed in our reports. Allprofessional reports required by consultants should be forwarded direct to theoffice of the chief surgeon.

XIV. Class A men.-Surgeons of the base ports who arecharged with the evacuation of patients report that there are an increasingnumber of class A men, or men to become class A shortly after their arrival inport hospitals, being evacuated to base ports with the idea of their being sentto the United States. This is contrary to all instructions. Commanding officersand evacuating officers will give special attention to this and see that none ofthis type of patients are sent to the ports.

WALTER D. MCCAW,
Colonel, Medical Corps, Chief Surgeon.

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Circular No. 66:

AMERICAN EXPEDITIONARYFORCES,
OFFICE OF THE CHIEFSURGEON, SERVICESOF SUPPLY,
February 4, 1919.

I. Cafeteria system of messing patients.-(1) Duringthe crisis when personnel and equipment were being worked to the utmost limit,the line, or cafeteria, system of feeding patients was in many cases the onlypracticable one.

(2) Now that the number of patients is reduced to the normalcapacity of the units it is desired that the table service be substituted forpatients as rapidly as possible.

(3) Inspectors have reported on the presence of patients inpajamas and gowns standing in line in inclement weather. This should under nocircumstances be allowed to occur, and the substitution of table service forline will prevent this most undesirable condition.

(4) It is not expected that the table service can be used inall cases for large personnel and casuals on duty status, as in these cases theline system is perhaps the only feasible one. It is, however, desired thatpatients will not be messed in the line system.

II. Sales of excess medical property.-Sales to privateindividuals or associations can only be made through the French Government andshould be taken up with the "bureau liquidation stocks de guerre,"giving a list of medical supplies wanted with sufficient description to enablethe supply department to identify items requested with regular stock. Sales maybe made direct to all Governments of the Allied forces, Red Cross, Y. M. C. A.,and Knights of Columbus. Requests from all these latter sources should beforwarded to the office of the chief surgeon, A. E. F., with a list of itemsattached. The final decision covering all sales is made by the general salesboard under instructions of the War Department.

III. Accountability for medical supplies.-Section 3,Circular 3, office of the chief surgeon, line of communications, is herebyrescinded. All property received from whatever source, such as Red Cross,donation or purchase, will be taken up and accounted for in the same manner asregular supplies. All initial equipment of hospitals from the United Stateswhose initial equipment camp from the Red Cross sources should be taken up onproperty return.

Property belonging to the French Government, Service de Sante,to hotels under lease, etc., that has not been purchased by the United StatesGovernment will not be taken up on property return.

IV. Hospital funds-collection of amounts due from officerpatients.-Referring to collection of amounts due to fund from officerpatients as provided for in Bulletin No. 40, headquarters, Services of Supply,1918, every effort will be made, by correspondence or other suitable method, tosecure payment of amounts due from officers indebted for subsistence receivedwhile undergoing treatment, in order that the number of names placed upon theQuartermaster Corps stoppage circular may be reduced to a minimum. Attention isinvited to the fact that Bulletin No. 40, headquarters, Services of Supply,1918, affords a method of collection only after every other means of collectionby direct correspondence has been exhausted without success, and that it was notthe intention to relieve commanding officers, custodians of funds, or messofficers from responsibility in regard to such collections. In future, requeststo place delinquent accounts upon stoppage
circular must be accompanied by statement covering details ofefforts previously made to collect such accounts.

V. Narcotics.-In view of that fact that soldiers ofthe Medical Department have been recently arrested for selling morphine andcocaine stolen from the Medical Department, the attention of officers is invitedto the importance of carefully carrying out the regulations as prescribed inparagraphs 240 and 241, Manual of the Medical Department, for the care ofnarcotics. They should be kept at all times under lock and key, and theexpenditures checked up to the end of each month against the prescriptions. Careshould be taken not to carry on hand too large a stock of these drugs, andquantities in excess should be turned into a medical supply depot. Care shouldbe taken not to dispense narcotic drugs by salvage, as it is difficult to keeptrack of them in this way. They should in all cases where practical be turnedinto medical supply depots direct.

VI. Hospital fund.-The second certificate mentioned insection 1, paragraph 5, Circular No. 64, dated January 7, 1919, is herebyamended to read as follows:

I certify to have received the sum of ----------, from---------------------------------------------------------, being the balance onhand this date of hospital fund of-----------------------------------------------------------.

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VII. Daily reports of changes.-Commanding officers ofMedical Department formations will forward to this office carbon copies of theirdaily reports of changes on Form 647 and 648, S. D., A. G. O.

VIII. Daily reports of casualties and changes.-In thefuture daily reports of casualties and changes, on Forms 647 and 648, will berendered separately for the permanent Medical Department personnel of thehospitals and for casual detachments of patients and convalescents.Consolidation of these reports on one sheet leads to confusion in the centralrecords office.

IX. Orders for return of Medical Department organizationsto the United States.-The provisions of paragraph 2, section 5, EmbarkationOrders, No. 13, will be complied with only after receipt of formal orders forthe return of the Medical Department organizations to the United States. A greatdeal of confusion is resulting at present through commanding officers of basehospitals and other Medical Department units reporting to G-1, theseheadquarters, after receipt of notice from this office that they were to preparefor return to the United States. This notification is not final notice, which isonly given by G-4, these headquarters.

X. Class B and C men.-Many men evacuated fromhospitals as of class B and C are still being received at the Americanembarkation center, Le Mans, presumably intended for return to the UnitedStates. The second depot division was discontinued at this place in accordancewith telegram No. 446, G-1, Services of Supply, on December 7.

The above practice will be discontinued, and the menforwarded in accordance with General Orders, No. 5, general headquarters,January 5, 1919.

XI. Colored soldiers.-Complaint has been made thatcolored soldiers have been erroneously evacuated from hospitals to organizationsconsisting only of white men. This causes considerable difficulty in quarteringand messing the colored men pending their departure for their properorganizations. The only colored divisions which have formed a part of theAmerican Expeditionary Forces have been the 92d and 93d. Care will be exercisedin evacuating this class of patients to prevent cause for complaint.

XII. Lost baggage of patients.-Paragraph 2, CircularLetter No. 24-A, in which it is directed that communications regarding lostbaggage of patients should be addressed to lost baggage bureau, Tours, France,is changed to read "central baggage office, Gievres, A. P. O.
713," in accordance with General Orders 62, Services ofSupply 1918.

XIII. Members of the Army Nurse Corps.-Since theappearance of members of the Army Nurse Corps, either singly or in groups, whenthey are traveling or after they reach the United States will be the onlyindication to the casual observer of the discipline, morale, and the standardsof those in responsibility for them and the standards which they have made forthemselves, it is most important that instead of relaxing their efforts now thatthe time of demobilization draws near, chief nurses should continue to makeevery effort to enforce the regulations in regard to the wearing of uniform.

XIV. Priority lists in selecting cases for evacuation.-Complaintshave been made that hospitals have not made use of priority lists in selectingcases for evacuation. It is appreciated that many features enter into theselection of a group of men for transfer to the United States. It is desirable,however, that, when compatible with existing instructions, those who have beenawaiting evacuation longest should be given preference to avoid discontent onthe part of patients and any semblance of injustice.

XV. Recruiting of military police.-Authority has beengiven to the provost marshal general to established recruiting parties in allServices of Supply hospitals for the purpose of recruiting military police fromclass A men. Commanding officers of hospital centers and base hospitals willgive all assistance possible to these parties.

XVI. Ordnance property.-The chief ordnance officer hasdirected that the following disposition be made of ordnance property uponabandonment of hospitals: Unserviceable web leather and miscellaneous equipmentto intermediate salvage depot No. 8, St. Pierre de Corps; rifles, revolvers, andpistols to ordnance repair shop, Mehun; serviceable mess and personal equipmentto intermediate ordnance depot No. 2, Gievres.

WALTER D. MCCAW,
Colonel, Medical Corps, Chief Surgeon.

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Circular No. 67.

AMERICAN EXPEDITIONARYFORCES,
OFFICE OF THE CHIEFSURGEON, SERVICESOF SUPPLY,
February 8, 1919.

I. Typhoid and paratyphoid fever.-Date of onset oftyphoid and paratyphoid fever: All commanding officers of hospitals in theAmerican Expeditionary Forces, when reporting suspected cases of typhoid orparatyphoid fever, or a case in which the diagnosis is based on clinicalgrounds, or a case proved by laboratory methods to be typhoid or paratyphoid, incompliance with Section XII, Sick and Wounded Reports, will add to the data nowrequired by telegram the word "onset" and the date of the appearanceof the initial symptoms of the disease; i. e., the date when the patient firstfelt really ill. This date is to be obtained by careful inquiry into the historyof each case; the day when the patient first reports sick or when he is admittedto hospital or when he first goes to bed is not necessarily the date of onset ofthe disease and is not uncommonly a week or more after the true date of theonset of the disease as diagnosed by careful clinical history.

In order to accomplish effective control of typhoid andparatyphoid fever the personal attention of the commanding officer of everyhospital formation in the American Expeditionary Forces must be given to thisdetailed report. The office of the chief surgeon can then give immediate andaccurate information to surgeons of organizations which will permit of theirdiscovery of cases and the tracing of the source of infection among the troops.

Typhoid and paratyphoid fever to be reported on clinicaldiagnosis: In order to comply with Section XII, Sick and Wounded Reports, thefollowing will be observed:

(a) All suspected cases of typhoid and paratyphoidfever must be reported as such by telegram without waiting for clinical orlaboratory confirmation.

(b) All cases which present a clinical picture ofthese diseases must be reported as clinical typhoid or paratyphoid as soon asthe diagnosis of typhoid or paratyphoid is made.

(c) All cases in which the diagnosis of typhoid orparatyphoid is confirmed by bacteriological methods or by autopsy must bereported as proved cases of these diseases.

(d) Cases originally reported as suspected or clinicalcases of typhoid or paratyphoid, if subsequently proved by laboratory methods orby autopsy to be cases of these diseases, must be again reported indicating thatthey are now proved cases.

(e) If cases originally reported as suspected orclinical typhoid or paratyphoid are found subsequently not to have either ofthese diseases, correction of report must be made, by telegram, giving change ofdiagnosis.

(f) Individuals who are found to be excreting typhoidor paratyphoid bacilli in stools or urine, but who have not been sick recentlywith a disease resembling typhoid or paratyphoid, must be reported as carriers.These individuals may be temporary or permanent carriers.

(g) Individuals who are found to be excreting typhoidor paratyphoid bacilli in stools or urine and who have recently had a febriledisease known to be typhoid or paratyphoid, or a disease which in the absence ofproof to the contrary and in the face of known facts might have been typhoid orparatyphoid, must be reported as convalescent carriers.

In all instances reports to the chief surgeon will be bytelegram.

II. Evacuation of typhoid carriers.-Whenever itbecomes necessary or desirable to evacuate a carrier of typhoid or paratyphoidfever to the United States, the carrier shall be evacuated as a patient on sickreport. The office of the chief surgeon shall be notified of the name, rank,organization, and home address of the patient as well as of the fact and date ofsuch evacuation. A special communication calling attention to the fact that theman is a carrier and that special precautions must be taken to avoid spread ofinfection shall be sent with the transfer slip or field medical card whichaccompanies the patient.

III. Reports.-The attention of all medical officers isinvited to the fact that personal reports of change of status should be renderedto this office as promptly as possible and that monthly personal reports shouldinvariably be mailed on the last day of the month. These reports have beenneglected to a great extent through the active operations of the past year, andit has been very difficult to keep track of locations and status of officers.

IV. Daily reports of changes of hospital personnel andpatients.-The attention of all commanding officers of Medical Departmentunits is invited to Section IV, General Order No. 16, c. s., generalheadquarters, A. E. F.

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V. Psychiatric department, hospital center, Allerey.-Attentionof all concerned is directed to the fact that the psychiatric department for thereception, observation, early treatment, and evacuation of mental cases is nolonger in operation at the hospital center, Allerey. Paragraph 2 ofCircular Letter No. 35-A should be corrected accordingly.

VI. Base hospitals abandoned and being abandoned: (1)The following listed base hospitals have closed their records and ceased tofunction on the dates shown in each case:

Base Hospital No. 20, Chatel Guyon (Puy de Dome), January 20, 1919.
Base Hospital No. 30, Royat (Puy de Dome), January 20, 1919.
Base Hospital No. 66, Neufchateau (Vosges), December 31, 1918.
Base Hospital No. 117, La Fauche (Hte. Marne), January 12, 1919.

(2) The following base hospitals are being abandoned:

Base Hospital No. 83, Revigny (Meuse).
Base Hospital No. 71, Vauclaire (Dordogne).
Base Hospital No. 202, Orleans (Loiret).
Base Hospital No. 236, Quiberon (Morbihan).
Base Hospital No. 218, Poitiers (Vienne).

(3) Hospitalization at the following places has been abandoned:

Pau (Basses Pyrenees).
Lourdes (Haute Pyrenees).
Caen (Calvados).
Autun (Saone et Loire).

VII. Circulars Nos. 73 and 75, War Department.-CircularNo. 73, War Department, November 18, 1918, and Circular No. 75, War Department,November 20, 1918, relating to the discharge of officers and soldiers, mentionedin Circular No. 61, dated December 18, 1918, this office, have been republishedin General Order No. 230, general headquarters A. E. F., December 16, 1918.

VIII. Hospitals to be furnished with dubbin, or shoepolish.-(1) By direction of the commander in chief, A. E. F., all hospitalswill keep on hand, for use of hospital detachments and patients, a supply ofdubbin, or shoe polish, to be used on the shoes. Commanding officers ofhospitals will insist on shoes being treated with this material.

(2) Should a supply of dubbin, or shoe polish, not be onhand, requisition will immediately be made for this material.

WALTER D. MCCAW,
Colonel, Medical Corps, Chief Surgeon.

Circular No. 68.

AMERICAN EXPEDITIONARYFORCES,
OFFICE OF THE CHIEFSURGEON, SERVICESOF SUPPLY,
February 8, 1919.

I. Accountability for medical property.-Disbursingofficers, property officers at medical supply depots, including base storagedepots, also at base hospitals and at schools, will continue to account formedical property, as required by existing orders.

Formal accountability for medical property is not requiredfrom any other officers.

Invoicing and receipting for supplies transferred bydisbursing officers, property officers at medical supply depots, base hospitals,and schools will be done in the manner prescribed by Army Regulations and Manualfor the Medical Department, but the receipts given by all other officers thanthose above mentioned will be for the sole purpose of clearing theaccountability of the issuing officer.

Officers who are relieved from formal accountability formedical property which is in their care or under their control must rememberthat their duty to protect the interest of the Government is in no waydiminished thereby. Attention is called to Section II of General Orders, No. 74,as to their duty in this connection and as to the means which will be taken toenforce proper care and use of Government property.

II. The attention of all officers coming to Tours is invitedto the fact that the address of the finance and accounting division is No. 4,Rue de Clocheville, and that the sick and wounded division is at No. 17, PlaceForre-le-Roi.

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III. All medical officers are directed to remove thefollowing drugs from salvage before turning same in to salvage depots: Morphine,cocaine, heroin, codeine, chloral, and opium preparations.

These drugs will be sent to the nearest medical supply depotby courier, with list covering shipment; depot officer concerned receiptingthereon.

WALTER D. MCCAW,
Colonel, Medical Corps, Chief Surgeon.

Circular No. 69.

AMERICAN EXPEDITIONARYFORCES,
CHIEF SURGEON'SOFFICE, SERVICESOF SUPPLY,
February 17, 1919.

TYPHOID-PARATYPHOID FEVERS

I. INTRODUCTION
In view of the appearance and continued incidence offevers of the typhoid-paratyphoid group in many units of the AmericanExpeditionary Forces during the past five months, it is deemed essential toreview this subject at the present time, particularly from the viewpoint ofearly diagnosis, prevention, and control.

The occurrence and distribution of typhoid-paratyphoid in ourtroops has constantly and continuously been brought to the attention of allmedical officers serving with the A. E. F. through the medium of the WeeklyBulletin of Diseases. It would appear, however, that many officers have utterlyfailed to grasp the significance of these reports and warnings, a fact which maybe due to a false sense of security under the popular belief that vaccinationagainst typhoid and paratyphoid gives a complete immunity even in the midst ofgross unsanitary conditions.

Notwithstanding the fact that typhoid and paratyphoid feversare endemic in the United States, and in spite of our extensive experience withthese diseases during the Spanish-American War and, later, during the period ofmobilization on the Mexican border, it is evident that many medical officershave gained but little knowledge of the fundamental principles underlyingprevention and control. It is also quite evident that some medical officers aregrossly careless and neglectful of their duties and responsibilities as medicalofficers and sanitarians.

This office realizes fully that the United States has raised,within a short period of time, an army of several millions of men who have beenpoorly instructed in personal hygiene and sanitation; it realizes that 2,000,000of these men have been brought to France where they have encounteredenvironmental conditions differing entirely from those existing in the UnitedStates; it is fully recognized that military necessity has at time renderedsanitary control extremely difficult, especially during the stress of activecombat.

To our regret, be it said, the high standards of sanitationand personal hygiene set by the Medical Department during the past 10 to 15years have not been lived up to during the past 1? years. This has been due toa combination of factors, the more important of which have been the lack offacilities and materials, transportation difficulties, and insufficient trainingand personnel. However, many medical officers serving with combatant andServices of Supply units have been able to overcome all handicaps and have bywise counsel and by eternal vigilance succeeded in keeping their units inexcellent fighting trim.

The actual physical fighting is now at an end, and thetime-worn excuse that "there is a war on" will no longer be tolerated.But the fight against disease still continues.

The greater part of the American Expeditionary Forces is nowrelatively stationary in training areas or with the armies of occupation, wheredefinite sanitary measures can be instituted and enforced, where instruction ofthe line troops can be carried out, and where opportunity is presented toinitiate rules of personal hygiene. Medical officers will therefore be heldresponsible for the proper supervision of the health of troops.

Carbon copies of all general recommendations of medicalofficers covering sanitation and personal hygiene, promulgated officially asorders and memoranda by superior authority, will be mailed to this office.

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II. SUMMARY OF TYPHOID PARATYPHOID INCIDENCE IN THE AMERICAN EXPEDITIONARY FORCES
In order that all medical officers in the American Expeditionary Forces may have a somewhat comprehensive view of the occurrence of these fevers in the American Expeditionary Forces, the following brief review is presented.

(a) From June 1, 1917, to June 1, 1918, but few casesoccurred. The rate was well within the limits to be expected in view of thesanitary conditions under which the troops were of necessity living. The caseswere sporadic and only occasionally did secondary cases develop.

(b) In July, 1918, a replacement unit consisting of248 men, from Camp Cody, N. Mex., reached England with typhoid prevailingextensively; 98 men, or 39.5 per cent, had typhoid, and the case death rate was8.42 per cent.

It was evident from the investigation that the men wereexposed to infection through contaminated drinking water while en route to theport of embarkation in the United States. The unit had been vaccinated a fewmonths prior to the occurrence of the epidemic. Most of the patients presentedthe typical clinical features of typhoid. The percentage of positivebacteriological findings from the blood, feces, and urine was low, as nolaboratory work could be done until late in the course of the disease.

(c) In August, 1916, a small but severe epidemicoccurred in a detachment of engineer troops stationed at Bazoilles. In this unit15 cases of typhoid occurred, with a death rate approximating 10 per cent.Typhoid was endemic in the civil population, and the epidemic was verydefinitely traced to a cook in the mess of this engineer detachment who remainedon duty as a cook for five days after the onset of the symptoms. The epidemicwas recognized in its early stages, and in all patients the disease wasconfirmed bacteriologically by positive cultures from the blood and feces.

(d) During the Chateau Thierry offensive diarrhoaldiseases were very prevalent in the troops engaged (approximately 75 per cent).It was demonstrated bacteriologically, in this area, that the prevailingintestinal diseases were simple diarrhoa, bacillary dysentery, typhoid,paratyphoid A and B. The sick and wounded from this sector were evacuated tobase hospitals in various parts of France. Very soon therafter this office beganto receive reports of cases of typhoid, paratyphoid, and bacillary dysenteryfrom base hospitals. In practically all instances the patients had beenevacuated from the Chateau Thierry sector. The high incidence of intestinaldiseases in this sector was due to the entire disregard of the rules ofsanitation. "Military necessity" and the impossibility of supplyingauxiliary labor troops, at that time, prevented immediate police of the battlefields. In some of the cases involved in this series the diagnosis of dysenteryor typhoid was made by the pathologist at autopsy. The percentage of positivebacteriological findings was low, as the correct diagnosis, if made, was notusually
arrived at until late in the course of the disease.

(e) Both dysentery and typhoid-paratyphoid fevers weredemonstrated to have prevailed to some extent in our troops after the St. Mihieloffensive, but the epidemics of influenza and pneumonia prevailing at that timeovershadowed all other medical admissions.

(f) Following the offensive in the Argonne sector,typhoid and paratyphoid began to be reported from practically all divisionsengaged in that offensive. It is quite evident that the initial cases were due,in large part, to drinking infected water. The initial cases, however, in largepart were not, in most instances, promptly diagnosed, and secondary cases fromcontact began to occur. In some divisions either the initial
exposure was not great, the organizations were under gooddiscipline, or the medical officers had a proper conception of their duties andresponsibilities and but few cases occurred. In other instances the contrary wastrue, and many cases have occurred. As examples of the two extremes may be cited the ----- Division, in which 5 cases occurred between October 1, 1918, andFebruary 1, 1919, and the ----- Division, in which 115 cases occurred in thesame period.

More than 300 cases of typhoid-paratyphoid may be attributedto the Argonne offensive. Eight hundred and seventy-four typhoids andparatyphoids have been reported in

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the American Expeditionary Forces since October 1, 1918. Thepercentage of confirmatory laboratory diagnoses has been low on account of thefact that the clinicians frequently failed to suspect the disease in its earlystages.

(g) A small but severe epidemic occurred in theJoinville concentration area in December and January. In a group of MedicalDepartment units (evacuation and mobile hospitals and sanitary trains)concentrated there 75 cases occurred, with a case death rate of approximately 20per cent. The cases were suspected in the early stages of the disease, and thepercentage of positive findings by culture of urine or feces has been greaterthan 75 per cent. The cause of this epidemic has not been completely analyzed asyet, but there is but little question that it was due to the use of infecteddrinking water.
III. REPORTS OF CASES

If epidemics are to be recognized in their incipiency andmeasures initiated to control and prevent further extension, it is manifestly ofthe utmost importance that reports of suspects and proven cases be transmittedto the medical officers of organizations directly concerned at the very earliestpossible moment. The large number of troops involved, methods of evacuation,delays in transmission of reports, necessary censorship regulations, frequencyof troop movements, laxity in making reports, unwarranted delay in makingdiagnoses, and other factors have tendered to hamper this most importantinstrument for the control of transmissible diseases. The medical officerscharged with the supervision of the health of all organizations must know at theearliest possible moment of the diagnosis or provisional diagnosis of typhoid orparatyphoid in a member of his organization, and for this diagnosis he mustdepend on the ward surgeon in the camp, evacuation, mobile, base,or other hospital unit of which the patient has been evacuated. Ward surgeonsand chiefs of medical service in hospitals charged with the care of thesepatients do not appear to comprehend their responsibility in this matter. As amatter of fact, they are jointly responsible with the medical officers of theorganization for any epidemics occurring in a command if they delay, in theleast, in making diagnoses or in reporting suspects or positive cases. Therecords of this office show that patients with typhoid have passed successivelythrough camp, field, evacuation, and base hospitals without any documentaryevidence that typhoid or paratyphoid were even suspected. There are records of astay of two weeks or more in a single base hospital without diagnosis, and not afew records are on file showing that it remained for the pathologist to make thediagnosis at the autopsy table. If a tentative or positive diagnosis of typhoidor paratyphoid does not reach the medical officer of an organization until twoor three weeks after the evacuation of the individual from the command, thedamage already is done, additional individuals already are infected, and theproblem of control becomes all the more difficult. If, on the contrary, wardsurgeons in hospitals are keenly alive to their duties andresponsibilities, will suspect typhoid and paratyphoid in all fevers ofundetermined origin, will endeavor to confirm their suspicions by early bloodculture, will promptly report all clinical cases as such and positive cases assuch, the necessary information can be transmitted immediately to the medicalofficer of the organization concerned, who can in turn institute measures forthe prevention of secondary cases.

In order that reports of cases of typhoid and paratyphoid maybe transmitted more promptly to the medical officer attached to organizations,the following procedure will be adopted:

(a) Commanding officers of Medical Department unitscaring for the sick will be held responsible for reporting promptly bytelegraph, as already provided for in Section XII, Sick and Wounded Reports; allsuspected, clinical and proved cases of typhoid and paratyphoid. The commandingofficers of such hospitals will hold the chiefs of their medical servicesdirectly responsible for the prompt submission of diagnoses in these cases. Anylaxity or incompetency in this respect will be immediately reported to thisoffice for necessary action.

(b) When reporting these cases, in addition to thedata now required by telegraph, the word "onset" followed by the dateof appearance of the initial symptoms of the disease will be included in eachcase. In securing these data it must be understood that the date of"onset" is not necessarily the day on which the patient first reportedsick or the date on

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which he was admitted to the hospital, but rather should beregarded as the day when the patient first had any symptoms indicative of thedisease.

(c) In reporting cases of typhoid or paratyphoid, incompliance with paragraph (a) above, the following classification will beobserved:

1. All suspected cases of typhoid and paratyphoid will bereported as "typhoid or paratyphoid suspects."

2. All cases which present a clinical picture of thesediseases will be reported as "clinical typhoid or paratyphoid," usingthe term "clinical typhoid or paratyphoid."

3. All cases in which the diagnosis of typhoid or paratyphoidhas been confirmed by bacteriological methods or autopsy will be reported as"proved typhoid or paratyphoid."

4. Individuals who are found to be excreting typhoid orparatyphoid bacilli in their stools or urine and who have recently had a febriledisease presenting the clinical symptoms of typhoid or paratyphoid, will bereported as "convalescent typhoid or paratyphoid carriers."

5. Individuals who are found to be excreting typhoid orparatyphoid bacilli in their stools or urine, but who have not been sickrecently with a disease resembling typhoid or paratyphoid, will be reported as"typhoid or paratyphoid carriers."

6. Cases originally reported as suspects or clinical cases oftyphoid or paratyphoid and which have subsequently been proved, by laboratorymethods or autopsy, to be one of these diseases will be again reported, statingthat they are now proved cases. The telegram reporting such proved cases willindicate clearly that they have formerly been reported as suspects or clinicalcases.

7. If cases originally reported as suspects or clinicaltyphoid or paratyphoid are subsequently found not to have been one of thesediseases, these cases will be reported by telegraph showing change of diagnosis.In all telegrams reporting such change of diagnosis, definite information willbe submitted indicating that they have been reported previously as suspects orclinical cases.

(d) All reports outlined above will be sent bytelegraph to the chief surgeon, A. E. F. If the hospital unit reporting suchcases is attached to one of the armies, a duplicate of this report will besubmitted to the chief surgeon of the army concerned, in such manner as he mayindicate. If the hospital unit is under the orders of a section surgeon, surgeonof the district of Paris, or surgeon of the American embarkation center at LeMans, a duplicate of this report will be submitted to the section, district, orembarkation center surgeon, in such manner as he may indicate.

Chief surgeons of the armies will establish close liaisonwith base, evacuation, and camp hospitals in the immediate vicinity of theircommands, but not a part of their commands, to which patients from theircommands are to be evacuated. If cases of typhoid or paratyphoid from armies arediagnosed in such camp, evacuation, base, or other hospitals, the commandingofficers of such units will, in addition to the reports called for above, makeimmediate report of such cases by telephone, telegraph or courier to the chiefsurgeon of the army concerned.

8. The special attention of all medical officers is invitedto section 189, Article III, Manual of the Medical Department, quoted below,which will be strictly complied with.

189. A report will be furnished in every case of typhoidfever or paratyphoid fever occurring in an officer, enlisted man, or civilianemployee who has received the typhoid vaccine, describing in detail the methodof arriving at diagnosis.

Special blank forms covering the information to be submittedwill be obtained on request to this office.
IV. CLINICAL DIAGNOSIS OF TYPHOID AND PARATYPHOIDFEVERS

In view of the fact that the ordinary clinical picture oftyphoid-paratyphoid is very frequently profoundly modified in vaccinatedindividuals, it is considered essential to enumerate briefly the usual clinicalmanifestations of these fevers, atypical modes of onset, differential diagnosis,and modifications of the usual clinical manifestations in vaccinatedindividuals.

1. Clinical manifestations of typhoid and paratyphoid.-Typhoidfever in the unvaccinated is commonly characterized clinically by symptoms dueto the gradual development

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of a general bodily infection. The onset is insidious, withlassitude, malaise, gradual step-like rise in temperature with slight morningremissions, until at the end of the first week a continuous fever of from 103?to 105? F. has been obtained. The beginning of the attack is usually associatedwith anorexia, headache, and frequently with diarrhoa, abdominal distress, andepistaxis. The pulse is not increased in proportion to the temperature, is oflow tension and dicrotic. The tongue is coated and white and the abdomendistended and tender. From the seventh to the tenth day the rash appears in theform of slighly raised flattened papules of from 2 to 4 mm. in diameter, whichcan be distinctly felt, are of a rose red color, and fade on pressure. Theserose spots, characteristic of typhoid and paratyphoid, appear singly or incrops, usually first on the skin of the abdomen and lower thoracic region, butmay occur only on the back or extremities. The individual rose spot persists forfrom two to three days, after which it fades, leaving a brownish stain whichpersists for some time. Toward the end of the first week the spleen enlarges,and its edge can be distinctly felt below the costal margin.

At the end of 10 days the symptom complex clinicallycharacteristic of typhoid-continous fever, rose spots, and enlarged spleen-isusually established. To this should have been added laboratory findings ofabsence of leucocytosis and in the majority of instances a positive bloodculture, which occurs most frequently during the early stage of the disease. Onenegative blood culture will not suffice, but repeated examinations at 48-hourintervals will be made in suspicious cases.

During the second week there is continued high fever, withslight morning remissions. The pulse becomes rapid and loses its dicroticcharacter, the patient becomes dull and stupid, the lips are dry, the tongue isdry and covered with a dirty brownish coat and tremulous. Abdominal symptomswhen present, tympanites and diarrhoa, are more pronounced, and the clinicalpicture becomes one of intense toxemia. In the third week, in favorable cases,the morning remissions in temperature become more marked, the fever becomesdistinctly remittent in type, and toward the end of this period a gradual fallin temperature by lysis is noted. Rose spots cease to appear. In severe casesthe pulse is weak, ranging from 110 to 130, and pulmonary complications,especially pneumonia and hypostatic congestion, may occur. The patient is dulland apathetic, and low muttering delirium and subsultus tendinum are common.During the fourth week convalescence begins, the temperature gradually reachesnormal, the abdominal symptoms subside, the tongue becomes clear, and the desirefor food returns. In
severe cases convalescence may be delayed until the fifth oreven the sixth week, in which case the fever continues high during the fourthweek, and it is only toward the end of this period that marked daily remissionsmake their appearance.

In individuals previously vaccinated against typhoid, but whohave completely lost their immunity, infection similar to that found in theunvaccinated occurs, giving rise to the symptom complex described above ascharacteristic of typhoid fever.

Infections occurring in the vaccinated individual who stillpossesses a certain degree of resistance to infection result in the appearanceof atypical clinical pictures, such as abortive types of typhoid and paratyphoidin which the constitutional symptoms are mild but with slight febrile reactionof atypical type and few if any rose spots. The onset may be either insidious,with headache, loss of appetite and fatigue, or acute and associated withchills, vomiting, intestinal cramps, and diarrhoa. Fever may be wholly absentor evanescent in character and determined only if observations are made withinthe first 48 to 72 hours. A low type of temperature, with daily fluctuations offrom 98.6? to 100.4?, suggestive of the presence of tuberculous disease, maypersist for a week or 10 days. It is in this class of cases that blood culturestaken early in the course of the disease, and repeated if negative, frequentlygive definite information concerning the nature of the infection. Ambulatorytypes of typhoid are not uncommon, and the first indication of the existence ofthe disease may be furnished by the occurrence of intestinal h?morrhage orperforation.

The vaccinated individual protected against general systemicinfection may still act as a carrier of typhoid infection, and frequently showsclinical manifestations of local disease of some portion of thegastro-intestinal tract, while the characteristic symptom complex of typhoidfever due to general infection, namely, continued fever, rose spots, andenlarged spleen, may be wholly absent.

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2. Distinctive complications.-Intestinal h?morrhageoccurs usually during the third and fourth weeks. The onset is marked by asudden and frequently pronounced fall in temperature associated with increasedgravity of the general condition and a rise in pulse rate.

Intestinal perforation occurs usually during the third orfourth week. Patients whose sensorium is not too clouded complain of suddenparoxysmal abdominal pain, usually referred to the right hypogastric region.Signs of peritoneal irritation rapidly become manifest. Vomiting is common.Hiccough and irritability of the bladder, with frequent micturition, may benoted. Physical examination of the abdomen reveals tenderness and musclerigidity most marked in the right hypogastric or iliac region. Obliteration ofliver dullness is frequently present and constitutes an important sign. Acuteabdominal symptoms associated with a suddenly appearing leukocytosis areindicative of perforation. The occurrence of intestinal hemorrhage or signs ofintestinal perforation in an individual giving a history of previous ill healthshould always lead to the suspicion of the existence of typhoid.

3. Atypical modes of onset.-(a) Acute onset,with symptoms simulating meningitis. Lumbar puncture differentiates.

(b) Acute onset with intense, usually generalizedbronchitis or symptoms suggestive of lobar or broncho-pneumonia.

(c) With chills, fever, vomiting, cramplike pain inabdomen, sometimes localized in right iliac fossa and suggesting appendicitis.

(d) With symptoms of acute nephritis. Attack beginssuddenly, with nausea, vomiting, pain in lumbar region, diminution in secretionof urine, which is highly colored and contains albumin and casts.

(e) Special mention should be made of the ambulatorytype of typhoid in which the symptoms are slight, consisting simply of headacheand lassitude associated with mild gastro-intestinal disturbances. The patientis at no time confined to his bed, and intestinal hemorrhage or perforation mayfurnish the first clue with regard to the existence of typhoid.

(f) In the above atypical modes of onset early bloodcultures are of importance in differentiation.

4. Paratyphoid fevers.-The paratyphoid fevers, due toinfection with A or B organisms, are evidenced clinically by the same generalsymptomatology as that of typhoid. They, however, as a rule, run a much mildercourse and the intense toxemia of typhoid, evidenced by marked apathy, mutteringdelirium, and subsultus tendinum is seldom present. The onset of paratyphoid isfrequently more abrupt, with acute gastro-intestinal symptoms resembling foodpoisoning. The intestinal symptoms are as a rule more marked in cases ofinfection with paratyphoid B than in cases in which paratyphoid A is thecausative factor. The fever in paratyphoid is not of as long duration nor is itas continuous as in typhoid, but is more distinctly remittent in type.Enlargement of the spleen, rose spots, and absence of leukocytosis are, as arule, present in all three infections. Attempts have been made by someauthorities to distinguish between the eruptions of paratyphoid A, paratyphoidB, and typhoid. Thus the spots in paratyphoid A are said to be larger, moremacular in type, of a darker reddish hue, and to
correspond more closely to the eruption of measles. However,histologically the rash is the same in all three instances, and it is doubtfulif a clinical distinction in type of eruption can be maintained. Rose spots maybe wholly lacking or may be profuse and widely distributed over the bodysurface. The occurrence of relapses is more frequent in paratyphoid than intyphoid proper, and particularly is that true in connection with type Ainfections. In contradistinction to the relapse of typhoid, that of paratyphoidis frequently more severe than the original attack. The distinction between mildtyphoid, paratyphoid A, and paratyphoid B can be made definitely only by theisolation of the infecting organism from cultures of the blood, urine, orstools.

5. Differential diagnosis-Influenza.-Many casesoriginally diagnosed as influenza in the American Expeditionary Forces havesubsequently proven to be typhoid. The symptoms which the two diseases have incommon are: Continuous fever without localizing symptoms and slow pulseassociated with absence of leukocytosis. The more abrupt onset, the intensity ofthe headache, the severe pain in the back and eyeballs, and the earlyprostration occurring in influenza are distinctive. Supposed influenza in whichthe fever persists for more

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than four days and which is not associated with signs ofrespiratory involvement, such as bronchitis, usually most extensive in the lowerlobes, a broncho or lobar pneumonia should be viewed with suspicion. It shouldbe remembered that a general bronchitis is not uncommon in typhoid. Theappearance of rose spots should determine typhoid. Intestinal types of supposedinfluenza should always be considered as possible typhoid until provenotherwise.

Acute miliary tuberculosis.-A family history ofassociation with tuberculous individuals, a personal history of previous attackof pleurisy or pulmonary hemorrhages, physical signs of old tuberculouspulmonary lesions, cyanosis appearing early in the disease associated withincreased rate of respiration, a greater irregularity of temperature curve, anda more rapid pulse with absence of dicrotism suggest acute miliary tuberculosis.Roentgenograms of the chest and blood cultures frequently give valuabledifferentiation.

Septicemia.-In cases of late typhoid admitted to thehospitals during or after three weeks of profound toxemia, together with the, bythis time, distinctly remittent temperature, may suggest septicemia. The slightdaily fluctuation in the general condition of the patient together with theabsence of chill and leukocytosis, suggest typhoid. Blood cultures will alwaysbe made in such cases and, if negative, cultures of the stools will be made forthe presence of typhoidlike organisms.

6. Local and unexplained gastro-intestinal derangements,gastritis, acute or chronic, diarrhea, dysentery, gastro-enteritis,enter-colitis, colitis, appendicitis, cholecystitis, and acute catarrhaljaundice, all occuring with or without fever, should be regarded with suspicionwhen admitted from commands in which cases of typhoid or paratyphoid haveoccurred, and examination of the stools for the presence of typhoidlikeorganisms should be made.

Medical officers will see that all cases of gastro-intestinalderangement enumerated above, as well as all fevers of undetermined origin, aresubjected to careful clinical and laboratory supervision. They will under noconditions be left in quarters, but will be sent at once to camp, evacuation,mobile, or base hospitals where accurate observation of temperature at four-hourintervals will be recorded for a period of at least four days. Blood cultureswill be taken in every case of fever of undetermined origin in which thetemperature has persisted for a period of 48 hours and, if negative, will berepeated provided unexplained fever persists from the second to the fourth day.

Daily physical examinations of such cases will be made,special attention being paid to physical examination of the abdomen for enlargedspleen, distention, and tenderness, either general or localized. A carefulsurvey of the entire surface of the body will be made for the possibleappearance of rose spots.

The precautions appropriate for a case of typical provedtyphoid or paratyphoid fever must be observed in all instances where atypical orundetermined fevers are held under observation, awaiting clinical orbacteriological diagnosis of specific enteric infections. The frequency withwhich atypical, mild, unrecognized cases of typhoid and paratyphoid fever haveoccurred in the American Expeditionary Forces among vaccinated men makes itabsolutely essential to surround all such cases of undetermined fever with thesame precautions which it is found necessary to apply to establish typhoid orparatyphoid patients, to avoid contact infections in the wards among otherpatients and hospital personnel.

7. Temperature records, clinical notes, and the originalreports of laboratory findings in all cases of typhoid, paratyphoid, fevers ofundetermined origin, and the above-mentioned list of gastrointestinal disorderswill accompany the patient if transferred to another medical unit, and will bepreserved and forwarded to the office of the chief surgeon as per instructionscontained in section VI, paragraphs 6-7, Sick and Wounded Reports for AmericanExpeditionary Forces, September 15, 1918. In no instance will the clinicalnotes, temperature, and laboratory records of these cases be destroyed upon thecompletion of the case.
V. LABORATORY DIAGNOSIS OF TYPHOID AND PARATYPHOIDFEVERS

Bacteriological procedures are of great value (1) for thecertain and early diagnosis of suspected cases, (2) to determine carrier statein convalescent positive cases, (3) to detect carriers in otherwise normalindividuals.

Blood cultures offer the most certain method for earlydiagnosis of undetermined fevers, and it should be kept in mind that the earlierin the disease the blood culture is taken the more

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likely is the result to be positive; thus, in positivetyphoid fever the chance of successful blood culture declines from 90 per centduring the first week to 40 per cent during the third week. In paratyphoid Afever, because of the frequently short and mild febrile period, the prompt andearly blood culture is all the more necessary. Relapses are more common inparatyphoid than in typhoid, and taken at such a time blood culture yieldspositive results in every case.

The following method of blood culture is recommended as beingsuitable in all cases of fever of undetermined etiology.

(a) When laboratory facilities are at hand, take 10 c.c. of blood from a vein at the elbow. Place 3 c. c. in each of two flaskscontaining 100 c. c. of plain broth. Place 1 c. c. in tube of agar (melted andcooled to 45? C.), immediately mix and pour plate. Place remainder of blood indry sterile test tube to separate serum for such serological tests as may besuggested.

The two flasks and plate are incubated and examined thefollowing day. Transplants are made to plain agar slants, or, better, Russell'sdouble sugar agar. In case of development of Gram-negative motile bacilli oragar slants, emulsions should be made and agglutination tests done with immunesera for final identification.

Frequency of nonagglutinability of recently isolated typhoidcultures should be kept in mind.^f Negative blood culturein suspected typhoid fever means little. Repeat if clinical conditions indicate.

(b) If the blood culture specimen can not be takendirectly to the laboratory, filtered sterile ox bile is most useful, 5 c. c. ina tube. To such sterile ox bile 5 c. c. of blood is added, the tube closed witha sterile paraffin cork, carefully packed, and sent for examination to thenearest laboratory. Bile medium is furnished in chest No. 1, transportablelaboratory, United States Army, expeditionary force model. Additional supply ofthis medium may be obtained as needed from central medical departmentlaboratory, A. P. O. 721.

Bacteriological examination of feces is second only to bloodculture as an important means of positive diagnosis. It is especially importantin paratyphoid B fever.

Typhoid or paratyphoid carriers.-Typhoid andparatyphoid patients excrete the bacilli, frequently with their urine andpractically always in their feces. This is most likely to occur during the thirdand fourth weeks of the disease; the condition may persist throughoutconvalescence and not infrequently longer. It is therefore important not torelease the convalescent typhoid or paratyphoid fever patient until he ceases toexcrete these bacilli.

Three negative cultures of the urine and feces at six-dayintervals should be required before release of patient, the first not earlierthan one week after temperature curve has become normal.

Some persons who have never had a clinical history of thedisease may excrete typhoid or paratyphoid bacilli. It is important to detectsuch carriers in any occupation, but especially among cooks and handlers offoodstuffs. In such a carrier survey, two examinations should be done on eachindividual.

For release of patients, therefore, and detection ofcarriers, the examination of feces is of especial importance. It is a procedurethat properly requires the most careful attention of the bacteriologist. A bitof fresh feces the size of a pea (or, better when feasible, 1 c. c. of liquidstool, obtained, if diarrhoa is not already present, by administration of asaline cathartic) is mixed with 10 c. c. of plain broth or sterile saltsolution, then allowed to stand and sediment for 15 minutes. One or moreloopfuls are taken from the top and placed on the surface of one plate ofhardened Endo medium. This droplet is carefully carried over the surface bymeans of a glass elbow rod or similar spreader, and without further inoculationthe same rod is used to seed a second Endo plate. In this way a satisfactoryseparation of the colonies may be secured. After incubation overnight,suspicious colonies are fished to plain agar slants or, better, Russell's doublesugar and the identification completed by agglutinationtests.

Evacuation of typhoid carriers.-Whenever it becomesnecessary or desirable to evacuate a carrier of typhoid or paratyphoid fever tothe United States, the carrier shall be evacuated as a patient on sick report.

^fAll strains of organisms of the typhoid paratyphoid group are of special interest and should be sent to the Central Medical Department Laboratory, A. P. O. 721.

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The Widal test, in view of previous vaccination with T. A. B.vaccine, has been generally held of little or no value; however, it should bestated that the determination of agglutinin titer of patient's serum atintervals of one week and the demonstration of progressive and marked increaseof agglutinin content of the blood offers, especially in the absence of positiveblood culture, excellent evidence as to the etiology of the diseases. Thus intyphoid fever an agglutinin titer (Widal test) of 1 to 40 during the first weekof the disease may advance to 1 to 1,280 during convalescence. In paratyphoid Bfever the titer frequently advances to 1 to 2,560; however, in paratyphoid Afever it may not reach 1 to 640. Formalinized and standardized bacterialsuspensions of B. typhosus, B. paratyphosus A, and B. paratyphosus Bmay be obtained on request from the central Medical Department laboratory, A. P.O. 721.

Post-mortem bacteriology.-At autopsy, on suspectedcases, cultures should be made from the mesenteric lymph glands and from thespleen.
VI. PATHOLOGY

1. The significant gross pathology of typhoid fever can bebriefly summarized as an acute process found in the lymphoid elements of theintestine (chiefly the ileum) and in the enlargement and softening of the lymphnodes in the mesentery and mesocolon. These nodes in the immediate neighborhoodof the lower end of the ileum, the appendix, and c?cum usually show the mostmarked change. The opened intestinal tract reveals hyperplasia of all thelymphoid elements, such as Peyer's patches and the solitary follicles. There maybe in most unusual cases only hyperplasia of these elements, but as a rule theyshow injection, exudation, and rather extensive ulceration, particularly in thelower end of the ileum. The lower third of the ileum is frequently the locationof an ulcerated Peyer's patch or solitary follicle that may have perforated ormay have become the source of considerable hemorrhage. The mucosa of theappendix and the c?cum are, in about one-third of the cases, also the seat oftyphoid ulcers.

The spleen is usually enlarged and the pulp is semidiffluent.The parenchymatous organs are somewhat enlarged and have a cooked appearance,suggesting cloudy swelling of a moderate or extreme degree. Broncho-pneumonia isfrequently present as a terminal lesion. This represents the usual list ofanatomical findings disclosed to gross examination; therefore, on opening theabdomen, the first important gross features that attract attention are the sizeof the lymph nodes in the mesentery and the upper part of the mesocolon and thesize and consistence of the spleen.

In children these structures may be misleading and in adultsafflicted with tuberculosis a confusing gross picture can be offered, but in theArmy of the American Expeditionary Forces, composed of young adults, any suchpicture found at autopsy should be thoroughly investigated. Such investigationcalls for the removal of the intestine and an examination of the intestinalmucosa for lesions related to the lymphoid elements. Any change noted should befollowed with supporting evidence gained by bacteriological examination.

It should be kept in mind that the American Army has beenvaccinated against typhoid, and as a result the gross pathological picture maynot be as clear as in unprotected individuals. Indeed, several protocolsreceived indicate that there are fewer gross lesions in the intestine and thatthey are prone to appear in the ileum at points very near the ileocecal valveand even in the appendix and c?cum. Other records indicate that death probablyoccurred during a relapse since there was evidence of a few almost healed ulcersnear the location of one or more acute ulcers, one of which had been perforated.

Cases of typhoid may escape attention at autopsy if early andcomplete regional examinations are not conducted and recorded in a methodicalmanner, and it is imperative that the pathologist support any suspicion oftyhoid fever gained on gross examination by a well conducted post-mortembacteriological examination. Cultures taken from the gall bladder and from thelumen of the bowel may offer the only positive findings of a "carrier"of the disease. Cultures offering the pathologist the best support may be takenfrom the spleen and lymph nodes in the drainage path of actual intestinallesions.

Cases possessing the pathology and bacteriology of typhoidshould be entered under the cause of death at the close of protocol as typhoidfever, and then, if desired, followed in parenthetical manner with any importantsequel present, such as "perforation." Several

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protocols have been received in which the completepathological and bacteriological pictures of typhoid fever were recorded, butthe cause of death was entered as "peritonitis," "perforation ofthe intestine," "broncho-pneumonia," "acuteenterocolitis."

Attention is directed to Section XVII of the pamphlet Sickand Wounded Reports (effective September 15, 1918). All diagnoses should conformto these instructions if a proper record of disease is to be made.
VII. PREVENTION AND CONTROL OF TYPHOID ANDPARATYPHOID FEVERS

Typhoid fever is increasing in the American ExpeditionaryForces; so are the paratyphoid fevers.

Vaccination is a partial protection only and must bereenforced by sanitary measures.

Faulty conditions of sanitation that may not be dangerous nowwill become serious menaces when the warm weather sets in. There is still timeto correct many of these conditions. If this is not done, many soldiers will notget back to the United States after completion of their arduous service, and itwill be in part your fault and our responsibility.

The means of conveyance are water and food. Water may becontaminated by drainage from latrines and indiscriminately depositeddefecations. Food may be contaminated by hands of carriers, by flies that cometo it from latrines and uncovered feces; therefore:

Remember that all water in France is regarded as contaminatedunless it is under constant supervision of water supply personnel. See thatGeneral Order 131, general headquarters, 1918, is carried out. Do not giveorders only; personally assure yourself that chlorination is properly carriedout. The responsibility ultimately falls upon those charged with sanitarycontrol and not upon the enlisted man who mixes the hypochlorites of lime withthe water. Study the means of prevention of drinking at unauthorized sources.The best way to do this is to see that an adequate supply of supervised water isconveniently available wherever men work or live. Other means are the marking ofwater points; the removal of faucets; the placing of guards, and last, but mostimportant, the education of the men.

Remember that the most dangerous carriers are the ones thatwork in the kitchens. Enforce the washing of hands by kitchen personnel beforethe preparation and serving of food. Do not leave this to orders alone. Have areliable officer or noncommissioned officer supervise this and see that themeans of washing are on hand. Also remember that many cooks who have been foundto be carriers have often given histories of recent intestinal disturbance;therefore, inspect your kitchen personnel at least twice a week and remove allthose who are suffering or have recently suffered from diarrheas. Repeatedattacks of diarrhea are particularly suspicious.

Remember that flies breed in manure, feces, and offal of manykinds. Policing of camp and the proper disposal of all such filth will keep downthe number of flies. A campaign of such policing, if now undertaken, should gofar to yield results by spring. Flies alone can not spread these diseases iflatrines are covered and access to feces are prevented. Look at the lids of yourlatrines. Correct the conditions which lead to uncovered feces in camps. Keepthe food covered so that any flies that get through this cordon can not get atit.

Remember that an outbreak of diarrhoa may mean typhoidfever. At any rate the occurrence of epidemic diarrhoa shows that there is ahole in your sanitary plan.

Remember that, even though your camp is a model one, theneighboring civilian population may be a source of danger. Try to keep informedof typhoidlike disease in the civilian population where you are stationed.

Remember that from the sanitary point of view the first caseis the most important one. If you evacuate a suspicious case and don't hear whatit has turned out to be, make inquiry through the available channels.

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CONTROL

1. Upon the occurrence of a single case of typhoid orparatyphoid fever in a command, reinvestigate all the above conditions andcorrect any deficiencies discovered in the barrier or protection abovedescribed.

Examine all vaccination records and administer a single doseof triple lipo-vaccine to all in whom there is the slightest doubt concerningcompletion of required vaccination.

Request bacteriological carrier examination of your kitchenpersonnel from the nearest available laboratory. This had best be done throughthe responsible sanitary authorities.

Before this has been done reinspect your kitchen personneland remove all who give a history of recent diarrhoas or other intestinaldisturbance.

Prohibit the use of all uncooked vegetables and unboiledmilk.

Investigate the conditions of the neighboring civilianpopulation as to prevalence of typhoid or typhoidlike fevers.

2. When two or more cases occur in the same command withinthe same two weeks, revaccinate the entire command, in addition to the aboveprecautions.^g If the outbreak takes an epidemic proportion,add to these precautions the hand washing of all men after defecation.

Further measures of control must be determined afterepidemiologic study of the individual situation.

Whenever typhoid or paratyphoid fever occurs in any command,the medical officer will address the officers and the men, at either roll callor retreat, instructing them in the mode of spread of intestinal diseases, inthe seriousness of the situation, and in the simple methods of personal hygiene,the importance of cleanliness, and the purpose of the sanitary regulationsinstituted for control of these diseases.

3. The special attention of all officers of the MedicalDepartment is invited to sections 184 and 185, Article III, Manual of theMedical Department. Compliance is enjoined.

4. All previous instructions from this office in conflictwith regulations prescribed herein are rescinded.

WALTER D. MCCAW,
Colonel, Medical Corps, Chief Surgeon.

Circular No. 70.

AMERICAN EXPEDITIONARYFORCES,
OFFICE OF THE CHIEFSURGEON, SERVICESOF SUPPLY,
February 20, 1919.

I. Hospital centers and base hospitals no longer operating.-(1)Supplementing Section VI, Circular 67, the following is a complete list ofhospital centers and base hospitals that have ceased operating:

HOSPITAL CENTERS

Angers (activities taken over by Base Hospital No. 85).
Clerment-Ferrand.
Commercy (activities taken over by Base Hospital No. 91).
Langres (activities taken over by Base Hospital No. 53).
Pau.
Vittel-Centrexeville.

^gDirections for vaccination with triple T. A. B. lipo-vaccine are being issued with the vaccine.

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No.	Location	No.	Location
1.	Vichy (Allier).	37.	Dartford, England.
2.	Etretat (Seine Inferieure), with British Expeditionary Force.	38.	Nantes (Loire Inferieure).
3.	Vauclaire (Dordogne).	39.	(Mobile Hospital No. 39).
4.	Rouen (Seine Inferieure), with British Expeditionary Force.	41.	St. Denis (Seine).
5.	Boulogne (Pas de Calais), with British Expeditionary Force.	42.	Bazoilles (Vosges).
6.	Bordeaux (Gironde).	43.	Blois (Loire et Cher).
7.	Tours (Indre et Loire).	44.	Mesves (Nievre).
8.	Savenay (Loire Inferieure).	45.	Toul (Meurthe et Moselle).
9.	Chateauroux (Indre).	46.	Bazoilles (Vosges).
11.	Nantes (Loire Inferieure).	47.	Beaune (Cote d'Or).
12.	Camiers (Pas de Calais), with British Expeditionary Force.	48.	Mars (Nievre).
13.	Limoges (Haute Marne).	49.	Allerey (Saone et Loire).
14.	Mars (Nievre).	50.	Mesves (Nievre).
15.	Chaumont (Haute Marne).	52.	Rimaucourt (Haute Marne).
17.	Dijon (Cote d'Or).	58.	Allerey (Saone et Loire).
18.	Bazoilles (Vosges).	61.	Beaune (Cote d'Or).
19.	Vichy (Allier).	62.	Mars (Nievre).
20.	Chatel Guyon (Puy de Dome).	66.	Neufchateau (Vosges).
21.	Rouen (Pas de Calais), with British Expeditionary Force.	67.	Mesves (Nievre).
22.	Beau Desert (Gironde).	68.	Mars (Nievre).
23.	Vittel (Vosges).	70.	Allerey (Saone et Loire).
24.	Limoges (Haute Vienne).	72.	Mesves (Nievre).
25.	Allerey (Saone et Loire).	76.	Vichy (Allier).
26.	Allerey (Saone et Loire).	83.	Revigny (Meuse).
27.	Angers (Maine et Loire).	84.	Perigueux (Dordogne).
28.	Limoges (Haute Vienne).	94.	Pruniers (Loire et Cher).
29.	Tottenham, England.	112.	Brest (Finistere).
30.	Royat (Puy de Dome).	115.	Vichy (Allier).
31.	Contrexeville (Vosges).	116.	Bazoilles (Vosges).
32.	Contrexeville (Vosges).	117.	La Fauche (Haute Marne).
33.	Portsmouth, England.	204.	Hursley Park, England.
34.	Nantes (Loire Inferieure).	206.	Remorantin (Loire et Cher).
35.	Mars (Nievre).	236.	Quiberon (Morbihan).
36.	Vittel (Vosges).	238.	Rimaucourt (Haute Marne).

(2) The following hospital centers are shortly to beabandoned:

Allerey, to be abandoned when patients are evacuated.
Beaune, to be abandoned and buildings turned over to general headquarters for use as a school. Base Hospital No. 77 to remain at this location to care for sick of the school.
Limoges, to be abandoned when patients are evacuated.
Vichy, to be abandoned when patients are evacuated.

(3) Additional lists will be published in succeeding circularsas base hospitals and hospital centers cease to operate.

II. Resharpening blades.-Machine horse clipper bladesin use by veterinary hospital units should be sent to Medical Department repairshop No. 1, Paris, for resharpening. These blades upon being resharpened will bereturned to the unit in question.

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III. Final report on Form No. 30.-When a basehospital, camp hospital, or medical detachment is disbanded, a final report onForm No. 30, A. G. O., will be rendered-the original forwarded to TheAdjutant General of the Army, Washington, D. C., and two copies direct to theadjutant general, general headquarters, A. E. F. These returns will be made outin accordance with the printed instructions on Form No. 30,A. G. O. The records of events will show the authority for thediscontinuance or breaking up of the hospital or detachment and the date and thedisposition of the personnel.

IV. The following instructions will govern with referenceto requisitions for engineer stores.-Requisitions for engineer storesoriginating with the Services of Supply must be submitted to and acted upon bythe local engineer section officer of the C. of C. and F., who, after taking thenecessary action, forwards the requisition to the nearest, or the speciallydesignated, engineer depot where it is to be filled. Requests emanating from thefollowing sections will be forwarded to the engineer section officer at theaddresses given below:

Base section No. 1, A. P. O. 701.
Base section No. 2, A. P. O. 705.
Base section No. 4, A. P. O. 760.
Base section No. 5, A. P. O. 716.
Base section No. 6, A. P. O. 752.
Base section No. 7, A. P. O. 735.
Intermediate section (west), A. P. O. 713.
Intermediate section (east), A. P. O. 708.
Advance section, A. P. O. 731.

V. Records of returning organizations.-Organizationsreturning to the United States are required by embarkation instructions No. 13to take with them all records pertaining to the organization as an organization.This has not been done in a number of cases. Steps will be taken to insurecompliance with these instructions.

VI. Correct Mail Address.-The postmaster at A. P. O.717-requests that members of the medical Corps, Sanitary Corps, VeterinaryCorps, Army Nurse Corps, and enlisted men of the Medical Department send theircorrect mail address to the medical section, A. P. O. 717, upon each change ofstation or change to another organization. It is desired that the commandingofficers of hospitals and medical detachments have this information placed onbulletin boards.

VII. Nurses.-In addition to the instructions regardingnurses traveling given in Circular No. 65, January 19, 1919, the following is tobe noted. When it is necessary for nurses to change trains at Tours or to remainat that station between trains, commanding officers of hospitals are instructedto telegraph to the headquarters commandant, Services of Supply, stating theprobable hour of arrival of the nurses and the number, in order thatarrangements for their accommodation may be made. The Red Cross officials atTours are doing all in their power to assist nurses going through that city, butto prevent embarrassment it is absolutely necessary that the probable numbersexpected and the time of their arrival be received beforehand.

VIII. Disposition of surplus subsistence on disbanding ofhospitals.-(1) The following decision of the Quartermaster Department ispublished for compliance of all hospitals:

(2) In view of the facts set forth in letter of the chiefsurgeon, A. E. F., to the judge advocate, A. E. F., of the 28th of January,1919, indicating deficits on operations hospital funds, the Quartermaster Corpsis willing to purchase back from hospital funds all surplus subsistence on handwhich is a good condition, and which was purchased from the Quartermaster Corps,that may be in the possession of Medical Department units at the time of theirdisbanding or when evacuating to the United States.

IX. Rates of commutation for patients.-Attention ofall commanding officers of hospitals is called to General Order No. 19, generalheadquarters A. E. F., dated January 29, 1919, which changes the rates ofcommutation for patients in hospital.

X. Clearance certificates.-Attention of all commandingofficers of hospitals is invited to Bulletin No. 40, headquarters, Services ofSupply dated October 22, 1918. In connection with the issuance of clearancecertificates, it is essential that this office (finance and accountingdivision), be notified immediately of indebtness of a deceased officer or of anofficer departing for the United States, and that this office also be notifiedimmediately upon expiration of the two months period in the case of officersoutlined in paragraph 3 of Bulletin No. 40.

WALTER D. MCCAW,
Colonel, Medical Corps, Chief Surgeon.

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Circular No. 71:

AMERICAN EXPEDITIONARYFORCES,
OFFICE OF THE CHIEFSURGEON, SERVICESOF SUPPLY,
March 8, 1919.

I. Hospital centers and base hospitals no longer operating.-(1)In addition to list given in Section I-Circular 70, the following hospitalcenters and base hospitals have ceased operating:

HOSPITAL CENTERS

Beaune (Base Hospital No. 77 to be returned to United Statesas skeletonized organization, and personnel retained to operate Camp HospitalNo. 107. Buildings have been turned over to general headquarters for use ofAmerican Expeditionary Forces University).

Allerey (Base Hospital No. 99 to be returned to United Statesas skeletonized organization, and personnel retained to operate Camp HospitalNo. 108. Buildings being turned over to general headquarters for use of AmericanExpeditionary Forces University).

BASE HOSPITALS

No.	Location	No.	Location
10.	Le Treport (Seine Inf.), with British Expeditionary Forces (All American Expeditionary Forces base Hospitals with British Expeditionary Force have ceased operating.)	97.	Allerey (Saone et Loire).
40.	Sarisbury Court, England. (All American Force base hospitals in England have ceased operating.)	105.	Kerhoun (Finistere.)^h
77.	Beaune (Cote d'Or).	112.	Kerhuon (Finistere).^h
92.	Kerhuon (Finistere).^h	202.	Orleans (Loiret).
96.	Beaune (Cote d'Or).	218.	Poitiers (Vienne). Reverts to former status as Camp Hospital No. 61.

(2) The following base hospitals are shortly to be abandoned:Base Hospitals Nos. 63, Chateauroux (Indre); 71, Vauclaire (Dordogne), and 109,Vichy (Allier).

II. Communications.-The attention of commandingofficers and of chief Nurses is called to the fact that official communicationsfrom nurses or women civilian employees addressed to the chief nurse or thedirector of nursing service, A. E. F., must be forwarded promptly, whetherapproved or disapproved and with reasons for the approval or disapprovalexpressed.

III. Mail addressed to patients in hospitals which are tobe discontinued.-(1) All hospitals discontinued will forward a roster ofpatients evacuated at the time the hospital was discontinued, together withtheir correct forwarding address, to the central post office, Bourges.

(2) In case a hospital is relieved by another unit, thecommanding officer of the hospital relieved will furnish the mail orderly of thehospital relieving his organization the mail orderly record on hand of all pastand present personnel and patients, including all evacuated patients, with theircorrect forwarding address.

IV. Death of prisoners of war.-On the death of aprisoner of war in any hospital, notification will be immediately made to thecommanding officer, central prisoner of war inclosure No. 1, A. P. O. 717,giving place, time, name, number, and description of prisoner.

V. Wound stripes.-At a recent inspection by thecommander in chief it was noted that there was a shortage of wound stripes atcertain hospitals. He directs that an adequate supply of these articles be keptin all hospitals. Requisitions will accordingly be made for wound stripes inorder that they may be on hand at all times.

VI. Evacuation of prisoners of war from hospitals.-Whenmembers of prisoner of war labor companies become sick and are sent to hospitalsthey are considered as still members of their companies. Upon evacuation fromhospitals on a duty status they will be returned to their original organizationor to the central prisoner of war inclosure, whichever is more convenient, andnot to a labor company to which they have never belonged.

VII. Pneumococcus vaccine.-The following additionalinstructions relative to records to be kept when pneumococcus lipo-vaccine isgiven will supplement those laid down in paragraph 5, section 1, Circular No.59, office chief surgeon, A. E. F., series 1918.

^hNever operated as independent unit.

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When large numbers of individuals from the same unit aregiven prophylactic inoculations of pneumococcus vaccine, the records may beconsolidated on nominal check list showing the character of vaccine used, batchnumber, serial number of individual, name, age, organization, date ofadministration.

The consolidated lists should be forwarded to the office ofthe chief surgeon, A. E. F. The fact that lipo-vaccine has been given and thedate of the administration should be entered on the individual record and paybook as well as on the service record of each soldier.

VIII. Disposition of ordnance property.-Section XVI,Circular 66, is amended to read as follows:

The chief ordnance officer has directed that the followingdisposition be made of ordnance property upon the abandonment of hospitals:Unserviceable web, leather, and miscellaneous equipment to intermediate salvagedepot No. 8, St. Pierre-de-Corps; rifles, revolvers, and pistols to ordnancerepair shops, Mehun.

Serviceable mess and personal equipment will be disposed ofas follows: Hospitals and medical units stationed east of a line drawn north andsouth through Gievres, to Gievres. Hospitals and medical units in base sectionNo. 1 to base ordnance depot No. 1, Montoir; base section No. 2 to base ordnancedepot No. 4, St. Sulpice; base section No. 4 to base ordnance depot No. 1,Montoir; base section No. 5 to base ordnance depot No. 1, Montoir; base sectionNo. 7 to base ordnance depot No. 4, St. Sulpice; intermediate section, west ofGievres to Montoir, base ordnance depot No. 1; advance section to intermediateordnance depot No. 2, Gievres.

IX. Medical organizations under orders for return.-Inorder that section 1, general staff, these headquarters, may be informedconcerning the whereabouts and movements of medical organizations under ordersfor return to the United States, the commanding officer of any separate MedicalDepartment unit will report by wire to G-1, headquarters, Services of Supply,all movements subsequent to receipt of orders to prepare for embarkation.

X. Salvage of quartermaster department material.-TheQuartermaster Department requests that in the future the commanding officers ofall hospital centers and base hospitals operating independently will not ship orendeavor to save any articles of clothing, shoes, or other quartermaster'smaterial which can not be placed in a serviceable condition by repairs, or whichhave no sales value amounting to considerably more than the cost of handling andtransportation.

XI. Patient's laundry.-Circular Letter No. 71, officeof the Surgeon General, February, 1919, is quoted, as follows:

1. Amendments of paragraphs 222 and 267, Manual for theMedical Department, have been approved as follows, and will be promulgated byformal change in due course:

Par. 222, strike out the words "before it is putaway" in the first sentence, so that that sentence shall read: "Thesoiled clothing of patients will be washed as a part of the hospital laundry(par. 267)."

Par. 267, change second clause so as to read: "Second,the washable clothing of patients under treatment in hospital (par. 222)."

2. Commanding officers of hospitals will govern their actionaccordingly.

XII. Records of inventions and licenses.-CircularLetter No. 59, office of the Surgeon General, dated January 29, 1919, is quotedfor the information of all concerned:

1. This office has received a request from the patentsection, office of the director of purchase, storage, and traffic, forinformation in regard to records of inventions and licenses. In order to enablethis office to furnish the information desired, you are requested to invite theattention of all medical, dental, veterinary officers, enlisted men, MedicalDepartment, and civilian employees serving under your direction, to paragraph 4,General Orders, No. 93, War Department, 1918, and direct such officers andenlisted men, and civilian employees as may come within the purview of thatorder to furnish the following information to this office, attention executiveofficer:

(a) Brief titles of all inventions relating tomilitary affairs made by them.

(b) Brief description of each invention, together witha statement as to whether or not it has been submitted to the War Department tobe patented, and whether formal tender or licenses to the United States to usethe same has been made.

2. It is requested that this matter be expedited.

WALTER D. MCCAW,
Colonel, Medical Corps, Chief Surgeon.

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Circular No. 72.

AMERICAN EXPEDITIONARYFORCES,
OFFICE OF THE CHIEFSURGEON, SERVICESOF SUPPLY,
March 15, 1919.

I. The following general instructions will govern when unitsare abandoned and equipment ordered turned into medical supply depots:

Upon receipt of instructions from the chief surgeondesignating depot or other station where supplies and equipment will be turnedin, the following instructions will be carried out:

(a) The medical supply officer will in each case beadvised in advance, by wire, as to the approximate number of cars to be turnedinto his depot, also date cars go forward, and statement in general of contentsof each car. The supply officer should also be advised of the car number and O.D. T. number. In every case, copy of loading list should be inclosed in anenvelope and tacked on the ceiling or some other convenient place in each car,showing contents of that particular car.

(b) Owing to the scarcity of lumber for packingmaterial, sandbags have been obtained from the Engineer Department for thepurpose of packing linen. These sandbags will be available for issue atintermediate medical supply depot No. 2, Gievres; advance medical supply depotNo. 1, Is-sur-Tille; and medical supply depot, Montierchaume. Upon receipt oforders to abandon hospital and turn in equipment, necessary requisition will besubmitted for the necessary number of these sacks. Tests have been made as tothe capacity of sandbags to be used, and the following results obtained:

One sack will hold 30 sheets, 30 pajama suits, 20 mattresscovers, 48 bath towels, 120 hand towels, 120 pillowcases.

(c) Bundling of linens or other preparation of sucharticles for shipment: All used bed linen and hospital clothing will be freshlylaundered and blankets, when necessary, will be washed and in every case thelatter will be sterilized before being turned into the depot.

Blankets will be sorted as to color and quality and thenbundled as follows: Each blanket is folded once from side to side and then twicefrom end to end, making a surface 21 by 34 inches. They are then securely tiedin bundles of 25, with folded sides all in one direction.

Sheets will be folded as commercially received, which is asfollows: Each sheet is folded from side to side twice; then endways three timesand then sideways once, making a fold about 8 by 12 inches. They are then tiedup in bundles of 10, or a multiple thereof, with the folded sides all in onedirection.

Pillowcases will be folded as follows: Each pillowcase isfolded to one-third its width on each side and this again folded once end toend, making a surface about 7 by 18 inches. They are then put up in bundles of12, with folded ends in one direction, and tied. Four of these smaller bundlesare again tied up in one bundle, making a total of 48 pillowcases in the largerbundles.

Towels, hand, will be folded and tied in bundles in exactlythe same manner as the pillowcases, with this exception-two towels will befolded together and but six of the doubled towels will be placed in the smallerbundles. Size of towels when folded will be about 6 by 18 inches. Total of 48towels in large bundles.

Towels, bath, will be put up in the same manner as the smallbundles of hand towels. Size when so folded is 8 by 24 inches. Total of 12towels in a bundle.

Pajamas should be folded as follows: The coat, buttoned, isplaced bosom downward. The pants, with the legs folded together, are placedlengthways on top of coat, projecting legs of trousers being folded over so asto bring such fold even with tail of coat. The sides are then folded over toone-third the width of coat and sleeves brought down lengthways of garment. Itis then folded once to bosom size and then once again to half bosom size, makinga package about 8 by 12 inches. The suits are then tied in bundles of 5 or inmultiples of 5, all folds in one direction.

Pillows should be sorted as to class-as hair, feather,cotton, and French or American. Each class is then tied up in bundles of 10.

Care should be taken to see that all bundles are neatlypacked and securely tied with material of sufficient strength to obviatebreaking.

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When shipped or stored, mattresses will be sorted and classedas to kind-such as hair, felt or cotton, or excelsior, and as to make asAmerican or French or the quartermaster type.

II. Loss of sick and wounded reports.-Owing to theincreasing number of monthly sick and wounded reports that are being lost by thetransportation department, it is requested that all monthly sick and woundedreports that are too bulky to be sent by mail will hereafter be sent bymessenger instead of by freight or express service.

III. Short course in reconstructive facial surgery.-Ashort course in reconstructive surgery of the face, facial cavities, and eyelidswill be offered at Paris by Drs. Pierre Sebelean, Victor Morax, and Fernand LeMaitre. This instruction will bear special reference to war casualties.Instruction will be didactic, demonstrative, clinical, and operative on thecadaver. Classes will be limited to 12, and the courses will continue threeweeks. A fee of about 50 francs will be charged to cover expenses due to the useof cadavers.

Any eye, ear, nose, or throat surgeons desiring this courseand who can be spared without replacement should forward application to thisoffice, stating the date on which it is desired to start. The courses will beginMarch 24 and every three weeks thereafter.

IV. Disposition of chronic carriers of typhoid andparatyphoid.-All chronic carriers of typhoid or paratyphoid A or B bacilliwill be evacuated to the United States as patients, accompanied by a statementof the specific diagnosis and records of the laboratory proof of the carrierstate.

V. Antirabies treatment at Base Hospital 57, Paris.-Anymember of the American Expeditionary Forces who has been bitten by an animalinfected or proved to be rabid should be sent at once, with a complete history,to Base Hospital 57, in Paris, where antirabies treatment will be carried out.For full details as to precautions to be observed in establishing diagnosis ofrabies in the attacking animal and for advised emergency treatment of the woundof the patient, see page 31, Bulletin on Transmissible Diseases and Use ofTherapeutic Sera in American Expeditionary Forces, May, 1918, to be obtainedfrom chief surgeon's office. Note that American Red Cross Military Hospital No.2, where treatments have been carried out heretofore, has been closed and thatBase Hospital 57 will be used instead.

WALTER D. MCCAW,
Brigadier General, Medical Department,
Chief Surgeon.

Circular No. 73.
AMERICAN EXPEDITIONARYFORCES,
OFFICE OF THE CHIEFSURGEON, SERVICESOF SUPPLY,
France, March 23, 1919.

I. Physical examination of permissionaires.-(1) Thesurgeons of all organizations are directed to make a complete physicalexamination of all men going on leave the day preceding or the day on which themen depart for leave areas.

II. Sick and wounded reports.-(1) The attention of allmedical officers is again invited to paragraph 2, section 11, Manual Sick andWounded Report of the American Expeditionary Forces, which directs that allmonthly sick and wounded reports be forwarded direct to the chief surgeon, A. E.F., Services of Supply. Strict compliance with these instructions is enjoinedupon all.

(2) No copy of the weekly medical report of sick and woundedpatients is required by the chief surgeon, A. E. F., Services of Supply. Thesereports should be forwarded to the central records office at Bourges. (SeeGeneral Order 100, general headquarters, A. E. F., June, 1918.)

(3) Commanding officers of hospitals and surgeons ofinfirmaries functioning as hospitals who are required to render monthly sick andwounded reports will, in the future, advise this office by letter, or on Form51-A, if no cases were completed during the month. In other words, a nil reportwill be required from all organizations hospitalizing patients for more thanthree days.

III. Telegraphic report to central records office on deathof officer or enlisted man.-(1) On the death of an officer or enlisted man,immediate telegraphic report will be made by

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commanding officer of hospital in which death occurs to thecentral records office, Bourges. This report will give name, rank, service,organization, serial number of enlisted man; time, place, and cause of death;whether in line of duty or not; whether result of his own misconduct or not.Confirmation copy of this telegram will be forwarded by courier service.

IV. Service records of evacuated patients.-(1)Attention is again called to provisions of General Order, No. 23, generalheadquarters, 1919, regarding the procurement of service records of patients tobe evacuated, and the method of transmitting the record to the station orhospital to which the patient is sent. These requirements are not beingcarefully followed. Immediate steps will be taken to insure their strictobedience.

V. Material for the prospective medical history of the war.-(1)Information has reached this office that in some instances medical officers,upon leaving the service, are taking with them official charts, photographs,models, and pathological specimens, etc., which were prepared in connection withtheir official duties while on duty in various hospitals or camps.

(2) It is desired that responsible medical officers informall subordinate medical officers that all medical records, charts, drawings,models, and pathological specimens, etc., as well as all writings relating tocases in hospitals, are the property of the Medical Department of the UnitedStates Army, and must not be removed from camps or hospitals by any officerwithout the authority of the Surgeon General of the Army in each specific case.

(3) It is desired that every effort be made to collect andforward to the Surgeon General's office all photographs, drawings, sketches,models, and pathological specimens, etc., in hospitals or camps which may be ofuse or value in the prospective medical history of the war. All pictures shouldbe forwarded to Col. Louis C. Duncan, M. C., Army Medical Museum, Washington, D.C. Models and pathological specimens should be forwarded to Col. Charles F.Craig, M. C., curator, Army Medical Museum, Washington, D. C.

VI. The following memorandum is quoted for the information ofall concerned:

Subject: Personnel ordered to the first replacement depot andbase ports.

1. In view of the fact that the majority of casual officersbeing released for return to the United States will be needed for duty withcasual companies and casual organizations returning to the United States,instruct all officers whom you may release and order to the first replacementdepot at St. Aignan-Noyers (Loie-et-Cher) or to the ports of embarkation thatthey may expect to be held at those places for assignment to such duty. This isto be done so that the officers may not expect to be forwarded at once from thefirst replacement depot to ports of embarkation or to sail on the firsttransport after the arrival at a port of embarkation.

2. All soldiers becoming surplus as a result of theabandonment of depots, stations, camps, etc., who are sent to the firstreplacement depot at St. Aignan-Noyers (Loir-et-Cher) are subject toreassignment. Many such men now arrive at the depot with the impression thatthey are immediately to be returned to the United States. In order, therefore,to prevent soldiers getting such impression, instruct all class A soldiers thatyou may release and all organizations and detachments that are sent to the firstreplacement depot, because their services are no longer required on theirpresent duty, that they are available for reassignment, that they have nopriority for going home, and the fact of their being sent to the firstreplacement depot does not mean that they are to be immediately embarked for theUnited States.

3. Soldiers released for return to the United States underthe provisions of Section III, General Orders No. 8, headquarters services ofsupply, 1919, do not fall under the above classes as such soldiers are releasedfor immediate return to the United States and are given immediate priority forreturn to the United States.

By order of the commanding general:

E. E. BOOTH,
Assistant Chief of Staff, G-1.

VII. Medical department entertainment.-(1) It iscontemplated that the Medical Department at these headquarters will shortlyproduce an entertainment, and information is desired of any members of theMedical Department who may have talents along these lines. In submitting thesenames the qualifications should be given in detail so as to enable this officeto pick out the best in the Medical Department in France.

VIII. Report of officers admitted, evacuated, discharged,or died.-(1) In order to enable the statistical division, adjutant general'soffice, to answer promptly the many inquiries now being made, all base and camphospitals will forward direct to the statistical division, adjutant general'soffice, general headquarters, by courier mail, a daily list of all officersadmitted,

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evacuated, discharged, or who have died. The list will givethe name, rank, service, and organization, and place to which sent, if evacuatedor discharged. This information may be sent on any form. Copies of the reportsthat are at present being made, which show the same data, will be acceptable.

IX. Association of nurses and enlisted men.-Theattention of the Medical Department personnel is called to the fact that thereis no authority in regulations for any such distinction between officers andenlisted men as is implied by a ruling that makes it an offense for a nurse toassociate with the enlisted man and not with the officer. The association ofnurses with men is to be governed by the needs of the service, by the rules andcustoms of polite society, and by constant consideration for the good name ofthe Nurse Corps of the Medical Department of the Army and of Americanrepresentation in France and not by social distinctions founded on militaryrank. Any instructions to the contrary are revoked.

WALTER D. MCCAW,
Brigadier General, Medical Department,
Chief Surgeon.

Circular No. 74.
AMERICAN EXPEDITIONARYFORCES,
CHIEF SURGEON'SOFFICE,
March 28, 1919.

I. Economy in use of blank forms.-(1) All officers ofthe Medical Department are directed to see that the utmost economy is exercisedin regard to blank forms. Requisitions received in this office for blank formsindicate that more are requested than are needed, or that a large wastageoccurs. In either case remedial measures should be applied promptly so that thepresent large expenditure for printing may be curtailed as much as possible.

II. Shoe-shining and tailoring establishments to beinstituted in all hospitals possible.-(1) The commander in chiefhas noticed that there is an absence of smartness in the appearance of personneland especially of convalescent patients. This criticismreflects greatly on the care and attention given to proper military duties bythe medical officers of hospitals. The commandingofficers of all hospitals will take proper steps to correct this deficiency.

(2) With this in view, places will be established in eachhospital where men will be able to shine their shoes, and wherever possibletailor shops where they will be able to have their uniform repaired and pressed,will be instituted.

III. Physical classification of officers.-(1) Reportsreaching this office indicate that some medical officers, members ofclassification boards, are both lax in their classification of officers examinedand ignorant of existing instructions. The ease with which officers canapparently be classified and sent home for conditions which would not haveseriously interfered with the performance of their duties prior to the cessationof hostilities is causing undesirable adverse comment and is materiallyinterfering with the integrity of the special services and staff departments ofthe American Expeditionary Forces.

IV. The following circular has been received from the SurgeonGeneral and is published for the information of medical officers. Communicationson this subject will not be sent through this office.

Criticisms and suggestions in re medical service of theArmy.-(1) A board of medical officers, consisting of Brig. Gen. Francis A.Winter, Brig. Gen. John M. T. Finney, and Col. L. A. Conner, has been appointedto consider criticisms and suggestions concerning the medical service of theArmy.

(2) With a view to correcting defects in and increasing theefficiency of the department, officers of the Medical Department, includingthose of the Medical, Dental, Veterinary, and Sanitary Corps, are invited tosubmit to the board any criticisms they may have to make of the present systemand methods, together with suggestions for improvements therein.

(3) Communications on this subject should be sent to Brig.Gen. Francis A. Winter Army Medical School, 462 Louisiana Avenue NW.,Washington, D. C.

(4) Camp surgeons, surgeons of ports of embarkation,department surgeons, commanding officers of hospitals, and other medicalofficers are requested to call the attention of officers to the provisions ofthis letter.

By the direction of the Surgeon General:

C. R. DARNALL,
Colonel, M. C., United States Army.

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V. Abandonment of hospitals.-When a base, camp,evacuation, or mobile hospital is abandoned, the commanding officer of thehospital will wire the chief surgeon's office the date upon which the hospitalrecords are closed and the hospital ceases to function. Attention of allcommanding officers concerned is invited to General Orders, No. 15, headquartersservices of supply, A. E. F., dated March 8, 1919, reference to the dispositionof records.

VI. Manual of the Medical Department to govern preparationof sick and wounded reports after embarkation for the United States.-(1) Theattention of commanding officers of medical units and surgeons of organizationsis invited to the fact that the Manual of the Medical Department will govern inthe preparation of all sick and wounded reports after embarkation for the UnitedStates. The system used in the American Expeditionary Forces will no longerapply.

VII. Carriers of meningococcus and diphtheria bacilli.-(1)Chronic carriers of meningococcus and of proved virulent diphtheria bacilli nowunder observation or treatment in hospitals in the American Expeditionary Forceswill be evacuated to the United States as patients, promptly. No diphtheriabacilli carrier will be evacuated unless the virulent character of the bacillihas been proved by appropriate tests upon the guinea pig.

VIII. Autopsy protocols.-(1) It is important, in viewof the continued spread and high incidence of typhoid and paratyphoid fevers,that protocols of all autopsies he forwarded to the director of laboratories, A.P. O. 721, within 24 hours of completion of the autopsy.

(2) Failure of the pathologist at the hospital to appreciatethe full significance of lesions of the enteric group of diseases in men dyingwith other more striking lesions, or with a clinical picture not recognized asthat of typhoid fever, can be corrected by review in the office of the directorof laboratories.

(3) In this way, several incipient epidemics of typhoid havebeen disclosed; and because of failure to send in autopsy reports promptly, atleast one of the existing local outbreaks was unrecognized for two weeks.

WALTER D. MCCAW,
Brigadier General, Medical Department,
Chief Surgeon.

Circular No. 75.
AMERICAN EXPEDITIONARYFORCES,
CHIEF SURGEON'SOFFICE,
April 10, 1919.

I. Preparation of records for final separation of officersand enlisted men from the service of the United States Army.-(1) Medicalofficers preparing records of physical examination of officers and enlisted menon final separation from the service in the United States Army are especiallycautioned to observe the provisions of General Orders, No. 230, generalheadquarters, 1918, and General Orders, No. 20, general headquarters, 1919.

(2) Attention is directed to paragraphs 1 and 2 (WarDepartment Circular 93, November 27, 1918) quoted in General Orders, No. 20,general headquarters, 1919.

(3) When disabilities are found which, in the opinion ofmedical examiners, were existant prior to induction into the service, eventhough the men examined were evidently placed in class A when inducted, anotation will be made setting forth reasons upon which their findings are based,in order that the examination at induction and that at discharge may bereconciled.

(4) In view of the fact that men under treatment for physicaltraining will not be discharged until the board of review certifies that themaximum of improvement has been obtained, or that the physical disabilities havenot been exaggerated or accentuated, when men are discharged with disabilities astatement will be made to the effect that further treatment will offer noprospect for improvement in physical condition.

II. Men evacuated without service records.-(1) Manycomplaints are arriving in this office from different organizations that men arebeing and have been evacuated without the service records being requested (seeGeneral Orders, Nos. 5 and 23, general headquarters), and without theorganization being notified that the men are not to return to theirorganization. Regarding the cases in the past, organizations will be immediatelynotified as to the

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name of men who have been evacuated from their organizationswithout service records, and in the future no man will be evacuated without theorganization being notified and the service record being requested.

III. Prophylaxis and prophylactic stations.-(1) Thefollowing telegram from the commander in chief has been received by this officeand is published for the information and guidance of all concerned:

HEADQUARTERS, A. E. F., April8, 1919.

CHIEF SURGEON,A. E. F., Tours:

During my inspections, following points have been brought tomy attention and should be remedied with all possible speed and vigor. All thefollowing criticisms and directions apply with emphasis to leave areaseverywhere.

A. (1) Prophylactic stations are often not well organized,equipped, or administered, and this fact alone would bring discredit upon thetreatment rather than confidence in its use. The equipment should be on a parwith that supplied for other functions of the Medical Department. Medicinesshould be prepared by the pharmacist and renewed at least every second day. Warmwater for washing should always be on hand to prevent delay in theadministration of the treatment.

(2) Treatment should be under direction and supervision ofthoroughly trained attendants and given absolutely according to directionsposted in the treatment rooms. Attendants must be carefully selected from themost intelligent and reliable men of detachments and especially trained inadministration of these treatments. Their appearance, deportment, and speechshould always be such as to place prophylaxis treatment on a par with othermedical surgical procedures and their number should be sufficient to allownecessary reliefs.

B. (1) Separate rooms or small buildings should be providedwhere treatments can be administered in private, with separate accommodationsfor officers where possible.

(2) The number and distribution of stations should be such asto make prompt and convenient treatments always possible. The number at mostpoints is entirely insufficient.

C. (1) Individual packets should be supplied to soldiers inconvoy or other duties which may carry them out of touch with prophylaxisstations. This is not at present generally done.

(2) The physical inspections are not being systematically andefficiently carried out in cases of undiagnosed and untreated venereal diseaseamong the troops arriving at certain stations.

(3) The education of commands through lectures by medicalofficers on personal hygiene is neglected at many posts. Lectures illustrated bydiagrams and drawings are one of the most effective means of urging continence.

(4) Little or no attempt is made by surgeons to locatesources of infections. Every effort should be made in every case to trace andeliminate the source by cooperation with military police and civil authorities,and this is the surgeon's duty.

(5) Little attention is being paid at rest points for leaveand troop trains and houses of prostitution are in many cases not put out ofbounds and no prophylaxis facilities are provided.

(6) Medical officers fully provided with facilities foradministering prophylaxis should accompany all troops and leave trains.

PERSHING

Medical officers will be held responsible for any lack ofsupplies.

WALTER D. MCCAW,
Brigadier General, Medical Department,
Chief Surgeon.

DIRECTIONS FOR GIVING PROPHYLAXIS

(To be posted in all prophylactic stations)

1. Patient will urinate and proceed as follows:

2. Wash hands.

3. Roll up shirt and drop trousers and drawers to knees.

4. Pull back foreskin and wash head of penis very thoroughlywith warm running water and liquid soap, great care being taken to cleanseundersurface around "G string" and back of head. After this, washshaft of penis and adjacent part of body. If there is no running water, cleanbasin with clean water and liquid soap will be used. The basin, after use, willbe washed with water and then partially filled with bichloride solution (1 to1,000) and allowed to stand for at least 15 minutes before being used again.

5. While foreskin is drawn back, wash penis, particularly thehead, with warm bichloride solution (1 to 1,000). This is best done by allowingthe solution to flow over it.

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6. The attendant, without touching genitals, will injectslowly one teaspoonful of a 2 per cent solution of protargol or a 10 per centsolution of argyrol into the penis and, as the syringe is withdrawn, he willdirect patient to close the opening of the penis with the thumb and forefingerand retain solution for five minutes.

7. Pull back the foreskin; rub one teaspoonful of calomelointment all over the head of the penis and the inner surface of the retractedforeskin, being careful to rub it in on the undersurface, around the "Gstring" and in the furrow behind the head. The rubbing of this ointmentshould continue for three minutes. After this the surplus ointment will be wellrubbed over the shaft of the penis.

8. The penis is then wrapped in a toilet paper and thepatient directed not to urinate for at least four hours.

9. If more than three hours have elapsed since exposure, thepatient, after having taken the regular prophylaxis, will be directed to reporttwice a day for two days for an injection of 1 per cent of solution ofprotargol. This will be held in 10 minutes.

Circular No. 76.
AMERICAN EXPEDITIONARYFORCES,
CHIEF SURGEON'SOFFICE,
April 21, 1919.

I. Identification disks of prisoners of war patients.-(1)Identification disks of prisoners of war patients undergoing treatment will notbe removed from the patient except in case of death.

(2) In event of the latter, one portion of the disk will beburied with the body or attached to the grave marker; the other will betransmitted to the central records office, prisoners of war information bureau.

(3) The information bureau reports that many hospitals havebeen forwarding them in all cases. Such practice will be discontinued, as itcauses considerable confusion.

II. Disposition of unserviceable medical property.-(1)Commanding officers of hospitals and other medical units, upon receipt of ordersto abandon and turn in equipment, will forward without delay to this office alist of all unserviceable property on hand. Upon receipt of this information,instructions will be given from this office as to disposition of same.

III. The following telegram from general headquarters, isquoted for your guidance:

Sd four nine eight five period Vocational strength return hasbeen discontinued period Orders will be issued shortly period Please notify allconcerned period Ulio.

IV. Discontinuance of use of lipo-vaccines.-(1) Thefollowing circular from the office of the Surgeon General, United States Army,is published for the information and guidance of all concerned:

Circular Letter 134.

WAR DEPARTMENT,
OFFICE OF THE SURGEONGENERAL,
Washington, March 12, 1919.

Subject: Return to saline vaccines.

1. Beginning with date of receipt of this letter, salinetriple typhoid vaccine and saline pneumococcus vaccine, types I, II, and III,will be used in place of the corresponding lipo-vaccine used to date.

2. Lipo-vaccines were adopted as a war measure on account oftheir obvious advantages and have served their purpose. The technique ofmanufacture, however, needs further improvement, and the duration of theirprotective power as compared with that of saline vaccines needs furtherinvestigation. Saline vaccines will, therefore, be used as a routine andlipo-vaccines will be reserved for emergencies.

3. All surplus lipo-vaccines will be returned to the ArmyMedical School, Washington, D. C., and to such place as may be directed in theAmerican Expeditionary Forces.

4. Saline vaccines can be obtained by direct request to thecommandant, Army Medical School, Washington, D. C., as heretofore.

By direction of the Surgeon General.

C. R. DARNALL,
Colonel, Medical Corps, United States Army,
Executive Officer.

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2. In compliance with the above instructions all lipo-vaccine(triple typhoid and pneumococcus) manufactured in the United States will bereserved for emergency use. Saline vaccine will be used as a routine.

3. One carton from each batch number will be mailed to thecommanding officer, central Medical Department laboratory, A. P. O. 721, forfurther study of its biological and immunological properties.

4. Adequate supplies of triple typhoid saline vaccines areexpected in France at any moment and will be distributed immediately afterarrival.

5. In connection with saline vaccines, the particularattention of all medical officers administering them is directed to the factthat it will be necessary to revert to the system of administering three dosesat intervals of seven days, in accordance with instructions contained inCircular 16, Surgeon General's Office, 1916. Copy of instructions foradministration will be found in each carton of the vaccines.

6. Because of the unanticipated delay in the arrival ofvaccine from the United States, and the numerous changes in the location andstrength of the various organizations of the American Expeditionary Forces, allpending requisitions for typhoid lipo-vaccine heretofore submitted under theprovisions of Section II, General Order 31, general headquarters, A. E. F.,1919, are hereby canceled. The surgeon (senior medical officer) of eachdistrict, camp, post, or other independent command will make requisition for thenecessary saline vaccine, syringes, and needles, requisitioning for an adequatenumber of syringes and needles for the men to be revaccinated. If adequatesupplies of syringes and needles already are on hand, that fact will be noted onrequisitions and these items will be omitted.

a. The senior medical officer on duty at the firstreplacement depot, St. Aignan Noyers, will be held responsible for thevaccination of all casuals passing through that depot and will make requisitionsfor adequate amounts of vaccine for distribution throughout the area.

b. The division surgeon of each division of combatanttroops will make a consolidated requisition for all troops constituting hisdivision and arrange for its distribution through the divisional medical supplyofficer. If the division is attached to an army, the consolidated requisitionwill be forwarded to the chief surgeon of the army. If under the orders of theServices of Supply, the consolidated requisition will be forwarded as indicatedbelow.

c. Requisitions for all units, including divisions, inthe American embarkation center will be forwarded to the chief surgeon of thatcenter, who will authorize the issue of the necessary vaccine.

d. Except as indicated above, all requisitions will besent to the director of the division of laboratories and infectious diseases, A.P. O. 721, Dijon, for visa, and forwarded by him to the appropriate distributingcenter for issue. In making requisitions, each unit comprising a command will beenumerated, giving exact designation and location of unit, actual number in thatunit to be vaccinated, and American post office number.

e. Because of the scarcity of syringes and needles,the difficulty in getting a sufficiently large amount of the vaccine, and thenecessity for preventing the requisitioning of vaccine for the same individualsor units by different medical officers, extreme caution is enjoined in makingand forwarding these requisitions. A requisition will be forwarded until assuredby direct inquiry of the next higher or subordinate medical officer thatrequisition for vaccine for the command has not been made.

(7) Special attention is invited to the absolute necessityfor entering the exact status of the vaccination of each individual in thesoldier's individual pay record book, and in the case of officers making asimilar entry in the officer's record book of captains and lieutenants orfurnishing them with a certificate. These entries must be made at the time thevaccine is administered. This information must include the date of vaccinationand kind of vaccine used. If saline vaccine is administered, the date andwhether first, second, or third dose.

(8) Strict compliance with instructions outlined above isenjoined. The foregoing instructions are not to be construed as requiringfurther revaccination with saline triple vaccine of any member of the AmericanExpeditionary Forces who has been revaccinated with triple typhoid lipo-vaccinein France.

WALTER D. MCCAW,
Brigadier General, Medical Department,
Chief Surgeon.

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Circular No. 77:

AMERICAN EXPEDITIONARYFORCES,
CHIEF SURGEON'SOFFICE, SERVICESOF SUPPLY,
April 22, 1919.

Cases of typhus fever have recently been reported in France,and it is being reported constantly from central Europe.

Liberated people from Alsace-Lorraine and the Rhine Valley,and especially those who have been in Ukraine, Poland, and Russia, are theprincipal carriers of the disease. Allied prisoners returned from Germany arealso special source of danger.

It is therefore necessary that medical officers in theAmerican Expeditionary Forces be on the alert for the appearance of the diseaseamong United States troops.

Typhus fever may show all gradations in severity, from mildcases to those of malignant type. The following is a brief summary of clinicalevidence in a case of moderately severe typhus fever:

Prodromes are usually so light as not to attract attention orcause complaint. The individual may have a little "indigestion,"headache, or weakness. He may look tired, feel a little dizzy and"achy."

The onset is abrupt. Severe chills and violent headache andpains in the back and limbs are the rule, while often profuse nosebleed andvomiting occur. The temperature rises rapidly to 102? or 103? F. The patient'sface is flushed and his conjunctiv? injected. He feels very sick.

The eruption appears on the fourth or fifth day. It is rarelyaltogether lacking. It is often abundant and widespread. It appears first on thetrunk-the armpits and shoulders-then on the abdomen and limbs.

The eruption is of two types, (1) a deep subcuticularmottling or marbling and (2) rose-colored spots about the size of a pinhead orsomewhat larger. These spots at first disappear on pressure. In a few days manyof them appear somewhat petechial and do not disappear under pressure. Morerarely the ecchymotic character progresses to a distinctly purpuric appearance.The spots persist for 5 to 10 days.

The fever is sudden in onset, as has been stated, andcontinues high, with slight remissions, to terminate at the end of the secondweek by a defervescence during two or three days, sometimes by crisis.

Nervous and mental symptoms are prominent and may be presentfrom the beginning, a mild or more active delirium, later coma-vigil, subsultustendinum, prostration, and stupor are noted. The stuporous state of typhus isparticularly characteristic.

The pulse rate follows the temperature. The beat is full andrapid at first; later it is small and feeble.

Respiratory tract: Bronchial catarrh is common. A dry coughat first is the rule. Later the expectoration is increased and may becomeprofuse and even purulent.

Differential diagnosis, in the present situation, involves aconsideration of typhoid fever, influenza, and measles.

(a) Typhoid fever shows a much more gradual onset.Injection of conjunctiv? is absent. The rash comes later, is less abundant, andthe rose spots are rarely hemorrhagic; i. e., they disappear on pressure. The"typhoid state" comes later, and is more mild than in typhus. Promptlaboratory examinations will establish a positive diagnosis.

(b) Influenza includes so many clinical pictures thatit must be considered here. It may be confused with typhus during the firstthree or four days. But the decline of the temperature in influenza after thethird or fourth day and the absence of the rash will determine the diagnosis.

(c) Measles presents a rash that may be confused withthat of typhus. But the prodromal coryza and the defervescence following theeruption distinguish it from typhus. The eruption is prominent on the face inmeasles; facial eruption is rare in typhus.

Laboratory diagnosis of typhus fever.-The Felix-Weilreaction is of value. This is an agglutination of B. proteus X-19 by theserum of a patient sick with typhus fever. B. proteus X-19 is notthe cause of typhus fever. The reaction is therefore, not specific. But it hasconsiderable diagnostic value.

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Technique.-The bacterial emulsion should be preparedfrom a young agar culture (16 to 18 hours old). The emulsion should be freshlyprepared; old emulsions do not agglutinate well.

The macroscopic method is used.

Serum dilutions from 1 to 100 to 1 to several thousands areused. (Typhoid patient's serum will agglutinate B. proteus X-19 at 1 to25 or 1 to 50 in 10 per cent of cases.)

Time and temperature of the reaction.-Thirty-sevendegrees centigrade for one hour, or room temperature 10? to 15? C. for twohours is used.

A rapid agglutination of B. proteus X-19 in a serumdilution of 1 to 100 or 1 to 200 in 30 minutes is of great value.

The agglutinins appear in the blood in typhus fever betweenthe fourth and eighth days, reach their maximum titer (1 to 500 to 1 to 10,000)about the eleventh day, and decrease rapidly after the twentieth day.Agglutinins may be demonstrable in the blood of typhus convalescents as late astwo months after recovery.

Cultures of B. proteus X-19 will be furnished onapplication to central Medical Department laboratory, A. P. O. 721.

Prophylaxis and sanitary control of typhus fever is based onthe following facts:

(1) It is transmitted by the body louse (Pediculusvestimenti) and perhaps also by the head louse.

(2) The louse having bitten a typhus patient, does not becomecapable of transmitting the disease until nine days have elapsed.

(3) The incubation period of the disease-that is, the lapseof time between the infectious bite and the appearance of symptoms-is 6 to 10days.

From these facts it follows that the most effectiveprotection consists in careful delousing of all members of the AmericanExpeditionary Forces.

The early diagnosis and discovery of all cases of the diseaseis an essential element in prophylaxis.

Mild or abortive cases, because they are likely to beoverlooked, are a special source of danger. The possibility of the diseaseshould be constantly borne in mind.

In the event of the occurrence of a case, the organizationand quarters will be subjected to strict quarantine.

Men and their equipment will be deloused every third day.

Careful examinations of the individual men will be madedaily.

Quarantine will not be lifted until 21 days after thediscovery of the last case. A delousing of the men and their equipment and adisinfection of their quarters will be made on the last day of the quarantine.

The same measures will be applied to hospitals. A rigidquarantine of all personnel coming in contact with the case will be enforced.

WALTER D. MCCAW,
Brigadier General, Medical Corps,
Chief Surgeon.

Circular No. 78.

AMERICAN EXPEDITIONARYFORCES,
CHIEF SURGEONS'OFFICE
April 25, 1919.

1. The following regulations will govern the investigation ofcases of venereal disease and the control of venereal prophylaxis.

2. All cases of venereal diseases following failure to takeprophylaxis will be investigated and the reason for the failure ascertained andrecorded.

3. All cases of venereal disease which develop after havingtaken prophylaxis will be investigated and the cause of the failure of thetreatment ascertained and recorded.

4. Medical officers, so far as possible, will collect all menat present in their charge who have had syphilis, and explain to them the courseto pursue after demobilization in order to insure a complete cure.

5. All men who have had chancroids since enlistment will haveWassermann tests done before returning to the United States. If the blood isfound positive, they will be retained

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for one course of specific treatment. If the responsibilityfor this treatment being given on ship or in the United States will be assumedby the medical officer, the patient may be allowed to proceed with hisresignation.

PROPHYLAXIS STATIONS

Attendants.-The attendants will be selected from amongthe best men in the organization. A noncommissioned officer will be in charge ofeach station. The men will be instructed on the following things:

(a) The meaning and method of obtaining surgicalcleanliness.

(b) Simple facts about pathogenic micro-organisms,with special reference to those causing venereal disease. This instruction willinclude laboratory demonstrations of cocci, bacilli, and spirochet?.

(d) Descriptions of the ordinary symptoms and courseof the three venereal diseases.

(e) In the making of solutions of protargol andbichloride.

(f) Method of prophylaxis and scientific reasons foreach step.

(g) Each section surgeon will form a central school atwhich all men having charge of the prophylactic stations will be trained.

(h) The importance of the work will be impressed onthe attendants, and everything possible will be done to arouse their interest,pride, and a cooperative spirit in the work.

Technique.-The technique of administration of theprophylaxis will be on a par with that of a minor surgical procedure. Anythingless than this will be faulty.

Stations.-Care will be exercised in the placing ofstations; regard for privacy will be observed. At least one room will be givento the station, which will be painted white and made as inviting as possible. Awaiting room for large stations is desirable. The general arrangement andcleanliness of the station will correspond to that of a modern surgicaldispensary.

Running water will be installed wherever practicable. Themost economical plan is to have several faucets arranged over a washing troughmade of concrete or zinc; if available, porcelain sinks (individual) arepreferred. When possible, individual booths will be made by the erection ofpartitions or curtains. Near each faucet will be a bottle of liquid soap with asplit cork. Warm water will be provided if possible. When a water system is notat hand, running water will be supplied by means of an elevated galvanized-ironcan to which a pipe or hose is connected. In temporary stations where basinswill be used, a sufficient supply will always be on hand to insure thecleanliness of the individual basins.

Washing possesses the following advantages:

(a) It has been shown that soap is germicidal for thespirochet? pallida.

(b) It removes mucoid substances and allows betterpenetration of the calomel ointment.

(c) It opens minute wounds or cracks in whichmicro-organisms may have lodged and allows the calomel ointment to come incontact with them.

(d) It mechanically removes a large portion of theorganisms present.

Bichloride solution.-The washing with bichloridesolution is essential and is necessary in connection with the washing with soapand water to destroy Ducrey's bacilli, since it has been shown that neithercalomel ointment nor protargol solution is germicidal for this organism. Themost satisfactory method for use of the bichloride is to have a large bottle,demijohn, or earthenware vessel holding not less than a gallon, with a rubbertube attached, placed on a wall bracket just above the trough. The bichloridesolution will immediately follow the soap and water.

The following articles are the minimum requirements of astation:

1. A Primus oil stove for sterilization.

2. A stew pan or fish kettle with cover, for boiling.

3. A sterilizer for the sterilization of sponges. This may bemade out of two tin buckets, one slightly larger than the other so that thelarger may be inverted over the smaller. A rack of some kind is placed on thebottom of the inner bucket so as to hold the sponges or other articles above thewater.

1048

4. A long clamp for the removal of the sterile syringes,wooden spatulas, and sponges from their respective containers, thus avoiding thenecessity of the patient putting his hands in these containers.

5. A sufficient number, never less than 12, of good workablesyringes.

6. A closed receptable in which to keep the sterile syringes.

7. A number of wooden spatulas, which will be made by theattendant. These are for the removal of the ointment from the jar.

8. A closed glass receptable in which to keep the sterilewooden spatulas.

9. A glass jar or some kind of vessel for the sterile gauzesponges.

10. An adequate supply of wash basins, certainly not lessthan 10, if running water is not at hand.

11. Small glasses similar to ordinary medicine glasses inwhich protargol will be poured just prior to its being used.

12. A supply of gauze sponges.

13. One 8-ounce dark-colored bottle for the stock solution ofprotargol.

14. A supply of 30 per cent calomel ointment.

15. A supply of protargol or argyrol.

16. Some means of weighing or measuring the protargol so thatsmall quantities of the solution may be made up, thus avoiding the necessity ofusing a whole ounce at one time.

17. A supply of bichloride tablets.

18. A small clock placed where the patient may see it.

19. A roll of paper.

20. A place for the patient to wash his hands.

21. A sufficient number of small towels 8 by 10 inches sothat each patient may have a clean one.

Regulations.-1. The syringes will be sterilized byboiling and will be kept in a sterile vessel. Bichloride solution will not beused for this purpose.

2. The calomel ointment will be removed from the container bymeans of sterile spatulas.

3. Solution of protargol will be a uniform strength of 2 percent, will be made fresh each week, and will be kept in a dark bottle. The dateof making solution will be written on bottle.

4. Protargol solution will never be left standing in an openglass.

5. Basins will always be sterilized with bichloride solutionafter use.

6. The bichloride will have a uniform strength of 1 to 1,000.

7. Cake soap will not be used.

8. When prophylaxis is given to any soldier who is not amember of the organization to which the station belongs, a duplicate prophylacticrecord will be sent on the following day to the man's organization.

9. The data on the prophylactic cards will be transferred toa book which will be kept for permanent record.

Circular 79.

AMERICAN EXPEDITIONARYFORCES,
CHIEF SURGEON'SOFFICE,
May 9, 1919.

I. Disposition of medical supplies.-1. On receipt ofan order by a medical unit to cease to function, such medical unit will pack upand prepare for shipment all of their hospital property and turn over such tothe group or center medical supply officer prior to their departure. Thepersonnel of a medical unit will not be relieved until this is done in asatisfactory manner.

2. The following instructions as to preparation of medicalproperty, to be turned in to group medical supply depots, will be observed:

This property will be classified as follows:

(a) Articles that are new and havenever been used.

(b) Articles that have been usedbut which are serviceable and fit for reissue.

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(d) Articles which are not worth repairing but whichare of value for the raw material of which they are composed.

After the above classification has been made, all propertywill be put up in compact and easily handled packages. One type of article onlywill be placed in the same package, and the number of articles in a package willbe nearly as possible as commercially received. Whenever possible, baling,sacking, or crating should replace boxing, and except in case of large bulkyarticles contents should be in 5's or 6's, or multiples thereof. Fragilearticles will not be packed loosely or without packing material. All enamel wareshould be wrapped in paper or such material as will prevent chipping.

(a) Medicines will be carefully packed in boxes, withexcelsior. Amount in boxes will be as follows:

1-quart in bottle, 12 bottles to box.
1-pint or pound bottles, 25 bottles to box.
?-pint or ?-pound bottles, 50 bottles tobox.
3-ounce or smaller bottles, 100 bottles tobox.

Attention is called to the instructions in Circular No. 68,III, that narcotics, morphine, cocaine, etc., must not be turned in to salvagedepots, but must be sent to the nearest medical supply depot.

Save in exceptional cases, no more than 100 bottles ofmedicine will be packed in a case, and only one kind of medicine or size ofbottles will be packed in a box. Mineral acids or inflammable or corrosivesubstances will be packed in sand or some noncombustible material and ispreferably packed in small quantities.

(b) Tables, bedside, French, will be tied in bundlesof 5.

(c) Tables, bedside, folding, American make, whencrated will be in bundles of 10, and when not crated will be tied in bundles of5.

(d) Chairs, folding, will be arranged as are foldingbedside tables, American make.

(e) Bedsteads will be sorted as to kind and make andmay be sent in unpacked.

(f) Mattresses will be sorted as to kind and make andwhere possible will be burlapped in bundles of 5.

(g) Bedding and linens will be arranged as indicatedin Circular 72, chief surgeon's office, A. E. F., March 15, 1919, and section(b), paragraph 1, of that circular is modified as follows:

One sack (18 by 36 inches) will hold approximately asfollows: 24 sheets, 20 pajama suits, 36 bath towels.

(h) X-ray apparatus as follows:

(1) All fluroscopic and intensifying screens should be packedin a separate case, carefully protected from moisture and abrasion.

(2) All X-ray tubes in good condition for service should beshipped in the same form of container as received from the depot.

(3) Broken or punctured X-ray tubes should be broken and themetal parts wrapped up, labeled, and forwarded to the depot, where they will betaken up in place of the tube.

(4) Plates and films should be shipped in a separatecontainer and properly labeled.

(5) Milliammeters should be removed from machine, exceptingin the case of the bedside or the United States Army portable, and shipped in aseparate box with excelsior or paper to protect them from injury.

(6) All small parts which might become loosened or lost inshipment should be tied or wired to the part to which they belong.

All property will be thoroughly cleaned before being turnedin. Attention is invited to paragraphs 512 and 526, Manual of the MedicalDepartment, 1919, and particularly to paragraph 524 relative to packing oftypewriters.

All unserviceable articles will be turned in as salvage only.They will be properly listed in the order and in the nomenclature of the supplytable and must have a certificate, with supporting affidavits if obtainable,stating whether condition was due to fair wear and tear in the service.

No supplies or property of any kind will be turned in to agroup depot without first furnishing the medical supply officer with a list ofsuch articles, with the approximate amounts of same, and making with thatofficer such arrangements as will prevent confusion in their

1050

receipt. Duplicate loading lists will be sent with everytruck load of supplies sent to local depot. One of these copies will be returnedto consigner, signed by the receiving checker.

3. Group or center commanders will effect such cooperation onthe part of the unit supply officer and the group or center medical supplyofficer as will aid and facilitate the work of the latter and will arrange forthe detail of a sufficient force from the nonfunctioning units of his center aswill be necessary for the final disposal of all medical property at such center.

4. Group or center medical supply officers and supplyofficers of independent medical units will be guided by instructions containedin paragraph 2 above, wherein they apply to the preparation of their ownsupplies for shipment, whenever orders are issued for discontinuance of suchorganizations and for the final disposal of their complete stocks.

II. Correction.-l. Attention is invited to Circular 78(minimum requirements for prophylactic stations), item 21, which is changed toread as follows: "A sufficient number of small towels 8 or 10, so that eachpatient may have a clean one."

III. Treatment of chancroids before embarkation.-1.Due to inability to procure dark field microscopes and to the absence ofspecially trained medical officers in certain centers, many of the cases whichwere diagnosed as chancroid were either chancre or mixed infections. Recentcareful examinations have shown that about 40 per cent of all sores occurring inthe American Expeditionary Forces are syphilitic. In view of this it isrequested that the attention of all organizations under your jurisdiction bedirected to collect from all of their available records the names of all men whohave had chancroid. All of these men who are available will be given animmediate Wassermann, and those found positive will be given one course of thestandard treatment for syphilis. These cases will not be reported, as new cases,but each will be given a syphilitic register. Those preparing for embarkationwill be given treatment provided there is time before sailing, but they will notbe detained for it.

IV. Nurses' records of assignment and pay.-1. Inreference to paragraph 8, Circular 52, this office, October 22, 1918, theattention of all concerned is invited to the fact that records of assignment andpay of nurses should accompany them on change of station and should not bemailed to this office. Strict compliance with these instructions is necessary inall cases to avoid delay in payment of nurses.

WALTER D. MCCAW,
Brigadier General, Medical Department,
Chief Surgeon.

Circular No. 80.
AMERICAN EXPEDITIONARY FORCES,
CHIEF SURGEON'S OFFICE,
May 15, 1919.

I. Discontinuance, central Medical Department laboratoryand Army laboratory No. 1.- (1) The central Medical Department laboratory,Dijon (Cote d'Or), and United States Army laboratory No. 1, Neufchateau(Vosges), will cease to operate May 15, 1919. After that date pathological,bacteriological, and serological examinations not possible of accomplishmentwith the facilities at hand will be made for such units as remain in the advancesection and intermediate section, by the base laboratory, intermediate section,Tours. Therapeutic biological products, containers for specimens, and preparedculture media, formerly furnished by the two laboratories mentioned above, willbe obtained, after May 15, from the nearest base laboratory still operating.

(2) Laboratory animals, agglutinating sera for diagnosticuse, and amboceptor and antigen will be obtained from base laboratory, basesection No. 5, Brest, by all Medical Department units in France, and in theinstance of units in occupied territory in Luxembourg and Germany, from theThird Army laboratory, Coblenz, Germany.

(3) Bacteriological cultures for confirmation of diagnosisfrom Medical Department units serving in the Services of Supply, A. E. F., willhereafter be sent to base laboratory, base section No. 5, Brest, those from theThird Army to Coblenz, Germany.

(4) Pathological specimens, photographs, and other museumspecimens will hereafter be carefully packed in compliance with the instructionsin Circular No. 58, chief surgeon's office, A. E. F., December 2, 1918, andshipped direct to the Army Medical Museum, Seventh and B Streets SW.,Washington, D. C.

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(5) The office of the director of laboratories, Dijon (Coted'Or), will be transferred to the office of the chief surgeon, A. E. F., Tourson June 1, 1919. All correspondence, requisitions, reports, and returnsheretofore submitted to the office of the director of laboratories, Dijon (Coted'Or), (A. P. O. No. 721) will, after June 1, be directed to the director oflaboratories, chief surgeon's office, Tours (A. P. O. No. 717).

(6) Such provisions of Memorandum No. 21, office of the chiefsurgeon, division of laboratories and infectious diseases, September 18, 1918,as may conflict with the above provisions, are hereby rescinded.

II. Reports of communicable diseases when closing hospitalformations.-1. In carrying out the final evacuation of patients, failure toreport cases of communicable diseases which have developed in or have beenadmitted to the hospital within a few days prior to the evacuation is common.The confusion of the process of closing of a hospital is no excuse for theneglect of Section XII, Sick and Wounded Reports, which must be complied withpromptly under all circumstances.

III. Sale of unserviceable material and supplies.-1.The following instructions have been received from the United States LiquidationCommission, War Department:

PARIS, May 8, 1919.

COMMANDING GENERAL,Tours:

Authority has been obtained from French Government forAmerican Expeditionary Forces to sell in France unserviceable material andunserviceable supplies now on hand or such as may accumulate at the variousstations throughout France.

The unserviceable material and unserviceable supplies aredefined as junk, scrap material, unserviceable salvage material and supplies,and unserviceable property and material and supplies not worth transporting todepots.

These sales may be made under direction of the chiefs of thevarious services without reference to United States Liquidation Commission, WarDepartment, for approval.

Please advise all services interested, but instruct them tomake no sales in excess of authority granted herein.

Suggest necessary publicity be given to sales by advertisingin newspapers where advisable and by handbills, posters, and circularadvertisements.

KRAUTHOFF, G. S. A.

A-182.

By authority of United States Liquidation Commission, WarDepartment.

2. Under the above authority, all unserviceable property andsupplies, as well as material and supplies not worth transporting to depots,will be disposed of on the ground, after survey, under the provisions ofparagraph 678, Army Regulations. It is desired that survey be instituted with aview of directing sale in compliance with the above instructions.

3. The proceeds of sales held under the above authority willbe forwarded to the receiving finance officer, office of the general salesagent, Paris.

IV. Authority to drop property issued from depots fromreturns.-1. The following memorandum is quoted for guidance of allconcerned:

AMERICAN EXPEDITIONARYFORCES,
HEADQUARTERS SERVICESOF SUPPLY,
FOURTH SECTION,GENERAL STAFF,
May 9, 1919.

1. Depot and other accountable officers who have shippedproperty to regulating stations for distribution to combat organizations, whohave been unable to obtain a receipt from the regulating officer or the combatorganization concerned, are authorized to drop this property from their returns,with a certificate that the property in question was duly shipped, and that itwas impossible, due to the exigencies of the service, to obtain a proper receiptfor the property. This certificate should be accompanied, when possible, by theordre de transport covering the shipment of the property, or a true copythereof.

2. Regulating officers have been instructed to return anyinvoices which they are unable to accomplish to the proper depot with allinformation they are able to give on the shipment in question.

By order of the commanding general:

J. C. RHEA, Assistant Chief ofStaff, G-4.

WALTER D. MCCAW,
Brigadier General, Medical Department,
Chief Surgeon.

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Circular No. 81.

AMERICAN EXPEDITIONARYFORCES,
CHIEF SURGEON'SOFFICE,
June 3, 1919.

I. The optical division, medical repair shop, in Paris, isclosed and further prescriptions will not be filled.

II. Venereal rate.-1. The venereal rate has beenrising for a month past and has now reached a point 25 per cent above itsgeneral average for several months. The attention of all medical officers iscalled to the fact that the Medical Department is held largely responsible forvenereal rates, and that it has taken just pride in its work. There must be norelax action, and the greatest activity must be carried on to the very end.Every effort must be made to influence the enlisted men, to obtain the full andhearty cooperation of commanding and other officers, and of the military policeand to maintain prophylactic stations at the highest point of efficiency. Put agood ending on a good work.

III. Hospital funds.-1. Hospital funds do not comeunder the provisions of General Order 77, general headquarters, May 10, 1919.They should be accounted for to the chief surgeon in the regular manner.

IV. Promotions in American Expeditionary Forces.-1.Medical officers are informed that no more promotions are being made in theAmerican Expeditionary Forces, and it is therefore useless to continue to sendrecommendations to the chief surgeon's office. No action has been taken uponrecommendations which reached this office after March 25, 1919.

V. Property.-1. Upon transfer to the French Governmentof movables pertaining to the Medical Department in any section of the AmericanExpeditionary Forces under authority contained in letter from headquarters,Services of Supply, fourth section, general staff, dated May 27, to sectioncommanders, a report will be made, before transfer is started, to the chiefsurgeon's office, attention supplies division, by the section surgeon; givinglocation of unit and in general terms, supplies and equipment to be turned over,such as: "25-bed infirmary, 100-bed camp hospital, etc." It isessential that this information be furnished as early as practicable in orderthat disposition may be given on any part of equipment which it may not bedesired to turn over to the French. A record will be maintained in this officeof all units transferred to the French Government in order to check same againstbills for final payment; also to have data showing outstanding accounts. Sectionsurgeons are advised that it is the desire of the Medical Department to disposeof as much movable property in every instance as the French will agree to takeover on the ground without shipping same into depots.

WALTER D. MCCAW,
Brigadier General, Medical Department,
Chief Surgeon.

Circular No. 82.

  AMERICAN EXPEDITIONARYFORCES,
  CHIEF SURGEON'SOFFICE,
  June 6, 1919.

I. Disposition of records.-1. Confusion seems to existin the minds of registrars of hospitals closing for return to the United Statesas to the disposition of clinical records of the Form 55 series and othersimilar records.

2. These will be carried with the unit to the United States,to be held until disposition by the Surgeon General's office.

3. The only retained records which will be accepted by thechief surgeon's office are Form 22, Form 52 (register card), and retainednominal check lists. Every unit closing its site permanently will, in compliancewith Circular No. 61, chief surgeon's office, forward these records, togetherwith final monthly report of sick and wounded, to the chief surgeon's office, incharge of the registrar and such personnel as are necessary to insure its promptand safe delivery.

II. The following letter is quoted for your information andguidance:

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1. The following telegram from general headquarters, datedMay 19, 1919, repeated for your information and action necessary:

"Qualification cards of officers of staff corps havebeen delivered to the chiefs of services at headquarters Services of Supply,Tours. Cards for officers of divisions and corps, not a part of the Third Army,have been delivered to the personnel adjutant of their respective divisions andcorps. Cards for officers on duty with base and intermediate sections, Servicesof Supply, not members of the staff corps, have been delivered to the personneladjutants of these sections. In the future, requisitions for cards of officersreturning to the United States will be made to the heads of staff corpsdepartments instead of to the officers' qualification section, generalheadquarters. Authority for the execution of blank cards will be obtained fromthe head of the sections above indicated.

"DAVIS."

2. Hereafter application for the qualification cards ofofficers in the various staff corps, returning to the United States, will bemade to the chief of the staff corps to which the officer belongs.

3. If an officer is transferred from any staff corps his cardwill be put in a sealed envelope and given to him to present to the properofficer at his new station.

By command of Major General Harbord.

L. H. BASH, Adjutant General.

WALTER D. MCCAW,
Brigadier General, Medical Department,
Chief Surgeon.

Circular No. 83:

AMERICAN EXPEDITIONARYFORCES,
CHIEF SURGEON'SOFFICE,
June 16, 1919.

I. Circular Letter No. 223, office Surgeon General, is quotedherewith:

Subject: Record card, Form 627, A. G. O., enlisted men ofstaff corps and departments.

1. Attention is invited to paragraph 41, Manual for theMedical Department, which directs that:

"When a man is enlisted for, reenlisted in, ortransferred to the Medical Department, the medical officer who first receiveshim will prepare and forward a record card of the soldier directly to theSurgeon General, except in the case of a man stationed in the Philippines,Hawaiian, or Panama Canal Department, when the card will be sent through thedepartment surgeon." (As amended by C. M. M. D. No. 3, September 29, 1917.)

2. It is directed that in cases of those who have beenenlisted for, reenlisted in, or transferred to the enlisted forces of theMedical Department since February 28, 1919, a record card be furnished thisoffice and that in future paragraph 41 of the Manual for the Medical Departmentbe strictly complied with.

II. Sick and wounded reports.-1. Attention of allcommanding officers of medical detachments is again called to the AmericanExpeditionary Forces requirements regarding sick and wounded reports. Anymedical formation habitually hospitalizing for more than three days is requiredto render to the chief surgeon, A. E. F., a daily report of casualties andchanges for patients in hospital (Form 22), and to make monthly report on fieldmedical card and Forms 51 and 52. Infirmaries, small post hospitals, and othersimilar units will invariably comply with this when so hospitalizing, and willnotify the chief surgeon's office, immediately by telegraph, that they arebeginning to care for patients that, heretofore, would have been hospitalized ina larger formation.

2. Beginning with the report for July 3, weekly telegraphicreport of sick and injured, Form 86, M. D., A. E. F., will be made direct to theoffice of the chief surgeon, A. E. F., instead of to the surgeons of firstreplacement depot, embarkation center, Le Mans, and district of Paris, andsections, Services of Supply. Great care will be exercised to see that the formchecks before the telegram is sent. All units rendering reports mentioned inparagraph 1 are required to submit this weekly report. The above does not applyto units of the army of occupation, which will continue to report as heretoforethrough the surgeon of that army.

3. At the time of report for June 26, each surgeon of sectionServices of Supply and independent center will forward to the chief surgeon,
A. E. F., a final list of units sending this report through hisoffice, giving designation, location, strength, and complete "K" linefor each unit so reporting.

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III. Method of closing accountability for medical suppliesupon turnover to French authorities.-1. Upon completion of turnover to theFrench authorities under the provisions of letter, headquarters, Services ofSupply, fourth section, general staff, dated May 27, 1919, of property andsupplies for which a medical property return is being rendered, an extra copy ofthe receipted inventory as furnished by the French and American representativeswill be submitted with final return of medical property and constitute a vouchercovering the entire accountability to be dropped. If it is impracticable toobtain an additional copy of this inventory signed by both representatives, acertified true copy of same will be furnished in lieu thereof.

WALTER D. MCCAW,
Brigadier General, Medical Department,
Chief Surgeon.

Circular No. 84.

AMERICAN EXPEDITIONARYFORCES,
CHIEF SURGEON'SOFFICE,
July 1, 1919.

I. Sale of property.-1. Sales of unserviceableproperty as indicated in Section III, Circular 80, this office, May 15, 1919, issuspended. Due notice will be given when such sales may be resumed; and whensuch is done, the following instructions, contained in letter, commandinggeneral A. E. F., Services of Supply, June 29, 1919, regarding the disposal ofsuch supplies, will be observed:

In order to put a stop to practices which have obtainedheretofore in the disposal of Government property, the following instructionswill be communicated to all concerned and steps taken to see that the fullintent of these instructions is complied with when sales are again authorized.

(a) No material will be sold under the heading ofscrap or junk which ought not to be so classed.

(b) Property such as typewriters, wagons, motorvehicles, and miscellaneous machinery and equipment, which is not in immediateworking order and can be so placed with little expense, will not be classed asscrap or junk. Such property and all property which can be rendered fit for goodsecond-class sale with some slight repair will be cared for and property listedfor sale.

(c) When sales are resumed, sales of any kind,including sales of junk, will not be made at stations where there are troopsuntil or unless it is necessary to make such sales in order not to delay thedeparture of troops at that station, and then only sales of material which isreally junk and beyond repair.

WALTER D. MCCAW,
Brigadier General, Medical Department,
Chief Surgeon.

Circular No. 85:

AMERICAN EXPEDITIONARYFORCES,
CHIEF SURGEON'SOFFICE,
July 30, 1919.

The following revised instructions as to civilian laborersare published for the information and guidance of all concerned:

1. Laborers of the administrative labor companies are in allcases entitled to the same medical care and infirmary treatment awarded toUnited States troops. When hospitalization is necessary, agreement has been madewith the French Government whereby French civilian laborers will be evacuated toFrench civilian hospitals.

2. In cases of emergency any laborer may be admitted toAmerican Expeditionary Forces' hospitals, but as soon as practicable these casesshould be evacuated.

3. Cases of venereal disease are to be evacuated to thehospital when necessary in the same way as other cases, but for this class ofcases French hospitals shall be used exclusively.

4. By agreement with the French Government, the AmericanExpeditionary Forces are not required to pay for care and subsistence for casesof venereal disease while in hospital.

5. Transportation of sick and injured laborers to and fromhospital is furnished and provided for by section 1, paragraph 4, General Order26 Services of Supply, as follows:

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The transportation department will furnish the necessarytransportation for all laborers who may be discharged, transferred, or leave bythe termination of contract, upon the request of the commanding officer of thelabor company to which the laborer belongs.

6. Subsistence for laborers in American Expeditionary Forces'hospitals is provided for by section 1, paragraph 8, General Order 26, Servicesof Supply, c. s., as follows:

When laborers employed under contract through the generalpurchasing agent are admitted to a United States military hospital, they willreceive the same subsistence furnished United States troops. The QuartermasterCorps will reimburse the hospital fund at the rate prescribed in existing ordersapplicable when soldiers of United States Army are admitted to hospitals.

7. The surgeon on duty with the labor companies will havegeneral supervision over the sanitary conditions of these companies, reportingupon same under paragraph 5, Form No. 2, M. D. L. B.

8. The surgeon, medical division, labor bureau, Army ServiceCorps, A. P. O. 717, should be notified at once by the surgeon attached to thelabor company on Form No. 1, M. D. L. B., in all cases when laborer is-

(1) Admitted to hospital,
(2) Transferred to French hospital,
(3) Dies, or
(4) Suffers from any condition, though not necessitating admission to hospital, may have bearing on any future claims against the Government.

The same action will be taken in cases of emergency admissions to American Expeditionary Forces' hospitals or infirmaries by the commanding officers of the latter.

9. Diseases and injuries will be described in all reports inaccordance with nomenclature prescribed in article 17, page 18, Sick and WoundedReports for American Expeditionary Forces.

10. It is requested that special care be taken in reportinginjuries, namely, giving definitely the nature of injury, manner incurred, andanatomical parts involved.

11. Form No. 2, M. D. L. B., will be submitted promptly eachweek, the week ending midnight Tuesday, and will embody all the data called forupon said report.

12. Whenever laborers are employed or discharged, the surgeonwill make a thorough physical examination embraced under the following headings:"Height," "weight," "general examination,""head," "chest," "abdomen," "genital organsand anal region," "extremities." These reports should beforwarded promptly to chief of medical division, labor bureau.

13. Venereal disease is not necessarily a case for rejection,but all acute cases and every case that may make the individual a menace to hisassociates should be considered sufficient grounds for rejection. The presenceof developmental and acquired abnormalities or defects, that in themselves arenot sufficient cause for rejection, should always be noted on the physicalexamination report.

14. All reports and correspondence relating to civilianlaborers by surgeons attached to labor companies will be made to the chief ofthe medical division, through the base surgeon.

By order of the chief surgeon:

L. MITCHELL,
Lieutenant Colonel, Medical Corps, United States Army,
Chief, Medical Division, Labor Bureau.

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