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Dr. William J. Mayo of Rochester, Minn., was awarded a gold medal by the National Institute of Social Sciences at its annual banquet in New York City, on the evening of January 18. The medal was bestowed in recognition of Dr. Mayo's humanitarian work,

No Meeting in March-Members of the Medical Society of the Missouri Valley will please bear in mind that at the last meeting, a resolution was adopted to the effect that the March meeting of the society would be omitted during the period of the war. All members who are in the service will have their dues remitted. The secretary would be pleased to receive the names of all who have accepted commissions as he wishes to print a list in the Medical Herald soon.

MEASLES AND PNEUMONIA IN OUR

CAMPS*

VICTOR C. VAUGHAN, M. D., Ann Arbor, Mich.

Measles and pneumonia are so closely associated in military camps that it is well to consider them together. Measles is one of the most infectious diseases and its restriction in camps seems well nigh impossible except under exceptional conditions when the soldiers can be scattered over large areas. This requires so much housing in the form of tents or barracks. and interferes so greatly with drill and other military activities, that measles is justly greatly dreaded.

The soldier who has had this disease in childhood is fortunate, and a command made up of immunes is doubly so. One attack seems to give life-long protection. It is true that occasionally a soldier, who is sure he has had measles, develops this disease; but it is more than probable that the former attack was due to some other eruptive disease. Organizations recruited from sparsely settled districts are more prone to this infection than those from urban or more thickly settled communities, on account of the larger number of susceptible individuals.

Measles, among our people at least, is seldom fatal so long as it remains uncomplicated and without more serious sequelae. This is so generally true that it has been seriously suggested that all susceptibles should be exposed to it in order to secure immunity, but until the complications and sequelae can be more certainly controlled, this procedure can not be recommended. The control of epidemics of measles is more difficult because it is transmissible before it is recognizable in the individual. This however, should not deter medical officers from the daily inspection of all men under their charge, and especially of all recent additions to their commands.

On the first evidence of the disease, the soldier should be sent to the hospital and his tentmates should be quarantined for 14 days. This time is believed to cover the period of incubation. The contacts may be drilled in a squad by themselves, but should not be allowed to mingle with others. Their drill master and attendants should be selected from those known to be immune.

A soldier sick with measles should be im

mediately sent to the hospital, with his clothing and blankets. On arrival at the hospital, the clothing and blankets should be sterilized by steam, rolled in paper, or placed in a paper bag. labeled and put away awaiting the recovery of their owner.

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*Editorial in The Journal of Laboratory and Clinical Medicine, January, 1918.

In the hospitals, patients with measles should not be crowded more than is absolutely necessary. However, when the bed capacity is doubled by the number of patients, as has happened in more than one base hospital recently, overcrowding seems unavoidable unless additional cot space can be secured by the immediate erection of hospital tents. When the beds must be brought within four feet of one another, an improvised clotheshorse carrying a sheet kept moist with a 5 per cent solution of carbolic acid, or a 1:1000 solution of bichloride of mercury, should be placed, as a screen, between the cots. This may seem wholly unnecessary, and it might be asked why it is necessary to try to protect one measles patient against another. The purpose of this recommendation is not to prevent the spread of the measles; but some of these patients, experience indicates that many of them, are carriers of virulent pneumococci and streptococci, and the purpose of this precaution is to prevent the dispersion of these virulent organisms. The sputum cups should be burned and the floors should be kept moist and dry sweeping should not be permitted. The patients should be kept warm and given hot drinks. The plates, knives, and forks should be boiled. Drinking cups should not be exchanged, but each patient should have his own. Paper napkins should be used and should be burned with the sputum.

A mistake made in many of our camps is the too early return to duty of soldiers recovering from measles. They should be placed in convalescent hospitals and kept at rest for a period of ten to fourteen days before returning to duty. While uncomplicated measles seldom or never kills, it lowers the resistance to infection with pneumococci and streptococci. Too often it has happened that a soldier returned to duty after recovery from measles is sent back to the hospital within two or three weeks or earlier with pneumonia. On the other hand, in those camps in which the convalescents from measles have had proper care, the number of cases of pneumonia is relatively low. It should be impressed upon every medical officer that a convalescent from measles is especially susceptible to pneumococcic and streptococcic infection, and in order to protect him from these infections, he should have proper and prolonged professional supervision.

When a soldier recovers from measles and leaves his bed in the hospital, the bedding should be sterilized by steam before it is occupied by another patient. The absence of any provision for this procedure is, up to the present time, a striking feature of most of our base hospitals. Sterilizers, we are told, have been ordered, but up to the early part of December we found no base hospitals fitted with facilities for sterilizing

mattresses and blankets. It is claimed by many that exposure for a few hours to the air-we will not say to sunlight because this is by no means always in evidence-is sufficient to disinfect bedding which has been occupied by patients with measles and pneumonia, but some are still skeptical on this point.

That overcrowding has been a factor in the spread of respiratory diseases in our camps seems quite evident. The transmission of these diseases is in inverse ratio to the distance between individuals. With men sufficiently scattered, even measles-as contagious as it is-is not transmissible. The Surgeon-General, with his extensive experience with septic pneumonia in the Canal Zone and in South Africa, has recognized the danger from the respiratory diseases and has insisted from the first that every man in barracks or tents should have a minimum of 50 square feet of floor space. With nine men in a tent 16x16, the space is reduced to less than 29 square feet and in some camps the number of men in such tents was as great as 12. Soldiers have been overcrowded in tents, barracks, and even in hospitals.

The viruses of the respiratory diseases are transmitted for the most part, at least, through the spray present in coughing, sneezing, and rapid talking. It is true that a virulent pneumococcus has been found in dust, and this cannot be omitted from the list of distributing agencies. Some of our camps have been very dusty, and how greatly this has contributed to the prevalence of the respiratory diseases can not be accurately determined.

Medical officers should be awake to the danger of overcrowding and should do what they can to avoid it. Line officers have certain valid reasons for preferring compact organizations. It favors administrative purposes. However, there should be no unreasonable conflict on this point among intelligent men, all of whom must recognize the fact that the strength of an army lies in its effective men and is in inverse ratio to those on sick report and in hospital. The medical officer is supreme in the hospital, and still some wards have been overcrowded while others are vacant. Because a ward is intended, in the construction of the hospital for surgical cases, is no reason why it should remain vacant for weeks while pneumonia wards are carrying twice the number of patients they were built for. If the sterilization of bedding is secured by a few hours' exposure to out-of-door air, a ward should be safe after the removal of all the beds and a few days' exposure with open windows and doors.

In our base hospitals in this country, with no wounded, the greater part of the space, which means the greater number of the wards,

should be used for medical cases and especially for respiratory diseases.

It should not be forgotten that overcrowding in sleeping quarters is determined, to some extent, by the position of the cots with reference to one another. So far as the spread of respiratory diseases is concerned, men may be overcrowded in the open air. It has not been unusual to find men sleeping in cots so arranged that four heads are brought close together. The medical officer should see to the arrangements of cots in tents and barracks. On account of the shortage of blankets and the absence of heating facilities, it is not rare to find two cots brought close together so that the same. blankets may cover two men.

It seems to have been assumed by those who had supervision of the housing of our soldiers, that camps and cantonments in the southern states did not need to be warm, and has probably been a contributing factor in the greater prevalence of pneumonia in the southern camps compared with those located in the north. Moreover, it is an old and well certified medical observation that pneumonia is not only more common, but more fatal, in the south than in the northern states. While the average winter temperature in Michigan is lower than that of South Carolina, one may suffer from the cold quite severely in the latter state. The same general idea seems to have prevailed among those whose duty it was to provide winter clothing. This was distributed last in the southern camps, and as late as early December many of the soldiers at Fort Worth, Texas, were not provided with woolen clothing. By one who has experienced the chilling effects of a Texas norther, this defect will be appreciated.

Another mistake in the construction department was to leave the base hospital for the last building to be erected. At Fort Worth, early in December, the base hospital was without running water and sewers, and all bed pans had to be carried a long distance-in some wards as far as a quarter of a mile. There were absolutely no bathing facilities in the base hospital. At Fort Sill, the base hospital was in process of construction, and some of the wards, partially built, were crowded with patients. There were no trained nurses, and the soft coal used in the small stoves was tracked over the floor and the dust was deposited on sheets and pillow cases. In camps and cantonments in this country, the base hospital should be completed, and furnished with every facility, before troops are moved in.

The excellence of the barracks of the aviation corps, and the relative freedom from disease among those occupying them is shown when comparison is made between them and the division housing. It is said that the former

were constructed by the aviation corps, not by the quartermaster's department. The construction cost more in money, but, so far, has cost much less in sickness and deaths.

A great sin has been committed in sending troops from a camp known to be badly infected, to one relatively free from infection, without proper precaution. At Camp Wheeler, Macon, Georgia, and at Camp Beauregard, Alexandria, Louisiana, the statement is made that their infection came from Camp Pipe, Little Rock, Arkansas. At the last mentioned place, the claim is made that their infection came from Camp Funston, Fort Riley, Kansas. Indeed, the charge is openly made that one camp intentionally emptied its hospitals into another camp. While this undoubtedly is a gross exaggeration, there is some truth in these statements. Men have arrived at their destination actually ill with measles, pneumonia, or meningitis, and have been sent directly from the train to the hospital. Such procedure would not be permitted by civil health authorities. Moreover, this is not the worst of it. Men coming from an infected camp have been immediately distributed among the different organizations at the place of arrival. In this way, the infection has been planted and scattered widely in a most fertile soil. Under no condition, except under the stress of actual warfare, should troops be sent from one camp to another without isolation for a period under medical supervision both before departure and after arrival. This precaution should be taken on all transfers of troops from one camp to another occupied camp. When the movement is from an infected camp, extra precautions should be taken. New arrivals, whether they come from another camp, or from recruiting stations, or directly from their homes, should be quartered apart and inspected individually and daily before distribution among organizations. The trasfers of troops should be under the supervision of medical officers, and these should report to the medical officers at the place of destination all infections which have appeared among the arrivals or to which they have been exposed. These precautions might not be necessary among well-seasoned troops who have been in the field. for months and possibly for years, but with raw soldiers they are absolutely necessary if infection is to be reduced to a minimum. Within a few months, we should have a constant stream of troops moving from their homes through one camp and another to points of embarkation across the ocean to the battlefields of Europe. To protect these millions from infection, or to reduce infection among them to the minimum, will require the constant attention and care of our most experienced epidemiologists. We can not hope to avoid loss from infection

altogether, but we must reduce it so far as possible. We must pay a penalty for the unprepared state into which we allowed ourselves to fall, notwithstanding the warning which came to us so plainly more than three years ago. The seasoned soldier learns to take care of himself, and, if we are correctly informed, the infectious diseases are infrequent among the French and English veterans, but they have had long training. At best, we are to pay dearly for our apathy.

When the new select men are called, each should come to camp with a card from the health officer of his home, giving a list of the communicable diseases observed in that locality during the past month. These men should be housed in groups of not more than 30, and preferably in much smaller groups, kept in quarantine with daily medical inspection for at least two weeks. Their civilian clothes should be disinfected and sent home. The men should have thorough cleaning in supervised baths and under the care of an officer. They should be clothed in proper uniforms and supplied with an extra suit of underclothing. During the period of detention, the men should receive their vaccines and undergo all necessary special medical examinations. Each group, or squad, should be drilled or exercised by itself. At the end of two weeks, groups which have remained free from infection, might be brought together -not more than two groups at first. After shorter intervals, companies may be formed, and finally regiments, but for two months the groups should not be larger than companies. After this, regiments and larger masses may be organized. In the primary training camps, the arrangement should be such that each company could be isolated from every other part of the camp at short notice. Medical officers especially skilled in the recognition and effective management of communicable diseases, should daily examine every man, stripped and while in his bath. Daily bathing should be a routine exercise. Medical officers, during this preliminary period, should live with the men, eat at the same mess, sleep in the same quarters, and should, at the end of that time, have some voice in the selection of noncommissioned officers. Besides, success in this work should be given weight in fixing the rank of medical officers. All the camps and cantonments now in this country should be maintained at least as long as the war lasts. This is recommended in order that overcrowdeing may not again be necessary, and, if the number now existent is not enough to prevent overcrowding, more camps and cantonments should be provided. The barracks and base hospitals now in existence should be painted and kept in repair. This should include the water supply, sewerage, bath, etc. Let us pro

ceed as though we expect the war to continue indefinitely. When it does stop, these camps and cantonments may be used for the universal military training for which it is to be hoped we will be wise enough to provide. Some of the base hospitals would be excellent for tuberculosis sanitoriums, if kept in repair. There is nothing more demoralizing to camp sanitation than the idea that the camp is soon to be abandoned.

With the restriction of the death rate from tuberculosis, pneumonia is fast winning the rank of "Captain of the hosts of death." There is a general impression that it is most prevalent among children and the aged, but Cole states that more than half the cases fall between 20 and 50 years the period of greatest activity. It was the most serious disease met with by the Surgeon-General in the Canal Zone and he was called to South Africa to advise concerning its restriction among the miners in the Rand region. With the exception of dysentery and typhoid fever, pneumonia caused more deaths among the soldiers of the Civil War than any other disease, and with the elimination of typhoid fever. pneumonia in all probability will claim more deaths in our army than any other disease. Experience shows that it is especially prevalent among recruits. It levies a heavy tribute upon those who are passing through the transition from home life to that of the soldier. Many fall its victims in the process of being adapted to the altered conditions of life. Especially is this true when the period of this transition is acThe fact of this greater prevalence and fatality companied by exposure to unusual cold and wet. among the inhabitants of our southern states. has already been mentioned, as has the special susceptibility of those convalescent from meas

les.

It is highly

It is customary to speak of lobar and bronchopneumonia. This distinction is useful from the standpoint of the pathologist, but how useful it is from an etiologic or epidemiologic viewpoint remain to be seen. Both forms may be primary and both may follow measles. It is generally believed that lobar pneumonia is more frequently primary, while bronchopneumonia is the form most likely to follow measles. However, up to the present time there are no convincing statistics on this point. desirable that accurate observations should be made and recorded in our base hospitals as to the relation of the two forms of pneumonia to measles. The records should show in each case as to whether it was lobar or bronchopneumonia, but what is of more importance, whether it was primary or post measles pneumonia? accurate observations on these points, properly recorded, we should soon have information of great value in an epidemiologic way, and this

With

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