Part II. General Prophylactic Measures

One of the most remarkable things about the 1918 pandemic was the great rapidity with which it spread to all parts of the world. From the report of the first cases which landed in Boston until the epidemic arrived in San Francisco the time consumed was less than two months, and the peaks of the two epidemics were just about one month apart. Apparently no part of the world escaped. Asia, Europe, Africa, North and South America, 135and some of the remote islands of the Pacific, all reported large epidemics, with high mortality and great suffering. The deplorable failure of precautionary measures in controlling the spread, or at least in limiting the disease, may be offset in a measure by the unusual conditions under which almost everybody had been living. Vast numbers from all over the world were gathered together because of the war. Thousands of men were housed together in army camps or in training cantonments. Other thousands were doing relief work or engaged in the manufacture of munitions. Most of those at home were doing double duty, and were on a severe nervous strain. Everyone everywhere was working to the limit and was consequently fatigued. The necessities of war had cut down the amounts of food generally, and sugar and fat rations particularly. Traffic, both between nations and at home, had never been so great nor accommodations so insufficient. So that it is likely that all of these and many more changes in the daily routine of individuals led to a condition of lowered resistance, and at the same time increased their chances of exposure. One point, at least, stands out prominently, and that is that “influenza as it occurred clinically during the first great wave was different from those cases which appeared later.” This was seen in the acuteness of the onset, in the severity of symptoms, and in the high mortality rate. Therefore, any measure which afforded protection, if only for the time being, is worthy of retrial.

In view of the fact that recurrences have followed closely in the wake of all former influenza epidemics, and with the hope of stimulating concerted investigation of preventive measures, the American Public Health Association (57), at its meeting in Chicago in December, 1918, appointed a committee to outline “a provisional working formula, based on the facts and opinions brought out at the meeting.” A summary of the opinions as taken from the report of the committee is given here. They reported that the disease was probably due to some micro-organism or virus as not yet identified; that while it was known as “influenza,” it was not known to be identical with the disease generally known under that name; that there was no known laboratory method of differentiating it from ordinary colds, bronchitis, etc.; that there was no known laboratory method of determining when a patient ceased to be infective; and that the 136deaths from influenza were due to secondary pneumonia resulting from an invasion by one or more forms of streptococci, or by one or more forms of pneumococci, or by the so-called influenza bacillus or bacillus of Pfeiffer. Because of the clear and concise manner in which this report brings out the opinions held, at the time, by a majority of the medical profession a portion of the report is given here verbatim.

“Evidence seems conclusive that the infective micro-organisms or virus of influenza is given off from the noses and mouths of infected persons. It seems equally conclusive that it is taken in through the mouth or nose of the person who contracts the disease, and in no other way except as a bare possibility through the eyes by way of the conjunctivæ or tear ducts.

“If it be admitted that influenza is spread solely through discharges from the nose and throats of infected persons, finding their way into the noses and throats of other persons susceptible to the disease, then, no matter what the causative organism or virus may ultimately be determined to be, preventive action logically follows the principles named below, and, therefore, it is not necessary to wait for the discovery of the specific micro-organism or virus before taking such action.

“1. Break the channels of communication by which the infective agent passes from one person to another.

“2. Render persons exposed to infection immune, or at least more resistant, by the use of vaccines.

“3. Increase the natural resistance of persons exposed to the disease by augmented healthfulness.”

The ways and means of carrying out these principles are many and varied, and it is merely the intention of this paper to put together a sort of digest of some of the more important arguments for and against some of the seemingly more important measures proposed.

Methods Proposed for Breaking the Channels of Communication

(a) Rigid quarantine for all persons suffering from the disease and all contacts. During the epidemic quarantine was advocated by many people. It was pointed out that the disease spread most rapidly in camps, in ships, and in quarters generally where large numbers of persons were closely associated; that it was quite as 137contagious and more rapidly fatal than most diseases which are regularly quarantined; that while it was admitted that there is no laboratory method to make certain the diagnosis, and no method of telling how long convalescents are capable of transmitting the disease, as there is, for instance, in diphtheria, still there is no question of the value of the arbitrary quarantine used in measles, scarlet fever and smallpox, all of which are diseases in which the parasitic causes are not known. Further, the opinion was expressed that complete isolation and quarantine would not only protect the community from influenza, but that it would also in a measure protect the patient from contact with numerous outside strains of pneumococci and streptococci, and so lessen secondary infection and reduce the general mortality.

There are many reasons why quarantine is not applicable in epidemic influenza. Most important of all is probably the inability to make certain the diagnosis, especially during the early stages in light cases. This would work detrimentally in several ways. Really ill patients would delay calling a physician until late, for fear of unnecessary quarantine. Many needless and unjust quarantines would result when the diagnosis was uncertain and the physician anxious to carry out quarantine measures efficiently. Many patients would have contacts running about and infecting their neighborhoods while a delayed diagnosis was being made. Influenza was so contagious during the epidemic that it would have necessitated general quarantine not only of all infected persons but also of all contacts to have obtained any favorable results, and since nearly everyone was either a patient or a contact, all lines of business would literally have been paralyzed by the procedure. If it is true that the infected person is most dangerous to others before he has developed symptoms himself, he is a carrier impossible of detection and control. Points in favor of the hypothesis that infected persons spread the disease before they develop symptoms are found in the following facts. As the disease passed from community to community officials became alert for the appearance of the first case. In army barracks and in large institutions it was often possible to determine the first case at its development. The case was, in many instances, removed at once and isolated, but I have seen no instance in which such a measure was successful in curbing the disease. As subsequent cases appeared they 138were likewise immediately removed, but the cases continued to spread just the same. Bloomfield (38) cited the incident of a student who spent a few hours visiting his sister in a part of the country where there had been no influenza. He appeared well at the time, but six hours after his return to school he developed influenza. Two days after the contact the sister came down with the disease. On the other hand, he told of a student who did not contract the disease, though he slept for two nights in the same bed with his roommate, who had returned to school with a well-developed case of influenza. The unsuccessful attempts to transmit influenza in the experiments of Rosenau (37), McCoy (37a) and others already cited would indicate that the cases from whom the material was taken were no longer infectious, although some of them had been showing symptoms for only about 12 hours. Bloomfield observed that the general use of face masks in the wards did not alter the course of the epidemic, and stated that if face masks are protective, infection from early unisolated cases must be assumed.

Provided influenza is generally transmitted during the period of incubation, a theory which seems consistent with the facts, rigid quarantine for epidemic influenza is impracticable and probably useless.

Partial Isolation by Means of the Cubicle System

The so-called cubicle system consists in the dividing of rooms, or more particularly of wards, into small compartments by means of suspending sheets from wires so that each bed is separated from its neighbor. Capps (39) reported favorably on the method as used at Camp Grant, where sheets or halves of tents were suspended from wires or from the mosquito netting frames which were a part of the standard beds. Doctors, nurses and attendants were forced to wear masks in the wards, and patients were not allowed out of the cubicles without them. In discussing this paper Thayer emphasized the value of screening, masking and the wearing of gowns, and also recommended thorough washing of the hands between the examination of each two patients; and Emerson called attention to the fact that the first demonstration of the cubicle system as an adequate means of preventing acute respiratory diseases was made at the Pasteur Institute of 139Paris, where it had been in operation for 10 years. The latter stated that the system had been used in various hospitals in America and was essential for the care of diphtheria, measles and scarlet fever. He further indicated that if the technique of personal cleanliness of nurses, doctors and attendants could be perfected, it was probable that the height of the cubicle partition could be reduced to that of a “red string.” The method certainly seems worthy of consideration and trial, particularly in large general hospitals and public institutions.

The Use of the Face Mask

The question of the value of wearing a gauze mask over the mouth and nostrils during an influenza epidemic is still an open one. Masks, however, have been found useful in protecting against some other diseases of respiratory origin. In December, 1917, Weaver (40) reported favorably on the use of gauze masks in the Durand Hospital of Infectious Diseases. The masks were used by nurses in attendance upon patients with contagious diseases, and also by patients who were convalescing from diphtheria, meningitis or pneumonia and who were in the same wards with those having other respiratory diseases. In a later article Weaver (41) stated that by the use of masks they had been able to reduce the percentage of diphtheria carriers among their nurses in the diphtheria wards to 5.2 per cent., as compared to the average of 23.25 per cent. during the 20 months immediately preceding their adoption of their use. He recommended the general use of masks for physicians when in contact with all types of respiratory diseases. In March, 1918, Capps (39a) reported encouraging results in the control of infections through the masking of all patients at Camp Grant. During the epidemic the wearing of masks became quite general, and was very popular in many sections.

Several sets of laboratory experiments have been carried out recently to determine whether the masks are of practical value or not. The experiments have generally consisted in spraying cultures of living bacteria over sterile bacterial plates which were protected by one or more layers of gauze. A number of variations were made in the manner in which this was done: (a) the distance between the nozzle of the spray and the mask was 140varied, and the distance between the plate and the mask kept constant; (b) the distance between the plate and the mask varied, and the distance between the nozzle and the mask kept constant; (c) the use of masks both over the nozzle of the spray and over the plate being kept constant, and the distance between the two masks varied. In a somewhat different set of experiments the mask was placed over the mouth of a person, who was told to talk or cough over an agar plate, and the bacterial plate being held at various measured distances from the face. By counting the number of colonies which developed upon the plates it was possible to get fairly reliable data as to the efficiency with which the bacteria were intercepted by the gauze. Weaver (42) found that if enough gauze was used, it would filter out all of the bacteria passing from the spray in the direction of the plate. The efficiency of the mask being in direct proportion to the fineness of the mesh and the number of layers employed. Doust and Lyon (43) made a series of experiments to determine the distance through which droplets are carried when expelled under different circumstances. They found that in ordinary speech infected material is projected for about four feet, and that during coughing the material is carried about ten feet. They demonstrated that masks of medium meshed gauze, two to ten layers thick, worn by the person coughing did not prevent the passage of infectious material into the air, but that a three-layer buttercloth mask was much more efficient. Haller and Colwell (44) used three distinct sets of experiments—one with the mask over the mouth of the patient, one with the mask over the plate, and the third with masks over both—and concluded that a five-layer mask made up of 24 × 20 mesh protected the plate in the second series of experiments. They suggested marking one side of the mask, so that it would always be worn with the same side out. Leete (45), in England, by a similar series of experiments concluded that a dry mask of six to eight layers of butter muslin worn by a contact would protect him against droplet-carried infections. Dannenberg (46) suggested making the gauze mask over a copper screen wire frame to give it shape and keep it away from the mouth, thus keeping it relatively dry. All observers agree that masks while dry are more efficient than they are after they have become moist.

141The efficiency of the mask has also been widely discussed from the clinical standpoint. Mink (47) in discussing their use at the Great Lakes Training Station said that he had no objection to the mask as it is “intended to be worn,” but that as it “was worn” by the medical corps men at the station 8 per cent. of those who used the mask developed influenza, as compared to 7.75 per cent. of those who did not; 30 per cent. of the dental officers at the station developed the disease in spite of the fact that they were all accustomed to wear masks during their work. In discussing the mask Vaughan (48) said: “With reference to the mask, I am strongly of the opinion that we have overestimated its value. * * * When I went to Camp Devens they were not using the mask. I called the doctors together and told them its use was not compulsory, but I said: ‘Every doctor who took care of cases of pneumonic plague and did not wear a mask died from it, and every man who cared for pneumonic plague cases and didn’t wear a mask did contract it.’” They were then allowed to choose for themselves. It has been pointed out that the epidemic dropped off at once in San Francisco with the universal compulsory use of the mask on the street, but it is also said that the epidemic in Los Angeles, which ran a course parallel to that in San Francisco and in which masks were only indiscriminately used, began to drop off simultaneously. While it is difficult to get at the facts, it seems that, provided epidemic influenza is carried through the air or by means of droplets, the universal use of masks should decrease the number of exposures. The claim has been made that masks merely tend to prolong the epidemic, and that susceptible persons develop the disease after the epidemic proper has passed. If the mask will protect the susceptible individual until the virulence of the disease has decreased, it will better that individual’s chances for recovery, and so is worth the trouble.

General Closing Orders

In most large cities orders were issued closing churches and theatres and prohibiting public gatherings of all kinds. In New York these places of public gathering were not closed, and it has been pointed out, as an argument against closing orders in the future, that the death rate there was less than in Boston, Philadelphia, 142Pittsburgh, etc. Copeland (49), of the New York Board of Health, stated that the unventilated picture shows were closed, but that the theatres were used as places of public instruction. New York’s relatively low death rate was difficult of explanation, but it is very certain that it had nothing to do with the fact that closing orders were not in vogue. If it were possible to obtain the figures, it would be interesting, indeed, to compare the death rate from influenza among New York’s theatre-attending public during the epidemic with the death rate of the community in general.

Generally speaking, any unnecessary public gatherings are inadvisable during any epidemic. While our exact knowledge of the mode of transmission of influenza is incomplete, it is unquestionably a contact disease. People who have been exposed and who have not yet contracted the disease are known to have transmitted it to a third person. A certain number of people from infected homes will attend public gatherings as long as they are able, for it is impossible to get together any large group of persons all of whom are going to play fair. It is true that these meeting places may be used in a measure to allay panic and to instruct the public in health measures, but there are many efficient and far less dangerous methods of accomplishing the same results. Vaughan in discussing assemblies in large halls mentioned that in a hall at Camp Forest, which held 9,000 people, the individuals had a space of about 16 inches laterally between their noses. He pointed out that if many of them were talking, coughing or sneezing, the air contamination would soon become so great that it could make little difference whether there was a roof over the building or not. He emphasized the fact that it is just as possible to crowd men in the open as it is indoors. Ventilation is undoubtedly an important factor, but it cannot correct overcrowding. As far as the educational value of the public gatherings was concerned, it may be observed that regular attendants of theatres and moving-picture houses during the year of 1918 had become quite accustomed to appeals regarding all sorts of public movements from speakers who appeared between the acts, or pictures, but that the closing of these places threw a wholesome scare into them which made them pay far closer attention to prophylactic measures than almost anything 143that could have happened. “Object-lessons are always superior to didactic teaching.” In Chicago a new argument for the closing of theatres was advanced. It was said that with no place to go many people retired earlier and obtained more than their accustomed amount of rest. It was believed that this aided in increasing their natural resistance. The argument that the closing of these places served only to delay the epidemic is an argument in favor of the measure, because the virulence of the disease decreased rapidly as the epidemic progressed.

The Closing of Schools

Boards of Health generally were opposed to the closing of the public schools. This position gave rise to innumerable clashes with anxious parents. The health authorities took the position that children were relatively insusceptible to influenza; that while they were quiet in a well-ventilated schoolroom they were little exposed; that those who coughed or sneezed could be examined at once, and that daily school inspection would lead to early discoveries of all cases, so that doctors and nurses could take immediate steps to treat the patients and to protect the families from which they came. Copeland advocated the continuance of the schools in New York, and based his position on the fact that out of 1,000,000 children in New York City 700,000 came from tenement homes. He believed these children were far better off in school, where they received daily medical attention, than upon the streets or in unhygienic homes.

In Pittsburgh the school children were quizzed as to the number of sick at home, and this gave valuable information on the stage of the epidemic. They were sent home with printed warnings against sneezing, coughing and spitting, and were thus used as a means of instructing their parents. The Pittsburgh schools were kept open until the sickness of a number of teachers and the withdrawal of many scholars made it advisable to close.

Three very potent arguments have been brought forward in favor of closing the schools: (1) As long as the schools are open children from infected homes are forced into contact with children from uninfected homes, and we are at present unaware of the extent to which the disease may be carried by a third person. (2) Children in as yet uninfected homes which are comfortable 144and hygienic are far better off than they are in school, and can hardly be considered in the same class with children from unclean tenements. (3) If the period of greatest contagion is before symptoms develop, inspection, while valuable for the institution of treatment, cannot hope to aid in curbing the epidemic. It is evident that different measures must be employed in applying closing orders to crowded cities, moderately large towns and rural districts. The difficulty lies in determining the best means for serving each community.

The Closing of Public Dance Halls

Public dances should undoubtedly be prohibited during epidemics. They not only present all the bad features of other public gatherings, but during the dancing people are brought in very close contact and often breathe directly into each other’s faces. In addition, air currents are stirred up and a certain amount of dust is raised. During the exercise the dancers breathe more rapidly and deeply, thus inhaling unusually large amounts of dust, droplets and contaminated air. Another feature is found in the “resistance-breaking” element of alternate overheating and rapid cooling of the body.

Regulation of Public Eating and Drinking Places

Public eating places are a necessity and cannot be closed. People should be cautioned against using them as places of amusement and of congregation during epidemics. Boards of Health should feel it just as much their duty to see to the sterilization of dishes and eating utensils as they do to the enforcing of any other public health functions, and they should also insist on the daily inspection of the employees of such establishments. The beer saloon question may be passed over for the present, but the soda-water fountain as conducted during the 1918 epidemic was undoubtedly a great menace. Ice cream, syrupy mixtures, etc., of various kinds are readily contaminated by pathogenic organisms which may serve as secondary infectors, if in no other capacity. The syrups, moreover, adhere to the spoons and glasses, which are rarely thoroughly washed and are practically never sterilized between customers. The use of paper 145dishes and glasses is probably a step in the right direction, but the spoons should be thoroughly washed and sterilized. The fact that soda-water employees are not always selected for high-grade intelligence, and are generally left largely to their own hygienic procedures, makes the chances of transferring infections at these places enormous. If soda fountains are allowed to continue business at all during the epidemics, it should be only under the very strictest supervision by Boards of Health. The scalding of all utensils should be enforced by law.

People generally should be cautioned to use exceptional cleanliness in the preparation of all foods in the home. In discussing the recent epidemic Lynch and Cummings (50) stated that “the mess-kit wash water proved the major route of transmission from sick to well in the army.” Vaughan said: “I am pretty certain, not convinced, that hand-to-mouth infection is of more importance than droplet infection.”

Regulation of Traffic

Business must be conducted in epidemic as well as in normal time, and employees must go to and from their places of occupation. In cities where the distance from the residence to the business districts is great, street cars and other public conveyances must be used. Their use undoubtedly increases the number of contacts and leads to a wider distribution of the disease, but, like eating in public restaurants, it is a chance which many have to take. Few places offer better opportunities for exposure than street cars—where people of all grades of intelligence, representing all states of health and degrees of cleanliness and uncleanliness, are crowded closely together, breathe into each other’s faces, and handle the same straps and supports.

In Pittsburgh the cars have a seating capacity for from 30 to 50 persons, but during the morning and evening hours they are crowded to capacity, and are commonly seen to carry more than 100 passengers at a time. Here, too, the unkempt, indifferent foreign element is conspicuous, and these people are known to disregard all hygienic teachings. A few days after the appearance of the epidemic the street cars were placarded with warnings against coughing, spitting and sneezing. The cards instructed people who became ill to go home, to go to bed and 146to remain there until they were well. Later a second order appeared which gave notice that all windows in street cars were to be kept raised six inches and that no heat was to be allowed in the car. The order was intended to improve ventilation, and, for a wonder, it was enforced. During the first few days the weather was fine, warm and clear, and the draught caused by the open windows brought no discomfort; but later the weather became cold and several days of drizzling rain set in. The cars with open windows became very uncomfortable, but the streetcar employees insisted upon obeying the order to the letter. No judgment was exercised by them, and the windows were kept open night and day, cold or warm, crowded or empty, in fair and rainy weather alike, and no heat was allowed to be turned on. Many people preferred standing to exposing their backs and necks to the cold draughts, and it is more than likely that such use of open windows did far more harm than good. As above quoted, Vaughan pointed out that crowding is just as dangerous out of doors as indoors, and it is certain that crowding in cold, draughty cars is dangerous, both from the close contact and because of the added danger of lowering bodily resistance.

In an attempt to decrease the crowding on public conveyances the so-called “stagger-hour” system was adopted in New York. Under this arrangement manufacturers and business houses changed their working hours in such a way that the morning and evening travel was spread out and the average number of people carried per hour was proportionately decreased.

Looking backward over the methods used to decrease the spread through the use of public conveyances, it seems that the following procedures have the best claims for retrial: (1) Placarding the cars. This appeared to reduce the amount of coughing and sneezing, even in face of the fact that the cars were unusually draughty and chilly. (2) The adoption of the “stagger-hour” system where the practice is feasible. (3) The instruction of the people to use the street cars as little as possible.

Enforcement of Anti-Spitting Ordinances

All street cars and trains carry anti-spitting notices either to the effect that spitting will be prohibited on penalty and fine and imprisonment, or giving stated amounts of the fine. Yet 147spitting is constantly indulged in in these places and one rarely sees or hears of the enforcement of the law. If the ordinance was worth making a law, it is certainly worth enforcing, and yet there is probably no law so flagrantly broken. Ordinary police officers pay no attention to the enforcement of the spitting ordinance and have been known to refuse to even reprimand spitters. The incident of a sanitary officer wearing a uniform and a cap, indicating to the public his official position, who was seen sitting in the smoking car in a local suburban train and spitting profusely on the floor has been recounted on very reliable authority. Another incident is known in which a street car conductor was asked by one passenger to stop another who was expectorating abundant mucoid sputum upon the floor. The conductor replied that he had orders not to notice such things. It is no wonder that people are indifferent to such impotent measures. Whether it is possible to convey epidemic influenza or not by means of sputum, it is certain that tuberculosis is spread in this way, and that influenza predisposes to tuberculosis and causes old healed tuberculous foci to become active. People should be made to understand that they may have tuberculosis without knowing it themselves, and that by spitting it may be transmitted to other persons. Spitting by persons aware that they have tuberculosis is criminal negligence and such persons should undoubtedly be prosecuted. If a person knows that he has tuberculosis and deliberately spreads about the infection so that other persons contract the disease and die from it, he is directly responsible for the deaths. It would be hard to imagine trying to control manslaughter committed in any other way by merely putting up signs in conspicuous places forbidding the act. The average boy acquires the spitting habit between the ages of 8 and 12 years, and in many instances carries it to the grave. The one possible way of stopping spitting seems to lie in teaching the dangers of it to children, beginning in the kindergarten and emphasizing it throughout the child’s education. It is possible that in this way spitting may become obsolete in two or more generations.

Increasing Natural Resistance by Augmented Healthfulness

If there is any way of increasing the natural resistance against epidemic influenza, it is a most desirable goal toward which to work, but it must first be determined along what lines the effort 148is to be directed. It was not the aged, the unconditioned nor the physically unfit who suffered most from influenza, but was rather the best trained, most healthful and most robust young persons we had. Those in the army had been selected because of their physical fitness and they had further received excellent physical training in the various camps and cantonments. It would not be possible to bring any large percentage of the general public up to such a stage of “augmented healthfulness” as healthfulness is generally understood. It has been said that men in the military camps were more commonly infected because they were more active, went about more and were, therefore, more frequently exposed. In one particular this statement is true, for men marching rapidly and exercising violently breathe more deeply and at a faster rate than they do under ordinary conditions, so that they naturally draw greater quantities of air into their lungs. It was an obvious fact that those persons given to sedentary lives were less often affected than the active and vigorous. Practically speaking, it would seem that during influenza epidemics people should be instructed to take more than the usual amount of sleep and rest, to indulge only in mild exercises, to eat good, wholesome food, to wear warm clothing, to seek mental and physical relaxation at home, and, above all, to avoid crowds and public gatherings.

In some instances the constant use of oils in the nose and throat was advised, the theory being that the oil served the double purpose of preserving the healthy condition of the mucous membranes by lessening crusting, crevicing and drying, and of mechanically protecting from infection by the presence of the layer of oil. Many of the different liquid paraffins, both medicated and in the natural state, were used. It is probably advisable to apply such oils either with a swab or from a medicine dropper, rather than to attempt to spray them, since in the latter method there is some danger of blowing infectious material down into the trachea and larynx.

It is hardly necessary to point out the importance of augmented cleanliness of the mouth, teeth and throat by means of mild antiseptic washes and tooth-cleansing materials during an epidemic.

General Measures

Public Health Administration

Unless one had had a wide experience in the administrative 149side of public health matters, it would be useless for him to try to discuss the details of handling any sort of an epidemic, and even then local conditions vary so much in different cities and States that each administrator’s experience must differ greatly. The difficulty with reports of epidemics by public health officials is usually found in the fact that the reports are impersonal compilations and convey no idea to the reader, or rather to the student (for no mere reader is attracted to them), of what situations were faced, of what difficulties were in the way, of how the conditions were met, or what the administrator after due reflection would advise doing next time under similar circumstances. In the face of inexperience the writer ventures the following suggestions for improvement, though no originality is claimed for the ideas.

The administrative powers should be centralized in one individual, or in an executive officer acting for a competent board of advisers, who should be endowed with the powers to carry out the measures which seem best suited to meet the situation at hand, and who should be beyond the pale of political interference and in position to prevent political fiascos, built more or less directly on health regulations.

The United States Public Health Service should work toward standardizing health laws and penalties for all States.

Thorough enforcement of ordinances requiring the reporting of all cases and all deaths as now demanded by public health rulings should be insisted upon. These reports are so important to a knowledge of the progress of the epidemic that the section on preventive medicine of the American Medical Association (51) has just advised the consideration of eliminating from membership in the Association any physician who willfully fails or refuses to comply with the regulations requiring the reporting of communicable diseases. Additional information can be obtained by daily canvasses of the schools, when open, of the large industries, and of the daily admissions to hospitals. Data on the daily facilities for the handling of additional cases in hospitals should be on file in the office of the administrator of health.

Printed instructions giving in detail the proper procedures for isolation of the patient and the protection of the family should be supplied to physicians for distribution at the first visit to suspected cases.

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Desirable Laws

Some specific laws governing the following points would be of great advantage during the progress of an epidemic: (a) A law providing for the commandeering by boards of health of vaccines, sera or other substances for which a sudden unusual demand may occur, and for the distribution of such substances by the authorities to the public at the prices ordinarily asked. (b) A law permitting the exclusion from the daily papers by boards of health of advertisements containing obviously false and fraudulent statements relative to the epidemic. (c) A law permitting the health authorities to go into public eating places and demand proper sterilization of dishes and eating utensils with the alternative of closing the establishment. (d) A set of laws making the penalties sufficient to prevent violations of the regulations.

Education of the Public

From the beginning to the end of an epidemic the health authorities, aided by the medical profession, should take the public wholly into their confidence. At the first news of the approach of the disease a general bulletin should be issued giving all of the main facts that are available. This was done in a way by the American Public Health Service, but the bulletin reached only a small fraction of the people, and although parts of it appeared later in the daily papers, it was pretty generally missed. The papers should be used freely and the space paid for when necessary, so that the news of the epidemic is featured emphatically. The establishment of a question and answer department or a bureau of information would take care of a great deal in the way of denying misinformation. The public should be encouraged to report helpful facts of all kinds, but with the understanding that no rumors would be published without investigation and confirmation. In this way it would be possible to prevent articles advising harmful and useless remedies from reaching the press, and aid in suppressing some of the “Sure Cures,” so many of which appeared to abuse the confidence of the unwary during the 1918 epidemic. Several such cures have been most interestingly discussed in a recent bulletin of the United States Public Health Service. The bulletin divides the “Sure Cures” into three different classes, as follows: “First 151comes the individual who has a specific remedy, the formula of which he will sell for a price * * *; next comes the person with a pseudo-scientific treatment, e. g., isotonic sea water, ‘orzono therapy,’ ‘harmonic vibrations.’ * * * Still another type, who gives freely of his advice that humanity may be spared from pestilence.” Among the latter are found advice for placing sulphur in the shoes, wearing of amulets, inhaling of alcohol, chloroform, etc., as well as numerous religious and mental science treatments, etc. A frank statement of facts and a discussion of the ridiculous side of many of these claims would undoubtedly benefit the entire public. The placarding of the cars and the warnings posted in conspicuous places no doubt helped greatly, and this method undoubtedly should be continued. As long as theatres are allowed to remain open, speakers may be used to advantage to emphasize important points. The County Medical Societies should be asked to appoint committees for supplying information or for seeing that the information given to the public is authoritative. In large cities committees may be organized among hospital superintendents, so that the heartiest co-operation between health authorities and hospitals will be available. The ever-ready aid of the Red Cross and of every other auxiliary body should be employed to the fullest extent to allay apprehension and relieve suffering.

Summary

The exact knowledge of the mode of transmission of epidemic influenza is still wanting, but it is known to be spread by contact. Attention should be directed toward every practical means of decreasing the number and intimacy of contacts. Publicity campaigns and other educational measures should be pushed strongly. Health Departments should adopt a policy of preparedness during inter-epidemic times, should make every effort to centralize and standardize their work, and should take steps to obtain sufficient legal backing, so that upon the appearance of the epidemic they can take the lead, speak with authority and enforce their ordinances and measures. The physician’s duty is to inform himself on the value of the various measures, and if he is at odds with the public health methods, he should settle them between epidemics, so that when he is called upon to carry out public health 152orders he can do it to the letter and without criticism. Laymen should learn that quiet living without violent exercise, the keeping of good hours, the avoidance of public gatherings and of unnecessary exposure is the best policy to pursue during influenza epidemics. They should strictly obey the orders of those who have specialized in the control of epidemics, and all business men must stand ready to help in every possible way and to make their business interests subservient to the public good.

BIBLIOGRAPHY

1. Rosenau, Keegan, Goldberger and Lake Public Health Report, 1919; xxxiv, No. 2, p. 33.

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